Value Co-Creation in Social Marketing Wellness Services A thesis submitted to Queensland University of Technology in fulfilment of the requirements for the degree of Doctor of Philosophy, 2011 by Nadia Zainuddin B Bus (Marketing) (Hons) QUT School of Advertising, Marketing and Public Relations QUT Business School, Queensland University of Technology Supervisory Panel Members Professor Boris Kabanoff (Panel Chair) School of Management QUT Business School, Queensland University of Technology Professor Rebekah Russell-Bennett (Principal Supervisor) School of Advertising, Marketing and Public Relations QUT Business School, Queensland University of Technology Dr Josephine Previte (Associate Supervisor) UQ Business School Faculty of Business, Economics and Law, University of Queensland Associate Professor Anne Pisarski (Faculty Representative) School of Management QUT Business School, Queensland University of Technology 1 October 2011
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Value Co-Creation in Social Marketing Wellness Services
A thesis submitted to Queensland University of Technology in fulfilment of the
requirements for the degree of Doctor of Philosophy, 2011 by
Nadia Zainuddin
B Bus (Marketing) (Hons) QUT
School of Advertising, Marketing and Public Relations
QUT Business School, Queensland University of Technology
Supervisory Panel Members
Professor Boris Kabanoff (Panel Chair)
School of Management
QUT Business School, Queensland University of Technology
Professor Rebekah Russell-Bennett (Principal Supervisor)
School of Advertising, Marketing and Public Relations
QUT Business School, Queensland University of Technology
Dr Josephine Previte (Associate Supervisor)
UQ Business School
Faculty of Business, Economics and Law, University of Queensland
Associate Professor Anne Pisarski (Faculty Representative)
School of Management
QUT Business School, Queensland University of Technology
1 October 2011
STATEMENT OF ORGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.
______________________________
Nadia Zainuddin
on 1 October 2011
“Great discoveries and improvements invariably involve the co-operation of many
minds. I may be given credit for having blazed the trail but when I look at the
subsequent developments I feel the credit is due to others rather than to myself”
Alexander Graham Bell
ACKNOWLEDGEMENTS
I would first like to acknowledge the contributions of my supervisors; Professor Rebekah
Russell-Bennett and Dr Josephine Previte. I am lucky to have had the opportunity to be
supervised by two incredibly talented, knowledgeable, and high-achieving women; who have
such complimentary skill sets and supervision styles from which I felt that I was able to
benefit most greatly. Rebekah, I‟ve come to deeply admire and respect you as an academic,
but am also deeply appreciative of you as a mentor. I feel as ready as I can be for this next
adventure because of you. Jo, I truly admire your passion for what you do and your
commitment to the endeavours that you take on. Your enthusiasm for research is contagious
and now I feel a sense of excitement for things to come.
The support I received from the School of Advertising, Marketing and Public Relations has
also been invaluable. I would like to thank the Head of School, Associate Professor Robina
Xavier, for providing me with support and access to the resources that were necessary in
supporting the completion of my PhD. My appreciation also goes to my panel members;
Professor Boris Kabanoff and Associate Professor Anne Pisarski for lending their
expertise to the development of the final version of this thesis. Thank you to Ms Trina
Robbie from the Research Students Support Centre for looking after me during my
candidature.
I would also like to acknowledge my appreciation for every academic who has ever given me
advice on the various aspects of my research. In particular, I am grateful for the contributions
of Associate Professor Ian Lings and Dr Larry Neale. Thank you, Ian, for being so kind in
my panic-stricken moments. I‟m glad that generosity, talent, pragmatism, and the ability to
face a crying girl have found their way into someone like you! I always felt a sense of relief
after seeking your advice and you have made a huge difference to my experiences with
research. Larry, I have never met another academic who is always happy like you! Your
easy-going attitude, humour and ability to seemingly take everything in your stride are
qualities that I appreciate and hope to emulate. The laws of emotional contagion are true!
Thank you for teaching me about the “softer” side of life as an academic.
This research was conducted with the support of Queensland Health‟s BreastScreen
Queensland and in particular, I would like to thank Ms Jennifer Muller and Ms Michelle
Tornabene. Their enthusiasm for my research has made me feel incredibly valued as a
researcher and I am glad that my research findings have been able to make a positive impact
on the community so far.
FINAL THANKS
My final thanks go to my friends and loved ones; I would not have been able to navigate my
way around this endeavour as gracefully as I would‟ve liked without all of you!
For the many years of support that I have received from Mr Damien McDonald, I am
incredibly grateful. Thank you for your friendship, encouragement, and patience (especially
your patience) over the many years of our friendship. You are the original inspiration for my
own wellness paradigm, which has shaped me as a researcher and as a person.
To my friend, Ms Lindsay Lim, who epitomises wellness and inspires me on this journey of
living well and being well, thank you also for always being real and keeping me grounded.
I am grateful to Ms Lisa Wessels who is one of the kindest friends that I have had the good
fortune of knowing. Your compassion, enthusiasm and sincerity are qualities that I
appreciate and I am blessed to have a wonderful friend in you.
To an incredible role model, Dr Cheryl Leo, thank you for sharing your own journey with
me. Your pragmatism has allowed me to keep perspective despite my many bleary moments
and for that, I am grateful. I look forward to navigating my way around this next journey
with you, my friend!
To another incredible role model, Dr Dominique Greer, for whom I have deep admiration
of her talent, determination and grace, I could only hope to be as naturally talented a
researcher as you!
For being the sort of friend who is like family, thank you to Mr Bernard Li. I am glad for
having a friend like you around whom I can really be myself.
My heartfelt thanks and gratitude also go to Joe & Michelle McDonald for looking after me
and making me feel truly cared for; your kindness and generosity will never be forgotten.
Most importantly, I would like to thank my family for all their love and support, as well as
their undying belief in me despite the distance and despite my absence over the many years;
my parents Zainuddin & Latifah, and my brother Azri. Undertaking such monumental
challenges are never easy without one‟s family, but in the end, such endeavours only serve to
develop character and build resilience. In the end, this journey has been about living well,
being well, and doing well, and the development of the strength necessary to achieve this. As
such, I would like to dedicate this thesis to my Mother. Who is the strongest person I know.
ABSTRACT
Customer perceived value is concerned with the experiences of consumers when
using a service and is often referred to in the context of service provision or on the
basis of service quality (Auh, et al., 2007; Chang, 2008; Jackson, 2007; Laukkanen,
1.1 INTRODUCTION........................................................................................................................ 1 1.2 MARKETING THEORETICAL FRAMEWORKS ........................................................................... 3 1.3 PURPOSE OF RESEARCH .......................................................................................................... 5 1.4 RESEARCH QUESTIONS AND OBJECTIVES ............................................................................... 6 1.5 OVERVIEW OF RESEARCH PROGRAM ................................................................................... 11
1.5.1 Study 1: Qualitative ..................................................................................................... 14 1.5.2 Study 2: Quantitative ................................................................................................... 15
1.6 CONTRIBUTIONS TO THEORY AND PRACTICE ....................................................................... 15 1.6.1 Theoretical contributions ............................................................................................ 15 1.6.2 Practical contributions ................................................................................................ 18
1.7 STRUCTURE OF THESIS .......................................................................................................... 19 1.8 CONCLUSION ......................................................................................................................... 21
CHAPTER 2 LITERATURE REVIEW ...................................................................................... 22
2.1 INTRODUCTION...................................................................................................................... 22 2.2 PREVENTIVE HEALTH AND A WELLNESS PARADIGM ............................................................ 22
2.2.2 The role of government in preventive health .............................................................. 23 2.2.3 Using marketing theory in preventive health and wellness ........................................ 24
2.3 SOCIAL MARKETING AND PREVENTION ................................................................................ 27 2.3.1 Justification for use of social marketing .................................................................... 30 2.3.2 Typology of social marketing activities ...................................................................... 31
2.4 PREVENTIVE HEALTH AND WELLNESS SERVICES ................................................................. 33 2.4.1 Significance of health services .................................................................................... 34 2.4.2 Service quality and health services ............................................................................. 35
2.5 VALUE .................................................................................................................................... 37 2.5.1 Perspectives on value ................................................................................................... 37 2.5.2 Experiential value: moving away from an economic approach ................................. 38 2.5.3 Dimensions of value .................................................................................................... 41 2.5.4 Experiential value in wellness services ....................................................................... 44
2.6 VALUE CREATION .................................................................................................................. 45 2.6.1 Value co-creation and service-dominant (S-D) logic ................................................. 46 2.6.2 Value co-creation in social marketing ........................................................................ 47 2.6.3 Sources of value ........................................................................................................... 48 2.6.4 Consumer participation as a source of value ............................................................. 51
2.7 SUMMARY OF GAPS AND PROPOSITIONS ............................................................................... 54 2.8 CONCLUSION ......................................................................................................................... 55
3.1 INTRODUCTION...................................................................................................................... 56 3.2 PHILOSOPHICAL PERSPECTIVES ........................................................................................... 58 3.3 RESEARCH CONTEXT: BREAST CANCER SCREENING SERVICES ........................................... 59 3.4 OVERALL RESEARCH PROGRAM ........................................................................................... 63
3.4.1 Multi-method approach ............................................................................................... 65 3.4.2 Objectives of qualitative Study 1 ................................................................................. 65 3.4.3 Objectives of Quantitative Study 2 .............................................................................. 67 3.5.1 Justification for individual in-depth interviews .......................................................... 68 3.5.2 Sample and unit of analysis ........................................................................................ 69 3.5.3 Interview procedure ..................................................................................................... 70 3.5.4 Analysis of qualitative data ......................................................................................... 72
3.6 RESEARCH DESIGN OF QUANTITATIVE STUDY 2 .................................................................. 76 3.6.1 Reliability and validity ................................................................................................. 76 3.6.2 Sampling ...................................................................................................................... 79
3.6.3 Survey design and measures ....................................................................................... 80 3.6.4 Analysis of quantitative data ....................................................................................... 97
CHAPTER 4 RESULTS OF QUALITATIVE STUDY 1 .......................................................... 103
4.1 INTRODUCTION.................................................................................................................... 103 4.2 SAMPLE OF STUDY 1 ............................................................................................................ 103
4.3 DIMENSIONS OF VALUE ....................................................................................................... 108 4.3.1 Dimensions of customer perceived value .................................................................. 109 4.3.2 Activity aspects of experiential value ........................................................................ 113 4.3.3 New conceptualisation of value in wellness services using social marketing ......... 115
4.4 SOURCES OF VALUE ............................................................................................................. 120 4.4.1 Organisational sources of value ................................................................................ 122 4.4.2 Consumer participation sources of value ................................................................. 130 4.4.3 Third party sources of value ...................................................................................... 133 4.4.4 New categorisation of sources of value and stages of consumption ........................ 135
4.5 CONSUMER GOALS & RELATIONSHIPS BETWEEN VALUE DIMENSIONS AND SOURCES ...... 137 4.5.1 Consumer goals ......................................................................................................... 137 4.5.2 Relationships between dimensions and sources explained by consumer goals ....... 147
CHAPTER 5 THEORETICAL MODEL AND HYPOTHESES ............................................... 153
5.1 INTRODUCTION.................................................................................................................... 153 5.2 PROPOSED MODEL AND HYPOTHESES ................................................................................. 157 5.3 VALUE IN WELLNESS SERVICES .......................................................................................... 158
5.3.1 Functional value in wellness services ....................................................................... 158 5.3.2 Emotional value in wellness services ........................................................................ 158
5.6 RELATIONSHIP BETWEEN INTERACTION AND VALUE ........................................................ 165 5.6.1 Administrative quality and functional value............................................................. 166 5.6.2 Technical quality and functional value .................................................................... 167 5.6.3 Interpersonal quality and emotional value ............................................................... 168
5.7 RELATIONSHIP BETWEEN MOTIVATIONAL DIRECTION AND FUNCTIONAL VALUE ............ 169 5.8 RELATIONSHIP BETWEEN CO-PRODUCTION AND FUNCTIONAL VALUE ............................. 170 5.9 RELATIONSHIP BETWEEN STRESS TOLERANCE AND EMOTIONAL VALUE ......................... 171 5.10 MARKETING OUTCOMES OF VALUE CREATION IN WELLNESS SERVICES ...................... 172 5.11 RELATIONSHIP BETWEEN VALUE AND MARKETING OUTCOMES: SATISFACTION AND
BEHAVIOURAL INTENTIONS................................................................................................. 173 5.11.1 Relationship between value and satisfaction ....................................................... 173 5.11.2 Relationship between satisfaction and behavioural intentions ........................... 174
5.12 SUMMARY OF PROPOSITIONS, HYPOTHESES AND MODEL TO BE TESTED ...................... 175 5.13 CONCLUSION .................................................................................................................. 177
CHAPTER 6 RESULTS OF QUANTITATIVE STUDY 2........................................................ 178
6.1 INTRODUCTION ............................................................................................................... 178 6.2 SAMPLE AND RESPONSE RATE ........................................................................................ 178 6.3 TESTS FOR NON-RESPONSE BIAS, MISSING DATA AND COMMON-METHOD BIAS ........... 182
6.11.1 Non-hypothesised relationships between sources and dimensions of value ....... 204 6.11.2 Non-hypothesised relationships between the dimensions of value ...................... 204 6.11.3 Non-hypothesised relationships between sources of value and satisfaction ....... 205 6.11.4 Non-hypothesised relationships between sources of value and behavioural
intentions ............................................................................................................... 205 6.11.5 Non-hypothesised relationships between dimensions of value and behavioural
intentions ............................................................................................................... 205 6.11.6 Mediated relationships in the model .................................................................... 206 6.11.7 Summary of SEM output for hypothesised and non-hypothesised relationships 208
CHAPTER 7 DISCUSSION AND CONCLUSION ................................................................... 211
7.1 INTRODUCTION ............................................................................................................... 211 7.2 VALUE DIMENSIONS IN WELLNESS SERVICES ................................................................ 212
7.2.1 Value dimensions in wellness: the prominence of functional and emotional value
and the diminished role of social and altruistic value .............................................. 212 7.2.2 Experiential value in wellness: incorporating new understanding of consumer goals .................................................................................................................................... 214 7.2.3 Experiential value in wellness: the prominence of reactive over active value ........ 214 7.2.4 Experiential value in wellness services: the development of a new typology of value .. .................................................................................................................................... 215 7.2.5 Summary of findings for RQ1 ................................................................................... 216
7.3 VALUE SOURCES IN WELLNESS SERVICES ...................................................................... 217 7.3.1 Providing empirical evidence for sources of value in wellness services .................. 217 7.3.2 A new development of categorisation of sources of value in wellness services ....... 218 7.3.3 Summary of findings for RQ2 ................................................................................... 222
7.4 INTER-RELATIONSHIPS OF VALUE SOURCES AND DIMENSIONS IN WELLNESS .............. 223 7.4.1 Organisational sources of value and the value dimensions ..................................... 223 7.4.2 Consumer participation sources and the value dimensions ..................................... 223 7.4.3 Summary of findings ................................................................................................. 224
7.5 ADDITIONAL FINDINGS ................................................................................................... 224 7.5.1 The influence of emotional value over functional value in wellness ....................... 225 7.5.2 The influence of emotional value on behavioural intentions .................................. 225 7.5.3 The curious case of co-production ............................................................................ 226 7.5.4 Consumers co-create value through motivational direction and stress tolerance ... 227 7.5.5 The direct influence of technical quality on satisfaction ......................................... 228 7.5.6 Summary of findings ................................................................................................. 229
7.6 THEORETICAL CONTRIBUTIONS..................................................................................... 230 7.6.1 Contributions to service quality ................................................................................ 230 7.6.2 Contributions to consumer value .............................................................................. 231 7.6.3 Contributions to S-D logic ......................................................................................... 232
7.7 PRACTICAL CONTRIBUTIONS ......................................................................................... 233 7.8 LIMITATIONS AND FUTURE RESEARCH .......................................................................... 235
7.8.1 The context of secondary prevention ........................................................................ 235 7.8.2 The nature of women................................................................................................. 235 7.8.3 The nature of Baby Boomer women ......................................................................... 236 7.8.4 The context of an Australian study ........................................................................... 236 7.8.5 The selection of current users of the service ............................................................ 236 7.8.6 The focus on functional and emotional value .......................................................... 237
7.8.7 The exclusion of environment and third parties....................................................... 237 7.8.8 A consideration of other social marketing activities ................................................ 238
Much of the early literature on preventive health is represented from a biomedical
perspective (Kirscht, 1983). However, the area of health psychology has since been
able to provide an alternative, psychosocial view into this area. Specifically,
preventive health issues have been typically investigated using a public health
approach. Public health focuses predominantly on population-level changes (Hoek &
Chapter 1: Introduction 2
Jones, 2011) and utilises approaches that target public policy and the development of
a supportive environment to facilitate behaviour change. These approaches are seen
as higher order priorities than those focussed at the individual-level (World Health
Organisation, 1989). The development of appropriate public policy and a supportive
environment enables individuals with necessary information, motivation, and skills
in prevention and self-management, which are all essential in achieving effective
prevention in society (World Health Organisation, 2002).
However, part of the responsibility of ensuring that preventive health behaviours are
undertaken is borne by individuals themselves. While public health research does not
discount the importance of individual-level interventions, its philosophy is one that
believes a greater overall change can be achieved through population-level
interventions (Hoek & Jones, 2011). In contrast, marketing research is an area driven
by the identification, segmentation, and subsequent targeting of a section of the
population (see Smith, 1956). This is geared towards the maximisation of profits – or
in the case of preventive health and wellness, the maximisation of successful
behaviour change. The sub-discipline of social marketing is a suitable approach in
investigating preventive health and wellness behaviours, with the aim of maximising
success in behaviour change strategies in specific segments of the population.
Social marketing concerns itself with influencing voluntary behaviours for the
benefit of individuals themselves, groups, or society as a whole (Kotler, Roberto, &
Lee, 2002). Specifically, social marketing is concerned with „„the application of
commercial marketing technologies to the analysis, planning, execution, and
evaluation of programs designed to influence the voluntary behaviour of target
audiences in order to improve their personal welfare and that of their society‟‟
(Andreasen, 1995, p.7). The performance of preventive health or wellness behaviours
has benefits for the individual as the purpose of undertaking this behaviour would be
to prevent or detect disease in an asymptomatic state (Kasl & Cobb, 1966). These
individual prevention efforts collectively ease the burden of disease on societies by
reducing the negative economic impact on countries (World Health Organisation,
2002). This demonstrates the improvement of personal welfare, as well as that of
society and as such, the use of social marketing is appropriate in this research
enquiry.
Chapter 1: Introduction 3
1.2 Marketing theoretical frameworks
This research is informed by three marketing frameworks; service quality, consumer
value, and Service-Dominant (S-D) logic. In this thesis, these three marketing
frameworks are applied to social marketing, which formed the basis of this research
inquiry, situated in the context of preventive health.
Service quality is a subjective evaluation of an individual‟s experience with a service
and is not just made on the basis of the outcomes of the service, but also the process
of the service delivery (Zeithaml, Parasuraman & Berry, 1985). Many preventive
health behaviours are supported by the health care system through the provision of
preventive health or wellness services. Steele and McBroom (1972) define
preventive behaviour as the use of professional services in an asymptomatic state to
avoid illness. The provision of such services provides “behavioural opportunities”
(Kirscht, 1983, p. 282) for individuals to engage in preventive health behaviours
through their use. Preventive health services are those aimed at secondary
prevention, which revolves around issues of detection and early treatment (Fielding,
1978). As such, the use of a services (and subsequently, service quality) approach is
also appropriate for this inquiry.
Social Marketing
Service quality
Consumer value
S-D logic
Chapter 1: Introduction 4
Social and health behaviours have much in common with services marketing
(Hastings, 2003) as they share similar issues and challenges compared to the
commercial marketing of tangible goods. Aspects of the service such as competence
of staff, interactions, and administrative elements all have an impact on the
individual‟s experience with performing preventive health behaviours through the
use of a service. This demonstrates the relevance of service quality as a theoretical
framework in this investigation. The service quality theoretical framework utilises a
customer-orientation approach in understanding individuals‟ service experiences,
which is useful in determining future use of the service again, resulting in long-term
maintenance of the desired behaviour.
Consumers typically continue to use services because of the value that they
subjectively evaluate and derive from the service experience. This leads to the
second theoretical framework, which is consumer value. Consumer value is derived
from an interactive relativistic preference consumption experience (Holbrook, 2006).
In order to incentivise individuals into action (i.e. using preventive health services), it
is necessary to provide them with a value proposition (Dann, 2008; Kotler & Lee,
2008). Individuals often act out of self-interest (Rothschild, 1999), and a value
proposition will encourage their use of preventive health services due to the value
they derive and self-interest they fulfil. The continued use of these services can be
achieved through ensuring that users derive value from their experiences as
consumers seek satisfying experiences (Abbott, 1995) rather than simply outcomes
alone.
In light of the need for individuals to be proactive in managing their health, this
coincides with the need to recognise the increasing importance and significance of
the role of the consumer in a service consumption experience. As such, a third
theoretical framework is used to guide this research; Service-Dominant (S-D) logic.
S-D logic recognises the role of customers as operant resources in a service setting
(Vargo & Lusch, 2004) such as in preventive health services. The skills and
knowledge of the consumer are considered to be useful, important, and necessary
resources in the co-creation of value in a service consumption experience and
consumers are seen as operant resources which are dynamic and produce effects
(Vargo & Lusch, 2004). Consumers using preventive health services are not only
Chapter 1: Introduction 5
proactive participants in the value that is created for them, but they are also
empowered in determining the type of value they seek.
These three marketing frameworks have been used separately in much of the existing
consumer research. However they have never been integrated and used in
combination in a single research inquiry. This research integrates and combines the
use of these three theoretical frameworks by situating these theories in social
marketing. As social marketing considers the voluntary nature of behaviour
performed by individuals (Andreasen, 1995), it requires a need for relational thinking
and customer orientation and the use of the three theoretical frameworks of service
quality, consumer value, and S-D logic fulfils this need.
1.3 Purpose of research
The purpose of this research is to understand how value can be created in social
marketing wellness services for the achievement of maintaining quality of life
through sustained wellness behaviour. Specifically, this research seeks to investigate
individuals‟ use of government-provided wellness services. The selection of
government-provided services is justified by two reasons. First, it is the role of
government to shape the nature of society (Ryan, Parker & Brown, 2003) and one
way of doing so is through the provision of basic health services to members of
society regardless of socioeconomic status. This shapes the nature of society by
ensuring the good health of its citizens. Second, governments often use social
marketing in targeting individual behaviour to seek societal gain (e.g. the
establishment of the Preventative Health Taskforce by the Australian Government).
As such, a government-provided wellness services would be an appropriate context
for this research enquiry.
A core aim of this research is to identify the consumer value that is experienced
during the use of government-provided wellness services. Examining the service
experience through service quality indicators as well as incorporating an
understanding of S-D logic will offer insights into understanding why individuals
perform wellness behaviours through the use of services and how their continued
Chapter 1: Introduction 6
performance of wellness behaviours can be sustained. This is achieved through the
identification of the value experienced during the use of these services, and the
various factors that influence the creation and experience of this value. As such, this
leads to the development of the overall research question of this thesis:
Overall RQ: How is value created in social marketing wellness services?
The offer of a value proposition is critical in encouraging the uptake and
maintenance of wellness behaviours in individuals. As such, there is a need to
determine what value consumers seek and how it can be created. Examples of a value
proposition in wellness not only include the promise of feeling good, looking good,
and enjoying better quality of life, but can also include the ease and convenience of
achieving these outcomes. In spite of the lack of research demonstrating how
customer value is created in wellness services, there is great importance in
understanding the nature of value in this context. Consumer value perceptions
influence satisfaction with the service (Day & Crash, 2000) and consequently,
satisfaction with the service influences consumers‟ decisions to use the service again
in the future (Bolton & Lemon, 1999). In the context of wellness services and social
marketing, this affects the long-term maintenance of wellness behaviours through
individuals‟ continued use of wellness services.
1.4 Research questions and objectives
To address the overall research question, there were three research objectives that
this thesis sought to achieve. First, this thesis sought to understand the nature of
value in a social marketing wellness services context as most of the existing research
in value has been undertaken in the commercial marketing treatment services
context. Second, this thesis sought to identify the factors that influence this value in a
wellness services context. Third, this thesis sought to understand the relationships
between these factors and the value experienced by consumers in order to understand
value co-creation in wellness services.
Chapter 1: Introduction 7
There are two alternate approaches that can be taken in the investigation of value;
economic or experiential. Although the economic approach is traditionally utilised,
the experiential approach was undertaken in this thesis. This experiential approach
has started to gain more attention in marketing research in recent years. This
approach defines value as an interactive relativistic preference experience (Holbrook,
2006) which considers the subjective experience of an individual with a consumption
experience. This approach acknowledges that value can vary for different individuals
who use the same service, and accepts that the consumer is very much involved in
the determination and creation of value sought through the consumption experience.
An example of a subjectively determined value preference experience for an
individual can include convenience, which is a functional type of value. This is
subjectively determined and experienced through the consumption process and is not
experienced by all individuals, only those who seek it.
In comparison, the economic approach sees a greater focus on the outcomes of the
consumption experience rather than the process, and the utilitarian aspect of using a
service is emphasised, rather than the experiential aspect. An example of a utilitarian
outcome of a wellness service consumption experience can include the avoidance of
illness, which is consistent across all individuals. This is not a subjectively
determined outcome, and is one that is experienced by all individuals.
The economic approach is the more commonly used approach in value research,
whereby value is an outcome of an evaluation of costs against benefits (Zeithaml,
1988). This is often based on a utilitarian outcome and has been the more common
value approach thus far as it relates to the economic heritage of marketing (Sheth &
Uslay, 2007). Despite this, the economic approach has become an insufficient means
in ensuring long-term continuation of behaviour as consumers are now active
participants in the consumption process and are empowered to determine the value
that they seek. As such, consumers now seek satisfying experiences that are
subjectively determined, in addition to the utilitarian outcomes of their consumption
experiences. The current dominance of an economic approach signifies a gap in the
research where an experiential approach is under-used but is relevant.
Chapter 1: Introduction 8
It is important to address this gap because individuals‟ decisions to perform wellness
behaviours are complex and not limited to a utilitarian outcome alone. A common
utilitarian outcome measured using the economic approach in value is financial cost.
However, with a number of government-provided wellness services provided at no
cost (i.e. free) or at a subsidy, the importance of financial cost is minimised and other
indicators become increasingly significant in consumers‟ considerations to use
wellness services. Other considerations such as the smooth transaction in the
consumption process become more important indicators in consumers‟ decision-
making. Such aspects of the service in delivering social marketing programs
highlights that the service experience is an important influence on consumers‟
likelihood to perform the behaviour again. Thus, it is important to use the
experiential approach in this value investigation as it allows for an understanding of
why individuals‟ make decisions to behave beyond economically rational reasons.
Value is conceptualised as a multi-dimensional construct, commonly made up of four
dimensions; functional value, emotional value, social value, and altruistic value
(Holbrook, 2006). These four dimensions can co-occur for consumers as an
individual can experience multiple dimensions of value from the same consumption
experience. For example, an individual can experience functional value from going
to the gym because they experience health benefits, but at the same time they also
experience social value because they could have friends who go to the same gym and
they exercise together. Individuals seek satisfying experiences which are attained
through activities (Abbott, 1995) and experiential value is derived as a result.
Experiential value is important in social marketing because if consumers derive
experiential value from performing social marketing activities, then they are likely to
also derive satisfaction. Subsequently, there is an increased likelihood of their
continuation with these activities in the future. In social marketing, this is important
as sustained wellness behaviour is then achieved. These value dimensions have been
conceptualised and tested in commercial marketing, but there is limited empirical
evidence for these value dimensions in social marketing. Thus, this leads to the first
sub-research question:
RQ1: What are the dimensions of value experienced by users of wellness
services in social marketing?
Chapter 1: Introduction 9
Upon understanding the nature of value in a social marketing wellness services
context, the next step is to understand the various factors that can influence this
experiential value for users of a wellness service. As value creation is considered to
be contextual (Hilliard, 1950; Holbrook, 1994), it can be influenced by different
factors or sources where there is currently limited empirical understanding of these
sources. It has been conceptually proposed that some sources, known as sources of
value, include sources such as information, interaction, environment, service,
customer co-creation, and social mandate (Prahalad & Ramaswamy, 2004; Russell-
Bennett et al., 2009; Smith & Colgate, 2007).
Some of these sources of value refer to activities and processes within and between
organisations that create value for customers in a commercial marketing context such
as information, interaction, and environment (Smith & Colgate, 2007). These sources
of value refer to those that are generated by the organisation and as such, service
quality is used as a framework to guide this inquiry. Service quality includes aspects
of the service such as the technical skills (i.e. technical quality) and interpersonal
skills (i.e. interpersonal quality) possessed by staff members, the environment quality
(Brady & Cronin, 2001; Rust & Oliver, 1994), and the administrative processes (i.e.
administrative quality) of the service (McDougall & Levesque, 1994). Some of the
sources of value conceptualised by Smith and Colgate such as information and
interaction are derived through consumers‟ interactions with staff members and as
such, service quality dimensions such as technical quality and interpersonal quality
are important sources of value. On the other hand, other conceptualised sources of
value such as environment are derived through consumers‟ assessment of the service
quality dimension of environment quality.
In contrast, other sources of value such as customer co-creation are generated by the
customers themselves and not the service organisation. Customer co-creation is
driven by consumers‟ increasing knowledge and skills, resulting in their desire and
ability to interact with organisations in order to “co-create” value (Prahalad &
Ramaswamy, 2004). This relates to the S-D logic framework, which considers
consumers to be co-creators of value (Vargo & Lusch, 2004). As this research seeks
to understand why consumers voluntarily use wellness services as opposed to being
mandated into using them, the use of S-D logic allows for the consideration of
Chapter 1: Introduction 10
consumers of wellness services as proactive co-creators of value. Aspects of
customer co-creation of value include motivational direction, which refers to the
activities to which an individual directs and maintains effort (Katerberg & Blau,
1983). For example in wellness, this can refer to understanding the importance of
using a specific wellness service and ensuring that it is used. Another aspect of
customer co-creation includes co-production, which refers to the participation of the
consumer in the service process to produce the core service offering with the service
provider (Bendapudi & Leone, 2003). This can include physical or behavioural
contributions of the consumer that are essential to produce the core service offering,
such as removing any items of clothing so that the consumer may be examined or
keeping still during physical examination if required. Additionally, stress tolerance is
another aspect of customer co-creation which involves the management of emotions
for the attainment of a specific goal (Mayer & Salovey, 1997). This is likely to be
important in a wellness context due to the highly personal nature of health and the
stress that this can create for many people.
The notion of sources of value can be applied to a social marketing context. It is
equally important in social marketing to understand the various influences on
consumers‟ experience of value since this is likely to impact their decisions to
perform wellness behaviours again in the future. However, as these sources of value
have only been conceptualised in the existing literature, there is no empirical
evidence in commercial marketing or in social marketing for them, which represents
the next gap in the research. Thus, this leads to the second sub-research question:
RQ2: What are the sources of value that exist in wellness services in social
marketing?
Upon identifying and understanding the value dimensions present in a social
marketing wellness services context, as well as the sources of value, it is necessary to
determine how the dimensions and sources of value relate. An understanding of the
relationship between the value dimensions and sources will provide health service
organisations with a framework for identifying the various aspects of the
consumption experience that can influence experiential value for consumers. This
Chapter 1: Introduction 11
understanding will provide insight as to how value can be created for users of
wellness services. Currently, no research has addressed how the sources of value
specifically influence the dimensions of value in a wellness services context. It is
important to address this gap because this will provide social marketers and health
organisations with specific knowledge as to how to create specific dimensions of
value for individuals who use the service. For example, advertising messages
(information) can use statements that illicit positive emotions (emotional value) in
target audiences. This knowledge can provide wellness services with a framework
that will allow them to tailor their services marketing mix in order to provide the
specific value that their users seek. As such, a third sub-research question was
proposed:
RQ3: What is the relationship between the sources and dimensions of value
in wellness services?
In summary, this research sought to understand how value can be created in wellness
services that use social marketing and the inquiry was guided by three theoretical
frameworks; service quality, customer value, and S-D logic. In determining how
value can be created in wellness services, three sub-research questions were
developed to address the gaps inherent in the literature. The following section
provides an overview of the research program that was used to answer the three sub-
research questions.
1.5 Overview of research program
In investigating wellness services, the research investigation was situated in the
context of breast cancer screening services in Australia. This type of service
represented a wellness service provided by the government that recommends women
in the target age group of 50 to 69 years to have a breast screen once every two years.
Breast cancer screening services are services aimed at secondary prevention, which
revolves around detection and early treatment (Fielding, 1978). Breast cancer
screening services are provided to Australian women in the target age group free by
the government, making this service available to all women who voluntarily choose
Chapter 1: Introduction 12
to use it. However, despite the government agenda for this service to available to all
in the target segment, this research acknowledges that there are still disadvantaged
groups (e.g. on the basis of location or ethnicity) who may still be unable to access
these services.
In order to answer the three sub-research questions, a multi-method two-study
research program was developed. A multi-method approach is advantageous as it
allowed for the ability to use a more comprehensive approach to the research inquiry
and to triangulate results, allowing for a broader set of research questions to be asked,
and enabling discovery (Gil-Garcia & Pardo, 2006). The process of discovery was
pertinent in this research as the use of the three theoretical frameworks of service
quality, customer value, and S-D logic had never been previously undertaken in a
single research enquiry based in social marketing. Multi-method approaches
typically use a combination of both qualitative and quantitative methodology
(Creswell, 2003), which was the approach used in this research.
Study 1 was a qualitative exploratory study, while Study 2 was a quantitative
confirmatory study and both studies sought to address each of the three sub-research
questions. Study 1 sought to qualitatively determine the dimensions and sources of
value present in a wellness service, addressing RQ1 and RQ2. It also sought to
provide insight into the possible relationships between these dimensions and sources,
addressing RQ3. A theoretical model describing the value co-creation process was
then developed as an outcome of the qualitative analysis, which was then tested in
the second study. This theoretical model described a proposed model of value co-
creation in breast cancer screening services, identifying the specific constructs
present in the model as well as the various hypothesised relationships within this
model.
Subsequently, Study 2 sought to quantitatively confirm the dimensions and sources
of value present in a wellness service that were identified qualitatively in the
previous study through the testing of the proposed theoretical model. This
empirically addressed RQ1 and RQ2. Additionally, it sought to provide empirical
evidence for the relationships that were qualitatively derived from the results of the
first study, through the use of a large-scale online survey. This empirically addressed
Chapter 1: Introduction 13
RQ3. A detailed description of the methodology is provided in Chapter 3; however a
summary of the overall research design is presented here in Table 1.1.
Table 1. 1 Overview of research program
Research Questions
Gaps Addressed
Study that addresses
RQs
Objectives of Research
Research Method
Analysis
RQ1: What are the dimensions of value experienced by users of wellness services?
GAP 1: Lack of
empirical evidence for dimensions of value in social marketing wellness service context
Study 1
To identify the dimensions of value experienced by individuals when performing wellness behaviours To identify the sources of value experienced by individuals when performing wellness behaviours To identify the constructs necessary for value co-creation in wellness
Qualitative
1. Use of 1 focus group discussion (n=5) for the development and refinement of an individual-depth interview guide 2. Semi-structured individual-depth interviews (n=25)
Thematic analysis using NVivo
RQ2: What are the sources of value that exist in wellness services?
GAP 2: Lack of
empirical evidence for sources of value in social marketing wellness services
Study 1
RQ3: What is the relationship between the sources and dimensions of value in wellness services?
GAP 3: Limited
empirical evidence demonstrating the relationship between value dimensions and sources in a social marketing wellness service context
Study 1
and Study 2
To understand the relationships between the individual dimensions and sources of value in wellness
Quantitative
Survey 1. Initial validation sample (n=397) 3. Final sample (n=400)
Reliability analysis, exploratory factor analysis (EFA) using PASW18 Confirmatory factor analysis (CFA) using PASW 18 Structural equation modelling (SEM) using AMOS 18
Chapter 1: Introduction 14
1.5.1 Study 1: Qualitative
Study 1 was a qualitative exploratory study which sought to determine the value
dimensions experienced by individuals who use breast cancer screening services, as
well as the sources of value that influence the dimensions of value experienced. This
was achieved through the use of individual in-depth interviews. A focus group was
first conducted to develop and refine the instrument, which was an interview guide.
Upon refinement of the interview guide, individual in-depth interviews with 25
participants who were users of government-provided breast cancer screening services
were interviewed. Thematic analysis was undertaken to reveal themes which
reflected four dimensions of value; functional, emotional, social, and altruistic. Also
revealed were three categories of sources of value; organisational, consumer, and
third parties. Detailed findings of these results are presented in Chapter 4.
As a consequence of the qualitative analysis, a theoretical model of value creation
was developed for testing in Study 2. It was determined that Study 2 would limit its
focus on empirically testing functional and emotional value only as these were
determined to be the most important value dimensions to the women interviewed.
Furthermore, the study limited its focus to the interaction between the organisation
and consumer, as these were determined to be the most important value sources in
breast cancer screening services. As such, this limited the focus to organisational and
consumer sources of value only. The theoretical model included 10 constructs used
for hypotheses testing. This included 2 value dimension constructs (functional value
and emotional value), 3 organisational sources of value constructs (technical quality,
interpersonal quality, and administrative quality), 3 consumer sources of value
constructs (motivational direction, co-production, and stress tolerance), and 2
outcome variables (satisfaction and behavioural intentions). A detailed description of
the theoretical model and the hypotheses developed for testing are presented in
Chapter 5.
Chapter 1: Introduction 15
1.5.2 Study 2: Quantitative
Study 2 sought to test the relationships between the sources of value and dimensions
of value in a social marketing wellness service using the constructs identified in the
theoretical model of value co-creation. The measures used for the model testing were
taken from existing, established scales in the literature. However, the scale measures
were modified to reflect more appropriate scale items for the specified context of
breast cancer screening. These items were tested with a pilot sample of n=397
through exploratory factor analysis (EFA) and reliability analysis using PASW 18
software program. Then, the model was tested through the use of a large-scale
quantitative online survey with a sample of n=400. Confirmatory factor analysis
(CFA) was conducted using PASW 18 software program as well as regression
analysis through structural equation modelling (SEM) using AMOS 18 software
program. Detailed findings of these results are presented in Chapter 6.
1.6 Contributions to theory and practice
In conducting this research enquiry, this research provides several contributions to
both theory and practice, which are described in the following sections.
1.6.1 Theoretical contributions
The major theoretical contribution of this research is that this inquiry has
demonstrated the dynamism and complexity of value co-creation in social marketing
wellness services. The findings of this research add to the existing knowledge on
consumer value by showing that value is a dynamic construct that changes
throughout the consumption process and is determined, created, and experienced
differently by different individuals. These results show that the context of value co-
creation is important as its complexities suggest that its nature is likely to change in
different consumption situations. A significant gap in the literature was addressed by
situating three marketing theoretical frameworks (service quality, consumer value,
and S-D logic) in social marketing and in doing so, an alternative means for
Chapter 1: Introduction 16
understanding individual consumer behaviour in a domain that has been traditionally
focussed in public health, psychology and medicine was provided.
The following theoretical contributions were made to the area of service quality:
Service quality dimensions that are keys to value co-creation in wellness
services were identified. Empirical evidence for the service quality
dimensions of interaction quality, technical quality, and administrative
quality were provided by both the qualitative and quantitative studies of this
research, while empirical evidence for the service quality dimension of
environment quality was provided by the data from the qualitative study only.
The development of a value co-creation model in wellness identifies specific
service quality constructs that lead to specific dimensions of value. Empirical
evidence was provided to show that the service quality dimensions of
administrative quality, and technical quality specifically led to the creation of
functional value, while interpersonal quality specifically led to the creation of
emotional value.
The following theoretical contributions were made to the area of consumer value:
The use of the experiential approach to investigating value reflects the current
academic shift from the traditional and often-used economic approach in
understanding consumer value. This acknowledges the growing importance
of an experiential perspective in academic inquiry into value co-creation.
Empirical evidence for experiential value dimensions was provided through
the development of a typology of experiential value in wellness. This
typology identifies the various types of value present in the value co-creation
process, and through the use of social marketing, clarifies the concept of
value in government wellness services.
Empirical evidence for sources of value was provided through the
development of a categorisation of the sources of value. This categorisation
Chapter 1: Introduction 17
identified the sources of value that are present in wellness services using
social marketing and explains the influences of the different sources of value
on the dimensions of value in social marketing wellness services.
And understanding of how the value dimensions and sources relate was
provided through both the qualitative and quantitative studies identifying the
specific relationships between the experiential value dimensions with the
identified sources of value. The nature of these relationships is explained by
consumer goals identified from the qualitative study.
Empirical evidence was also provided to show that in the context of wellness
services in social marketing, emotional value has a positive and significant
influence over the experience of functional value. This demonstrates that the
different dimensions of value in social marketing are inter-related and are not
separate and distinct.
The following theoretical contributions were made to the area of S-D logic:
The identification of consumer participation as one of the categories of
sources of value provides empirical evidence for S-D logic, showing that
consumers are co-creators of value in wellness. Empirical evidence for this
was provided in both the qualitative and quantitative studies.
Consumer participation was delineated further to identify motivational
direction, co-production, and stress tolerance as aspects of participation that
lead to value co-creation. This demonstrates that while consumers are co-
creators of value in wellness, they are able to co-create this value in multiple
ways. It demonstrates that consumers are not just empowered in their
determination of the type of value that they seek, but also in how they choose
to create it with the service.
The development of a model of value co-creation identifies how the different
aspects of consumer participation create value. Specifically, consumer
participation aspects of motivational direction and stress tolerance led to both
Chapter 1: Introduction 18
functional and emotional value. However, while the consumer participation
aspect of co-production did not lead to value, it led directly to the outcome
variables of satisfaction with the service and behavioural intentions to use the
service again.
The qualitative data provided further empirical evidence for S-D logic
through demonstrating the complexity of the role of the consumer in the co-
creation of value and showing that the consumer plays a key role in value co-
creation.
1.6.2 Practical contributions
This research also provided a number of practical contributions that are beneficial to
wellness services, social marketers, governments and other policy makers in the area
of wellness. Specifically, this research has provided the following practical
contributions:
This research outlines the expectations of value that consumers have from
free wellness services provided by the government and makes these
expectations clearly identifiable to service organisations, governments, and
social marketers who seek to target users of wellness services. This
knowledge is useful for wellness services in their planning and allows for the
setting of more realistic targets to achieving consumer satisfaction through
the provision of customer value.
A diagnostic tool for improving organisational competences was provided by
the value co-creation model developed in this research. This diagnostic tool
can be utilised by wellness service organisations in identifying the different
factors within the service experience that have an impact on consumers‟
determination of value when using the service. This provides wellness service
organisations with an understanding of how to manage these various factors
in order to maximise the desired positive outcomes and minimise negative
outcomes.
Chapter 1: Introduction 19
A more practical understanding of the causes of behaviour change in
consumers engaging in health prevention is also provided by this research
through the identification of the sources and dimensions of value in wellness.
This research also provides wellness services with insights into consumers‟
consumption experiences that would allow for the identification of areas of
strengths, weaknesses, as well as opportunities. This would lead to a greater
likelihood of achieving organisational strategies and objectives, as well as
greater consumer satisfaction and repeat usage, through more effective
delivery of the service and provision of value to consumers. Additionally,
these insights can aid in the development of more effective organisational
strategies revolving around service provision and social marketing efforts.
1.7 Structure of thesis
This thesis is comprised of seven chapters. Following this introductory chapter, a
review of the literature is provided in Chapter Two. This chapter provides a detailed
discussion of the current literature on preventive health, social marketing, health
services, and consumer value. The chapter also identifies the research gaps inherent
in the literature and the subsequent research questions developed in order to address
those gaps.
Chapter Three then describes the philosophical underpinnings of this research and
follows with the research methodology for this thesis. This chapter provides a
justification for the use of a two-study multi-method approach, utilising a qualitative
exploratory study (Study 1), followed by a quantitative confirmatory study (Study 2).
A justification for the use of a qualitative approach through the use of individual in-
depth interviewing technique for Study 1 is provided, as well as a justification for the
use of a quantitative approach through the use of an online survey for Study 2. The
research procedures for both studies are outlined in this chapter, which then
concludes with a discussion of the ethical considerations of this research.
Chapter 1: Introduction 20
Chapter Four follows with a report of the qualitative findings of Study 1. This
chapter reports the evidence provided for four dimensions of value in a social
marketing wellness service context by describing six themes that reflect the
functional, emotional, social, and altruistic dimensions of value. It also provides
evidence for three categories of sources of value in wellness services, which are
organisational sources, consumer sources, and third party sources of value.
Chapter Five then presents a proposed model of value co-creation that identifies the
constructs for testing in Study 2. This model identifies and describes the
hypothesised relationships between the constructs in value co-creation. This chapter
provides a set of propositions and justifications and presents nine hypothesised
relationships for testing in Study 2.
Chapter Six reports the analysis procedure and results of the model testing in Study
2. This chapter reports the response rate as well as sample characteristics of the
respondents who participated in the online survey used for this study. The results of
construct reliability and validity tests are also presented, with a descriptive analysis
of the constructs and a discussion of the theory assumptions. The hypothesis testing
outputs are then presented, identifying the supported and non-supported hypotheses.
This is followed by a report of the post hoc tests, which identify the non-
hypothesised significant relationships evident in the data, as well as mediated
relationships evident in the data.
Chapter Seven then discusses the key findings of the overall investigation by
drawing upon the findings of both Studies 1 and 2. The theoretical and managerial
contributions of this research are discussed, as well as the limitations of the current
study. Suggestions for future research are then presented, which not only seek to
overcome the existing limitations of the current study, but also to expand the current
scope of understanding as a result of this research enquiry.
Chapter 1: Introduction 21
1.8 Conclusion
In summary, this chapter has provided an overview of this thesis. It outlines the
research background as well as significance and justification for the research. A
summary of the research program is presented, showing the research gaps as well as
research questions developed to address these gaps. Theoretical and practical
contributions are also provided and an overview of the structure of the thesis is
presented. The following chapter offers a discussion of the relevant literature that
forms the basis of this investigation and explains the research gaps in detail as well
as demonstrating the derivation of the research questions.
Chapter 2: Literature review 22
CHAPTER 2 LITERATURE REVIEW
“No longer do the dominant theories view the individual as a passive vessel
„responding‟ to „stimuli‟; rather, individuals now are seen as decision
makers, with choices, preferences, and the possibility of becoming masterful,
efficacious, or, in malignant circumstances, helpless and hopeless”
Martin E.P. Seligman
2.1 Introduction
This chapter provides a review of the literature on social marketing wellness services
and the role of value in facilitating behaviour maintenance. This review begins by
demonstrating the emergence of preventive health efforts within a wellness
paradigm, followed by a review of social marketing and its use in preventive health.
Next, a justification for the use of a services marketing framework is provided,
followed by a review of the literature on the area of consumer value. Additionally,
three research gaps inherent in the literature are identified and subsequently, research
questions developed to address these gaps are presented.
2.2 Preventive health and a wellness paradigm
In Australia, there is a great focus on public health issues and the provision of health
services by the government. The Preventative Health Taskforce was launched by the
Minister for Health and Ageing on 9 April 2008 with the objective of providing
evidence-based advice to governments and health providers on preventive health
issues (Preventative Health Taskforce, 2009b). Subsequently, a National Preventative
Health Strategy was launched on 1 September 2009 outlining strategies to achieve
the broad objective of achieving the status of healthiest country by 2010
(Preventative Health Taskforce, 2009a). This demonstrates the importance and
prominence of preventive health issues in Australian society.
Chapter 2: Literature review 23
2.2.1 Preventive health
Preventive health behaviour refers to activities undertaken by individuals who
believe themselves to be healthy, in an attempt to prevent disease or detect disease in
an asymptomatic state (Kasl & Cobb, 1966). Health prevention involves the
interference of the processes of disease or trauma (Kirscht, 1983) and includes
multiple types of prevention. Primary prevention focuses on the prevention of the
occurrence of a condition, secondary prevention focuses on detection and early
treatment, while tertiary prevention focuses on the alleviation of the effects of a
condition after its occurrence (Fielding, 1978). Prevention behaviours are comprised
of the seeking of positive, healthy behaviours (e.g. exercising) or the avoidance of
negative, unhealthy behaviours (e.g. smoking) and preventive health behaviours can
be undertaken by individuals outside of the medical care system or within the
medical care system. This demonstrates the complexity and multi-faceted
characteristic of preventive health behaviours and the most appropriate strategy in
achieving behavioural change is contingent on the specific type of prevention effort
(primary, secondary, or tertiary; starting positive behaviour, or stopping negative
behaviour; operating within the medical care system, or operating outside the
medical care system). This thesis focuses its enquiry on secondary prevention efforts,
for the achievement of positive, healthy behaviours among the target audience,
within the medical care system.
2.2.2 The role of government in preventive health
The establishment of the Preventative Health Taskforce demonstrates the
significance of preventive health issues to government. The role of government is
typically seen as one that provides a variety of public services to its citizens, such as
transport, criminal justice, and public health. Many public health services are
provided by the government as the role of government lies in its responsibility for
shaping the nature of society (Ryan, Parker & Brown, 2003). This would include
ensuring that adequate public health services are available to all citizens in order to
maintain reasonable quality of life. The provision of these public services is made on
the basis of equality and community (Laing, 2003) and thus the government agenda
Chapter 2: Literature review 24
is that no individual citizen is excluded from the ability to benefit from such services.
Despite these efforts, there are still disadvantaged citizens that exist in any society
who may still experience exclusion from the use of these services.
Health services represent a type of public service that is of great importance to
society. Government-provided health services represent a focus of this research as
these public services are provided to target populations on the basis of social justice
and equity (Van der Hart, 1991), rather than economic or financial ability to use
these services. This is in contrast to the provision of health services by non-
government or private health services, which target consumers on their ability to pay
for such services. This excludes populations that do not have the means to afford or
access these services. Government public health services are provided on the basis of
a collectivist philosophy, whereby the needs of society and social justice are
emphasised over the needs of an individual. The use of government-provided public
health services, while fulfils the needs of the individual who uses them, also fulfils
the broad needs of society. The achievement of community goals is a typical
objective held by many government public health services. Despite this agenda, as
mentioned previously, this research acknowledges that disadvantaged groups that are
unable to access such services will continue to exist in society despite government
effort to make public health services accessible to all.
2.2.3 Using marketing theory in preventive health and wellness
In terms of resource allocation by government to public health services, there is a
predominance of health treatment services over health prevention services. This is
evidenced by the large proportion of government expenditure on treatment services
comparative to preventive services. For example, from 2000 to 2001, the health
expenditure in Australia on cancer treatment accounted for 90% of the total
expenditure on disease and injury, while in comparison the expenditure on cancer
prevention was 1.8% (Australian Institute of Health and Welfare, 2005b).
A possible reason for the lower emphasis on prevention (in terms of resource
allocation) thus far could be that negative situations and experiences may be
Chapter 2: Literature review 25
perceived to be more urgent and override positive situations and experiences
(Seligman, 2002). There is greater urgency experienced by an individual who is
feeling unwell to get treated to feel better again. In response, an individual may
respond in a reactive manner (seeking treatment) as they are behaving in response to
an external stimulus (falling ill). Furthermore, the burden of disease poses a
significant threat to society and represents a pertinent problem that governments are
required to address appropriately and urgently.
In the marketing area, little research exists in the examination of preventive health
services, while more occurs in the context of health treatment services (e.g. Dagger,
Sweeney & Johnson, 2007). There is an opportunity for a marketing approach
towards understanding preventive health behaviours through the use of consumer
behaviour theories. This approach can be used to compliment the work that exists in
public health research, as a marketing approach offers insights into specific target
segments, rather than a population-level approach which public health research
appears to favour (see Hoek & Jones, 2011).
A marketing approach in a research investigation of health services allows for the
consideration of users of such services as customers or consumers of the service.
This has the potential to provide insight into consumers‟ attitudes and how these
attitudes influence their decisions to use these services. This responds to a call by
Maddux (2002) who highlights the need for new ways of thinking about human
behaviour in health psychology, as it adds an alternative perspective of thinking of
preventive health behaviour that is complimentary to the existing biomedical and
public health perspectives that are typically used in this area of investigation.
In the pursuit of health, as discussed previously, there are many different types of
health behaviours that can be undertaken in a variety of situations and contexts. The
quest for good health from a current state of poor health can be seen as activity
within health treatment, while the quest to maintain or enhance good health can be
seen as activity within health prevention. The quest for good health from a current
state of poor health can be described as a function of an illness paradigm, whereby
activities undertaken by individuals to reach their goal are reactive and in response to
an existing problem or issue. In contrast, the quest to maintain or enhance good
Chapter 2: Literature review 26
health can be described as a function of a wellness paradigm (Zainuddin et al., 2001),
whereby activities undertaken by individuals to achieve these goals are proactive and
not in response to any existing health problems or issues. Activities undertaken in a
wellness paradigm are inclusive of preventive health behaviours as individuals can
be motivated by the desire to prevent disease or detect it (among other possible
motivations).
Figure 2.1 provides an illustration of the health continuum which summarises the two
paradigms of illness and wellness and identifies examples of different activities
involved in both the illness and wellness paradigms. The specific points on which
individuals find themselves on the continuum depend on their current health status.
The activities described are placed along the continuum in order of the extent of an
individual‟s poor health or good health. As shown in the continuum, activities within
the illness paradigm reflect reactive behaviours that individuals engage in to improve
their poor health, while activities at the wellness paradigm reflect the opposite. These
activities reflect proactive behaviours that individuals engage in anticipation of
potential future issues as well as to maintain their already good health.
Figure 2. 1 Health
continuum
Some of the activities within health prevention and the wellness paradigm are
activities that individuals can undertake on their own, outside of the medical care
system as discussed previously. Similarly, other activities require the use of health
Chemotherapy
Hospitalisation
Dialysis
Basic GP
services
Diet & Exercise
Sun-smart
practices
Regular health
checks
Cancer
screening
WELLNESS
PARADIGM
ILLNESS
PARADIGM
Health
Treatment
Health
Prevention
Source: Zainuddin, Previte and Russell-Bennett (2011)
Chapter 2: Literature review 27
care providers, such as cancer screening services in the case of secondary prevention
efforts. The provision of preventive health services by governments or the medical
care system offer behavioural opportunities for individuals to undertake health
prevention efforts. The use of preventive health, or wellness, services is an example
of a socially desirable behaviour that individuals can engage in. This results in
benefits for the individual, and subsequently, benefits for society. These outcomes
are consistent with the goals of social marketing, which are to improve the personal
welfare of a target audience, as well as that of their society through the successful
influencing of their behaviour in a voluntary fashion (Andreasen, 1995). As such, it
would be appropriate to investigate consumers‟ use of wellness services using social
marketing to guide the inquiry.
2.3 Social marketing and prevention
The origins of social marketing are found in sociology in the early 1950s by G.D.
Wiebe (1951-52) who examined social campaigns to determine the conditions that
led to their success. Wiebe (1951-52) asked, “Why can‟t you sell brotherhood like
you sell soap?” referring to the effectiveness of selling commodities (goods) and the
relative ineffectiveness of selling social causes or ideas. Social marketing is “the
application of commercial marketing technologies to the analysis, planning,
execution and evaluation of programs designed to influence the voluntary behaviour
of target audiences in order to improve their personal welfare and that of society of
which they are a part” (Andreasen, 1994) and is can be described as a process that
creates and delivers value to individuals in an effort to influence their behaviour
(Kotler, Lee, & Rothschild, 2006 cited in Kotler & Lee, 2008, p.7). Thus, social
marketing is a useful technique in influencing individuals‟ wellness behaviours.
The academic roots of social marketing are found in work by Kotler and Levy (1969)
who suggest that marketing can be a socially useful activity, expanded beyond the
marketing of goods towards the marketing of services, people, and subsequently
ideas. The concept of social marketing was more formally defined and described by
Kotler and Zaltman (1971) as the design, implementation, and control of programs
calculated to influence the acceptability of social ideas and involving considerations
Chapter 2: Literature review 28
of product planning, pricing, communication, distribution, and marketing research.
Essentially this definition refers to the use of the marketing mix to influence
consumers‟ uptake of ideas (and subsequently behaviour). There have since been
many definitions for social marketing, but what is consistent across many definitions
is that social marketing is the application of commercial marketing understanding,
for the achievement of individual benefit, as well as societal benefit (Dann, 2008).
The achievement of these benefits centres on some form of behaviour change or
modification that is mutually beneficial to the individual who performs the behaviour
as well as the society that they live in including other people within that society.
Aspects of social marketing that form the social marketing theoretical framework for
this thesis include a customer-centred focus (Kotler & Lee, 2008), voluntary
behaviour of individuals (Kotler et al., 2002), and motivation, opportunity and ability
(e.g. Babin, Darden, & Griffin, 1994), social and altruistic. The dimensions of value
are synthesised in Table 2.3.
Table 2. 3 Comparisons of conceptualisations of value
Sheth, Newman and Gross
(1991)
Holbrook (1994)
Sweeney and Soutar (2001)
This thesis
Research paper Quantitative Qualitative Quantitative Qualitative Quantitative
Dimensions Functional Social
Emotional Epistemic
Conditional
Economic Social
Hedonic Altruistic
Price/Quality Social
Emotional
Functional Social
Emotional Altruistic
Relationship between
dimensions
Independent
Inter-related
Inter-related
Inter-related
The dimensions of value have been developed in a commercial marketing context,
physical goods context, or both. Sweeney and Soutar‟s (2001) value dimensions were
developed in a commercial marketing, goods-based context and example of a value
dimension item includes, “this product has poor workmanship.” Other
conceptualisations of value dimensions have been developed in a services context,
but those that represent commercial services still representing a commercial
marketing context. One example of an item representing a value dimension in a
commercial services setting includes one by Huber, Hermann, and Hennesberg
(2007) which used an automobile mechanic service context for their research, “I was
treated courteously by the mechanic.”
Chapter 2: Literature review 42
There is a lack of conceptualisation and use of value dimensions in a social
marketing services context. This research seeks to fill this gap by investigating the
value dimensions present in government-provided public health services, specifically
wellness services which are often provided free or at a subsidy (e.g. breast screening
services). The removal of cost in the consumption of these services reduces the
effectiveness of using the economic approach in investigating value as a cost-benefit
assessment of value is no longer adequate in determining the value dimensions
consumers experience. The investigation of value in non-commercial and non-goods
based contexts is slowly on the rise as evidenced by Nelson and Byus‟s research,
which investigates value dimensions in consumers‟ perceptions and support of
government-provided public services (2002). Nelson and Byus (2002) investigate the
value that citizens place on public services using the value dimensions adapted from
Sheth et al. (1991).This represents value research conducted in not only a services-
based context, but also a non-commercial context. The non-commercial context of
Nelson and Byus‟s (2002) research does not precisely reflect a social marketing
context. But, their adaptation of the items by Sheth et al. (1991) that were originally
developed in a goods-based commercial context demonstrates that there is potential
for adaptation of commercial services or commercial goods value dimension items in
social marketing services.
Table 2.4 shows a typology of customer value developed in commercial marketing
by Holbrook (2006) which informed the conceptualisation applied to the social
marketing context in this research. This thesis proposes that functional (economic),
social, emotional (hedonic), and altruistic dimensions of value exist in a social
marketing wellness service.
Table 2. 4 Holbrook’s typology of value
Extrinsic Intrinsic
Self-oriented Economic value Hedonic value
Other-oriented Social value Altruistic value
Functional value (economic value) is extrinsically-motivated (a means to an end),
and for the benefit of the self rather than others (Holbrook, 2006). This value shows a
focus on performance and functionality (Russell-Bennett, Previte, & Zainuddin,
Source: Holbrook (2006, p.715)
Chapter 2: Literature review 43
2009; Sheth et al., 1991; Sweeney & Soutar, 2001) which can include economic
benefit in a commercial context or the utility provided by the consumption of a
product or service (Tellis & Gaeth, 1990). The functional value dimension is likely to
be applicable to a government social marketing service that delivers a service as part
of the social marketing mix. This relates to the consumption of a social marketing
service as a means to a consumer‟s own objectives (Holbrook, 2006), which in this
context is the maintenance of good health.
Social value is also extrinsically-motivated however it is directed at others
(Holbrook, 2006). This type of value focuses on influencing other people as a means
to achieving a desired goal such as status or influence (Russell-Bennett et al., 2009).
Utility in social value is acquired from a product or service‟s association with social
groups (Sheth et al., 1991) as well as its ability to enhance an individual‟s self-
concept (Sweeney & Soutar, 2001). In social marketing, this value dimension may
also be relevant as women choose to perform socially-desirable behaviours in order
to fulfil social belonging needs or influence others to perform the same behaviours.
Social value is sought when individuals seek to shape the response of others
(Gallarza & Saura, 2006; Holbrook, 2006), which is also relevant in the social
marketing context as consumers seek congruence with the norms of friends and
associates when projecting their health status (Sánchez-Fernández, & Iniesta-Bonillo,
2006).
Emotional value on the other hand, is intrinsically-motivated (an end in itself) and
self-oriented whereby products are consumed for the emotional experience and for
no other end-goal (Holbrook, 2006).This value is related to various affective states,
which can be positive (e.g., confidence and pleasure) or negative (e.g., anger and
fear) (Sánchez-Fernández, & Iniesta-Bonillo, 2006). Utility in emotional value is
derived from the feelings or affective states generated or aroused by the consumption
of a product or service (Sheth et al., 1991; Sweeney & Soutar, 2001). Similarly, in
the context of government social marketing health services, consumers are likely to
experience some form of emotion, particularly when thinking about personal health
and wellbeing. As such, it is believed that this value dimension is relevant as women
may choose to seek tension or anxiety reduction.
Chapter 2: Literature review 44
Altruistic value is also intrinsically-motivated but directed towards others (Holbrook,
2006) whereby the goal may be self-fulfilment or a sense of well-being. It describes
an individual‟s concern for how their consumption behaviour affects others
(Holbrook, 2006) which is particularly relevant in social marketing. Many consumers
may be motivated to perform socially-desirable behaviours for the good of others and
society than for themselves. Arguably, this value is central to prevention messages,
which aim to identify illness early, so that citizens do not become a cost on society in
the future.
As these dimensions of value have been conceptualised in a commercial marketing
context, it is not known if these dimensions of value are also relevant in social
marketing. This leads to the first sub-research question:
RQ1: What are the dimensions of value experienced by users of wellness
services in social marketing?
2.5.4 Experiential value in wellness services
A key characteristic that differentiates the social marketing context from commercial
marketing is the non-monetary costs such as time and effort (Joyce & Morris, 1990;
Wang, Lo, Chi, & Yang, 2004) involved in most exchanges. This feature minimises
the economic aspect of value that has been central to commercial exchanges and
instead places emphasis on the psychological and emotional dimensions of value.
Alongside economic barriers, the social and emotional forms of value are significant
barriers to the adoption and maintenance of desired wellness behaviours, such as
quitting smoking and moderate drinking.
Additionally, consumers‟ use of government wellness services is voluntary, which is
consistent with the purpose of social marketing in achieving voluntary behaviour in
target audiences (Andreasen, 1995). This voluntary nature suggests that the activity
dimension of experiential value (Holbrook, 1994) is an important consideration in
investigating value in wellness services. Holbrook (1994) distinguishes between
passive value and active value, whereby passive value is experienced by consumers
Chapter 2: Literature review 45
reactively in response to the consumption of an object or experience, while active
value is participative and requires collaboration between the consumer and the
service. It is important to consider active value in wellness services as consumers‟
use of these services is proactive and voluntary.
This research proposes that in order for governments to achieve sustainable
behavioural change among target consumers, consumers must first see value in
changing their behaviours. In order to provide value to consumers, there must be an
understanding of how value can be created.
2.6 Value creation
Value creation is a paradigm (Sheth & Uslay, 2007) that involves multiple
stakeholders in the marketing process, working together at various points of the
consumption process to create value. Value creation differs from the exchange
paradigm as the value consists of more than utility and the consumption experience is
a critical component. This value creation paradigm is still in infancy and there is a
lack of consensus on the conceptualisation of value. To date, there has been limited
theorisation or empirical evidence to support the value creation process (Smith &
Colgate, 2007).
Value creation is a process in which an organisation and consumers interact at
various stages of the consumption process in order to co-create the product or service
(Prahalad & Ramaswamy, 2004). This notion of value creation is different from an
earlier, traditional conception of value creation which was understood as a process
occurring within the firm without the involvement of the consumer (Prahalad &
Ramaswamy, 2004). This organisation-centric perspective of value creation is
characterised by the “value-chain” concept (Porter, 1985). This perspective
describes the exchange paradigm as only the firm is responsible for creation, while
consumers are only responsible for consumption. It is necessary to move towards
value co-creation as it is important for consumers to be involved in the value
development process so that the best value may be achieved (Lusch & Vargo, 2006;
Sheth& Uslay, 2007).
Chapter 2: Literature review 46
2.6.1 Value co-creation and service-dominant (S-D) logic
The involvement of consumers in the value development process is a tenant of
service-dominant (S-D) logic. S-D logic is a paradigm that shifts the marketing
orientation from a service-centric approach towards a consumer-centric approach. S-
D logic argues that value can only be determined by the user in the consumption
process (Lusch & Vargo, 2006), which is relevant in wellness services as users of
these services determine the type of value that they seek. As such, value can only be
created by organisations with consumers (Lusch & Vargo, 2006). This describes one
of the foundational premises (FPs) of S-D logic, which identifies that “The customer
is always a co-creator of value” (Vargo & Lusch, 2006, p. 44). As such, open,
collaborative effort shared between consumers and organisations is a key tenant of S-
D logic (Lusch & Vargo, 2006). However, despite the importance of the role of the
consumer, there exists little empirical evidence in the current literature to
demonstrate the significance of the role of the consumer in the value co-creation
process.
Customer co-creation of value with organisations denotes co-production, which is a
central principle of the S-D logic (Vargo & Lusch, 2004). Co-production can lead to
consumer empowerment (Auh et al., 2007), which is highly relevant in the context of
consumers‟ use of wellness services. The need for consumers to be proactive in their
decisions to use wellness services suggests that consumer empowerment may be an
important factor in their decision-making. As consumers are recognised as
endogenous resources involved in co-production activities (Lusch & Vargo, 2006,
p.281) and operant resources in a service setting (Vargo & Lusch, 2004), there is a
need to acknowledge that value co-creation must occur with both the service
organisation and the consumer. This emphasises aspects identified in S-D logic that
are important considerations in value creation, which include interactivity,
connectivity, and ongoing relationships (Vargo & Lusch, 2004) between service
organisations and consumers.
Furthermore, the use of an experiential approach in understanding consumer value
denotes an approach that is process-oriented and predominantly services-based. This
orientation shares great similarities with a service-dominant logic, which focuses on
Chapter 2: Literature review 47
the shift away from a unit that is exchanged towards the process of exchange (Vargo
& Lusch, 2004). Service-dominant (S-D) logic is a reflection on a shift in marketing
thinking away from tangibles and the production of tangibles, toward intangibles and
the use of intangibles such as skills, information, and knowledge (Vargo & Lusch,
2004) in a service consumption experience. This is important in social marketing, as
the goals of social marketing a focussed predominantly on the adoption of
behaviours and ideas, which are intangible. Therefore, the need for investigating
value co-creation, guided by the use of the experiential approach together with S-D
logic, is important in social marketing as there is a need for a value proposition in
order to incentivise individuals into action (Dann, 2008; Kotler & Lee, 2008).
2.6.2 Value co-creation in social marketing
Value creation is important in social marketing as Kotler, Lee and Rothschild (2006
cited in Kotler & Lee, 2008) describe it as “a process that applies marketing
principles and techniques to create, communicate and deliver value to influence
target audience behaviours that benefit society as well as the target audience.” In
understanding how value is created in a social marketing health service, there is a
need to identify where value comes from and how value is created. Ulaga (2003) and
Huber, Herrmann and Morgan (2001) describe value as a subjective construct that is
comprised of multiple value components. Some of these value components are called
sources of value. Early research identifies sources of value that stem from the value-
chain processes both within and between organisations (e.g. Porter, 1985).
Traditionally in commercial marketing, the purpose for organisations in achieving
customer value is for the achievement of competitive advantage (e.g. Slater &
Narver, 1994; Woodruff, 1997) to gain financial profit. However, in social marketing
and for social marketing organisations, the objective is not the achievement of
financial profit, but for socially desirable ends (Donovan & Henley, 2003). This can
be achieved through consumers‟ use of some services (like health screening services)
because value is relative by virtue of its comparative, personal, and situational nature
(Holbrook, 1994; 1999).
Chapter 2: Literature review 48
2.6.3 Sources of value
In understanding where experiential value in social marketing comes from and how it
is created, there is a need to identify and understand the sources of value. Based on
the consideration for the importance of active value in experiential consumption,
Mathwick et al. (2001) developed a typology of experiential value on the basis of
active and passive value types against the intrinsic and extrinsic benefits derived
from the consumption which is presented in Table 2.5.
Table 2. 5 Typology of experiential value
Active value Reactive value
Intrinsic value Playfulness Aesthetics
Extrinsic value Customer return on investment Service excellence
They identify aesthetics, service excellence, customer return on investment (CROI),
and playfulness as dimensions of experiential value (Mathwick et al., 2001) but later
describe them as active/reactive sources of intrinsic/extrinsic value. Their typology
reflects sources of value as the elements they identify, aesthetics, service excellence,
customer return on investment (CROI), and playfulness, are all elements that have an
impact on consumers‟ determination of value from the consumption experience.
These four elements describe sources of value that originate from the organisation as
well as consumers. For example, aesthetics and service excellence reflect sources of
value that originate from the organisation and thus, consumers respond passively to
these elements. Aesthetics refers to the visual elements within the consumption
environment, while service excellence refers to the perceived performance of the
service (Mathwick et al., 2001). On the other hand, CROI and playfulness reflect
sources of value that originate from the consumer out of their participation and use of
the service and thus, consumers respond actively to these elements. CROI refers to
the inputs consumers make into a consumption experience, expecting to yield some
return, while playfulness refers to the engagement of the consumer in the activity
(Mathwick et al., 2001). Smith and Colgate (2007) also present a conceptualisation
that offers examples of how different value sources influence a consumer‟s value
construction. They identify five sources of value, which are information, product,
Source: Mathwick, Malhotra and Rigdon, 2001, p. 42
Chapter 2: Literature review 49
interaction, environment, and ownership/possession transfer (Smith & Colgate,
2007).
Information relates to the marketing materials produced by the organisation that
convey information including promotional material, website, brochures, and
instructions. Information influences economic value by educating and informing
compared to emotional value which is influenced by the creative execution or
sensory experience of the information (Smith & Colgate, 2007). Information can help
consumers identify with peers or social groups thus creating social value (Smith &
Colgate, 2007) and finally it can create altruistic value by showing the benefits to
society that the interaction provides.
The second source of value they identify is product (Smith & Colgate, 2007).
Although goods-oriented, this conceptualisation can be extended to services, and in
line with Vargo and Lusch (2004) adopt the service perspective. Service relates to
the service system (Vargo, Maglio, & Akaka, 2008) and benefits or needs met
through core and supplementary service processes. Services provide value in terms
of the benefits/needs they meet though core and supplementary service delivery.
Functional value is created by the service solving a problem for the consumer i.e. a
water use monitoring service solves the problem of locating where excess water use
is located within a home. The service provides sensory experiences for the consumer
such as the relief of pain by a medical service that provides medication resulting in
feelings of relief, this creates emotional value. Social value is created when the
service allows the consumer to express themselves to other‟s through the experience
of the service and altruistic value is the “sense of doing good” created by receiving
the service.
The third source of value is the interaction with employees within the service system
(Smith & Colgate, 2007) and service-for-service exchange and configuration of
resources (including people and technology). This is the interpersonal aspect of the
service, which also relates to interaction and systems service quality. When the
interactions allow the consumer to achieve the desired outcome, functional value is
created. Additionally the interactions may also influence the emotional state of the
consumer and emotional value may also be experienced. If the interaction allows the
Chapter 2: Literature review 50
consumer to gain status or protect their ego, social value is created. Finally if the
interaction results in positive outcomes for others (perhaps the employee or other
customers who are present) then the value is altruistic.
The physical environment is another source of value (Smith & Colgate, 2007). The
physical environment includes atmospherics, social servicescape and the physical
aspects of the consumption experience such as the building. In retailing,
atmospherics is important in influencing consumers to visit (Donovan & Rossiter,
1982; Mehrabian & Russell, 1974) which is also applicable in a health service setting
where it is important to have consumers return to the service provider for subsequent
appointments. On the other hand, the social environment includes other consumers of
the service at the time of the service experience. Functional value is influenced if the
physical environment facilitates the consumption of the service such as having
lighting that allows the consumer to read instructions more clearly. Emotional value
is created by the affective state invoked by the environment, for example a non-
crowded reception may put the consumer at ease and relieve anxiety. Social value is
created when the environment increases a consumer‟s status or protects the ego such
as in situations where the service being consumed is prestigious. Finally, altruistic
value is created when the environment allows the consumer to be pro-social, for
example when a consumer chooses a service that performs energy-saving practices,
and this may create altruistic value.
The final source of value they identify is ownership/possession transfer, which
includes activities such as delivery and contracts (for transfer of possessions) (Smith
& Colgate, 2007). This source of value was not included in this research as it relates
to goods-specific products. Ownership/possession transfer is not applicable to
services as the intangible nature of services does not allow a person to “own” a
service, nor does it allow a service provider to “transfer” the service to the consumer
since service provision and consumption occurs simultaneously (Lovelock,
Patterson, & Walker, 2004).
Smith and Colgate‟s (2007) conceptualisation of sources of value only include those
that originate from the organisation. This conceptualisation of value sources has been
developed from an organisational perspective and as such, does not take into
Chapter 2: Literature review 51
consideration consumers‟ input in the value creation process. On the other hand, the
typology presented by Mathwick, Malhotra and Rigdon (2001) include a
conceptualisation of sources of value that are also contributed by the consumers
themselves based on active value, which is the result of active collaboration on the
part of the consumer.
This is important in social marketing wellness services because consumers are active
in their consumption of wellness services and therefore there is a need to consider
their contribution towards the value they derive from a consumption experience.
Furthermore, in social marketing there are other value creation collaborators apart
from the organisation, which includes the consumers, society, community, or even
government.
To date, there has been no empirical evidence of these conceptualisations of sources
of value, nor is there empirical evidence of additional sources of value. Therefore, an
objective of this research is to discover exploratory evidence for sources of value, as
well as additional sources of value that may be relevant. This leads to the next
question:
RQ2: What are the sources of value that exist in wellness services in social
marketing?
2.6.4 Consumer participation as a source of value
Given the inseparability of services (Zeithaml, Parasuraman & Berry, 1985) it is
anticipated that the consumers themselves are likely to be a source of value in a
consumption experience. Collaboration can be considered a form of joint
participation (Meuter & Bitner, 1998) as this describes a service situation where both
the consumer and the service employees interact, participate and collaborate in
production (Bendapudi & Leone, 2003). The idea of the customer as a collaborator is
a popular focus in contemporary marketing. Recently for example Lusch, Vargo and
O‟Brien (2007) identified the consumer as an endogenous resource that is also
Chapter 2: Literature review 52
involved in co-production activities (such as advising a radiographer during a
screening process).
However, this idea of collaboration is insufficient in describing individuals‟
involvement in social marketing behaviours because collaboration is limited to the
service encounter as it is part of the interaction with the service provider. In social
marketing, there are other stages in the consumption process in which individuals are
participants, but do not interact (and therefore do not collaborate) specifically with
service providers. These stages include events outside of the actual service
encounter.
Russell-Bennett et al. (2009) identify various consumption stages in a social
marketing service where an individual can experience value. These stages include a
pre-consumption stage, consumption stage (i.e. the service encounter), and a post-
consumption stage (Russell-Bennett et al., 2009). An understanding of the different
consumption stages is especially important in wellness behaviours which are
sustained over the long-term or in situations where there is a long time lapse between
service encounters (e.g. yearly dentist visits as opposed to daily visits to the gym).
The individual is still a participant in this consumption process outside of the service
encounter and therefore, participation is a more appropriate term to use to describe
the involvement of consumers in the creation of value in social marketing.
Participation is currently described as the degree to which the consumer is involved
in producing and delivering the service (Dabholkar, 1990, p.484). However, in a
social marketing context which considers consumption stages outside of the service
interaction to be of equal importance, this research seeks to conceptualise
participation more broadly as an act of taking part in an activity. In wellness
behaviours, the individual is a participant in the entire consumption process which
includes the interaction with the service provider during the service encounter (i.e.
collaboration), as well as interaction with others outside of the service encounter
(during the pre- and post-consumption stages for example). Interaction with others
can include interaction with experts outside of the service organisation, or with peers.
In the context of wellness, experts can include any health professional such as a
general practitioner. There are also stages in the consumption process where
Chapter 2: Literature review 53
individuals do not interact with others but the individual‟s experience during these
stages are also an important consideration in understanding sustained, long-term
wellness behaviour.
Mathwick et al. (2001) identify that inputs from the consumer can come in the form
of cognitive, behavioural, or financial investment. In the context of a government
social marketing service that is free, financial investment is not as relevant. However,
cognitive and behavioural investments are still important. Specifically, the cognitive
and behavioural investments can be refined as mental, physical and emotional inputs
(Hochschild, 1983; Larsson & Bowen, 1989; Silpakit & Fisk, 1985). These are all
dimensions of consumer participation that are likely to be evident in a social
marketing wellness context. These inputs are all contributed at various staged of the
consumption process and are not limited to only the service encounter. For example,
physical inputs may be important during the consumption stage as the individual may
need to follow the service provider‟s instructions as to how to place themselves
appropriately during the service. On the other hand, mental inputs may be important
during the pre-consumption stage where the individual needs to remember to
organise and appointment or turn up on time. Similarly, emotional inputs may be
important during the post-consumption stage where the individual may need to
assure themselves that the results of their health screen appointment are likely to be
fine. This suggests that individuals have the potential to be highly involved during
the consumption process in social marketing.
It is useful then, to employ relational thinking, which has been identified as being
absent from social marketing theory and practice despite the potential it has for the
high involvement behaviours that social marketing target (Hastings, 2003). The
sources of value incorporate relational thinking with the inclusion of participation,
which is based on building relationships, creating trust, and subsequently
commitment to performing the behaviour long-term. To summarise, the sources of
value proposed for wellness services include information, interaction, service,
environment and participation.
Upon identification of the dimensions as well as sources of value that are present in a
social marketing wellness service, there is then a need to understand how the sources
Chapter 2: Literature review 54
of value influence the dimensions of value. This leads to the next sub-research
question:
RQ3: What is the relationship between the sources and dimensions of value
in wellness services?
In summary, there is a need to investigate value in a social marketing wellness
service as value is an important proposition in achieving sustained wellness
behaviour over the long-term. This thesis will seek to identify the dimensions of
value present in this context, as well as the sources of value that are likely to have an
influence on them.
2.7 Summary of gaps and propositions
To summarise, there is a lack of investigation in health prevention from a consumer-
centric, marketing perspective. Much of the existing research into wellness
behaviours lies within the areas of public health and medicine. The lack of
investigation from a marketing approach results in a lack of use of consumer value
theories to understanding why individuals perform wellness behaviours, which have
the potential to offer relevant and timely insights. As such, the first research gap is as
follows:
GAP 1: There is a lack of empirical evidence for dimensions of value
in a social marketing wellness service context
Secondly, it is proposed that a value proposition is necessary in incentivising
individuals into performing wellness behaviours, through using wellness services.
However, much of the existing research in value has been conducted in commercial
marketing, often in a goods-oriented context, using an economic perspective. This
presents the next research gap:
GAP 2: There is a lack of empirical evidence for sources of value in
social marketing wellness services.
Chapter 2: Literature review 55
Finally, it is expected that value dimensions and sources conceptualised in
commercial marketing will be present in social marketing. However, in both
commercial and social marketing it is not known how the dimensions and sources of
value relate as there is no evidence to describe this relationship. As such, the next
research gap is as follows:
GAP 3: There is limited empirical evidence demonstrating the
relationship between value dimensions and sources in a social
marketing wellness service context.
To summarise, value can be created through a value creation process at different
stages of the consumption experience. However it is not known how this process
operates in social marketing wellness services. Study 1 will explore how the sources
of value create dimensions of value for a wellness service and a value creation model
will be developed on the basis of the findings from Study 1. This model will then be
tested in Study 2, to provide the empirical evidence required to support this
hypothesised model of value creation.
2.8 Conclusion
In conclusion, this section has reviewed the streams of literature that form the
theoretical basis of this investigation into value creation in social marketing wellness
services. Specifically, this chapter has discussed preventive health and introduced the
wellness paradigm; social marketing and its role in understanding preventive
behaviours; health services, specifically government wellness services; value and the
dimensions of value; and value creation and the sources of value. The following
chapter describes the methodology for this thesis, which incorporates a multi-study
mixed-method approach in addressing the three sub-research questions.
Chapter 3: Methodology 56
CHAPTER 3 METHODOLOGY
“Wisdom is not wisdom when it is derived from books alone”
Horace
3.1 Introduction
In the previous chapter, the theoretical foundations for this research were established,
the theoretical frameworks underpinning this research were identified, and the
research gaps were highlighted. This current chapter presents the research
methodology for this thesis which seeks to fill the identified research gaps and
answer the overall research question: “How is value created in social marketing
wellness services?” In addressing this overall research enquiry, three sub-research
questions were developed to answer the research gaps. The three sub-research
questions sought to identify the dimensions of value (RQ1) and sources of value
(RQ2) in wellness services, as well as to understand the relationships between these
dimensions and sources of value (RQ3). Addressing these sub-research questions
would aid in the understanding of value co-creation in wellness services using social
marketing.
To answer the three sub-research questions, a two-study multi-method approach was
utilised. Study 1 comprised of a qualitative exploratory study, while Study 2
comprised of a quantitative confirmatory study. The aim of Study 1 was of
exploration and discovery, in which the results were used to develop a theoretical
model of value co-creation in wellness services as well as a set of hypotheses for
testing in Study 2. Subsequently, the aim of Study 2 was to test the model and
hypotheses developed and provide empirical evidence for the constructs and
relationships uncovered in Study 1.
This chapter begins with a discussion of the philosophical underpinnings of this
research (Section 3.2). The next section (Section 3.3) situates this enquiry in the
research context selected, which was government-provided, free breast cancer
Chapter 3: Methodology 57
screening services. Following this, the overall research program is presented (Section
3.) which includes a discussion of the appropriateness of a multi-method approach.
This is followed by an explanation of the objectives of each of the two studies
undertaken in this thesis.
The detailed research design of Study 1 is presented (Section 3.5), including a
discussion of the qualitative methodological approach used, which informed the
choice of method; individual in-depth interviews. An initial focus group was
conducted to aid in the development of the research instrument, which was an
interview guide (see Appendix A). This was then followed by data collection through
individual in-depth interviews with 25 information-rich respondents. Following this,
coding and thematic analysis of the individual in-depth interview transcripts were
undertaken and facilitated by NVivo 8 software program.
The detailed research design of Study 2 is then presented (Section 3.6), including a
discussion of the quantitative methodological approach used, which informed the
choice of method; large-scale online survey. This section discusses the reliability and
validity of this study, as well as sampling. The survey design and measures are also
presented, followed by an explanation of the quantitative data analysis, which
included Confirmatory Factor Analysis (CFA) and Structural Equation Modelling
(SEM), undertaken using PASW18 and AMOS 18 software programs respectively.
Finally, this chapter concludes with the ethical considerations for the overall research
program, as well for the individual studies undertaken (Section 3.7). The following
chapter (Chapter 4) presents the results of the qualitative inquiry of Study 1. Then,
the theoretical model of value co-creation in wellness services developed based on
the findings of Study 1 is presented and discussed (Chapter 5). In this chapter, the
constructs to be used for empirical testing of the model are identified, as are the
hypotheses for testing in Study 2. Subsequently, the results of the quantitative
inquiry of Study 2 are presented in Chapter 6, followed by a discussion of the
complete findings from both Studies 1 and 2 in the concluding Chapter 7. The
limitations of the research design are also discussed in Chapter 7, where suggestions
for future research to overcome these limitations are posed.
Chapter 3: Methodology 58
3.2 Philosophical perspectives
Paradigms are sets of propositions, which are used by researchers to explain how the
world is perceived (Sarantakos, 1993). There are four categories of scientific
paradigms; positivism, realism, critical theory, and constructivism (Guba & Lincoln,
1994). In marketing, positivism is the dominant paradigm (Marsden & Littler, 1996).
However, a limitation of the positivist approach is that it does not utilize the
necessary methods to inductively and holistically understand human experience,
which seeks to understand and explain phenomenon (Karami, Rowley, & Analoui,
2006).
In order to overcome the limitation of the positivist paradigm, this study is conducted
within a post-positivist paradigm, which accepts that reality is imperfectly captured
and understood (Guba & Lincoln, 2005). Post-positivism relies on mixed methods as
a way of capturing as much of reality as possible and emphasis is placed on the
discovery and verification of theory (Denzin & Lincoln, 2000). Internal and external
validity are relied upon as evaluation criteria, and qualitative procedures are used to
lend themselves to structured and sometimes statistical analysis (Denzin & Lincoln,
2000).
Consistent with this post-positivist paradigm is the ontology of critical realism (Guba
& Lincoln, 2005). The epistemology of this research is modified dualist or
objectivist, whereby the research findings are likely to be true (Guba & Lincoln,
2005) and never fully understood but only approximated. This epistemology suggests
that appropriate methodologies include modified experimentation or manipulation,
critical multiplism, falsification of hypotheses and some qualitative methods (Guba
& Lincoln, 2005).
Chapter 3: Methodology 59
3.3 Research context: breast cancer screening services
Theoretically, the context of this research lies within wellness services that use social
marketing. As described in Chapter 2 (Section 2.2) it was explained that it would be
appropriate to investigate consumers‟ wellness behaviour through their use of
wellness services provided by the government as such services are available and
accessible to all members of society. The previous chapter (in Section 2.4) also
describes the appropriateness of situating the investigation in cancer prevention
services and identifies BreastScreen Australia as the only cancer screening program
in Australia that offers a free, government-provided service. Subsequently, the
service context selected for this research investigation is breast cancer screening
services provided by BreastScreen Australia.
Screening services by BreastScreen Australia commenced in 1991 and BreastScreen
Australia operates in over 500 locations nationwide, which includes fixed,
relocatable, as well as mobile screening units (BreastScreen Australia, 2010). The
aim of the screening program is to achieve 70% participation rate among women in
the target age group of 50-69 years but the current participation rate is 56.9%
(BreastScreen Australia, 2010). BreastScreen Australia operates through its state
components for each of the states and territories in Australia. This includes
BreastScreen Queensland, BreastScreen New South Wales, BreastScreen Victoria,
BreastScreen ACT, BreastScreen Tasmania, BreastScreen South Australia,
BreastScreen Western Australia, and BreastScreen Northern Territory. All state
components operate in accordance to national standard guidelines, thus the service
process at each of the states and territories across Australia are consistent. Although
BreastScreen Australia provides free breast cancer screening services to women in
the target age group, these services are also available at other private medical
facilities (such as private hospitals) at a cost.
The challenge and organisational desire to reach targets indicate a need to investigate
the value perceived by women who use the BreastScreen Australia services, and to
identify their motivations for continued use. The use of social marketing allows
BreastScreen Australia to achieve three outcomes. First, it has the potential to
Chapter 3: Methodology 60
increase participation rates among women in the target age group through the uptake
of screening behaviour among non-users of the service. This refers to women who
have never used breast cancer screening services before despite being in the target
age group. Second, it also has the potential to increase participation rates among
women in the target age group through the uptake of the behaviour again among
lapsed users of the service. This refers to women who have used breast screening
services in the past but have not maintained their use in the long-term and have
stopped using these services. Finally, it has the potential to maintain participation
rates among women who are current users of the service through the maintenance
of their wellness behaviour in the long-term.
This thesis focuses exclusively on current users of breast cancer screening services,
and investigates issues pertaining to long-term use of these services. The focus on
issues of continued use of these services in the long-term is consistent with social
marketing aims of maintaining desired behaviour in the long-term.
As individual in-depth interviews were conducted face-to-face for Study 1,
BreastScreen Queensland (BSQ) was selected as the research site for this stage of the
research. On 26 September 2007, BSQ launched a social marketing campaign, which
aimed to achieve a 30% increase in participation of women aged 50 to 69 years by
addressing the barriers to regular screening and by dispelling myths about breast
cancer (BSQ, 2009d). In Queensland, the participation rate for the target age group in
the period 2006-2007 was 56.4% (BSQ, 2009b), which is below the state and
national target participation rate. Within Queensland, the screening service is
available to the target audience through a number of distribution channels including
11 fixed site screening and assessment services, 16 satellite services (screening only),
5 relocatable services and 4 mobile services, all of which span more than 200
locations in Queensland (BSQ, 2009a). BSQ operates according to the national
standard guidelines (BSQ, 2009a) and uses a fixed operating process shown in Figure
3.1.
Chapter 3: Methodology 61
Figure 3. 1 Service operating process of BSQ and corresponding stages of consumption
The first stage of this process is the personal invitation stage where women in the
target age group are contacted by Queensland Health using the state Electoral Roll
(BSQ, 2009c). BSQ has permission to use the Electoral Roll on the condition that all
information remains confidential and not used for other purposes in order to protect
client confidentiality. The personalised invitation letter contains information about
how to make an appointment for a free breast screen at the nearest BSQ service. This
stage occurs during the pre-consumption stage of the consumption experience and is
initiated by the service organisation.
The second stage of the process is arranging an appointment with BSQ. Women are
able to organize an appointment over the phone by calling 13 20 50, which will
connect them to the nearest BSQ service for the cost of a local call (BSQ, 2009c).
During the booking process, the caller will be asked by an administration officer for
their essential details such as their name, current residential or mailing address, date
of birth, time and place of previous breast screens (if any) and the presence or
absence of a breast implant (BSQ, 2009c). Provisions are made for those who have
breast prostheses, disabilities or those who require an interpreter. The caller will be
asked by the administration officer for when they would like an appointment and will
proceed to book the caller in. Then, a letter of confirmation for the appointment will
be posted approximately a week prior to the appointment, including a “Consent for
Personal invitation letter
Making the appointment
Arriving at the service
Having a breast screen
After the breast screen
Follow-up (if any)
Pre-consumption
stage
Consumption stage
Post-consumption
stage
Chapter 3: Methodology 62
Screening” information sheet and a “Consent and Personal Questionnaire Form.”
The information sheet explains the BSQ program and screening process, which
recipients are encouraged to read prior to completing the consent and personal
questionnaire form. This stage also occurs during the pre-consumption stage of the
consumption experience and the process of calling to organise an appointment is
initiated by the consumer.
Arriving at the service is the third stage of the process. Customers are required to
bring any images or results of their most recent breast screens if they were done at a
place other than a BSQ service (BSQ, 2009c). Upon arrival, customers proceed to the
reception desk and are greeted by a female staff member who will check the
customers, have them sign the consent and personal questionnaire forms and then
show then to the screening waiting area. The fourth stage of the process is the actual
breast screen. This is taken by a radiographer who will explain the procedure to the
customer (BSQ, 2009c). The radiographer will then develop and check the images
taken to ensure that the quality is good enough such that as much breast tissue can be
seen. In some instances, the radiographer may need to take another image. The entire
visit takes under 30 minutes. These two stages comprise the consumption stage of the
consumption experience. These stages require both the service organisation and the
consumer to work together (i.e. co-produce) to complete the process.
At the fifth stage, after the breast screen, the results will be posted to the customer
within 10 working days (BSQ, 2009c). If there are no abnormalities, the customer
will be sent another letter for a routine breast screen in two years‟ time. However,
approximately seven out of every 100 women will be asked to return because their
screens showed changes that require further investigation (BSQ, 2009c). These
changes are not necessarily an indication of breast cancer and a nurse counsellor or a
medical officer will telephone customers to explain the reason for their return and
will ask for the customer‟s consent before any tests are carried out. The tests will be
explained to the customer and are provided free of charge by BSQ. These tests could
be carried out by any health care professional including radiologists, nurses and
radiographers and customers are able to consult with these professionals. This
encompasses the post-consumption stage of the consumption experience and is
initiated by the service organisation.
Chapter 3: Methodology 63
Despite the use of BSQ clients in Study 1, the use of online survey methodology in
Study 2 allowed for the expansion of the scope of the research. As such, women in
other states and territories in Australia were also included in Study 2 as the online
nature of the data collection allowed for nation-wide participation of all eligible
respondents.
3.4 Overall research program
In order to identify the dimensions and sources of value in breast cancer screening
services and understand how they relate, a two-study multi-method research program
was developed. This overall research program sought to answer the three sub-
research questions developed to fill the research gaps inherent in the literature. Study
1 was a qualitative exploratory study that qualitatively addressed the three sub-
research questions, while Study 2 was a quantitative confirmatory study that
quantitatively addressed the three sub-research questions. The objectives and
research methodology of the two studies are discussed further in this section, as are
the analytical techniques used. A summary of the overall research design is
presented in Table 3.1.
Chapter 3: Methodology 64
Table 3. 1 Overview of research program
Research Questions
Gaps Addressed
Study that addresses
RQs
Objectives of Research
Research Method
Analysis
RQ1: What are the dimensions of value experienced by users of wellness services?
GAP 1: Lack of
empirical evidence for dimensions of value in social marketing wellness services context
Study 1
To identify the dimensions of value experienced by individuals when using wellness services To identify the sources of value experienced by individuals when using wellness services To identify the constructs necessary for value co-creation in wellness services
Qualitative
1. Use of 1 focus group discussion (n=5) for the development and refinement of an individual-depth interview guide 2. Semi-structured individual-depth interviews (n=25)
Thematic analysis using NVivo 8
RQ2: What are the sources of value that exist in wellness services?
GAP 2: Lack of
empirical evidence for sources of value in social marketing wellness services
Study 1
RQ3: What is the relationship between the sources and dimensions of value in wellness services?
GAP 3: Limited
empirical evidence demonstrating the relationship between value dimensions and sources in a social marketing wellness service context
Study 1
and Study 2
To understand the relationships between the individual dimensions and sources of value in wellness services
Quantitative
Survey 1. Initial validation sample (n=397) 2. Final sample (n=400)
Reliability analysis, exploratory factor analysis (EFA) using PASW18 Confirmatory factor analysis (CFA) using PASW 18 Structural equation modelling (SEM) using AMOS 18
Chapter 3: Methodology 65
3.4.1 Multi-method approach
A multi-method approach was used in this research program and refers to the use of
multiple methods in conducting research, typically using quantitative and qualitative
methods (Creswell, 2003). The advantages of using a multi-method approach include
the ability to use a more comprehensive approach to the research inquiry, the ability
to triangulate results, allowing for a broader set of research questions to be asked,
and enabling discovery (Gil-Garcia & Pardo, 2006). Due the advantages it provides,
the use of a multi-method approach is recommended by a number of scholars in
investigating complex social phenomena (Brewer & Hunter, 1989; Creswell, 2003;
Newman & Benz, 1998).
However, despite these benefits, there are limitations to multi-method approaches
such as the cost of multi-method studies and the perceived incompatibility between
resources for successful execution and completion and in some research studies, the
combination of qualitative and quantitative methods present challenges from the
perceived differences between them (Reichardt & Cook, 1979). However, these
limitations did not pose significant threat to the research inquiry of this thesis and the
combination of both qualitative and quantitative methods were considered
compatible and complementary in this research, which is consistent with the
perspective of other scholars (e.g. Brannen, 2005).
3.4.2 Objectives of qualitative Study 1
The research undertaken in this thesis is based on the experiences of users of
wellness services using social marketing. Specifically, this research seeks to
understand consumers‟ experiential consumption of breast cancer screening services.
Study 1 was a qualitative exploratory study with the purpose of investigating
women‟s experiences with using breast cancer screening services by using an
experiential value approach in the investigation. The first objective of Study 1 was to
qualitatively identify the dimensions of value experienced by users of breast cancer
screening services, which answers the first sub-research question: “What are the
dimensions of value experienced by individuals in a wellness service?” This
Chapter 3: Methodology 66
addresses the first research gap: There is a lack of empirical evidence for dimensions
of value in a social marketing wellness service context.
The second objective of Study 1 was to qualitatively identify the sources of value
that influence the experiences of users of breast cancer screening services. This
answers the second sub-research question: “What are the sources of value in a social
marketing wellness service context?” This addresses the second research gap: There
is a lack of empirical evidence for sources of value in social marketing wellness
services.
In identifying the dimensions and sources of value in a social marketing wellness
service context, Study 1 also sought to fulfil a third objective, which was to
qualitatively understand how the dimensions and sources of value relate in a wellness
service context. This answers the third sub-research question: “What is the
relationship between the sources and dimensions of value in wellness services?”
This addresses the third research gap: There is limited empirical evidence
demonstrating the relationship between value dimensions and sources in a social
marketing wellness service context.
In achieving these objectives, the results of Study 1 were used to inform the
development of Study 2 in two ways. Firstly, the qualitative findings identified the
relevant constructs necessary for value co-creation in social marketing wellness
services. These constructs were used as the basis for selection of the relevant
measures for quantitative testing in Study 2. Secondly, the qualitative findings
provided an understanding of the relationships between the dimensions and sources
of value, allowing for the development of hypotheses for quantitative empirical
testing in Study 2. In identifying these relevant constructs and their relationships, the
results of Study 1 allowed for the development of a theoretical model that describes
the value co-creation process in a wellness paradigm. This model formed the basis
for hypotheses testing using Structural Equation Modelling (SEM) in Study 2.
Chapter 3: Methodology 67
3.4.3 Objectives of Quantitative Study 2
Study 2 was a confirmatory study with the purpose of quantitatively addressing the
three sub-research questions of this thesis. The purpose of Study 2 was to empirically
validate the results of Study 1 by testing the theoretical model and hypotheses that
were generated from the results of the Study 1. This second study sought to
quantitatively identify the dimensions and sources of value present in the value
creation process in a wellness service, and describe the relationships between the
dimensions and sources of value in this context.
Study 2 focussed on examining the relationships between the sources of influences
and the end value types experienced by Australian women who were current users of
breast cancer screening services. A quantitative methodology was used in this
confirmatory study, which informed the choice of method: online survey
questionnaire. Following the data collection, exploratory factor analysis (EFA)
followed by confirmatory factor analysis (CFA) was conducted using PASW 18 and
AMOS 18 statistics software respectively. Following this, structural equation
modelling (SEM) was undertaken, facilitated by AMOS 18.
3.5 Research design of Qualitative Study 1
Social marketing remains strongly influenced by positivist methods and objective
evaluation frameworks. In line with other contemporary areas of marketing and
consumer research however, some social marketers (e.g. Hastings, 2007; Kotler et
al., 2002) are moving toward “softer” research approaches that yield consumer
insights that are more closely aligned with the everyday reality of marketing (Tapp &
Hughes, 2008). The inquiry in Study 1 is guided by interpretive consumer research
(ICR) and draws upon qualitative methods to explore and explicate consumers‟
experiences with breast cancer screening services. An exploratory research approach
is appropriate because there is currently little research that has examined consumers‟
perceptions of experiential value, particularly in a social marketing wellness service
context. This information is necessary, as health practitioners, government and social
marketing decision-makers need to be better informed about experience-based value
Chapter 3: Methodology 68
which is contextually bounded and subjectively experienced during the process of
consumption (Holbrook, 2006; Mathwick et al., 2001). This research is an attempt to
understand the world from the subject‟s point of view, to unfold the meaning of
people‟s experiences, and to uncover the lived world (Kavale, 1996). Applying this
understanding in this study involved talking to women about their consumption
experiences before and after they had used a breast cancer screening service in an
individual in-depth interview setting.
3.5.1 Justification for individual in-depth interviews
Individual in-depth interviews were suitable for this study as qualitative interviews
allowed for the investigation of respondents‟ „perceptions, meanings, definitions of
situations and constructions of reality‟ (Punch, 2005; Strauss & Corbin, 1998).
Furthermore, the purpose of the individual in-depth interviews is to yield explanatory
data (Hesse-Biber & Leavy, 2006). Given that the aim of this research is to
understand the experiences and subjective views of participants, interviewing a
discrete sample of experienced consumers was considered a suitable approach that
provided three major benefits.
Firstly, interviewing enabled the acquisition of multiple perspectives on consumers‟
experiences of the population screening services. King (1994, p.33) argues that
interviews are “ideally suited to examining topics in which different levels of
meaning need to be explored”, such as understanding women‟s experiences of
screening services. Secondly, interviewing a small sample of women was useful
because interviewing is a research tool which occurs in a social context. For
example, 15 women were interviewed at BSQ services during the data collection
period. This was valuable because as Berg (2004, p.75) suggests, the researcher was
able to conduct the interviews as a “conversation with a purpose”, and participants
were more likely to be familiar with the research context and more comfortable, and
thus be more willing to share their experiences with the researcher.
The third reason why interviewing a small, but experienced sample of women was
appropriate was again related to the purpose of the research, which is not
Chapter 3: Methodology 69
quantification. In contrast, its purpose is to gain a holistic and detailed understanding
of lived experiences by women accessing population screening. This makes the
interview appropriate as Denscombe (1999, p.111) recommends interviewing in
situations where the researcher is seeking in-depth information which can be gained
from a smaller number of informants than a survey would require. The interviews
conducted were semi-structured and lasted between 20 minutes and 50 minutes.
During the interview, a guide was followed however, the list of questions was not
followed with rigidity and it was revised based on the ideas that emerged from a
breadth of women interviewed.
3.5.2 Sample and unit of analysis
Purposeful sampling was used in this research, which involved the selection of
information-rich individuals to interview (Coyle, 1997) and this allows for the use of
a sample which is meaningful and relevant to the research questions (Mason, 2005).
The use of a purposeful sampling technique is not uncommon in marketing research
(e.g. Chiu, Hsieh & Li, 2005; Long & McMellon, 2004) and much of sampling is
purposive and defined prior to the commencement of data collection (Coyle, 1997).
This non-probability sampling method is useful for naturalistic enquiry (Lincoln &
Guba, 1985) and appropriate for the exploratory nature of Study 1. The difficulties of
recruitment due to the sensitive nature of the topic are overcome with the use of this
sampling technique. Furthermore, Study 1 does not seek to achieve sample precision,
rather its aim is to discover patterns and generate hypotheses for testing in Study 2
(Singleton Jr. & Straits, 2005). The respondents were also selected based on their
willingness to give up their time to participate in the research.
The sampling unit for this research are women aged 50 to 69 years who have never
been diagnosed with breast cancer and have used BSQ screening services at least
once. Women in this age group represent the primary target audience for BSQ. It was
essential that the women who participated in this research have no history of breast
cancer as this fulfils both theoretical and managerial criteria. Theoretically, an
objective of this research is to understand consumers‟ social marketing behaviour
that is undertaken proactively and in the context of health, for the maintenance of
Chapter 3: Methodology 70
good health rather than in response to ill health. Managerially, an objective of BSQ
as a government social marketing wellness service organisation is to ensure the
regular and continued use of their breast screening services amongst “well women”
who represent their primary target audience. Thus, it was imperative that the women
who participated in this research represented “well women” and did not have any
personal history of breast cancer. A description of the recruitment of these
respondents is provided in Section 4.2 Sample of Study 1.
3.5.3 Interview procedure
All interviews were conducted using an interview guide (see Appendix B) which was
developed based on the focus group pre-test. All questions used in the interviews
followed a “zero-order level of communications” style, which is the simplification of
the questions to minimize potential communications problems (Berg, 2009, p.116).
Each interview commenced with general small talk to “warm” the interview and ease
the respondent into the discussion. Questions like: “How are you?” were used to set
the subject at ease. An opening question was then used to begin the discussion. This
allowed for the establishment of rapport between the interviewer and respondent
(Fotana & Frey, 2008). A typical opening question used was: “To begin, I would like
to hear about your thoughts, feelings and opinions about your experiences with
having a breast screen. To start, can you tell me about your experiences?”
Throw-away questions were also used in the early stages of the interview schedule.
Throw-away questions were useful in this study for collecting demographic
information about respondents (Berg, 2009) and an example of a throw-away
question that was used in this study was: “So how long have you been having breast
screens?” This helped to establish the experience level of the respondent with breast
screening and was often followed by probing questions like: “So how old were you
when you started breast screening?” This helped to draw a more complete story
from the respondent (Berg, 2009) about their experience with breast screening and
establish their current age without directly asking them. Some respondents would
offer this information on their own, so this type of question was only asked if they
had not provided this information on their own accord. Subsequent questions in the
Chapter 3: Methodology 71
interviews were the essential questions, which have the purpose of eliciting specific
desired information about their experiences with breast screening.
These questions were ordered in a sequence that mirrored the BSQ screening process
in Figure 3.1. The discussion typically began with questions and discussion revolving
around the pre-consumption stage of the process without directly asking the
respondent about the reminder letter. An example of a question that would be used
at this stage of the interview is: “When do you start thinking about your next breast
screening appointment?” or: “What usually gets you to start thinking about your
next breast screening appointment?” Probing questions were used to allow the
respondent to elaborate on points they had discussed like: “Why do you find the
reminder letter useful?” A structured series of probes triggered by specific responses
to essential questions were incorporated for the benefit of eliciting more information
(Berg, 2009).
Once the discussion about the respondent‟s experiences at the pre-consumption stage
appeared to diminish, the interviewer would then initiate a discussion about the
experiences revolving around the consumption stage by using statements such as:
“Let‟s now talk about once you are at the service itself on the day of your
appointment.” Probing questions such as: “How did you feel?” and “What do you
think about this whole experience?” were used.
After the discussion about the respondent‟s experiences at the consumption stage, the
discussion then moved on to the respondent‟s experiences revolving around the post-
consumption stage. The interviewer would then introduce this phase of the
discussion with questions like: “Now that your screen is over, what happens next?”
or “After your screen is complete and you are allowed to leave, what happens?”
This strategy helped to ensure that the interview discussion encompassed the entirety
of the respondent‟s experience with breast screening that extended beyond the
service interaction.
Following the discussion about the consumption experience, the interviewer would
then ask the respondent for their general opinions of the process as a whole. An
example of a question would be: “What are the things that make you decide if you
Chapter 3: Methodology 72
were happy or not happy about your experience?” The purpose of this discussion
was to gain a sense of the respondent‟s attitudes towards the act of breast screening.
This was then followed by a discussion of the respondent‟s opinions about service
providers of breast screening services. Questions asked included: “I would now like
to quickly ask you about your opinions of BreastScreen Queensland. What do you
think of BSQ as a service?” and “Have you ever been to a service other than BSQ?”
At the end of the interview, all respondents were asked the same final question:
“Lastly, what is the most important thing that you hope to get out of having a breast
screen?” to determine their primary motivation for continuing to have breast screens.
The respondents were also given the opportunity to provide any final comments or
thoughts about breast screening. After the discussion is complete, the interviewer
would express appreciation by making statements like: “You were a wealth of
information, I really appreciate that” and “Thank you for taking the time to speak to
me.” All respondents were then presented with a small scented candle as a thank-you
gift as a token of appreciation for their time and thoughts.
3.5.4 Analysis of qualitative data
The analysis of the qualitative data in Study 1 commenced with manual transcription
of the audio recordings of the interviews. The data was transcribed verbatim and
each transcript was assigned with a code to de-identify the transcripts but ensure that
all quotes were attributed to the correct respondent. Thematic analysis was conducted
on the data, which involves the encoding of qualitative information by identifying,
analysing, and reporting patterns of responses (i.e. themes) (Braun & Clarke, 2006).
This analytical technique was suitable for this study as the purpose of Study 1 was to
explore and describe the phenomenon (Ryan & Bernard, 1998).
Despite the study being informed by the theoretical frameworks, the initial analysis
of the qualitative data was conducted inductively as the use of thematic analysis
allows for categories to emerge from the data, rather than using predefined categories
(Ezzy, 2002). This was suitable for the purpose of this study, which was for the
discovery of the dimensions and sources of value that exist in wellness services.
Chapter 3: Methodology 73
However, since the objective of Study 1 was to inform the development of Study 2,
the inquiry returned to a deductive approach, guided by theory and resulting in the
identification of a set of constructs and proposed theoretical model for quantitative
testing in Study 2.
Thematic analysis was undertaken using NVivo 8 software to identify themes in the
interviews. The use of NVivo software for the analysis of qualitative data was
necessary given the multiple phases of analysis and coding that was conducted. The
use of software such as NVivo is useful in maintaining the effectiveness of the
analysis despite the complexities attributed to the multiple cycles of coding. This
allowed for a greater level of detail to be achieved in the analysis of the data, as
opposed to manual analysis without the aid of software.
The analysis of the qualitative data was undertaken in two phases consisting of open
coding (first phase), followed by axial coding (second phase). The first procedural
step undertaken was the undertaking of open coding as recommended by Strauss and
Corbin (1998). Open coding is a form of unrestricted coding of the data, which
allows for close examination of the data to determine the concepts and categories that
fit (Berg, 2009). Open coding was used in the First Cycle of coding and was
conducted using an inductive process, which typifies qualitative research and begins
with observations of specific instances, then seeking to establish generalisations
about the phenomenon being investigated (Hyde, 2002). The codes that resulted from
this First Cycle of coding included words, short phrases, or complete sentences that
represent an attribute (Saldaña, 2009).
The next phase of analysis involved the undertaking of axial coding, which consists
of intensive coding around categories (Strauss and Corbin, 1990). Coding frames
were used to assist in the organisation of the data and to identify the findings more
clearly (David & Sutton, 2004). This phase of axial coding was conducted using a
deductive process, which is typically a theory-testing process that commences with
an established theory or generalisation, and then seeks to determine if the theory
applies to specific instances (Hyde, 2002). Although deductive processes are not
formally typical of qualitative enquiry, this was an important step in the analysis of
the data as deductive processes are useful in ensuring “conviction” of any qualitative
Chapter 3: Methodology 74
findings (Hyde, 2002). Furthermore, this was appropriate given that the purpose of
Study 1 was to inform the development of Study 2, which is a quantitative, theory-
testing study.
Axial coding was undertaken in a further four cycles of coding that revolved around
answering the three sub-research questions. The Second and Third Cycles of coding
sought to address RQ1 by determining the dimensions of value that exist in wellness
services. This inquiry was guided by existing research on value dimensions
conceptualised in commercial marketing from an economic value perspective
(Second Cycle) as well as from an experiential value perspective (Third Cycle). The
outcomes of these stages of analyses include the identification of experiential value
in wellness services, which will be discussed in further detail in Chapter 4.
The Fourth Cycle of coding sought to address RQ2 by identifying the sources of
value that exist in wellness services. This inquiry was guided by existing research on
the sources of value conceptualised in the literature. Similarly, an outcome of this
stage of analysis included a comprehensive identification and categorisation of
sources of value, which will be discussed in further detail in Chapter 4.
Finally, the Fifth Cycle of coding sought to address RQ3 by investigating the
relationships between the dimensions of value identified in the Second and Third
Cycles of coding, and the sources of value identified in the Fourth Cycle of coding.
As an outcome of this stage of analysis, an identification of consumer goals in
wellness service experiences was developed which explained the value co-creation
process in wellness services consumption. These findings will also be discussed in
further detail in Chapter 4. The procedure undertaken in the qualitative analysis of
the data is summarised and described in Table 3.2.
Chapter 3: Methodology 75
Table 3. 2 Summary of research procedure undertaken in Study 1
Phase 1
Coding cycle
Procedure Purpose Outcomes
1 Open coding
Unrestricted coding of data, allowing for themes to emerge
Identification of various in vivo codes
Phase 2
Coding cycle
Procedure RQ
addressed
Literature informing
each phase Purpose
Outcomes
(discussed further in Chapter 4)
2 Axial coding
RQ1 Holbrook (1994; 2006)
Identification of dimensions of value (commercial, economic value) i.e. functional, emotional, social, altruistic value
Synthesis of social marketing experiential value in wellness services, i.e. active & reactive functional value, active & reactive emotional value, active social value, active altruistic value
3 Axial coding
RQ1 Holbrook (1994), Mathwick et al. (2001)
Identification of activity aspects of value (commercial, experiential value) i.e. active, reactive value
4 Axial coding
RQ2 Smith and Colgate (2007), Dabholkar (1990)
Identification of sources of value conceptualised in existing literature Identification of consumer participation sources of value
Development of a further classification of sources of value in wellness services value creation, extending beyond existing classification identified in existing literature
5 Axial coding
RQ3 Vargo and Lusch (2004), Prahalad and Ramaswamy (2004)
Identification of how value dimensions and sources relate
Identification of consumer goals & value creation through the achievement of consumer goals
The analysis of the qualitative data revealed evidence for functional, emotional,
social, and altruistic dimensions of value present in the breast cancer screening
service experience. In addition, evidence was found for organisational, consumer,
and third party sources of value. These findings formed the basis for the selection of
constructs to be used in Study 2, which included functional value, emotional value,
interpersonal quality, motivational direction, co-production, and stress tolerance.
Two outcome variables were also used in Study 2, which were satisfaction and
behavioural intentions. Multiple item scales for each latent construct were drawn
from existing literature, which were well-established scales that have been
empirically-validated in previous studies. A multi-dimensional scale was used in the
survey with 8 items for the dimensions of value (4 items for functional value, 4 items
for emotional value), and 26 items for the sources of value (9 items for organisational
sources, 17 items for consumer participation sources). For satisfaction, 5 items were
used, while 8 items were used for behavioural intentions. It was important to orient
any questions towards a specific act (Azjen & Fishbein, 1980), hence some of the
items were modified to reflect the context of consumers‟ use of breast cancer
screening services as they were contextually inappropriate in their existing form.
Lead-in questions were also used to explain the purpose for each of the different sets
of questions. Each of the constructs were measured using a 5-point Likert-scale with
1=strongly disagree and 5 = strongly agree.
Screening questions
In Section 1 of the survey, screening questions were used to ensure that the eligibility
criteria were met by respondents. Although the use of a consumer panel allowed for
the specification of age, it did not allow for the specification of the other selection
criteria; experience with breast cancer screening services, and a “well-woman”
background. As such, two screening questions were required. Respondents were first
asked if they had used breast cancer screening services at least once, as previous
Chapter 3: Methodology 82
experience with this wellness service was necessary in order to complete the survey
(see Appendix E).
Q1: Have you ever used breast screening services, or have had a
mammogram before?
Yes, I have had a breast screen/mammogram before.
No, I have never had a breast screen/mammogram.
Women who have never had breast screens before were directed to a page thanking
them for their interest, but informing them that they were ineligible to complete the
survey (see Appendix F). The page displayed the following message:
“Thank you for your interest in participating in this survey. However, this
research seeks to understand your experiences with breast screening services.
As you have indicated that you have never had a breast screen before, we
regret to inform you that you are unable to progress any further in this survey.
We thank you again for your time and appreciate your interest in this
research.”
The respondents who had indicated that they had used breast cancer screening
services before were then prompted to complete a second screening question (see
Appendix G). This second screening question asked respondents if they had ever
been diagnosed with breast cancer.
Q2: Have you ever been diagnosed with breast cancer?
Yes, I have been diagnosed with breast cancer previously.
No, I have never been diagnosed with breast cancer.
Respondents who had been diagnosed with breast cancer before were screened out of
the survey as the focus of the investigation was on healthy “well-women.” The
respondents who indicated that they had been diagnosed with breast cancer
previously were then directed to a page thanking them for their interest, but
Chapter 3: Methodology 83
informing them that they were ineligible to complete the survey (see Appendix H).
The page displayed the following message:
“Thank you for your interest in participating in this survey. However, this
research seeks to understand the experiences of women who have never been
diagnosed with breast cancer. As you have indicated that you have been
diagnosed with breast cancer previously, we regret to inform you that you are
unable to progress any further in this survey. We thank you again for your
time and appreciate your interest in this research.”
Section 1: Breast cancer screening service providers
Next, in Section 1, the respondents were asked to identify the breast cancer screening
provider that they usually use (see Appendix I). As the study sought to sample
women who had used government-provided breast cancer screening services, the
names of the BreastScreen Australia service providers for the different states and
territories in Australia were provided as options. The respondents were also provided
with an option if they could not remember the name of the service provider. In
addition, in order to accommodate respondents who were users of private services
(i.e. not provided by the government), an “other” option was provided that allowed
them to indicate the name of the service provider if it was not a BreastScreen
Australia service. Furthermore, in order to ascertain if these service providers were
free or paid services, a question was included asking the respondents to indicate if
they pay for their breast screens or if they were free.
Section 2: Dimensions of value in breast cancer screening
The next section of the survey sought to measure the functional and emotional
dimensions of experiential value experienced by users of wellness services (see
Appendix J). Items from Sweeney and Soutar (2001) and Nelson and Byus (2002),
were used. Items from Sweeney and Soutar (2001) best reflect the functional reasons
as to why consumers use a physical product and are similar to the purpose of this
research, which is to understand the functional and emotional reasons as to why
consumers use a wellness service. Items from Nelson and Byus (2002) best reflected
Chapter 3: Methodology 84
emotional value as they included terms that best described affective states that could
be achieved through the experience of emotional value.
However, the items developed by Sweeney and Soutar (2001) were very product-
oriented, thus providing some limitations even after the items had been modified to
become breast screening-oriented. However, as the purpose was to capture the utility
and functionality of breast screens (the act), these items were deemed suitable. A
lead-in statement was used at the start of this section.
Lead-in statement:
In this section, we would like to know about the reasons why you have chosen
to have breast screens/mammograms. Please indicate whether you strongly
disagree (1) or strongly agree (5) with each statement.
Items for functional value
In order to measure functional value in wellness services, items from Sweeney and
Soutar (2001) were used as these original items were based on functionality of a
product and consumers‟ use of a physical product for functional reasons. The items
were modified to reflect the context of breast screening services as the original items
reflected the acquisition of physical products (see Table 3.3). Two items were
removed as they were particularly goods-oriented creating an inability to modify
them to suit a services context. In the context of wellness services, a breast screen is
the core “product” provided to women who use the service. The items were
aggregated to form a single summated score with 1 = low functional value and 5 =
high functional value.
Chapter 3: Methodology 85
Table 3. 3 Items for functional value
Original items Modified items
This product has consistent quality Breast screens have consistent quality
This product is well made Breast screens are well delivered
This product has an acceptable standard of quality
Breast screens have an acceptable standard of quality
This product has poor workmanship (*) Item removed
This product would not last a long time (*) Item removed
This product would perform consistently Breast screens perform consistently
Items for emotional value
In order to measure emotional value in wellness services, items from Nelson and
Byus (2002) were used and modified to reflect the context of breast screening (see
Table 3.4). Similarly, the “product” that is referred to in the original items refers to a
breast screen in the context of this study. The items were aggregated to form a single
summated score with 1 = low emotional value and 5 = high emotional value.
Table 3. 4 Items for emotional value
Original items Modified items
Protected Having breast screens makes me feel protected
Comfortable Having breast screens makes me feel comfortable
Safe Having breast screens makes me feel safe
Happy Having breast screens makes me feel happy
Calm Having breast screens makes me feel calm
Relieved Having breast screens makes me feel relieved
Proud Having breast screens makes me feel proud
Section 3: Organisational sources of value; administrative quality, technical
quality, and interpersonal quality
The subsequent section of the survey sought to measure the organisational sources
that influence the dimensions of experiential value experienced by users of wellness
services (see Appendix K). Items from McDougall and Levesque (1994), Brady and
Cronin (2001), and Rust and Oliver (1994) were used. A lead-in statement was used
at the start of this section.
Chapter 3: Methodology 86
Lead-in statement:
Think about the breast screening service that you usually use. In this section,
we would like to know about your experiences with this service. Please
indicate whether you strongly disagree (1) or strongly agree (5) with each
statement.
Administrative quality items for interaction with systems and processes
In order to measure consumers‟ interaction with the systems and processes of
wellness services, administrative quality items from McDougall and Levesque
(1994) are used. Administrative quality is a primary dimension of service quality and
comprises of administrative service elements to facilitate the production of a core
service for consumers and adds value to the consumer‟s service consumption
experience (Grönroos, 1990; McDougall and Levesque, 1994). These include aspects
such as timeliness and operation, which were found in the qualitative data and
supported by the literature (e.g. Dagger, Sweeney and Johnson, 2007; Thomas,
Glynne-Jones and Chaiti, 1997; Meterko, Nelson and Rubin, 1990).
These items from McDougall and Levesque (1994) have been modified and used in
the context of health treatment services by Dagger et al. (2007). As such, these scale
items appeared to be most appropriate for use in the context of this study, which was
health prevention or wellness services. These items were then modified again to
reflect the context of wellness (breast screening) services as the original items
reflected health treatment (cancer treatment) services (see Table 3.5). The items were
aggregated to form a single summated score with 1 = low administrative quality and
5 = high administrative quality.
Table 3. 5 Items for administrative quality
Original items Modified items
The administration system at the clinic is excellent
The administration system at the place I usually go to is excellent
The administration at the clinic is of a high standard
The administration at the place I usually go to is of a high standard
I have confidence in the clinic's administration system
I have confidence in the administration system at the place I usually go to
Chapter 3: Methodology 87
Technical and interpersonal quality items for interaction with staff
In order to measure consumers‟ interaction with staff of wellness services, two sets
of items from Brady and Cronin (2001) and Rust and Oliver (1994) are used. The
first set of items relates to technical quality of the staff, which refers to the technical
competence of the service provider (Ware, Davies-Avery and Stewart, 1978), thus
influencing the outcomes achieved (Grönroos, 1984; McDougall and Levesque,
1994). This includes aspects such as the competence, knowledge, qualifications, or
skill of the staff (Aharony & Strasser, 1993), or the high standard of service provided
by staff (Zifko-Baliga & Krampf, 1997). These aspects were found in the qualitative
phase of this research and as such, these scales were most appropriate for use in this
study.
These items from Brady and Cronin (2001) and Rust and Oliver (1994) have been
modified and used in the context of health treatment services by Dagger et al. (2007).
These items were then modified again to reflect the context of wellness (breast
screening) services as the original items reflected health treatment (cancer treatment)
services (see Table 3.6). The items were aggregated to form a single summated score
with 1 = low technical quality and 5 = high technical quality.
Table 3. 6 Items for technical quality
Original items Modified items
The quality of the care I receive at the clinic is excellent
The quality of the service I receive at the place I usually go to is excellent
The care provided by the clinic is of a high standard
The service provided by the place I usually go to is of a high standard
I am impressed by the care provided at the clinic
I am impressed by the service provided at the place I usually go to
The second set of items relates to interpersonal quality of the staff, which refers to
the interpersonal relationship and exchange between the consumer and service
provider (Brady and Cronin, 2001; Grönroos, 1984). This includes aspects such as
manner and communication of the staff, which were found in the qualitative data.
Manner of the staff describes their attitudes and behaviour during the service setting
(Bitner, Booms, & Tetreault, 1990; Brady & Cronin, 2001), while communication
describes the interactive element of service process (Wiggers, Donovan, Redman, &
Sanson-Fisher, 1990; Zifko-Baliga & Krampf, 1997) and includes the transfer of
Chapter 3: Methodology 88
information (Dagger et al., 2007), which includes instructions and information, as
identified in the results of the qualitative study. As these concepts were also
identified in the qualitative phase of this research, these scales were also appropriate
for use in this study.
Similarly, these items from Brady and Cronin (2001) and Rust and Oliver (1994)
have been modified and used in the context of health treatment services by Dagger et
al. (2007). These items were then modified again to reflect the context of wellness
(breast screening) services as the original items reflected health treatment (cancer
treatment) services (see Table 3.7). The items were aggregated to form a single
summated score with 1 = low interpersonal quality and 5 = high interpersonal
quality.
Table 3. 7 Items for interpersonal quality
Original items Modified items
The interaction I have with the staff at the clinic is of a high standard
The interaction I have with the staff at the place I usually go to is of a high standard
The interaction I have with the staff at the clinic is excellent
The interaction I have with the staff at the place I usually go to is excellent
I feel good about the interaction I have with the staff at the clinic
I feel good about the interaction I have with the staff at the place I usually go to
Section 4: Consumer participation sources of value; motivational direction, and
co-production
The fourth section of the survey sought to measure the consumer participation
sources that influence the dimensions of experiential value experienced by users of
wellness services, specifically motivational direction and co-production (see
Appendix L). Items from Kelley, Skinner and Donnelley (1992) and Auh et al.
(2007) were used. A lead-in statement was used at the start of this section.
Chapter 3: Methodology 89
Lead-in statement:
Think about the part that you have played in your use of breast screening
services (e.g. organising your appointment, following instructions from staff,
etc.). In this section, we would like to know about your role in using the
breast screening service you usually go to. Please indicate whether you
strongly disagree (1) or strongly agree (5) with each statement.
Motivational direction items for cognitive inputs
In order to measure consumers‟ cognitive inputs in their use of wellness services,
motivational direction items from Kelley et al. (1992) are used. Motivational
direction refers to the activities to which an individual directs and maintains effort
(Katerberg and Blau, 1983). Motivation drives consumers to fulfil their goals
(Maslow, 1943). In the context of breast screening, the qualitative data provided
evidence to show the cognitive effort input by consumers included aspects such as
understanding their role in the consumption process, leading them to make the effort
to organise their own appointments and remembering to turn up to their
appointments on time.
Items from Kelley et al.‟s (1992) motivational direction were used. These scale items
were selected as they most accurately depicted the cognitive effort required from
consumers in a service exchange. These items were modified to reflect the context of
breast screening services as the original items were developed in the context of
financial services (see Table 3.8). Examples were provided to increase the clarity of
the statements for respondents. The items were aggregated to form a single
summated score with 1 = low motivational direction and 5 = high motivational
direction.
Chapter 3: Methodology 90
Table 3. 8 Items for motivational direction
Original items Modified items
It is important for me as a customer to know how to use this service
It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one
I try to think out beforehand how I am going to get the service I want
I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment
It is important for me as a customer to understand my role associated with the service
It is important for me as a customer to understand my role associated with the service, e.g. filling in all my paperwork correctly
Having a plan is important to me as a bank customer
Having a plan is important to me as a breast screen customer, e.g. planning for waiting
Co-production items for behavioural inputs
In order to measure consumers‟ behavioural inputs in their use of wellness services,
co-production items from Auh et al. (2007) are used. Co-production refers to the
participation of the consumer in the service process to produce the core service
offering with the service provider (Bendapudi & Leone, 2003). In the context of
breast screening, the physical or behavioural contributions of the consumer are
essential to produce the core service offering, which is a breast screen. The
qualitative data offers evidence of physical or behavioural inputs from users of breast
screening services such as positioning their bodies in a more optimal way to produce
a better screen.
Items from Auh et al. (2007) were used as they most accurately depicted the co-
production inputs provided by consumers in a service exchange. The items were
modified to reflect the context of breast screening services. The original items were
developed in the context of physician-patient relationships, which was not accurate
for the breast screening context (see Table 3.9). Examples were provided to increase
the clarity of the statements for respondents. The items were aggregated to form a
single summated score with 1 = low co-production and 5 = high co-production.
Chapter 3: Methodology 91
Table 3. 9 Items for co-production
Original items Modified items
I try to work co-operatively with my doctor I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised
I do things to make my doctor's job easier I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily
I prepare my queries before going to an appointment with my doctor
I prepare my queries before going to a breast screen appointment
I openly discuss my needs with my doctor to help him/her deliver the best possible treatment
I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury
Section 5: Consumer participation sources of value; stress tolerance
The fifth section of the survey also sought to measure the consumer participation
sources that influence the dimensions of experiential value experienced by users of
wellness services, specifically stress tolerance (see Appendix M). Items from Bar-On
(1997) were used. A lead-in statement was used at the start of this section.
Lead-in statement:
Many women describe breast screening as something that can be
uncomfortable, unpleasant, or even stressful. In this section, we would like to
know about how you manage the stressful aspects of breast screening that
many women face. Please indicate whether you strongly disagree (1) or
strongly agree (5) with each statement.
Stress tolerance items for affective inputs
In order to measure consumers‟ affective inputs in their use of wellness services,
stress tolerance items from Bar-On (1997) are used. Stress tolerance is one of the
composite factors of the Emotional Quotient Inventory (EQ-i) which assesses
emotional intelligence (Bar-On, 1997). Stress tolerance is most relevant of the five
composite factors as it involves the management of emotions for the attainment of a
specific goal (Mayer & Salovey, 1997). In the context of breast screening services,
the qualitative data found evidence for the management of them women‟s emotions
in their use of breast screening services in order to achieve the goal, peace of mind.
Chapter 3: Methodology 92
Items from Bar-On (1997) were used and examples were provided to increase the
clarity of the statements for respondents (see Table 3.10). The items were aggregated
to form a single summated score with 1 = low stress tolerance and 5 = high stress
tolerance.
Table 3. 10 Items for stress tolerance
Original items Modified items
I know how to deal with upsetting problems I know how to deal with upsetting problem, e.g. if my results indicated that there were any problems
I believe that I can stay on top of tough situations
I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen
I can handle stress without getting too nervous I can handle stress without getting too nervous e.g. waiting for the results of my breast screen
I don't hold up well under stress* I don't hold up well under stress, e.g. wondering what my results might say to the point I get stressed*
I feel that it's hard for me to control my anxiety* I feel that it's hard for me to control my anxiety, e.g. when I wait for the result of my breast screen*
I know how to keep calm in difficult situations I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful
It's hard for me to face unpleasant things*
It's hard for me to face unpleasant things such as breast screens*
I believe in my ability to handle most upsetting problems
Item removed
I get anxious* I get anxious when it comes to having breast screens*
Section 6: Satisfaction with breast cancer screening and behavioural intentions
Section 6 of the survey sought to measure respondents‟ satisfaction with the act of
breast screening and their intentions to have a breast screen again in the future (see
Appendix N). The respondents were asked about satisfaction with screening, rather
than satisfaction with the service provider as the social marketing objective in this
context is for individuals to perform the wellness behaviour in the long-term. This
behaviour is facilitated through the consumer‟s use of a service (i.e. a breast cancer
screening service). As such, the focus of the individual‟s satisfaction was on the
behaviour, as opposed to the service provider consumers used to facilitate that
behaviour. Similarly, the objective of measuring behavioural intentions revolved
around assessing consumers‟ intentions to perform this wellness behaviour again in
the future. As such, items that were worded in a service-oriented fashion were
Chapter 3: Methodology 93
removed as these items did not allow for modification towards a behaviour-oriented
fashion.
In order to measure satisfaction and behavioural intentions, items from Greenfield
and Attkisson (1989), Hubbert (1995), Oliver (1997), Headley and Miller (1993),
Taylor and Baker (1994) and Zeithaml, Berry and Parasuraman (1996) were used. To
measure satisfaction, items from Greenfield and Attkisson (1989), and Hubbert
(1995) and Oliver (1997) were used, which were modified by Dagger et al. (2007) in
measuring consumers‟ satisfaction with a health treatment service. The items used by
Dagger et al. (2007) were modified again in this study to reflect the context of a
health prevention service, rather than a health treatment service. A lead-in
statement was used.
Lead-in statement:
Thinking again about the service where you usually go to have a breast
screen/mammogram, please answer the following questions. Please indicate
whether you strongly disagree (1) or strongly agree (5) with each statement.
Table 3. 11 Items for satisfaction
Original items Modified items
My feelings towards the clinic are very positive
My feelings towards breast screening are very positive
I feel good about coming to this clinic for my treatment
I feel good about having breast screens
Overall, I am satisfied with the clinic and the service it provides
Overall, I am satisfied with breast screening and the benefits it provides
I feel satisfied that the results of my treatment are the best that can be achieved
I feel satisfied that the results of my breast screen are the best that can be achieved
The extent to which my treatment has produced the best possible outcome is satisfying
The extent to which my breast screen has produced the best possible outcome is satisfying
In order to measure behavioural intentions, items from Headley and Miller (1993),
Taylor and Baker (1994), and Zeithaml, Berry and Parasuraman (1996) were used.
These items were also used and modified by Dagger et al. (2007) in measuring
consumers‟ behavioural intentions to continue using a health treatment service.
Chapter 3: Methodology 94
These items used by Dagger et al. (2007) were subsequently modified to reflect the
context of a health prevention service, rather than a health treatment service. The
behavioural intentions this research seeks to measure is consumers‟ intentions with
breast screening, and not with the specific service provider that they use.
Table 3. 12 Items for behavioural intentions
Original items Modified items
If I had to start treatment again I would want to come to this clinic
Item removed
I would highly recommend the clinic to other patients
I would highly recommend breast screening to other women
I have said positive things about the clinic to my family and friends
I have said positive things about breast screening to my family and friends
I intend to continue having treatment, or any follow-up care I need, at this clinic
I intend to continue having breast screens
I have no desire to change clinics I have no desire to stop breast screening
I intend to follow the medical advice given to me at the clinic
I intend to follow any medical advice given to me about breast screening
I am glad I have my treatment at this clinic rather than somewhere else
Item removed
In addition, a question about the respondents‟ intentions towards having breast
screens in the future was also asked.
Q60: How likely are you to have a breast screen again in the future?
Not very likely Not likely Neutral Likely Very likely
1 2 3 4 5
Section 7: Demographic questions
In the last section of the survey, respondents were then asked to answer a series of
questions about themselves and further general questions about their experiences
with breast screening (see Appendix O). The phrasing of these questions was
informed by the qualitative insight provided by Study 1. The purpose of this section
was to gather demographic questions about the respondents and their breast
screening behaviour and the following lead-in statement was used:
Chapter 3: Methodology 95
Lead-in statement:
We would now like to know a little bit about you. In this section, please
answer the following questions about yourself and your preferences with
breast screening.
Q61: How old are you now?
Q62: How old were you when you first started having breast
screens/mammograms?
Q63: Why did you decide to start having breast screens? Please select all
that apply.
I received a letter recommending that I start having breast screens
I saw some advertising and decided to start having breast screens
A small number of women interviewed also identified the community at large as a
tertiary beneficiary of their behaviour. Their belief informs the view that since their
behaviour contributes towards early detection and early treatment of breast cancer, it
benefited the community through a reduction in health costs. These women believed
that the cost of treatment is greater when treating advanced cancer than treating
early-stage cancer. According to one of these women:
“There are community costs involved in any kind of illness; so if I don‟t do
the screening and have my breast cancer diagnosed at a later stage, then
there are costs, higher costs in terms of hospitalisation costs and medical
cost. I believe that if the cancer is caught at an early stage then the impact is
much lower … yes, very definite benefits for me and my family and in terms of
health cost to the overall community” – Respondent 3; aged 54, 10 years‟
experience, employed.
This is reflective of the altruistic dimension of value, as the behaviour denotes a
sense of altruism. Performing desired behaviour for the benefit of others creates
Chapter 4: Results of Study 1 147
additional marketing value beyond the value received by the individual performing
the behaviour. From a societal perspective, the benefit is that the public health
system is not over-burdened and that the cost to society to treat individuals with
cancer is reduced due to prevention efforts.
In both instances of benefit to others (for social and altruistic gains), this goal is
sought actively by users of breast screening services as it requires their conscious
consideration for others and how others will be affected by their decision to use
breast screening services.
4.5.2 Relationships between dimensions and sources explained by consumer goals
These six consumer goals explain the apparent inter-relationships between the
dimensions and sources of value, which addressed RQ3. This section explains these
inter-relationships in further detail.
Table 4. 5 Relationships between organisational sources of value and dimensions of value
explained by consumer goals
Category of sources
Sources of value Dimensions of value
Functional Emotional
Organisational Interaction with systems
Utility (reactive)
Convenience (reactive)
Nil
Interaction with staff Utility (reactive)
Peace of mind (reactive)
Environment Utility (reactive)
Convenience (reactive)
Peace of mind (reactive)
Table 4.5 shows the inter-relationships between the organisational sources of value
and the dimensions of value. Specifically, the organisational sources of value appear
to be inter-related with the functional and emotional dimensions of value. The
qualitative data suggests that interactions with the organisation‟s systems and
processes create functional value for users of breast screening services. This
functional value is experienced reactively by women through the achievement of
utility and convenience.
Chapter 4: Results of Study 1 148
On the other hand, interactions with the organisation‟s staff members create both
functional and emotional value. Both functional and emotional value dimensions are
experienced reactively by women who use breast screening services. These value
dimensions are experienced through the achievement of utility and peace of mind for
the users respectively.
Finally, the organisation‟s environment sources of value also create both functional
and emotional value. These value dimensions are also experienced reactively by
women. The functional dimension of value is experienced through the achievement
of utility and convenience goals, while the emotional dimension of value is
experienced through the achievement of peace of mind goals.
Table 4. 6 Relationships between consumer participation sources of value and dimensions
of value explained by consumer goals
Category of sources
Sources of value
Dimensions of value
Functional Emotional
Consumer participation
Cognitive inputs Utility (active) Control (active)
NIL
Behavioural inputs Utility (active & reactive)
Control (active)
NIL
Affective inputs Control (active) Peace of mind (active)
Table 4.6 shows the inter-relationships between the consumer participation sources
of value and the dimensions of value. Specifically, the consumer participation
sources of value also appear to be inter-related with the functional and emotional
dimensions of value. The qualitative data suggests that cognitive inputs create
functional value for users of breast screening services. This functional value is
experienced actively by women through the achievement of utility and control.
On the other hand, behavioural inputs also create functional value, which is
experienced both actively and reactively by women who use breast screening
services. The achievement of utility causes functional value to be experienced both
actively and reactively, while the achievement of control causes functional value to
be experienced actively only.
Chapter 4: Results of Study 1 149
Finally, affective inputs create both functional and emotional value for women who
use breast screening services. These value dimensions are also actively by women
through the achievement of control and peace of mind goals respectively.
Table 4. 7 Relationships between third party sources of value and dimensions of value
explained by consumer goals
Category of sources
Sources of value
Dimensions of value
Functional Social Altruistic
Third parties Information Utility (active)
NIL NIL
Interaction NIL Self as influencer (active)
Benefit to others (active)
Benefit to others (active)
Table 4.7 shows the inter-relationships between the third party sources of value and
the dimensions of value. Specifically, the third party sources of value appear to be
inter-related with the functional, social, and altruistic dimensions of value. The
qualitative data suggests that information from third parties create functional value
for users of breast screening services. This functional value is experienced actively
by women through the achievement of utility.
However, interactions with third parties create social and altruistic value for users of
breast screening services and these value dimensions are experienced actively. Social
value is experienced actively through the achievement of self as influencer and
benefit to others consumer goals, while altruistic value is experienced actively
through the achievement of benefit to others.
In summary, the qualitative data yielded three broad findings that relate to the
relationships between sources and dimensions of value in wellness services. Firstly,
the data showed that different sources influence different dimensions of value in
wellness services. Secondly, the data also showed that some sources can influence
multiple dimensions of value and that some dimensions of value are influenced by
multiple sources. Finally, the data also showed that some dimensions of value can be
created both actively and reactively (i.e. functional and emotional value), while other
dimensions are only created actively (i.e. social and altruistic value).
Chapter 4: Results of Study 1 150
4.6 Conclusion
This chapter provided the qualitative findings for Study 1. The results addressed the
three sub-research questions by identifying the value dimensions experienced by
consumers in wellness, identifying the sources of value that exist in breast screening
consumption experiences, and explaining the inter-relationships between the
dimensions and sources of value in this context. These findings led to the
development of a conceptual model of value creation in wellness shown in Figure
4.2. This model identifies the different sources of value and the dimensions of value
they influence. It illustrates the relationships between these constructs and also
identifies satisfaction and behavioural intentions as outcomes of value creation in
breast screening.
Chapter 4: Results of Study 1 151
Behavioural
intentions
Satisfaction
Functional
value
Emotional
value
Tangibles
Timeliness
Operation
Expertise
Atmosphere
Interaction
Cognitive inputs
Behavioural
inputs
Affective inputs
Consumer
participation
Environment
Interaction with
systems &
processes
Interaction
with staff
Information
from third
parties
Interaction with
third parties
Social value
Third
parties
Altruistic
value
Organisational
sources
Figure 4. 2 Conceptual model for qualitative findings of Study 1
Chapter 4: Results of Study 1 152
The following chapter will explain this theoretical model in further detail and
identify aspects of the model that are likely to have a strong impact on experiential
value creation in wellness services. A series of propositions and hypotheses that have
been developed based on the findings in this chapter will be presented in the
following chapter. The proposed conceptual model, hypotheses and propositions then
form the basis for quantitative empirical testing in Study 2.
Chapter 5: Theoretical Model and Hypotheses 153
CHAPTER 5 THEORETICAL MODEL AND
HYPOTHESES
“I never see what has been done; I only see what remains to be done”
Budda
5.1 Introduction
The previous chapter presented the qualitative findings of Study 1, which addressed
all three sub-research questions. Firstly, the results addressed the first sub-research
question.
RQ 1: What are the dimensions of value experienced by users of wellness
services?
The data identified that the functional, emotional, social, and altruistic dimensions of
value were present in wellness services. In addition, the data revealed that active and
reactive value were experienced by users of wellness services and that reactive value
featured more prominently than active value for the women interviewed in Study 1.
In synthesising the understanding of value in wellness services, a conceptualisation
of value dimensions for wellness services using social marketing were presented;
functional and emotional value can be experienced actively and reactively, while
social and altruistic value are only experienced actively.
The results also addressed the second sub-research question.
RQ 2: What are the sources of value that exist in wellness services?
The data identified three categories of sources that influenced women‟s experiences
with breast screening services; organisational sources, consumer participation
sources, and third party sources. Within organisational sources, it was found that
Chapter 5: Theoretical Model and Hypotheses 154
information from the organisation, interaction with the organisation‟s systems,
processes, and staff, as well as the environment all had an influence on the value
experienced by the women interviewed. Within consumer participation sources,
cognitive inputs, behavioural inputs, and affective inputs from the consumers had an
influence over their value interpretations. Finally, information received from third
parties and interactions with third parties also had an influence on the dimensions of
value that the women experienced.
Finally, Study 1 also qualitatively addressed the third sub-research question.
RQ 3: What is the relationship between sources and dimensions of value in
wellness services?
The results suggest that some sources can influence multiple dimensions of value,
and that some dimensions of value can be influenced by multiple sources. In
addressing the research questions, a full conceptual model was presented in the
previous chapter with accompanying propositions, illustrating the potential
relationships between the specific sources of value within each of the three
categories of sources and the dimensions of value. The outcomes of value were also
identified in Study 1 as being satisfaction and behavioural intentions, thus the
relationship between value and these key outcome variables will also be included in
this chapter. Those relationships form the basis for the hypotheses to be tested in
Study 2.
While there are a number of potential relationships in the conceptual model in
Chapter 4, the aspects of the model to be tested in Study 2 are those that represent
greater importance in value creation in wellness services as identified in Study 1 and
in the extent literature. The purpose of this chapter is to therefore outline these
important aspects and justify the selection of specific variables and relationships that
will be empirically tested in Study 2. From the qualitative findings of Study 1, it
appears that organisational sources and consumer participation sources have a greater
impact on the value creation process in wellness services.
Chapter 5: Theoretical Model and Hypotheses 155
Two of the three aspects of organisational sources appear to have a greater impact on
value creation; these are “interaction with systems and processes,” and “interaction
with staff.” Thus, this chapter does not contain the third type of organisational
source, which is environment. Interaction with systems and processes is represented
by one service quality variable; administrative quality, while interaction with staff is
represented by two service quality variables; technical quality and interpersonal
quality. The consumer participation sources of value are represented by motivational
direction (cognitive input), stress tolerance (affective input), and co-production
(behavioural input).
The data in Study 2 indicates that two of the four value types are of more significant
importance in wellness services; functional and emotional value. These value
dimensions represent the core value dimensions that women seek from breast
screening services, as evidenced by the results of Study 1. While the achievement of
the other value dimensions (social and altruistic value) are also sought by some of
the women interviewed, they are sought together with functional and emotional value
and not on their own. Furthermore, the functional and emotional dimensions of value
typify experiential value well as they can be experienced both actively and reactively
by consumers. This is important in understanding the full nature of value co-creation
in wellness services.
This chapter also addresses two key outcomes of consumer value; satisfaction and
behavioural intentions. The receipt of value demonstrates the fulfilment and
achievement of consumer goals such as utility, convenience, and peace of mind, as
evidenced by the qualitative results of Study 1. Thus, the fulfilment of these goals is
likely to result in satisfaction for the consumer with their consumption experience. It
has also been well-documented in commercial marketing that satisfaction has an
influence of behavioural intentions, as such it is anticipated that this will apply in
social marketing as well.
This chapter will also present the hypotheses developed as a result of the knowledge
gained from the findings of Study 1. A summary of the propositions, hypotheses, and
research questions addressed in Study 2 is shown in Table 5.1. The table identifies
Chapter 5: Theoretical Model and Hypotheses 156
the propositions that developed as a result of the analysis of the qualitative data in
Study 1 as well as the subsequent hypotheses developed from those propositions.
Table 5. 1 Summary of propositions, hypotheses and research questions
Research questions Propositions Hypotheses
Overall RQ: How is value created in wellness services? RQ 1: What are the dimensions of value experienced by users of wellness services? RQ 2: What are the sources of value that exist in wellness services? RQ 3: What is the
relationship between sources and dimensions of value in wellness services?
Organisational sources will influence functional and emotional value for users of wellness services
H1 a: Administrative quality is significantly and positively associated with functional value for consumers of wellness services. H1 b: Technical quality is significantly and positively associated with functional value for consumers of wellness services. H1 c: Interpersonal quality is significantly and positively associated with emotional value for consumers of wellness services.
Consumer participation will influence functional and emotional value for users of wellness services
H2 a: Motivational direction is significantly and positively associated with functional value for consumers of wellness services. H2 b: Co-production is significantly and positively associated with functional value for consumers of wellness services. H2 c: Stress tolerance is significantly and positively associated with emotional value for consumers of wellness services.
The experience of value will lead to satisfaction of consumers using wellness services
H3 a: Satisfaction is significantly and positively associated with functional value in wellness services. H3 b: Satisfaction is significantly and positively associated with emotional
value in wellness services. Satisfaction of consumers who use wellness services will influence their behavioural intentions
H4: Behavioural intentions are positively associated with satisfaction in wellness services.
Chapter 5: Theoretical Model and Hypotheses 157
5.2 Proposed model and hypotheses
Based on the qualitative findings of Study 1, a proposed model (Figure 5.1) was
developed that will test the relationships between specific sources and dimensions of
value in wellness services.
Figure 5.1 shows the hypothesised relationships between the sources and the
dimensions of value. These relationships form the propositions of this research. The
model also illustrates that when consumers experience value within their service
experiences, it creates satisfaction with their experience, which influences their
intentions to use wellness services again in the future. The following section explains
in further detail the specific relationships between the sources of value and
dimensions of value in wellness services and will introduce four sets of hypotheses
based on the propositions.
Functional
value
Emotional
value
Satisfaction Behavioural
intentions
Administrative
quality
Technical
quality
Motivational
direction
Co-production
Stress
tolerance
H1a
H1b
H1c
H2a
H2b
H2c
H3a
H3b
H4
Interpersonal quality
SERVICE
INTERACTION
CONSUMER
PARTICIPATION
Figure 5. 1 Proposed model of value creation for testing in Study 2
Chapter 5: Theoretical Model and Hypotheses 158
5.3 Value in wellness services
The experiential approach defines value as an interactive, relativistic, preference
experience (Holbrook, 2006). The value experienced by consumers refers to value-
in-use and is process-oriented and services-based. Value is a multi-dimensional
construct, however only functional and emotional dimensions of value are
investigated in Study 2.
5.3.1 Functional value in wellness services
Functional value is focussed on the value that is derived from performance and
functionality (Russell-Bennett et al., 2009). This can include the utility provided by
the consumption of a good or service (Tellis & Gaeth, 1990), which in a wellness
paradigm can refer to the utility derived from using wellness services. In the context
of breast screening, this refers to the utility that women derived from having breast
screens, which is early detection of any cancerous breast lumps. From the results of
Study 1, having detected no cancerous lumps also provides utility to the women who
use breast screens because it gives them the all-clear on their health status in that
area. According to the qualitative results, utility was the most important goal for the
women interviewed. Their primary objective for having breast screens was to find
out if they were in good health or if they had developed any cancer since their last
check. The achievement of utility represents the experience of functional value and
given that this was the most important goal for the women, functional value will be
investigated further in Study 2.
5.3.2 Emotional value in wellness services
Emotional value is related to various affective states which can be positive or
negative (Sánchez-Fernández & Iniesta-Bonillo, 2006). Goals achieved that relate to
emotional value are those that are derived from the feelings or affective states that
are achieved through the consumption of a product or service (Sheth et al., 1991;
Sweeney & Soutar, 2001). In the context of breast screening, this refers to the peace
of mind achieved by the women from having breast screens. According to the
Chapter 5: Theoretical Model and Hypotheses 159
qualitative results of Study 1, peace of mind is achieved through the minimisation of
negative states such as anxiety, stress, or worry and the promotion of positive states
such as relief and calm. The qualitative results suggest that peace of mind is another
important goal for women who use breast screening. For some of the women, it is as
important at achieving utility, while for others, it is the next most important goal. The
achievement of peace of mind represents the experience of emotional value. Given
the importance of this goal for the women in Study 1, emotional value will also be
investigated further in Study 2.
5.4 Interaction in wellness services
Interpersonal interactions in a service often have the greatest effect on consumers‟
1994) of the service. Relationship refers to the relationship between a consumer and
service provider on the basis of closeness and strength of the relationship (Beatty,
Mayer, Coleman, Ellis, & Lee, 1996). In breast screening, it is unlikely that
relationship with have an impact on consumers‟ service experiences due to the long
time lag between service encounters. As such, there is little opportunity for the
service to develop ongoing, close relationships with their clients, which are attributes
that typify service relationships (Koerner, 2000).
Despite this, aspects of interaction such as manner, attitude, and communication of
the staff towards the consumers is important in breast screening. In the interviews,
many of the women highlighted that the manner and attitude of staff were influential
in their experiences with the service and that having pleasant staff made the service
interaction more pleasant. These aspects create peace of mind for the woman using
the service, thus will have an impact on the emotional value that is experienced.
Evidence was found in the qualitative findings for interaction, which is a sub-
dimension of the interpersonal quality construct. This contributes towards the overall
interpersonal quality of the service staff. As such, this gives rise to the third
hypothesis to be tested:
Chapter 5: Theoretical Model and Hypotheses 169
H1 c: Interpersonal quality is significantly and positively associated with
emotional value for consumers of wellness services.
The creation of emotional value occurs reactively through the consumers‟ interaction
with the organisation‟s staff. The value creation is reactive because the users are able
to assess the quality of their interactions at a distance without the need for heightened
engagement with the service provider.
5.7 Relationship between motivational direction and functional
value
It is hypothesised that motivational direction will influence functional value, because
consumers must be motivated to use breast screening services and utility from breast
screening cannot be achieved if women do not have breast screens. In the context of
breast screening, it is important that the women understand the contributions that
they have to make in order to achieve the outcomes they desire. Examples from the
qualitative data include knowing that it was the woman‟s responsibility to call BSQ
herself to organise her own appointment, or following the radiographer‟s instructions
during the mammogram despite any physical discomfort experienced. Motivation
drives consumers to achieve specific goals (Maslow, 1943) and for many of the
women interviewed, the qualitative data identified control and utility as two goals
they seek to achieve from their use of breast screening services. Control is achieved
when the women feel that they have contributed towards the core service production
by being an active participant in the service exchange. This creates utility out of the
service experience, thus influencing the functional value experience.
The creation of functional value occurs both actively and reactively. In active
creation of functional value, the women who provided cognitive inputs into their
service experiences were the ones who were more engaged and involved in the
consumption process, as evidenced by the qualitative results of Study 1. These
women tended to be more conscientious, and therefore more active in thinking about
how they could contribute towards achieving a better outcome from their service
experience. However, a basic understanding of the women‟s role in the consumption
Chapter 5: Theoretical Model and Hypotheses 170
process was also necessary in order to successfully achieve functional value from the
use of the service. This exemplifies the creation of functional value that occurs
reactively. The women are required to have a basic understanding of their roles as
consumers, such as the responsibility to organise an appointment rests with them and
not with BSQ.
Since consumers‟ motivational direction propels them to use wellness services,
which in turn creates utility from the use of the service, this gives rise to the
following hypothesis to be tested in Study 2:
H2 a: Motivational direction is significantly and positively associated with
functional value for consumers of wellness services.
5.8 Relationship between co-production and functional value
Co-production is hypothesised to influence functional value as women must know
how to co-produce a breast screen with the radiographer in order to achieve an
effective screen. For example, they must position or move their bodies according to
the instructions of the radiographer, or even wearing a two-piece outfit for easy
removal of the top to have a breast screen. These represent the physical aspects of
the contributions provided by the women that affect the efficiency and effectiveness
of breast screens. By acting as a co-producer of the service experience, this creates
control for the consumer as it allows the woman to be proactive in contributing
towards achieving a good outcome from the service with the service provider.
Subsequently, this leads to utility being created out of the service experience, thus
having an impact on the functional value experienced.
The creation of functional value can occur either reactively or actively when
behavioural inputs are supplied. This appears to be contingent on the extent of the
involvement the user is willing to have with the service experience. Some of the
women interviewed were satisfied in merely responding to the service provider‟s
request for behavioural inputs (e.g. holding their breath when asked to) and this
demonstrates the creation of functional value that is reactive and this achieves utility
Chapter 5: Theoretical Model and Hypotheses 171
for the consumer from the breast screen. This is supported by the literature, which
describes some customers as being reluctant to exert a high level of involvement in
the service process (Solomon, Suprenant, Czepiel, & Grutman, 1985).
On the other hand, other women interviewed were more active in supplying
behavioural inputs towards the service because they wanted to contribute towards
achieving the best outcome possible with the service provider. This achieves control
for the user and demonstrates the creation of functional value that is active. This
higher level of co-production is appealing to other customers because it allows them
to experience perceived control over the service delivery process (Bateson, 1985).
Co-production can be seen as the extent to which customers are engaged in the
service process as active participants (Lengnick-Hall et al., 2000) at the
customer/service provider level (Auh et al., 2007) demonstrating the active creation
of functional value. Since co-production of breast screening services is necessary for
the creation and delivery of the core service, this gives rise to the next hypothesis:
H2 b: Co-production is significantly and positively associated with functional
value for consumers of wellness services.
5.9 Relationship between stress tolerance and emotional value
Stress tolerance is hypothesised to influence emotional value, because the ability to
control their stress experienced from breast screening provides women with a sense
of control and allowed for the achievement of peace of mind, which is reflective of
the emotional dimension of value. Examples of contributions made by the women
that demonstrate stress tolerance include practicing positive thinking when
wondering what their results might say, or telling themselves that the discomfort or
embarrassment of breast screening is only momentary and does not outweigh the
benefits it provides. This creates emotional value for these women.
The creation of emotional value from affective inputs occurs actively. The qualitative
data revealed that the women who contributed to their consumption experiences by
practicing stress tolerance were also the ones who were more engaged and involved
Chapter 5: Theoretical Model and Hypotheses 172
in the consumption process. Since these women were more engaged and involved, it
was beneficial for them to provide affective inputs, particularly at the end of the
service encounter, so that they would not overthink about their results. Furthermore,
the women had to be active in their management of any stress or negative emotions
they might experience from wondering what their results might say. This is a form of
control for these women, which in turn results in peace of mind. Since peace of
mind is reflective of the emotional dimension of value, this leads to the next
hypothesis:
H2 c: Stress tolerance is significantly and positively associated with
emotional value for consumers of wellness services.
5.10 Marketing outcomes of value creation in wellness services
It is anticipated that the marketing outcomes of value creation in wellness services
are satisfaction and behavioural intentions. This proposition is guided by service
quality research which shows that consumers‟ perceptions of service quality lead to
their satisfaction with the service, which subsequently influences their behavioural
intentions (e.g. Dagger et al., 2007). This can be applied to wellness services and it
can be posited that consumers‟ experience of value can lead to their satisfaction with
the wellness behaviour, which subsequently influences with behavioural intentions to
perform the behaviour again in the future. This proposition is supported by research
in the Business-to-Business (B2B) area, which has found that consumer value leads
to satisfaction, which subsequently leads to behavioural intentions (Eggert & Ulaga,
2002). Thus, it is anticipated that the same will apply in the social marketing area.
Satisfaction is an evaluation of a consumption experience and is determined by the
consumer‟s overall feelings or attitudes they have about a product or service after it
has been purchased (Oliver, 1997). Satisfaction is applicable in the context of social
marketing and wellness because it can be an evaluation of a consumption experience
and in this context, a woman‟s evaluation of her experiences with breast screening.
In commercial marketing, satisfaction is an important predictor for future
behavioural variables such as repurchase intentions, word-of-mouth, and loyalty
Chapter 5: Theoretical Model and Hypotheses 173
(Liljander & Strandvik, 1995; Ravald & Grönroos, 1996). In social marketing and
especially in the use of wellness services, the long-term continuation of the desired
behaviour is key in successfully achieving social marketing goals. Thus, it is
important to explore the behavioural intentions of consumers in wellness services in
order to determine the likelihood of sustained behaviour over the long-term.
5.11 Relationship between value and marketing outcomes:
satisfaction and behavioural intentions
This thesis proposes that individuals‟ propensity to use wellness services would be
influenced by the value they experience from their use of these services. It is posited
that when consumers who use wellness services experience value from their
consumption experiences, this will influence their satisfaction with the experience.
This section will elaborate further the hypothesised relationships between value,
satisfaction, and behavioural intentions.
5.11.1 Relationship between value and satisfaction
The qualitative results provide evidence that the experience of value reflects the
achievement of goals for women who use breast screening services. Women can be
satisfied with their consumption experience if they have experienced functional
value, as this would indicate that utilitarian goals such as utility and convenience are
achieved. Likewise, satisfaction can arise from having experienced emotional value
through the achievement of peace of mind, another goal identified in the qualitative
results.
As consumers act out of self-interest (Rothschild, 1999), it is logical to expect that
they will be satisfied once they have experienced value and fulfilled the goals that
they sought from their use of wellness services. Although there is some research that
argues consumer value has a direct impact on behavioural outcomes and disregards
the role of satisfaction (e.g. Zeithaml, 1988, p.4) other research in the B2B area
suggests that while there is a direct relationship between consumer value and
Chapter 5: Theoretical Model and Hypotheses 174
behavioural intentions, consumer value does lead to satisfaction, which then leads to
behavioural intentions and that satisfaction is still a robust predictor of behavioural
intentions (Eggert & Ulaga, 2002). Therefore, it is worth investigating the
relationship between value and satisfaction in the context of wellness services. Thus,
it is anticipated that the experience of value will lead to satisfaction with overall
experience. Given that Study 2 will test the relationships between the identified
sources of value with functional and emotional value, the following two hypotheses
are developed:
H3 a: Satisfaction is significantly and positively associated with functional
value in wellness services.
H3 b: Satisfaction is significantly and positively associated with emotional
value in wellness services.
5.11.2 Relationship between satisfaction and behavioural intentions
The women‟s satisfaction with their consumption experiences will then have an
influence over their intentions to have breast screens again in the future as
satisfaction is a widely accepted predictor of behavioural intentions. The qualitative
results suggest that all of the women interviewed have the intention to have breast
screens again in the future and all of these women have had satisfying experiences at
BSQ. Some of the women interviewed expressed dissatisfaction with their
experiences at other service providers that they have used in the past but were current
users of BSQ‟s services at the time of their interviews. Many of the women
interviewed expressed their satisfaction with the preventive health behaviour of
breast screening, as it was an effective health check that provided them with utility
and gave them peace of mind that their health remains well.
Satisfaction is widely accepted as a strong predictor for behavioural variables such as
repurchase intentions, word-of-mouth, or loyalty (Liljander & Strandvik, 1995;
Ravald & Grönroos, 1996). In the context of wellness services, this can be likened to
consumers‟ intentions to use breast screening services again in the future, which is
Chapter 5: Theoretical Model and Hypotheses 175
similar to repurchase intentions. In addition, other intentions include spreading
positive word-of-mouth about breast screening to other women, which exemplifies
self-as-influencer, one of the goals identified from the qualitative results in Chapter
4. Another example of intentions is a commitment towards the act of breast screening
which reflects loyalty, specifically attitudinal loyalty (Parkinson, 2009). Thus, it is
anticipated that satisfaction with breast screening will influence women‟s
behavioural intentions around breast screening, which gives rise to the final
hypothesis:
H4: Behavioural intentions are significantly and positively associated with
satisfaction in wellness services.
5.12 Summary of propositions, hypotheses and model to be tested
Based on the theoretical model developed from the findings of Study 1, eight
hypotheses were developed to answer the three sub-research questions. In this
chapter, it was identified that only functional and emotional value will be tested in
Study 2. This will still address the first sub-research question as Study 2 will
quantitatively test for evidence of functional and emotional value in wellness
services:
RQ 1: What are the dimensions of value experienced by users of wellness
services?
This chapter also identified that only organisational and consumer participation
sources of value will be tested in Study 2. This addresses the second sub-research
question as Study 2 will quantitatively test for evidence of administrative quality,
technical quality, interpersonal quality, motivational direction, co-production, and
stress tolerance in wellness services:
RQ 2: What are the sources of value that exist in wellness services?
Chapter 5: Theoretical Model and Hypotheses 176
In identifying the dimensions and sources of value, Study 2 will also test the
relationships between them in order to answer the third sub-research question:
RQ 3: What is the relationship between sources and dimensions of value in
wellness services?
It is hypothesised that administrative quality, technical quality, motivational
direction, and co-production will be positively associated with functional value,
while interpersonal quality and stress tolerance will be positively associated with
emotional value. Table 5.2 summarises the propositions explained in Chapter 4 and
identifies the subsequent hypothesised relationships, as well as the goals that explain
these relationships.
Table 5. 2 Summary of propositions & hypotheses to be tested in Study 2 and relevant
goals
Propositions Goal(s) identified in Study 1
Hypotheses
Proposition 1:
Organisational sources will influence functional and emotional value for consumers of wellness services
Utility Convenience
H1 a: Administrative quality is significantly and positively associated with functional value for consumers of wellness services.
Utility
H1 b: Technical quality is significantly and
positively associated with functional value for consumers of wellness services.
Peace of mind H1 c: Interpersonal quality is significantly and positively associated with emotional value for consumers of wellness services.
Proposition 2:
Consumer participation will influence functional and emotional value for consumers of wellness services.
Control Utility
H2 a: Motivational direction is significantly and positively associated with functional value for consumers of wellness services.
Control Utility
H2 b: Co-production is significantly and positively associated with functional value for consumers of wellness services.
Control Peace of mind
H2 c: Stress tolerance is significantly and positively associated with emotional value for consumers of wellness services.
Proposition 3: The experience of value will lead to satisfaction of consumers of wellness services
NA H3 a: Satisfaction is significantly and positively associated with functional value in wellness services.
NA H3 b: Satisfaction is significantly and positively associated with emotional value in wellness services.
Proposition 4: Satisfaction of consumers who use wellness services will influence their behavioural intentions
NA
H4: Behavioural intentions are significantly and positively associated with satisfaction in wellness services.
Chapter 5: Theoretical Model and Hypotheses 177
Three additional hypotheses were developed to demonstrate that when consumers
experience value from their use of wellness services, they derive satisfaction, which
in turn influences their behavioural intentions to use wellness services again. This
fulfils the social marketing objective of achieving wellness behaviour that is
maintained in the long-term.
In addition, to the hypotheses presented, a measurement model was developed
(Figure 5.1). This model illustrates the hypothesised relationships discussed in this
chapter and shows the relationships between the constructs that will be tested in
Study 2. The model also illustrates the hypothesised relationship between functional
and emotional value with satisfaction with breast screening, and between satisfaction
with breast screening and behavioural intentions. The method for testing this model
is outlined in the next chapter.
5.13 Conclusion
In conclusion, this chapter provided detailed explanation of the hypothesised
relationships between the sources and dimensions of value in preventive, wellness
services and explains these relationships using the goals identified in Study 1. In
Study 2, these relationships will be tested and will quantitatively address all three
sub-research questions. These hypotheses were derived from the findings from Study
1, which qualitatively addresses all three sub-research questions. The following
Chapter 6 will present the results of the quantitative analysis of Study 1, and a
discussion of the overall findings from both studies will be presented in the
subsequent Chapter 7.
Chapter 6: Results of Quantitative Study 2 178
CHAPTER 6 RESULTS OF QUANTITATIVE STUDY 2
“By three methods we may learn wisdom: First, by reflection, which is noblest;
Second, by imitation, which is easiest; and third by experience,
which is the bitterest”
Confucius
6.1 Introduction
In the previous chapter, the research methodology for Study 2 was discussed in
detailed for the testing of the hypotheses presented in Chapter 5. In this chapter, the
results of Study 2 are presented, including the sample characteristics, data screening,
measurement model assessment and structural model fit. Initial analysis of the data
was undertaken using PASW 18 statistics software, followed by a structural equation
analysis using AMOS 18 software that was undertaken to test the relationships
between the constructs identified in the theoretical model. The analysis of the data is
presented in this chapter.
6.2 Sample and response rate
The data for this study was collected over a 12-day period between 23 September
2010 and 3 October 2010. Email invitations to 5,459 members of a consumer list
were sent to women 50 and 69 years old (inclusive) to seek their participation in the
survey. The members were recruited from First Direct Solutions, which acquired a
database of members through consumers‟ completion of the Australian Lifestyle
Survey. Of this group, 98.8% (n=5394) of the emails were successfully sent and
32.6% (n=1757) of these emails were opened by the recipients. However, 69.4%
(n=1219) of these recipients clicked on the survey link provided while the remainder
did not. Of the recipients who clicked on the survey link, 90.6% (n=1105) went on to
complete the survey. A summary is presented in Figure 6.1.
Chapter 6: Results of Quantitative Study 2 179
Figure 6. 1 Summary of online responses to email invitation to participate in Study 2
The number of survey completions based on the initial sample size of 5,459
represents a response rate of 20.2%. In order to ensure that the sample was reflective
of the primary target segment for breast cancer screening, the respondents were
screened to fulfil the three eligibility criteria. First, in order to fulfil the age criteria,
the email invitation to participate in the study was sent to women born between 1941
and 1960 in order to ensure that respondents were aged 50 to 69 years old
(inclusive). Next, in order to ensure that the respondents had used breast cancer
screening services at least once, a screening question was used However, the
respondents were screened further to ensure that the remaining eligibility criteria
were fulfilled.
The first screening question asked the respondents if they had used breast screening
services before. Of the 976 respondents, 88.8% (n=981) of them had used breast
screening services before while the remainder had not. The respondents who had
indicated that they have used breast screening service before were asked to answer
the second screening question, which was if they had ever been diagnosed with
breast cancer. Of this group, 6.4% (n=63) of the women indicated that they had been
TOTAL EMAILS SENT, n=5459
Successfully sent, n=5394
(98.8%)
Unsuccessfully sent, n=65
(1.2%)
Total opened, n=1757
(32.6%)
Total did not open, n=3637
(67.4%)
Clicked on link, n=1219
(69.4%)
Did not click on link, n=538
(30.6%)
Completed survey, n=1105
(90.6%)
Did not complete survey, n=114
(9.4%)
Chapter 6: Results of Quantitative Study 2 180
diagnosed with breast cancer before and were removed from the sample. The
remaining respondents were screened again according to the service provider that
they use. Women who indicated that they use BreastScreen Australia services in the
different states and territories were retained (n=804). The remainder of the
respondents either indicated that they use other breast screening services, or could
not remember the service provider that they use. Women who indicated that they
used mobile screening services and did not pay for them (n=6) were retained.
Similarly, women who could not remember the service provider they used but
indicated that they did not pay for them (n=21) were also retained as this indicated
that they were users of free government service providers. Finally, the remaining
respondents were then screened further to remove any women outside of the target
age group as the data indicated that some of the respondents fell outside of the 50-69
year age bracket. This produced a final sample size of n=797. A sample of this size is
deemed appropriate for theory testing, as the purpose of this study is to explore the
relationships between the sources and dimensions of value, as well as satisfaction
and behavioural intentions, rather than to provide parameters applicable to the
population (Ferber, 1977). A summary of the screening process is presented in
Figure 6.2.
Chapter 6: Results of Quantitative Study 2 181
Figure 6. 2 Sample screening process
TOTAL COMPLETIONS,
n=1105
Have had breast screens before, n =981
(88.8%)
Have never had breast screens, n = 124
(11.2%)
Never been diagnosed with breast cancer, n=919
(93.6%)
Have been diagnosed with breast cancer, n=63
(6.4%)
Cannot remember,
n=31
Use BreastScreen, n=804
Use other services,
n=83
Paid services,
n=5
Free services,
n=21
No response,
n=5
Private services,
n=77
Mobile and free
services, n=6
Below 50 years,
n=27 TARGET AGE GROUP,
n=797
70 years and above,
n=7
Sub-total,
n=831
Chapter 6: Results of Quantitative Study 2 182
6.3 Tests for non-response bias, missing data and common-
method bias
Using time-trend analysis (Armstrong & Overton, 1977), non-response biased was
assessed and no significant differences were found between early and late
respondents. In the treatment of missing data, the all-available approach (i.e. pairwise
deletion) was used as this provides fewer problems with convergence and factor
loading estimates are relatively free of bias (Hair Jr. et al., 2006). Data entry was
accurate as the data was entered directly into MS Excel, which was then copied into
PASW18. Harman‟s one-factor test was performed to assess common method bias
(Podsakoff et al., 2003) and no bias was present.
6.4 Sample characteristics
The respondents were asked a series of demographic questions such as their age,
employment status, state of residence, and ethnicity (see Table 6.1). The mean age of
the women who participated in the survey was 58.8 years and within this sample,
38.8% of women were in employment and 38.9% were retired. Data was collected
from women residing in all states and territories in Australia with the highest
proportion of the respondents residing in New South Wales (30.1%), followed by
Queensland (28.6%). The majority of the women who participated in the survey were
of Caucasian ethnicity (97.0%), although a small number of women of other
ethnicities also participated in the survey. These included women who were Asians,
Aboriginal or Torres Strait Islanders, Maoris, and Middle Eastern.
Chapter 6: Results of Quantitative Study 2 183
Table 6. 1 Sample characteristics – demographic information
Percent
Employment status Employed 38.8 Self-employed 7.7 Not currently in employment 14.6 Retired 38.9
State Queensland 28.6 New South Wales 30.1 Victoria 17.4 Tasmania 3.4 South Australia 7.9 Western Australia 10.1 Northern Territory 1.1 ACT 1.5
Ethnicity Caucasian 97.0 Asian 0.8 Aboriginal or Torres Strait Islander 0.4 Other 1.9
As the qualitative data of Study 1 suggested that the influence of family was an
important factor in women‟s determination of value from their breast screening
experiences, the respondents were also asked questions about their family
background. Most of the women in the study were married (53.2%) and most had
children (87.3%). The qualitative data of Study 1 also suggested that family history
of health problems (cancer or non-cancer) also had an impact on the women
interviewed. Thus the respondents of Study 2 were asked about any family history of
health problems. While most of the respondents indicated family history of health
problems (59.1%), a large proportion of the respondents indicated no family history
(40.9%). The respondents were also asked specifically if they knew of others with
breast cancer, including both family members and non-family members. A very large
proportion of the respondents (87.3%) indicated that they knew at least one woman
with breast cancer. A summary of these findings are presented in Table 6.2.
Table 6. 2 Sample characteristics – family background
Percent
Marital status Married 53.2 Never married 6.5 Divorced/separated 30.1 Widowed 10.2
Children Daughters only 17.2 Sons only 19.6 Both male and female children 50.6 No children 12.7
Know of others with breast cancer Yes 87.3 No 12.7
Family history of health problems No family history of health problems 40.9 Family history of health problems 59.1
Chapter 6: Results of Quantitative Study 2 184
Finally, the respondents were also asked a series of questions about their history of
use of breast screening services. In Study 1, it was found that more women
commenced breast screening before the age of 50. In Study 2, the respondents were
asked for their age when they commenced breast screening and it was found that the
largest proportion of women started breast screening in their forties (45.5%). This
was followed closely by women who started breast screening in their fifties (40.5%)
as recommended. The reason for commencement was also asked and it was found
that the majority of women commenced breast screening because they received an
introduction letter to screening (31.1%). This was in contrast to the qualitative
findings of Study 1 which indicated more of the women interviewed commenced
breast screening on the recommendation of their doctor. Doctor‟s recommendation
was the next highest cited reason for commencement (26.2%). Many women also
cited other reasons for the commencement of breast screening (23.5%); the discovery
of non-cancerous breast lumps was the most commonly cited reason. Most of the
respondents have their breast screens every 2 years as recommended (81.0%), while
the number of women who screen more frequently was comparable with the number
of women who screen less frequently (9.7% and 9.3% respectively). Approximately
two-thirds of the respondents have only used the same breast screening service
provider (66.3%).
Table 6. 3 Sample characteristics – breast screening history
Percent
Age when first started breast screening 60s or older 1.0 50s 40.3 40s 45.2 30s 8.7 20s or younger 1.8 Unsure 3.1
Reason for starting breast screening Introduction letter 30.9 Advertising 17.7 Doctor’s recommendation 28.4 Menopause 9.9 Other 22.8
Frequency of breast screening Less than every 2 years 9.5
Every 2 years 80.4
More than every 2 years 10.0
Service providers used Only use the same service provider 65.2 Have been to other service providers 34.8
Chapter 6: Results of Quantitative Study 2 185
6.5 Construct Reliability
Construct reliability (CR) is a measure of the reliability and internal consistency of
the indicators within a latent construct (Hair Jr. et al., 2006). The scales used in this
study were adapted from the literature as the existing scales were not specific to the
setting of this research. It was necessary to test the appropriateness of using these
scales in a different research context (Nunnally & Bernstein, 1994) thus reliability
tests were performed on all the items of the latent constructs. Cronbach‟s Alpha and
item-to-total correlations were used to assess internal reliability of the instrument
(Nunnally & Bernstein, 1994). The Cronbach‟s Alpha and item-to-total statistics for
the latent variables in this study are presented from Table 6.4 to Table 6.13.
Table 6. 4 Cronbach’s Alpha and Item-to-total statistics for functional value
Items Item-to-total correlation
Breast screens have consistent quality .70 Breast screens are well delivered .70 Breast screens have an acceptable standard of quality .72 Breast screens perform consistently .73 Breast screening helps women live healthy lives .71 Breast screening helps women prevent breast cancer .52 Breast screening helps women lead healthy lives .66
Cronbach’s alpha .88
Table 6. 5 Cronbach’s Alpha and Item-to-total statistics for emotional value
Items Item-to-total correlation
Breast screening is something that I enjoy .62 I want to have breast screens .61 I feel relaxed about having breast screens .67 Having breast screens makes me feel good .75 Having breast screens gives me pleasure .61 Having breast screens makes me feel protected .63 Having breast screens makes me feel comfortable .72 Having breast screens makes me feel safe .67 Having breast screens makes me feel happy .78 Having breast screens makes me feel calm .79 Having breast screens makes me feel relieved .64 Having breast screens makes me feel proud .65
Cronbach’s alpha .92
Table 6. 6 Cronbach’s Alpha and Item-to-total statistics for administrative quality
Items Item-to-total correlation
The administration system at the place I usually go to is excellent .91 The administration at the place I usually go to is of a high standard .93 I have confidence in the administration system at the place I usually go to .89
Cronbach’s alpha .96
Chapter 6: Results of Quantitative Study 2 186
Table 6. 7 Cronbach’s Alpha and Item-to-total statistics for technical quality
Items Item-to-total correlation
The quality of the service I receive at the place I usually go to is excellent .89 The service provided by the place I usually go to is of a high standard .90 I am impressed by the service provided at the place I usually go to .87
Cronbach’s alpha .95
Table 6. 8 Cronbach’s Alpha and Item-to-total statistics for interpersonal quality
Items Item-to-total correlation
The interaction I have with the staff at the place I usually go to is of a high standard
.91
The interaction I have with the staff at the place I usually go to is excellent .92 I feel good about the interaction I have with the staff at the place I usually go to .87
Cronbach’s alpha .95
Table 6. 9 Cronbach’s Alpha and Item-to-total statistics for motivational direction
Items Item-to-total correlation
It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one
.59
I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment
.69
It is important for me as a customer to understand my role associated with the service, e.g. filling in all my paperwork correctly
.57
Having a plan is important to me as a breast screen customer, e.g. planning for waiting
.60
Cronbach’s alpha .79
Table 6. 10 Cronbach’s Alpha and Item-to-total statistics for co-production
Items Item-to-total correlation
I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised
.66
I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily
.68
I prepare my queries before going to a breast screen appointment .65 I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury
.68
Cronbach’s alpha .83
Chapter 6: Results of Quantitative Study 2 187
Table 6. 11 Cronbach’s Alpha and Item-to-total statistics for stress tolerance
Items Item-to-total correlation
I know how to deal with upsetting problems, e.g. if my results indicated that there were any problems
.39
I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen
.60
I can handle stress without getting too nervous e.g. waiting for the results of my breast screen
.64
I don't hold up well under stress, e.g. wondering what my results might say to the point I get stressed*
.59
I feel that it's hard for me to control my anxiety, e.g. when I wait for the result of my breast screen*
.64
I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful
.46
It's hard for me to face unpleasant things such as breast screens* .58 I get anxious when it comes to having breast screens* .58
Cronbach’s alpha .83
Table 6. 12 Cronbach’s Alpha and Item-to-total statistics for satisfaction
Items Item-to-total correlation
My feelings towards breast screening are very positive .76 I feel good about having breast screens .71 Overall, I am satisfied with breast screening and the benefits it provides .80 I feel satisfied that the results of my breast screen are the best that can be achieved
.76
The extent to which my breast screen has produced the best possible outcome is satisfying
.79
Cronbach’s alpha .90
Table 6. 13 Cronbach’s Alpha and Item-to-total statistics for behavioural intentions
Items Item-to-total correlation
I would highly recommend breast screening to other women .80 I have said positive things about breast screening to my family and friends .71 I intend to continue having breast screens .81 I have no desire to stop breast screening .81 I intend to follow any medical advice given to me about breast screening .81
Construct validity is the extent to which a set of measured variables represent the
theoretical latent construct that the variables were designed to measure (Hair Jr. et
al., 2006) and convergent validity refers to the extent to which these variables
converge or share variance (Hair Jr. et al., 2006). Construct validity was conducted
on the indicators of the latent constructs using Exploratory Factor Analysis (EFA) in
PASW 18. Principal axis factoring using direct oblimin rotation was conducted in the
items after reliability analysis (Tabachnick & Fidell, 1996). Items with low loadings
Chapter 6: Results of Quantitative Study 2 188
below .60 as recommended by Nunnally and Bernstein (1994) and items that cross-
loaded onto multiple dimensions were removed on the basis of low loadings or split.
Exploratory factor analysis (EFA) was conducted on all the constructs after the initial
reliability analysis, resulting in seven factors. First, the items for functional value
(FV) loaded onto a single factor, as well as the items for emotional value (EV)
loading onto a single factor. In comparison, the items for administrative quality
(AQ), technical quality (TQ), and interpersonal quality (PQ) all loaded onto the same
factor. This could be attributed to these constructs belonging to an overall service
quality (SQ) construct. The items for motivational direction (MD), co-production
(CP), and stress tolerance (ST) loaded onto three separate factors. Finally, the items
for satisfaction (SAT) and behavioural intentions (BI) loaded onto a single factor.
This could be attributed to these constructs being outcome variables in the
hypothesised model.
The EFA also revealed two items cross-loading onto two separate factors. The first
item that cross-loaded was “I feel good about breast screens” which belonged to the
satisfaction construct, however it cross-loaded on to the emotional value construct.
Thus, this item was removed on the basis of cross-loading. The second item that
cross-loaded was “It is important for me as a customer to understand my role
associated with the service, e.g. filling in all my paperwork correctly” which
belonged to the motivational direction construct, however it cross-loaded on to the
co-production construct. This item was also subsequently removed on the basis of
cross-loading.
Finally, the EFA revealed one item that loaded onto the factor of a different
construct. The item “Having breast screens makes me feel protected” belonged to the
emotional value construct, however it loaded on to the functional value construct
with a low loading of .362 and thus, was removed. As such, three items were
removed in total after the initial EFA conducted.
Chapter 6: Results of Quantitative Study 2 189
A second EFA was then conducted on the individual constructs. For functional value,
the items continued to load onto the same factor with no cross-loadings and no low-
loadings. This resulted in four final items.
Table 6. 14 Summary of initial items for functional value
Item Factor loading
Breast screens have consistent quality .82 Breast screens are well delivered .80 Breast screens have an acceptable standard of quality .86 Breast screens perform consistently .85
Variance explained 69.3%
The second EFA conducted on emotional value also showed that the items continued
to load onto the same factor with no cross-loadings and no low-loadings. This
resulted in six final items.
Table 6. 15 Summary of initial items for emotional value
Item Factor loading
Having breast screens makes me feel comfortable .75 Having breast screens makes me feel safe .68 Having breast screens makes me feel happy .85 Having breast screens makes me feel calm .84 Having breast screens makes me feel relieved .68 Having breast screens makes me feel proud .67
Variance explained 56.0%
As the initial EFA revealed the three service quality constructs loading onto the same
factor, the items from these constructs were subjected to a second EFA as a
combined service quality construct. This revealed no cross-loadings and no low-
loadings. However, a third EFA was conducted with an attempt to force a three-
factor construct but this resulted in cross-loadings and low-loadings of two of the
items. Thus, a uni-dimensional construct of service quality was retained. This
resulted in nine final items.
Table 6. 16 Summary of initial items for service quality
Item Factor loading
The administration system at the place I usually go to is excellent .86 The administration at the place I usually go to is of a high standard .86 I have confidence in the administration system at the place I usually go to .87 The quality of the service I receive at the place I usually go to is excellent .91 The service provided by the place I usually go to is of a high standard .88 I am impressed by the service provided at the place I usually go to .91 The interaction I have with the staff at the place I usually go to is of a high standard
.86
The interaction I have with the staff at the place I usually go to is excellent .88 I feel good about the interaction I have with the staff at the place I usually go to .84
Variance explained 76.6%
Chapter 6: Results of Quantitative Study 2 190
The second EFA conducted on motivational direction showed that the items loaded
on to the same factor and there were no cross-loadings or low-loadings. This resulted
in three final items.
Table 6. 17 Summary of initial items for motivational direction
Item Factor loading
It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one
.64
I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment
.85
Having a plan is important to me as a breast screen customer, e.g. planning for waiting
.73
Variance explained 55.3%
The second EFA conducted on co-production showed that the items also loaded on to
the same factor and there were no cross-loadings or low-loadings. This resulted in
four final items.
Table 6. 18 Summary of initial items for co-production
Item Factor loading
I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised
.75
I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily
.81
I prepare my queries before going to a breast screen appointment .63 I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury
.64
Variance explained 50.7%
The second EFA conducted on stress tolerance showed that the items loaded on the
same factor and there were no cross-loadings. However, low-loadings occurred for
two of the items. The item with the lowest loading (.55) was removed, however the
second item with low-loading (.58) was not removed as a minimum of three items, as
is the recommended approach in the literature (e.g. Hau & Marsh, 2004) was
required to conduct confirmatory factor analysis (CFA) on the remaining items and
the loading was just below the minimum .60 required. This resulted in three final
items.
Chapter 6: Results of Quantitative Study 2 191
Table 6. 19 Summary of initial items for stress tolerance
Item Factor loading
I know how to deal with upsetting problem, e.g. if my results indicated that there were any problems
.55
I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen
.84
I can handle stress without getting too nervous e.g. waiting for the results of my breast screen
.89
I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful
.58
Variance explained 53.6%
As the initial EFA revealed that the items for satisfaction and behavioural intentions
loaded on to the same factor, a second EFA was conducted on these constructs
together. This revealed a two-factor structure, however two of the items cross-loaded
on to the two factors. These two items were word-of-mouth (WOM) items “I have
said positive things about breast screening to my family and friends” and “I would
highly recommend breast screening to other women.” These two items were
removed and a third EFA was conducted on the remaining items, which revealed a
uni-dimensional construct with no cross-loadings or low-loadings. However, as
satisfaction and behavioural intentions are two conceptually distinct constructs, a
fourth EFA was conducted on these constructs separately.
The EFA conducted on the satisfaction construct only revealed a uni-dimensional
construct with no cross-loadings or low-loadings. This resulted in four final items.
Table 6. 20 Summary of initial items for satisfaction
Item Factor loading
My feelings towards breast screening are very positive .72 Overall, I am satisfied with breast screening and the benefits it provides .88 I feel satisfied that the results of my breast screen are the best that can be achieved
.89
The extent to which my breast screen has produced the best possible outcome is satisfying
.85
Variance explained 69.7%
Chapter 6: Results of Quantitative Study 2 192
The EFA conducted on the behavioural intentions construct also included the word-
of-mouth items, and revealed a uni-dimensional construct with no cross-loadings or
low-loadings. This resulted in five final items.
Table 6. 21 Summary of initial items for behavioural intentions
Item Factor loading
I intend to continue having breast screens .96 I have no desire to stop breast screening .90 I intend to follow any medical advice given to me about breast screening .81 I would highly recommend breast screening to other women .84 I have said positive things about breast screening to my family and friends .72
Confirmatory factor analysis (CFA) was conducted on all construct indicators using
AMOS 18. Modification and standardised loadings (i.e. standardised regression
weights) verify the dimensionality of the measurement model and verify the model
fit. Modification indices (MI) comprise of variances, covariances and regression
weights and are assessed to evaluate model fit. None of the indicators were removed
as the factor loadings met the minimum threshold of .60 with the exception of one
indicator. This indicator “Having a plan is important to me as a breast screen
customer, e.g. planning for waiting” had a factor loading of .56 but was not removed
as the factor loading was deemed close to the minimum factor loading and a
minimum of three indicators were required for the latent construct (motivational
direction) for analysis in SEM (see Table 6.22).
Chapter 6: Results of Quantitative Study 2 193
Table 6. 22 Factor loadings for all indicators
Construct Indicators Final factor loading
FV Breast screens have consistent quality .87 Breast screens are well delivered .89 Breast screens have an acceptable standard of quality .84 Breast screens perform consistently .88
EV Having breast screens makes me feel comfortable .71 Having breast screens makes me feel safe .79 Having breast screens makes me feel happy .78 Having breast screens makes me feel calm .78 Having breast screens makes me feel relieved .75 Having breast screens makes me feel proud .69
AQ The administration system at the place I usually go to is excellent .96 The administration at the place I usually go to is of a high standard .97 I have confidence in the administration system at the place I usually go to .91
TQ The quality of the service I receive at the place I usually go to is excellent .93 The service provided by the place I usually go to is of a high standard .95 I am impressed by the service provided at the place I usually go to .90
PQ The interaction I have with the staff at the place I usually go to is of a high standard
.94
The interaction I have with the staff at the place I usually go to is excellent .97 I feel good about the interaction I have with the staff at the place I usually go to .90
MD It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one
.76
I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment
.86
Having a plan is important to me as a breast screen customer, e.g. planning for waiting
.56
CP I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised
.91
I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily
.86
I prepare my queries before going to a breast screen appointment .59 I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury
.65
ST I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen
.91
I can handle stress without getting too nervous e.g. waiting for the results of my breast screen
.73
I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful
.64
SAT My feelings towards breast screening are very positive .81 Overall, I am satisfied with breast screening and the benefits it provides .86 I feel satisfied that the results of my breast screen are the best that can be achieved
.78
The extent to which my breast screen has produced the best possible outcome is satisfying
.82
BI I would highly recommend breast screening to other women .83 I have said positive things about breast screening to my family and friends .74 I intend to continue having breast screens .85 I have no desire to stop breast screening .85 I intend to follow any medical advice given to me about breast screening .86
Achieved Fit Indices
CMIN/DF 2.121
RMSEA .053
Chapter 6: Results of Quantitative Study 2 194
The output produced a Chi-square = 1306.50, with df = 616 with probability level =
.000. For the dimensions of value, functional value was measured by 4 items and
emotional value was measured by 6 items. For the sources of value, administrative
quality, technical quality and interpersonal quality were all measured by 3 items
each, while motivational direction and stress tolerance were measured by 3 items
each, and co-production was measured by 4 items. Finally, satisfaction was measured
by 4 items and behavioural intentions was measured by 5 items. These items were
subject to CFA to determine dimensionality and assess whether the model was an
adequate fit to the data. The fit indices suggest that the model was a good fit to the
data.
The Average Variance Extracted (AVE) was also calculated for each of the
constructs. AVE is a measure of the shared or common variance in a latent variable
(Fornell & Larker, 1981) and is the amount of variance captured by the latent
variable in relation to the amount of variance due to its measurement error (Dillon
and Goldstein, 1984). The AVEs for all the constructs were calculated and compared
with the squares of the parameter estimates between factors (Ø2). All the calculated
AVEs were greater than the squares of the parameter estimates between factors (see
Table 6.23).
Chapter 6: Results of Quantitative Study 2 195
Table 6. 23 Squares of Parameter Estimate between Factors (Ø2) and Average Variance Extracted for Pairs of Factors
AVE Construct FV EV AQ TQ PQ MD CP ST SAT BI
.78 FV
.56 EV Ø = 0.61
(Ø2 = 0.37)
.90 AQ Ø = 0.60
(Ø2 = 0.36)
Ø = 0.53
(Ø2 = 0.28)
.86 TQ Ø = 0.62
(Ø2 = 0.38
Ø = 0.57
(Ø2 = 0.32)
Ø = 0.88
(Ø2 = 0.77)
.88 PQ Ø = 0.57
(Ø2 = 0.32)
Ø = 0.63
(Ø2 = 0.40)
Ø = 0.79
(Ø2 = 0.62)
Ø = 0.85
(Ø2 = 0.72)
.54 MD Ø = 0.29
(Ø2 = 0.08)
Ø = 0.29
(Ø2 = 0.08)
Ø = 0.19
(Ø2 = 0.04)
Ø = 0.18
(Ø2 = 0.03)
Ø = 0.23
(Ø2 = 0.05)
.59 CP Ø = 0.43
(Ø2 = 0.18)
Ø = 0.41
(Ø2 = 0.17)
Ø = 0.53
(Ø2 = 0.28)
Ø = 0.56
(Ø2 = 0.31)
Ø = 0.53
(Ø2 = 0.28)
Ø = 0.34
(Ø2 = 0.12)
.61 ST Ø = 0.43
(Ø2 = 0.18)
Ø = 0.46
(Ø2 = 0.21)
Ø = 0.39
(Ø2 = 0.15)
Ø = 0.45
(Ø2 = 0.20)
Ø = 0.45
(Ø2 = 0.20)
Ø = 0.26
(Ø2 = 0.07)
Ø = 0.43
(Ø2 = 0.18)
.68 SAT Ø = 0.73
(Ø2 = 0.53)
Ø = 0.73
(Ø2 = 0.53)
Ø = 0.64
(Ø2 = 0.41)
Ø = 0.70
(Ø2 = 0.49)
Ø = 0.66
(Ø2 = 0.44)
Ø = 0.27
(Ø2 = 0.07)
Ø = 0.57
(Ø2 = 0.32)
Ø = 0.48
(Ø2 = 0.23)
.68 BI Ø = 0.51
(Ø2 = 0.26)
Ø = 0.61
(Ø2 = 0.37)
Ø = 0.46
(Ø2 = 0.21)
Ø = 0.57
(Ø2 = 0.32)
Ø = 0.54
(Ø2 = 0.29)
Ø = 0.17
(Ø2 = 0.03)
Ø = 0.51
(Ø2 = 0.26)
Ø = 0.35
(Ø2 = 0.12)
Ø = 0.78
(Ø2 = 0.61)
Chapter 6: Results of Quantitative Study 2 196
6.8 Descriptive analysis of constructs
Descriptive analysis for all the indicators of all the constructs was undertaken to
determine the means and standard deviations. The descriptive for the final items are
shown in Table 6.24 and the bivariate correlations in Table 6.25.
Table 6. 24 Latent variable indicators and descriptives
Latent variable
Indicators N Min Max Mean Std. Dev
FV Breast screens have consistent quality 783 1.00 5.00 3.78 .73
Breast screens are well delivered 776 1.00 5.00 3.97 .70
Breast screens have an acceptable standard of quality
783 1.00 5.00 3.99 .64
Breast screens perform consistently 780 1.00 5 3.86 .74
EV Having breast screens makes me feel comfortable
782 1.00 5.00 3.00 1.06
Having breast screens makes me feel safe 779 1.00 5.00 3.65 .93
Having breast screens makes me feel happy
776 1.00 5.00 2.82 .96
Having breast screens makes me feel calm
781 1.00 5.00 2.89 1.01
Having breast screens makes me feel relieved
779 1.00 5.00 3.66 .94
Having breast screens makes me feel proud
781 1.00 5.00 2.91 .94
AQ The administration system at the place I usually go to is excellent
788 1.00 5.00 4.04 .73
The administration at the place I usually go to is of a high standard
784 1.00 5.00 4.05 .74
I have confidence in the administration system at the place I usually go to
783 1.00 5.00 4.10 .69
TQ The quality of the service I receive at the place I usually go to is excellent
785 1.00 5.00 4.14 .75
The service provided by the place I usually go to is of a high standard
783 1.00 5.00 4.15 .72
I am impressed by the service provided at the place I usually go to
783 1.00 5.00 4.03 .77
PQ The interaction I have with the staff at the place I usually go to is of a high standard
780 1.00 5.00 4.04 .78
The interaction I have with the staff at the place I usually go to is excellent
779 1.00 5.00 3.99 .83
I feel good about the interaction I have with the staff at the place I usually go to
781 1.00 5.00 4.00 .80
MD It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one
786 1.00 5.00 3.74 .91
I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment
783 1.00 5.00 3.75 .84
Having a plan is important to me as a breast screen customer, e.g. planning for waiting
783 1.00 5.00 3.72 .81
*table continued on following page
Chapter 6: Results of Quantitative Study 2 197
*table continued from previous page Latent
variable Indicators N Min Max Mean Std.
Dev
CP I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised
788 2.00 5.00 4.36 .56
I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily
788 2.00 5.00 4.34 .59
I prepare my queries before going to a breast screen appointment
784 1.00 5.00 3.88 .75
I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury
782 1.00 5.00 4.04 .69
ST I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen
790 1.00 5.00 4.00 .68
I can handle stress without getting too nervous e.g. waiting for the results of my breast screen
787 1.00 5.00 3.87 .78
I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful
784 1.00 5.00 3.83 .81
SAT My feelings towards breast screening are very positive
790 1.00 5.00 4.00 .80
Overall, I am satisfied with breast screening and the benefits it provides
789 1.00 5.00 4.16 .65
I feel satisfied that the results of my breast screen are the best that can be achieved
782 1.00 5.00 4.01 .73
The extent to which my breast screen has produced the best possible outcome is satisfying
784 1.00 5.00 4.01 .67
BI I would highly recommend breast screening to other women
789 1.00 5.00 4.39 .73
I have said positive things about breast screening to my family and friends
786 1.00 5.00 4.00 .91
I intend to continue having breast screens 784 1.00 5.00 4.39 .73
I have no desire to stop breast screening 789 1.00 5.00 4.28 .82
I intend to follow any medical advice given to me about breast screening
785 1.00 5.00 4.43 .63
Note: Range for latent constructs was 1-5
Chapter 6: Results of Quantitative Study 2 198
Table 6. 25 Bivariate correlations matrix
Functional
value
Emotional
value
Administrative
quality
Technical
quality
Interpersonal
quality
Motivational
direction
Co-
production
Stress
tolerance
Satisfaction
Emotional value .539**
.000
1
Administrative
quality
.579**
.000
.489**
.000
1
Technical
quality
.581**
.000
.515**
.000
.850**
.000
1
Interpersonal
quality
.537**
.000
.573**
.000
.773**
.000
.824**
.000
1
Motivational
direction
.295**
.000
.290**
.000
.212**
.000
.207**
.000
.245**
.000
1
Co-production .431**
.000
.421**
.000
.507**
.000
.520**
.000
.539**
.000
.402**
.000
1
Stress tolerance .377**
.000
.388**
.000
.350**
.000
.397**
.000
.406**
.000
.224**
.000
.363**
.000
1
Satisfaction .669**
.000
.634**
.000
.603**
.000
.647**
.000
.612**
.000
.286**
.000
.527**
.000
.411**
.000
1
Behavioural
intentions
.490**
.000
.558**
.000
.458**
.000
.541**
.000
.525**
.000
.199**
.000
.462**
.000
.344**
.000
.709**
.000
** Correlation is significant at the 0.01 level (2-tailed)
Chapter 6: Results of Study 2 199
6.9 Theory assumptions
This section addresses the assumptions applicable to this research in its undertaking
of SEM.
Sample size: The sample size of 400 did not violate this assumption in SEM. Sample
sizes of 200 is commonly accepted as sufficient and sample sizes of 200-400 are
commonly run for models with 10-15 indicators (Kaplan, 2009; Raykov &
Marcoulides, 2000).
Data level: The data was interval data
Multivariate normality: Normal data is the conventional assumption in the
estimation process (Bai & Ng, 2005). Non-normality is indicated by data distribution
with a highly skewed nature or high kurtosis, which has random effects on
specification or estimation (Hall & Wang, 2005). Values >1.96 mean there is
indicates skewness from -.97 to 1.76 and kurtosis values from -.51 to 5.24.
Chapter 6: Results of Study 2 200
Table 6. 26 Sample skewness and kurtosis
Latent variabl
e
Indicators Skewness Kurtosis Statistic Std.
Error Statistic Std.
Error
FV Breast screens have consistent quality -.24 .09 .11 .18
Breast screens are well delivered -.53 .09 .82 .18
Breast screens have an acceptable standard of quality
-.62 .09 1.82 .18
Breast screens perform consistently -.39 .09 .29 .18
EV Having breast screens makes me feel comfortable
-.17 .09 -.51 .18
Having breast screens makes me feel safe -.75 .09 .65 .18
Having breast screens makes me feel happy .07 .09 -.03 .18
Having breast screens makes me feel calm -.12 .09 -.32 .18
Having breast screens makes me feel relieved
-.87 .09 .85 .18
Having breast screens makes me feel proud .04 .09 .14 .18
AQ The administration system at the place I usually go to is excellent
-.34 .09 -.22 .17
The administration at the place I usually go to is of a high standard
-.51 .09 .40 .17
I have confidence in the administration system at the place I usually go to
-.48 .09 .43 .18
TQ The quality of the service I receive at the place I usually go to is excellent
-.71 .09 .75 .17
The service provided by the place I usually go to is of a high standard
-.71 .09 .94 .18
I am impressed by the service provided at the place I usually go to
-.50 .09 .08 .18
PQ The interaction I have with the staff at the place I usually go to is of a high standard
-.54 .09 .09 .18
The interaction I have with the staff at the place I usually go to is excellent
-.51 .09 -.02 .18
I feel good about the interaction I have with the staff at the place I usually go to
-.55 .09 .39 .18
MD It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one
-.86 .09 .56 .17
I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment
-.82 .09 .70 .18
Having a plan is important to me as a breast screen customer, e.g. planning for waiting
-.57 .09 .61 .18
CP I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised
-.22 .09 -.24 .17
I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily
-.51 .09 .59 .17
I prepare my queries before going to a breast screen appointment
-.38 .09 .26 .17
I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury
-.38 .09 .23 .18
*table continued on following page
Chapter 6: Results of Study 2 201
*table continued from previous page
Latent variable
Indicators Skewness Kurtosis Statistic Std.
Error Statistic Std.
Error
ST I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen
-.97 .09 2.42 .17
I can handle stress without getting too nervous e.g. waiting for the results of my breast screen
-1.03 .09 1.61 .17
I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful
-1.19 .09 2.16 .17
SAT My feelings towards breast screening are very positive
-1.05 .09 2.07 .17
Overall, I am satisfied with breast screening and the benefits it provides
-1.35 .09 5.40 .17
I feel satisfied that the results of my breast screen are the best that can be achieved
-1.03 .09 2.55 .18
The extent to which my breast screen has produced the best possible outcome is satisfying
-.79 .09 2.37 .17
BI I would highly recommend breast screening to other women
-1.57 .09 4.01 .17
I have said positive things about breast screening to my family and friends
-.80 .09 .58 .17
I intend to continue having breast screens -1.76 .09 5.24 .17
I have no desire to stop breast screening -1.65 .09 3.88 .17
I intend to follow any medical advice given to me about breast screening
-1.28 .09 4.15 .17
Valid N (listwise) = 602
Missing values: Pairwise deletion was used in the treatment of missing data.
Multiple indicators: Multiple indicators was used for each variable
Estimation: Maximum likelihood was used, which makes estimates based on
maximising probability (likelihood) that the observed covariance are drawn from a
population assumed to be the same as those reflected in the coefficient estimates
(Byrne, 2001). This meets the SEM estimation assumption.
Chapter 6: Results of Study 2 202
6.10 Hypothesis testing outputs
In order to address the research questions presented in Chapter 1, a theoretical model
and a set of hypotheses were developed and presented in Chapter 5. This model and
the subsequent hypotheses were developed as a result of the findings of Study 1,
which were presented and discussed in Chapter 4. The model and hypotheses were
tested in Study 2 by using the outputs of SEM. The hypothesised path results of the
theoretical model are reported in the following section to test the hypotheses.
The path terms used in this table are:
FV = Functional value
EV = Emotional value
AQ = Administrative quality
TQ = Technical quality
PQ = Interpersonal quality
MD = Motivational direction
CP = Co-production
ST = Stress tolerance
SAT = Satisfaction
BI = Behavioural intentions
Chapter 6: Results of Study 2 203
The reported findings of the SEM output in Table 6.27 are assessed based on the
estimated path coefficient β value with critical ratio (C.R. equivalent to t-value) and
p-value. The standard decision rules (t-value ≥ 1.96, and p-value is ≤ .05) apply here
to decide the significance of the path coefficient between DV and IV (Byrne, 2001).
When the Critical Ratio (CR) is >1.96 for a regression weight, that path is significant
at the .05 level, indicating that its estimated path parameter is significant (Blunch,
2008).
Table 6. 27 SEM output for hypothesised path relationships in the proposed model
Hypotheses Paths SEM Output Results* β S.E C.R (t) P
H1a AQ→FV .18 .10 1.90 .057 Non-significant
H1b TQ→FV .40 .09 3.92 p≤.001 Significant
H1c PQ→EV .50 .06 9.47 p≤.001 Significant
H2a MD→FV .16 .07 3.19 .001 Significant
H2b CP→FV .09 .07 1.55 .122 Non-significant
H2c ST→EV .22 .09 3.95 p≤.001 Significant
H3a FV→SAT .54 .05 11.13 p≤.001 Significant
H3b EV→SAT .42 .03 9.23 p≤.001 Significant
H4 SAT→BI .74 .05 13.55 p≤.001 Significant
*Results supported at Significance Level: p≤.001, p≤.01, and p≤.05
The output revealed that two of the hypothesised relationships were non-significant.
The hypothesised relationship H1a AQ→FV was non-significant due to its p-value of
.057, which was above the minimum p-value of .05. Similarly, the hypothesised
relationship H2b CP→FV was also non-significant due to its p-value of .122. All
other hypothesised relationships were found to be significant as they fell within the
significance levels of p≤.001, and p≤.01.
Chapter 6: Results of Study 2 204
6.11 Post Hoc tests
Post hoc tests were conducted on the data as the modification indices suggested eight
additional paths within the model. These additional paths were included in the
model, and the model was tested again. As a result, one of these non-hypothesised
paths was revealed to be non-significant, while the remaining seven were found to be
significant. This section discusses each of these non-hypothesised path relationships
and provides the estimated path coefficient β value with critical ratio and p-value for
each of these path relationships.
6.11.1 Non-hypothesised relationships between sources and dimensions of value
Non-hypothesised relationships between the sources of value and the dimensions of
value were tested and two relationships were found to be significant. It was found
that motivational direction had a positive influence on emotional value with an
estimated path coefficient β value of .24, with critical ratio (C.R.) 2.44 and p-value of
.015. This was the first significant non-hypothesised relationship identified in the
model. It was also found that stress tolerance had a positive influence on functional
value with an estimated path coefficient β value of .13, with critical ratio (C.R.) 1.90
and p-value of .057.
6.11.2 Non-hypothesised relationships between the dimensions of value
Next, non-hypothesised relationships between the two dimensions of value were
tested. While the path relationship FV → EV was non-significant, the path
relationship EV → FV was significant with an estimated path coefficient β value of
.20 with critical ratio 5.17 and p-value ≤.001 demonstrating that emotional value
positively influences functional value.
Chapter 6: Results of Study 2 205
6.11.3 Non-hypothesised relationships between sources of value and satisfaction
Non-hypothesised relationships between the sources of value and satisfaction were
also tested and two relationships were found to be significant. Technical quality and
co-production were both found to positively influence satisfaction. For TQ → SAT
the estimated path coefficient β value was .23 with critical ratio 4.90 and p-value
≤.001demonstrating that technical quality positively influences satisfaction. For CP
→ SAT the estimated path coefficient β value was .17 with critical ratio 3.32 and p-
value ≤.001 demonstrating that co-production also positively influences satisfaction.
6.11.4 Non-hypothesised relationships between sources of value and behavioural
intentions
Further path relationships between sources of value and behavioural intentions were
also tested and one relationship was found to be significant. Co-production was
found to positively influence behavioural intentions with an estimated path
coefficient β value of .14 with critical ratio 2.72 and p-value .007. A second path
relationship between administrative quality and behavioural intentions was also
tested, but was found to be non-significant. For AQ → BI the estimated path
coefficient β value was -.06 with critical ratio -1.37 and p-value .172 demonstrating a
non-significant path relationship.
6.11.5 Non-hypothesised relationships between dimensions of value and
behavioural intentions
Finally, path relationships between the value dimensions and behavioural intentions
were explored and only one relationship was found to be significant. Emotional value
was found to positively influence behavioural intentions with an estimated path
coefficient β value .09 with critical ratio 2.54 and p-value .01.
Chapter 6: Results of Study 2 206
6.11.6 Mediated relationships in the model
The post hoc tests also suggested that there were a number of mediated relationships
between constructs in the model. Mediation for two relationships was tested. To
establish mediation, steps suggested by Baron and Kenny (1986) and Judd and
Kenny (1981) were undertaken. The following section describes the findings of the
post hoc tests conducted on the possible mediated relationships.
The above model illustrates a basic mediational model whereby X represents the
independent variable, Y represents the dependent variable, and M represents the
mediating variable. In addition, a, b, and c‟ represent the paths between these
variables.
The data suggested that the effect of technical quality (TQ) on satisfaction (SAT) is
mediated by functional value (FV) (see Figure 6.2). The first step suggested by
Baron and Kenny (1986) and Judd and Kenny (1981) was to show that TQ is
correlated with SAT to establish that there is an effect that may be mediated. Using a
stepwise linear regression, it was found that TQ predicts 42% of SAT and is
significant (p<.05).
TQ SAT
FV a b
c’
X Y
M a b
c’
Figure 6. 3 Basic mediational model
Figure 6. 4 Mediational model for technical quality, satisfaction, and functional value
Chapter 6: Results of Study 2 207
The second step was to show that TQ is correlated with FV, treating FV as if it were
an outcome variable (Baron & Kenny, 1986; Judd & Kenny, 1981). Using a stepwise
linear regression, it was found that TQ predicts 45% of FV and is significant (p<.05).
The next step was to show that FV affects the outcome variable, SAT (Baron &
Kenny, 1986; Judd & Kenny, 1981). A hierarchical regression was conducted using
TQ and FV as predictors. The results indicated that TQ contributes 42% of variance
in SAT and is a significant predictor (p<.05). At the second step, the R Square
Change statistic and the Sig. F Change value indicates that FV makes a significant
unique contribution of 13% to the variance of SAT and is significant (p<.05).
Although TQ is a salient predictor of SAT, F(1.398) = 286.577, p<.05, the results
suggest that functional value (FV) acts as a partial mediator on the relationship
between technical quality (TQ) and satisfaction (SAT).
The data also suggested that the effect of co-production (CP) on behavioural
intentions (BI) is mediated by satisfaction (SAT). The same procedure suggested by
Baron and Kenny (1986) and Judd and Kenny (1981) was used. A stepwise linear
regression showed that CP predicts 21% of BI and is significant (p<.05). Next, it was
found that CP predicts 20% of SAT and is also significant (p<.05). Finally, a
hierarchical regression was conducted using CP and SAT as predictors. The results
indicated that CP contributes 21% of variance in BI and is a significant predictor
(p<.05). At the second step, the R Square Change statistic and the Sig. F Change
value indicates that SAT makes a significant unique contribution of 30% to the
variance of BI and is significant (p<.05). Although CP is a salient predictor of BI,
F(1,398) = 107.801, p<.05, the results suggest that satisfaction (SAT) acts as a partial
mediator on the relationship between co-production (CP) and behavioural intentions
(BI).
CP BI
SAT a b
c’
Figure 6. 5 Mediational model for co-production, behavioural intentions, and satisfaction
Chapter 6: Results of Study 2 208
6.11.7 Summary of SEM output for hypothesised and non-hypothesised
relationships
All the non-hypothesised path relationships were included in the proposed model
with the existing hypothesised relationships and the model was re-run in AMOS. The
SEM output indicated that all path relationships were significant, with the exception
of CP→FV which remained non-significant. Also, the non-hypothesised path
relationship ST→FV was significant at .058, which was deemed to be close to the
.05 threshold and thus this path relationship was retained. The SEM output for all
hypothesised and non-hypothesised relationships in the proposed model is presented
in Figure 6.6.
Table 6. 28 SEM output for hypothesised and non-hypothesised relationships in the
proposed model
Relationships Paths SEM Output Results
β S.E C.R (t) P
Hypothesised AQ→FV .20 .09 2.15 .032 Supported
TQ→FV .20 .09 2.18 .029 Supported
PQ→EV .57 .07 8.87 p≤.001 Supported
MD→FV .15 .07 2.21 .027 Supported
CP→FV .02 .07 .34 .735 Not
supported
ST→EV .31 .10 3.32 p≤.001 Supported
FV→SAT .34 .05 6.66 p≤.001 Supported
EV→SAT .20 .03 5.87 p≤.001 Supported
SAT→BI .54 .07 8.54 p≤.001 Supported
Non-hypothesised
MD→EV .24 .10 2.44 .015 Significant
ST→FV .13 .07 1.90 .057 Significant
EV→FV .20 .04 5.17 p≤.001 Significant
TQ→SAT .23 .05 4.90 p≤.001 Significant
CP→SAT .17 .05 3.32 p≤.001 Significant
AQ→BI -.06 .05 -1.37 .172 Non-
significant
CP→BI .14 .05 2.72 .007 Significant
EV→BI .09 .03 2.54 .011 Significant
*Results supported at Significance Level: p≤.001, p≤.01, and p≤.05
Chapter 6: Results of Study 2 209
Figure 6.6 shows the path diagram indicating the significant hypothesised
relationships, non-significant hypothesised relationships, and the significant non-
hypothesised relationships.
Figure 6. 6 Full path model with all relationships
The model produced a CMIN/DF of 2.54, with RMSEA of .06 and CFI of .93 which
suggested good fit. The model was found to be a good fit to the data as indicated by
its χ2 to degrees of freedom ratio (CMIN/DF = 2.54). Although this value does not
strictly meet the threshold ≤ 2 it was deemed to be of moderate fit. Similarly, its root
mean square error of approximation (RMSEA = .068) value closely met the threshold
of ≤.06 and was deemed to be of moderate fit as RMSEA values of ≤.05 indicate
models with good fit, while RMSEA values of ≥.10 suggest poor fit (Bollen & Long,
1993). Finally, its comparative fit index (CFI = .914), met the threshold of ≥.9
Description This project is being undertaken as part of a PhD project for Ms Nadia Zainuddin, who is a
PhD candidate with the School of Advertising, Marketing and Public Relations in the
Faculty of Business, Queensland University of Technology. Ms Zainuddin is working
under the supervision of Associate Professor Rebekah Russell-Bennett from Queensland
University of Technology, and Dr Josephine Previte from the University of Queensland.
This research is undertaken with the support of BreastScreen Queensland (BSQ), a breast
cancer screening service provided by the Queensland Government under Queensland
Health.
The purpose is to understand consumer experiences with breast cancer screening services,
specifically those offered by BreastScreen Queensland (BSQ). The objective is to identify
the benefits that consumers perceive to have experienced from such a service, as well as the
benefits that consumers perceive to not have received, but were expecting to receive.
Examples of questions that participants might be asked include “Describe your experience
with BSQ‟s screening service.” Secondly, this project also seeks to determine the various
factors that might influence consumers‟ expectations of benefits. Examples of questions
that participants might be asked include “How did you come about to expecting these
benefits?”
The importance of this research is twofold. First, it will allow for the improvement of
service delivery in order to better meet the needs of consumers. Secondly, it will allow for
the development of more effective social marketing campaigns that would involve better
informing consumers of the benefits that they will experience and receive from consuming
the service.
In order to identify the different benefits that are experienced by consumers and the things
that can or may affect this, our research has identified three stages of the service process
where consumers can experience benefits from the overall service process: the pre-
consumption stage (before you have your screen), the consumption stage (the day that you
have your screen), and the post-consumption stage (after you have your screen).
The research team requests your assistance because the aim of this research is to identify
from the consumer‟s perspective, the different types of benefits that can exist in such a
Appendices 287
service. Also, as this research aims to identify the different influences on consumers‟
determination of these benefits, this can only be achieved through the participation of
consumers through sharing their experiences with the research team, and using their own
words to describe the service experience and any accompanying benefits experienced from
consuming the service.
Participation Your participation in this project is voluntary. If you do agree to participate, you can withdraw
from participation at any time during the project without comment or penalty. Your decision to
participate will in no way impact upon your current or future relationship with QUT or with
BreastScreen Queensland.
Your participation will involve an individual-depth interview.
The interview is anticipated to last for approximately 45 minutes.
Expected benefits It is expected that this project will benefit you. Your participation will aid in the improvement
of breast screening services offered by BSQ, of which you are likely to be a customer.
Risks The research team anticipates that there are minimal risks beyond normal day-to-day living
associated with your participating in this project as questions of a clinical or medical nature will
not be asked as this research is focussed solely on the service delivery aspect of breast screening.
Where the research may cause distress, independent counselling services may be offered: QUT
provides for limited free counseling for research participants of QUT projects, who may
experience some distress as a result of their participation in the research. Should you wish to
access this service please contact the Clinic Receptionist of the QUT Psychology Clinic on
3138 4578. Please indicate to the receptionist that you are a research participant.
Confidentiality All comments and responses are anonymous and will be treated confidentially. The names of
individual persons are not required in any of the responses.
Discussions are likely to be audio recorded for transcription purposes. Transcripts of all
discussions will only be used for the research described in this form and not for any other
purpose. Only the principle researcher will have access to the audio recordings and transcripts.
After a research report is prepared, participants may be asked to verify if their views have been
represented accurately and if all identifiable traits of their identity have been adequately removed.
Consent to Participate We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to
participate.
Questions / further information about the project Please contact the researcher team members named above to have any questions answered or if
you require further information about the project.
Concerns / complaints regarding the conduct of the project QUT is committed to researcher integrity and the ethical conduct of research projects. However,
if you do have any concerns or complaints about the ethical conduct of the project you may
contact the QUT Research Ethics Officer on 3138 2340 or [email protected]. The
Research Ethics Officer is not connected with the research project and can facilitate a resolution
“Identifying consumer value and influencers of value in breast screening
services”
Statement of consent By signing below, you are indicating that you:
have read and understood the information document regarding this project
have had any questions answered to your satisfaction
understand that if you have any additional questions you can contact the research team
understand that you are free to withdraw at any time, without comment or penalty
understand that you can contact the Research Ethics Officer on 3138 2340 or [email protected] if you have concerns about the ethical conduct of the project
agree to participate in the project
understand that the project will include audio recording
understand that your contact information is required only for the purpose of a follow-up interview if required or to send you the results if you have indicated that you would like to receive this
Name
Contact no Email address
Date / / Signature
Would you like to receive a copy of the results from this study?
Please circle either “yes” or “no” to indicate your preference