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GRENOBLE ECOLE DE MANAGEMENT

DOCTORAL SCHOOL

WHAT ATTRIBUTES OF HEALTHCARE ARE THE MOST IMPORTANT TO IMPROVE PATIENT SATISFACTION IN LEBANESE PRIMARY CARE SETTINGS: THE CASE OF MOUNT LEBANON CLINIC.

A thesis submitted in partial fulfillment of the requirements for the degree of

Doctor of Business Administration

By Karim Kobeissi 2012

DECLARATION
This thesis contains no material that has been accepted for the award of any other degree or diploma in any educational institution and, to the best of my knowledge and belief, it contains no material previously published or written by another person, except where due reference is made in the text of the thesis.

ACKNOWLEDGMENT

First and foremost, Id like to express my gratefulness to God, The Almighty, for giving me the grace to accomplish this dream. All glory and adoration belongs to Him. Id also like to show gratitude to my supervisor, Dr. Benoit AUBERT (Director of the Doctoral School and of the Lebanese DBA program), for his invaluable contribution, guidance and useful suggestions which kept me on track. He has been a great role model and friend. Moreover, Id like to thanks Professor Jean-Jacques CHANARON (Associate Dean Scientific Director Doctoral School at Grenoble Ecole de Management, France), Dr. Laurent TOURNOIS and Dr. Franois DESMOULINS-LEBEAULT who were abundantly helpful. I cannot end without thanking my wife Rania and our three children, on their constant sustain and love. It is to them that I dedicate this work.

No one cares how much you know, 3

until they know how much you care - Don Swartz.

Table of Contents
Table of Contents............................................................................................................................4 List of Tables...................................................................................................................................6 List of Figures.................................................................................................................................7 ABSTRACT.....................................................................................................................................8 INTRODUCTION........................................................................................................................10
RESEARCH BACKGROUND ..........................................................................................................13 RESEARCH OBJECTIVES AND PERSPECTIVES.......................................................................15 .............................................................................................................................................................15 DELIMITATION OF SCOPE ...........................................................................................................17 RESEARCH ORGANIZATION........................................................................................................17

PART 1 - LITERATURE REVIEW.............................................................................................19


Introduction.........................................................................................................................................19

Chapter 1: Patient Satisfaction....................................................................................................20


1. 1 Conceptualization of Satisfaction................................................................................................22 1.2 Conceptualization of Patient Satisfaction ..................................................................................45 1.3 Measurement of Patient Satisfaction ...........................................................................................58 1.4 Patient Satisfaction: Conclusion...................................................................................................64

Chapter 2: Drivers of Patient Satisfaction...................................................................................66


2.1 Care Variables...............................................................................................................................67 2.2 Patient Variables...........................................................................................................................72 2.3 Drivers of Patient Satisfaction: Conclusion ................................................................................83 CONCLUSION LITERATURE REVIEW .......................................................................................84

PART 2: HYPOTHESES, METHODOLOGIES AND OUTCOMES........................................88


Introduction.........................................................................................................................................88

Chapter 3: Research Model and Hypotheses...............................................................................91


3.1 The Qualitative Pilot Study...........................................................................................................93

3.2 Design of the Research Model ....................................................................................................109 3.3 Research Hypotheses...................................................................................................................116 3.4 Research Model and Hypotheses: Conclusion ........................................................................123

Chapter 4: Methodologies & Outcomes.....................................................................................127


4.1 Characteristics of the Quantitative Study .................................................................................128 4.2 Measurement and Scaling...........................................................................................................133 4.3 Scales Validation..........................................................................................................................143 4.4 Testing the Hypotheses................................................................................................................154 4.5 Methodologies and Outcomes: Conclusion................................................................................193

Chapter 5: Managerial Contributions.......................................................................................196


5.1 Direct Implications for Primary Care Providers......................................................................197 5.2 A Holistic Process of Patient Satisfaction .................................................................................202 5.3 Managerial Contributions: Conclusion......................................................................................207 CONCLUSION HYPOTHESES, METHODOLOGIES AND OUTCOMES...............................208

CONCLUSION...........................................................................................................................210 Glossary of Statistical and Technical Terms.............................................................................216 Appendix 1..................................................................................................................................252 Appendix 2..................................................................................................................................253 Appendix 3..................................................................................................................................255 Appendix 4..................................................................................................................................259 Appendix 5..................................................................................................................................260 Appendix 6..................................................................................................................................261 Appendix 7..................................................................................................................................262 Appendix 8..................................................................................................................................263 Appendix 9..................................................................................................................................264

List of Tables

Table 1: Conceptual & operational definitions of satisfaction...................................................24 Table 2: Differences between service quality & satisfaction......................................................42 Table 3: Differences between perceived value & satisfaction ....................................................44 Table 4: Key definitions of patient satisfaction that are considered as references in the literature........................................................................................................................................49 Table 5: Key definitions of healthcare quality that are considered as references in the literature........................................................................................................................................55 Table 6: Meta analysis of patient satisfaction.............................................................................60 Table 7: Observed impact of socio-demographics variables on patient satisfaction.................78 Table 8: Overview of the Interviewees ........................................................................................97 Table 9: Definitions & Operationalization of the different variables, included in the research model ..........................................................................................................................................114 Table 10: Hypotheses of the present study................................................................................124 Table 11: Measurement of formative scales..............................................................................140 Table 12: Measurement of patient satisfaction.........................................................................142 Table 13: Results of the first order confirmatory factor analysis (distributive justice)...........145 Table 14: Results of the first and second order confirmatory factor analysis (SERVPERF) 145 Table 15: Reliability of the distributive justice & SERVPERF scales....................................147 Table 16: Distributive Justice and SERVPERF models estimates...........................................150 Table 17: Strong evidence of convergent validity......................................................................151 Table 18: Multicollinearity of items measuring patient satisfaction with healthcare dimensions .....................................................................................................................................................152 Table 19: Multiple regression analysis results (All predictors)................................................158 Table 20: Items used for measuring the mediating variables of the model.............................164 Table 21: Regression results of service quality mediating the relationship between physician care and patient satisfaction.......................................................................................................165

Table 22: Regression results of distributive justice mediating the relationship between price of care and patient satisfaction.......................................................................................................167 Table 23: Regression results testing the moderating effect of age...........................................171 Table 24: Regression results testing the moderation effect of income ....................................174 Table 25: Correlations between access to care and patient satisfaction for both groups........176 Table 26: Regression results of testing the moderating effect of gender.................................179 Table 27: Summary of hypotheses testing results.....................................................................183 Table 28: Classification of factors related to the physician care dimension along with their impacts on patient satisfaction...................................................................................................186 Table 29: Classification of factors related to the price of care dimension along with their impacts on patient satisfaction...................................................................................................187 Table 30: Classification of factors related to the access to care dimension along with their impacts on patient satisfaction ..................................................................................................189 Table 31: Classification of factors related to the atmospherics of care dimension along with their impacts on patient satisfaction .........................................................................................190

List of Figures

Figure 1: Organization of Part 1.................................................................................................20 Figure 2: Expectancy Disconfirmation Paradigm......................................................................34 Figure 3: Organization of Part 2.................................................................................................90 Figure 4: Research Model and the Hypotheses........................................................................123 Figure 5: Diagram of Reflective and Formative Measurement Models .................................138 Figure 6: An Unmediated Model...............................................................................................162 Figure 7: A Mediated Model......................................................................................................162 Figure 8: A Moderator Model....................................................................................................168 Figure 9: Plots of correlations between access to care and satisfaction for both groups.......176 Figure 10: A Holistic Process of Patient Satisfaction...............................................................206

ABSTRACT

Patients view about healthcare service delivery is a neglected subject in many developing countries such as Lebanon. Patients are viewed as passive beneficiary of healthcare service with muted voices. However, the patients perceptions of service quality and satisfaction with healthcare services can assist management and policy makers in the design, implementation and evaluation of services which in turn assist to better improve and deliver qualitative healthcare to the populace. Thus, the present research study aims to contribute to the development of knowledge on patient satisfaction. More specifically, it attempts to distinctively identify the key healthcare dimensions that impact patient satisfaction with primary care services in Lebanon.

To achieve this goal, a literature review is conducted in order to provide an original conceptualization of patient satisfaction and its drivers. Based on the literature review, an exploratory qualitative study is undertaken to gain insight into specific influencing factors which are incorporated into the conceptual satisfaction model. An original model is developed that illustrates the effects of four influencing factors (physician care, price of care, access to care, and atmospherics of care) on outpatient satisfaction and tested a set of hypotheses covering the mediating and moderating effects.

In order to explore effects and to transfer gained knowledge into management guidelines the empirical study is designed. The research is conducted at Mount Lebanon Clinic (which is the property of the researchers family and a typical case of clinics in Lebanon) on a sample of 385 outpatients. Multiple regression analysis is used to test the hypotheses. The results of this research are twofold. First, a model which details relationships between influencing factors and patient satisfaction is proposed and validated in the Lebanese context. Second, an advanced model of patient satisfaction is developed. It is designed to view patient satisfaction more holistically and to provide guidelines for healthcare providers. The existence of two mediating variables is unveiled: distributive justice and perceived healthcare quality. The moderating role of age, income and gender is also examined.

Keywords: Customer Satisfaction, Patient Satisfaction, Healthcare Service Quality, and Lebanon.

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INTRODUCTION
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The strategy for patient satisfaction in healthcare service requires effective marketing plans, policies, and practices to genuinely meet the needs of different strata of population (MacAlexander, Becker, & Kaldenberg, 1993). This concept drew the attention of the service providers since early 70s and the healthcare providers in advanced countries became conscious of satisfying patients (Cooper, Maxilla, & Rhea, 1979; P. Kotler & Zaltman, 1970; Woodside & Frey, 1989; Zaltman & Vertinsky, 1971). The major reasons that have necessitated a shift towards marketing approach are competitive pressures, alternate healthcare delivery

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mechanisms, changing cost structures, monitoring by public and private groups, and a markedly better-informed clientele (Andaleeb, 1988). The progress of service unit depends on the patient satisfaction and service quality in all developing and developed countries (Cronin & Taylor, 1992). Accordingly, patient satisfaction is no longer simply the nice or right thing to do; it is the only good business choice in the current highly competitive environment (Dingman, Williams, Fosbinder, & Warnick, 1999). Indeed, there are multiple returns from improving patient satisfaction: For one, patient satisfaction is a profitable competitive tool because studies have shown that the public is inclined to pay more for care from quality institutions which are better disposed to satisfy customers needs (Boscarino, 1992; Hays, 1987). Also, Hospitals that are patient focused have been able to enhance their images, which in turn translate into increased capacity utilization and market share (Andaleeb, 1988; Gemme, 1997; Gregory, 1986). Moreover, it has been shown that satisfied patients demonstrate greater compliance with their medical care than do dissatisfied patients (Bell, Krivich, & Boyd, 1997). They spend less time in the hospital and have improved outcomes that can result in cost savings to the healthcare facility. In addition, satisfied patients tend to remain loyal to that particular facility and are likely to use the hospitals services again (Atkins, Marshall, & Javalgi, 1996; Taylor, 1994). In contrast, patient dissatisfaction can result in lost revenue (Bell, et al., 1997). For example, negative word of mouth can occur (J. E. Howard, 2000). Dissatisfied patients often do not return to the same hospital and will avoid using other services associated with that facility, such as outpatient1 care, home care, or physician services (Press, 2002). Furthermore, dissatisfied
1

The technical terms used in this dissertation are precisely defined in the glossary at the end.

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customers tend to complain to the establishment or seek redress from it more often to relieve cognitive dissonance and failed consumption experiences (Nyer, 1999). In fact, dissatisfaction can have serious ramifications: patients are unlikely to follow treatment regimen (Bell, et al., 1997) and may fail to show up for follow-up care (Kahan & Goodstadt, 1999). The level of patient satisfaction affects contracts renewals between employers or managed care organizations and healthcare providers. Zimmerman et al. found that when patient satisfaction ratings fell below the expected standards, employers and managed care organizations failed to renew contracts with 50 percent of healthcare organizations (Zimmerman, Zimmerman, & Lund, 1997).

Delivering patient satisfaction is imperative because todays buyers of healthcare services are better educated and more aware than in the past (Vuori, 1991). These buyers carefully study and monitor the options available to them; they are, therefore, more discerning buyers, knowing exactly what they need. These changes are being driven by the abundance of information that is available to them from public and private sources. According to Kurz and Heistand, customers are relying less on doctors to choose the right hospital (Heistand, 1986; R.S. Kurz & Wolinsky, 1985). Reflecting on the importance of the patients point of view, Petersen suggests that: It really does not matter if the patient is right or wrong. What counts is how the patient felt even though the caregivers perception of reality may be quite different (Petersen, 1988). Medical settings that fail to understand the importance of delivering patient satisfaction may be inviting possible extinction. The abovementioned importance of patient satisfaction and the fact that no previous research was conducted on outpatient satisfaction in the Lebanese context led us to address such a topic in

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the present thesis, even if its primary focus is not to compare Lebanon to other countries but to add additional knowledge to the existing literature on patient satisfaction. To specify the nature and the merit of this work, the background to the research is presented hereafter. Especially, the role of patient satisfaction in modeling health related behaviour and treatment outcomes is discussed. Then, the research question and objectives are presented and their academic and managerial relevance are justified. Finally, the scope of this research is delimitated and the research organization is presented.

RESEARCH BACKGROUND

The Nature of Healthcare Services

Healthcare is a people processing service which involves tangibles actions to patients bodies (Lovelock, 2001). Healthcare services are by nature credence purchases (Butler, Oswald, & Turner, 1996). Originally touted by Nelson, purchases may be classified as having search, experiential and credence properties. Purchases high in search properties can be evaluated prior to consumption by a consumer (P. Nelson, 1974). Zeithaml notes that these are mostly physical goods such as furniture and automobiles. Purchases high in experience properties are more difficult to evaluate prior to purchase because they must be consumed before assessment is possible (e.g. restaurant meals, child care). At the extreme end of this continuum are purchases

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high in credence properties. These are the most difficult to evaluate prior to consumption because the consumer may be either unaware or lack sufficient knowledge to appraise the purchase adequately (V. Zeithaml, 1981). Healthcare was noted to be at the extreme end of the purchase continuum with the highest level of credence properties (Butler, et al., 1996). As such, a better understanding of the way in which healthcare service dimensions affect satisfaction is of crucial importance and will be at the heart of our research. Role of Satisfaction in Modeling Healthcare

The satisfaction construct may be analyzed in two ways. It may be considered as an independent variable that predicts consumer behaviors (with the assumption that differences in satisfaction influence what people do) (Donabedian, 1988; G.C. Pascoe, 1983; J. E. Ware, Davies-Very, & Stewart, 1977). For example, the degree of satisfaction is seen as contributing to subsequent patient commitment to, and compliance with, recommended treatment as well as affecting the likelihood of returning to the same provider and healthcare delivery program (Strasser, Aharony, & Greenberger, 1993). It may be also studied as a dependent variable to evaluate provider services and facilities (based on the assumption that patient satisfaction is one core service quality indicator) (Heinemann, Lengacher, VanCott, Mabe, & Swymer, 1996). This last approach is the one that we investigate in this research. Actually, such research is meaningful from a managerial perspective because for patients who have some choice of their provider and healthcare system, the degree of satisfaction with their current utilization and clinical progress should have differential effects on how often they use a health service or recommend it to other people and whether or not they will seek care elsewhere (C. W. Nelson & Niederberger, 1990).

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RESEARCH OBJECTIVES AND PERSPECTIVES

Objectives of the Research

The ambition of this study is to add to the limited knowledge and empirical evidences on the drivers of patient satisfaction in Lebanese primary care settings.

The specific objectives are: 1. Identify the key healthcare dimensions that impact patient satisfaction with primary care services. 2. To better understand the mechanisms linking healthcare dimensions to patient satisfaction by: Identifying what dimensions are most significant to improve patient satisfaction with primary care services in Lebanon. Investigating unexplored, but relevant, mediating variables, identified in the satisfaction literature as well as in the healthcare literature. Investigating relevant moderating effects.

Academic Relevance of the Research

More than a decade ago, Bernhart et al. called for additional research on patient satisfaction in developing countries, flagging the importance of such research in the design, implementation and

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evaluation of healthcare services in such countries (Bernhart, Wiadnyana, Wihardjo, & Pohan, 1999). Unfortunately, while this appeal had been abided by many scholars in various developing countries [e.g., (Al Tehewy & Salem, 2009; Andaleeb, Siddiqui, & Khandakar, 2007; Bernhart, et al., 1999)], it didnt have any echo in Lebanon where the literature doesnt mention the presence of any methodological study on outpatient satisfaction. The present study was undertaken to fill this gap in knowledge. Accordingly, it attempts to distinctively identify the key drivers of patient satisfaction with primary care services in Lebanon and investigate the mechanisms through which and the conditions under which care dimensions affect patient satisfaction. Thereby, results deepen existing knowledge on patient satisfaction.

Managerial Relevance of the Research

Findings of this research imply two main managerial contributions. First, the identification of the key dimensions of healthcare that influence patient satisfaction with primary care services in Lebanon. Such contribution will help the providers to redesign creatively their quality and satisfaction programs. Second, the development of the holistic process of patient satisfaction. It is a more practical and advanced process for approaching patient satisfaction implementation. Its applicability and potential advantages go beyond this study and its particular context. Local and international providers throughout the healthcare sector should be able to follow the proposed steps. In the course of its application, healthcare settings could be taken to a higher level, helping to serve patients more proficiently.

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DELIMITATION OF SCOPE

To accurately answer the research question and in order to meet the objectives, the scope of this thesis has been clearly delimited. An inclusion of all possible influencing factors would have made the research model too complex (Licata, Chakraborty, & Krishnan, 2008). Accordingly, only a limited number of factors that were identified from the literature review and the qualitative pilot study were included in the conceptual research model. Within a specific research context, four influencing dimensions of healthcare (physician care, access to care, price of care and atmospherics of care), three moderating variables (age; gender; income), and two mediating factors (service quality; distributive justice) are chosen. Theoretically, the study is situated within the wider area of services marketing. In terms of classification, the project falls in the customer satisfaction part of services marketing. More precisely, it is in the intersection of multiple influencing factors on outpatient satisfaction. In other words, the relative importance assigned to different healthcare dimensions by primary care patients and the possible effect of physician care, access to care, price of care and atmospherics of care is explored. From a context point of view, this study relies on the case of Mount Lebanon Clinic (MLC) which structure and portfolio of customers is quite typical of clinics in Lebanon. Thus, this is a representative case. RESEARCH ORGANIZATION

Following the INTRODUCTION, this research paper is divided into two parts covering five chapters. Part 1: Literature Review

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The objective of CHAPTER 1 is to provide an extensive literature review on PATIENT SATISFACTION. This chapter aims to provide a comprehensive examination of the conceptualization and measurement of the patient satisfaction construct. Then, CHAPTER 2 aims to elaborate on the drivers of patient satisfaction and situate them with respect to their theoretical foundations. Part 2: Hypotheses, Methodologies and Outcomes

The literature review and the pilot study were helpful to finalize the RESEARCH MODEL and develop the RESEARCH HYPOTHESES presented in CHAPTER 3. As the main study is based on a quantitative approach, CHAPTER 4 METHODOLOGIES AND OUTCOMES presents both the measures carried out and the results identified. Especially, the validation of existing scales and the construction of healthcare dimensions indexes is detailed. Then, the successive results of each hypothesis are presented. Multiple regression analysis is used to highlight the impact of the different dimensions and factors of healthcare on outpatient satisfaction. CHAPTER 5 MANAGERIAL CONTRIBUTIONS describes the practical consequences of the empirical results. The discussion centers on direct management implications and an advanced process of patient satisfaction. Finally the CONCLUSIONS of the research are drawn. First, a synthesis of the key results of the research is presented. Then, the key contributions of the research are pinpointed from theoretical and managerial perspectives. The limitations of the research and the paths for future research are also presented.

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PART 1 - LITERATURE REVIEW


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Introduction

Part one which forms the theoretical framework for this dissertation scans previous work in the field of patient satisfaction. Its objective is to find and present the pertinent work from the primary literature in a logical, critical, and organized manner and to bring the reader as up-todate as possible.

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PART 1: LITERATURE REVIEW Part 1 is organized in two chapters: CHAPTER 1: PATIENT SATISFACTION

Contributions of chapter 1:

- Provides a comprehensive examination of the conceptualization and measurement of the customer/patient satisfaction construct.

CHAPTER 2: DRIVERS OF PATIENT SATISFACTION Contributions of chapter 2:

- Provides a comprehensive examination of the drivers of patient satisfaction. The findings of part 1 will discover the knowledge gap and help to frame the research model

Figure 1: Organization of Part 1

Chapter 1: Patient Satisfaction

-------------------------------------------------------------------------------------------------------------------The single most important thing to remember about any enterprise is that there are no results inside its walls. The result of a business is a satisfied customer" - Peter Drucker.

Practically every organization is nowadays concerned with satisfying the users of its products are they known as clients, customers, consumers or patients. However, the concept of customer satisfaction is nothing new. It was management guru Peter Drucker who wrote long ago that

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there is only one valid definition of business purpose - to create a customer'. Having created customers, the next step is to satisfy them (Drucker, 1954). Similarly, in the marketing discipline which has been defined as the delivery of customer satisfaction at a profit (P. Kotler, 2002) and customer satisfaction engineering (Philip. Kotler & Levy, 1969), there is probably no concept that is at once more fundamental and pervasive than satisfaction (Czeplel & Rosenberg, 1977).

Customer satisfaction with healthcare has gained widespread recognition as a measure of service quality (Harris, Swindle, Mungai, Weinberger, & Tierney, 1999). This has arisen partly because of the desire for greater involvement of the customer in the healthcare process and partly because of the links demonstrated to exist between satisfaction and patient compliance in areas such as appointment keeping, intentions to comply with recommended treatment and medication use (Willson & McNamara, 1982). Since high quality clinical outcome is dependent on compliance which, in turn, is dependent on patient satisfaction the latter has come to be seen as a legitimate healthcare goal and therefore a prerequisite of quality care (Vuori, 1987). Consequently, this review assumes that satisfying patients is an essentially sound principle and that an understanding of the nature of satisfaction is required if healthcare providers are to deliver quality care and succeed in today's rapidly changing business and economic environment. Section one of this chapter presents an overview of the way satisfaction is presented in the marketing literature. Then sections two and three present a comprehensive view of the way in which the concept of satisfaction is conceptualized and measured in the healthcare environment. Finally, section four presents the conclusions and implications of this chapter.

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1. 1 Conceptualization of Satisfaction

1.1.1 Etymology of Satisfaction

When I use a word, Humpty Dumpty said in a rather disrespectful tone, it means just what I choose it to mean neither more nor less (Carroll, 1865). The word satisfaction first appeared in English during the thirteenth century. The word satisfaction itself is derived from the Latin satis (meaning enough) and the Latin ending -faction

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(from the Latin facere to do/make). Early usage centered on satisfaction being some sort of release from wrong doing. Later citings of the word emphasize satisfaction as a release from uncertainty (The Oxford Library of Words and Phrases, 1993). Modern usage of the word has tended to be much broader, and satisfaction is clearly related to other words such as satisfactory (adequate), satisfy (make pleased or contented) and satiation (enough). The difficulty faced when trying to define any word is that the meaning often depends on the context in which the word is used. In a marketing context, satisfaction is used to have a more specific meaning. 1.1.2 Definitions of Satisfaction

Before analyzing the definitions of consumer satisfaction, it is important to note that discrepant terms are used interchangeably in the literature, such as "consumer satisfaction", "customer satisfaction" or simply "satisfaction" (Giese & Cote, 2000). Researchers have used discrepant terms to mean satisfaction as determined by the final user: consumer satisfaction (e.g., (Cronin & Taylor, 1992; Spreng, MacKenzie, & Olshavsky, 1996; Tse & Wilton, 1988)), customer satisfaction (e.g., (G.A Churchill & Surprenant, 1982; C. Fornell, 1992; Smith, Bolton, & Wagner,
1999)), or simply, satisfaction (e.g. (Kourilsky & Murray, 1981; Mittal, Kumar, & Tsiros, 1999)).

These terms are used somewhat interchangeably, with limited, if any, justification for the use of any particular term. In this study, the term "customer satisfaction" will be used.

In spite of considerable investigations (e.g.(LaTour & Peat, 1979; Oh & Parks, 1997; Ross, Frommelt, Hazelwood, & Chang, 1987)) through the years since Cardozo's classic article (Cardozo, 1965), researchers have yet to develop a consensual definition of customer

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satisfaction. Cochran addressed this definitional issue by summarizing the emotion literature, recording that "There are as many definitions of customer satisfaction as there are customers " (Cochran, 2003) . This ambiguity is due to the fact that when discussing and testing theory it is critical to explicate the conceptual domain which unfortunately most satisfaction researchers dont: Without a clear focus, any definition of satisfaction would have little meaning since interpretation of the construct would vary from person to person (Giese & Cote, 2000). Consequently, "While everyone knows what satisfaction means, it clearly does not mean the same thing to everyone" (R. Day, 1980).

Table 1 presents the main definitions that are considered as references in the literature and which will be further discussed in sections 1.1.3 and 1.1.4.

Table 1: Conceptual & operational definitions of satisfaction


Nature of Source
(V.A. Zeithaml, Bitner, & Gremler, 2009) (Giese & Cote, 2000) A summary affective response of varying intensity, with a time specific point of determination and limited duration directed toward focal aspects of product acquisition and / or consumption. Affective Acquisition and consumption

Nature of the experience


Consumption

Definition
The customers evaluation of a product or service in terms of whether that product or service has met their needs and expectations.

the response
Cognitive and affective

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(Garbarino & Johnson, 1999)

Transaction specific customer satisfaction is an immediate post purchase evaluative judgment or an affective reaction to the most recent transactional experience with the firm. Overall satisfaction is a cumulative construct, summing satisfaction with specific products and services of the organization & satisfaction with various facets of the firm such as the physical

Cognitive and affective

Post purchase (in the case of transaction satisfaction ) Overall evaluation (cumulative

(R. L. Oliver, 1997)

facilities Satisfaction is the consumer's fulfillment response. It is a judgment that a product or service feature, or the product or service itself, provided (or is providing) a pleasurable level of consumption-related fulfillment,

Cognitive and affective

satisfaction Consumption

(E. W. Anderson, Fornell, & Lehmann, 1994) (Halstead, Hartman, & Schmidt, 1994) (C. Fornell, 1992) (Richard L. Oliver, 1992) (Yi, 1990)

including levels of under- or over fulfillment. An overall evaluation based on the total purchase and consumption experience with a good or service over time.

Cognitive

Cumulative (= relational)

A transaction-specific affective response resulting from the customers comparison of product performance to some prepurchase standard. An overall post purchase evaluation.

Affective

Consumption

Cognitive

Post purchase

It is a summary attribute phenomenon coexisting with other consumption emotions. It is a collective outcome of perception, evaluation and psychological reactions to the

Affective

Consumption

Cognitive and affective Cognitive

Consumption

(Tse & Wilton, 1988)

consumption experience with a product/service. The consumers response to the evaluation of the perceived discrepancy between prior expectations (or some norm of performance) and the actual performance of the product as perceived after

Consumption

(Cadotte, Woodruff,

its consumption An evaluative response to the perceived outcome of a particular consumption experience.

Affective

Consumption

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& Jenkins, 1987) (R. A. Westbrook, 1987) (R. L. Day, 1984) Global evaluative judgment about product usage/consumption The evaluative response to the current consumption event...the consumers response in a particular consumption experience to the evaluation of the perceived discrepancy between prior expectations (or some other norm of performance) and the actual performance of the (R. Westbrook & Reilly, 1983) product perceived after its acquisition. An emotional response to the experiences provided by and associated with particular products or services purchased, retail outlets, or even molar patterns of behaviour such as shopping and buyer behaviour, as well as the (G.A Churchill & Surprenant , 1982) (Engel & Blackwell, 1982) (R.L. Oliver, 1981) overall marketplace. An outcome of purchase and use resulting from the buyers comparison of the rewards and costs of the purchase relative to anticipated consequences. Operationally, similar to attitude in that it can be assessed as a summation of satisfactions with various attributes. An evaluation that the chosen alternative is consistent with prior beliefs with respect to that alternative. An evaluation of the surprise inherent in a product acquisition and/or consumption experience. In essence, the summary psychological state resulting when the emotion surrounding disconfirmed expectations is coupled with the consumers prior feelings about the (J. Swan & Trawick, 1980) consumption experience. A conscious evaluation or cognitive judgment that the product has performed relatively well or poorly or that the product was suitable or unsuitable for its use/purpose. Another dimension of satisfaction involves affect of Cognitive Consumption Cognitive Acquisition and consumption Cognitive Purchase Cognitive Affective Consumption( specifically at the post purchase stage) Acquisition and consumption Cognitive Acquisition and consumption Affective Consumption

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(R. Oliver, 1980) (LaTour & Peat, 1979) (J. I. Westbrook, Newman, & Taylor, 1978) (H. K. Hunt, 1977) (R. L. Day, 1977) (J. A. Miller, 1977) (R. E. Anderson, 1973) (J. A. Howard & Sheth, 1969) (Cardozo, 1965)

feelings towards the product It is the result of an evaluative process that contrasts prepurchase expectations with perceptions of performance during and after the consumption experience. A general evaluative response to a product, perhaps not discernibly different than the wellstudied concept of attitude. Satisfaction is an emotional or feeling reaction. It is the result of a complex process that requires understanding the psychology of customers. An evaluation rendered that the experience was at least as good as it was supposed to be. Customer satisfaction is a reaction to recognize and evaluate the differences before and after consumption. It is the interactive process of customers level of expectation and real cognition. The disparity between expectation & the perceived product performance. The buyer's cognitive state of being adequately or inadequately rewarded for the sacrifices he has undergone. The customers perception of product performance.

Cognitive

Consumption

Not defined Affective

Acquisition and consumption Post purchase

Cognitive and affective Cognitive

Consumption

Consumption

Cognitive

Consumption

Cognitive

Consumption

Cognitive

Not defined

Cognitive

Consumption

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1.1.3 Shared Perspectives in the Satisfaction Literature

The analysis of definitions presented in Table 1 as well as the analysis of complementary papers on satisfaction reveals that researchers generally agree on three common components: 1.1.3.1 The Relative Character of Satisfaction

Most researchers have suggested that Consumer Satisfaction / Dissatisfaction is influenced by a pre-experience comparison standard and disconfirmation, that is, the extent to which this preexperience comparison standard is disconfirmed (e.g., (R. E. Anderson, 1973; Cadotte, et al., 1987; Cardozo, 1965; R. L. Day, 1977; J. A. Howard & Sheth, 1969; LaTour & Peat, 1979; J. A. Miller, 1977; R. Oliver, 1980; J. Swan & Trawick, 1980; Tse & Wilton, 1988)). 1.1.3.2 The Time and Temporal Focus of Satisfaction

Satisfaction is an end state resulting from a consumption experience (E. W. Anderson, Fornell, & Lehmann, 1994; R. L. Day, 1984; J. A. Howard & Sheth, 1969; H. K. Hunt, 1977; R.L. Oliver, 1981; Richard L. Oliver, 1997) and notably from a post purchase consumption experience (G.A Churchill & Surprenant, 1982; C. Fornell, 1992; R. L. Oliver, 1997; Tse & Wilton, 1988; R. A. Westbrook, 1987). However, few exceptions exist in this perspective. For instance, the purchase decision may be evaluated after choice, but prior to the actual purchase of the product or it may

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occur prior to choice and even in the absence of purchase or choice (e.g., (R. Westbrook & Reilly, 1983)). The literature also recognizes that satisfaction has primarily a short term focus (e.g., (R. L. Oliver, 1997)). 1.1.3.3 The Level of Specificity of Satisfaction

While studies on satisfaction can be directed to different levels of specificity (e.g., satisfaction with a product (e.g., (G.A Churchill & Surprenant, 1982)), with a consumption experience (e.g., (LaTour & Peat, 1979)), with a purchase decision experience (e.g., (J. I. Westbrook, et al., 1978)), with the salesperson (e.g., (R.L. Oliver & Swan, 1985)), with a store (e.g., (R.L. Oliver, 1981)), with an attribute (e.g., (Bettman, 1974)), with a pre-purchase experience (e.g., (R. Westbrook, 1977)), and with product performance (e.g., (R. E. Anderson, 1973; Cardozo, 1965)); researchers agree that the level of specificity (focus - object of the consumers satisfaction) should be unambiguously clear (Czeplel & Rosenberg, 1977; Giese & Cote, 2000).

In the current thesis, the focus refers to the service provided during a primary healthcare visit. 1.1.4 Controversial Perspectives in the Satisfaction Literature

Five major components of the definition are not unanimously shared and are debated by researchers: 1.1.4.1 The Conceptualization of the Comparison Standard and Disconfirmation Constructs

While most researchers have agreed that satisfaction is influenced by a pre-experience comparison standard and that disconfirmation is the extent to which this pre-experience

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comparison standard is disconfirmed, they have not converged on the exact conceptualization of the comparison standard (consequently, on which comparison standard best predicts product satisfaction) and disconfirmation constructs. For example, the comparison standard has been conceptualized as expected (e.g., (R. Oliver, 1980)), ideal (e.g., (J. A. Miller, 1977)), or normative performance (e.g., (Tse & Wilton, 1988)). Similarly, disconfirmation has been modeled as the result of subtractive functions (e.g., (LaTour & Peat, 1979)) between product performance and some comparison standards or as the subjective evaluation (e.g., (R. Oliver, 1980)) of this discrepancy. 1.1.4.2 The Disposition of Satisfaction

A fundamental inconsistency is evident by the argument of whether satisfaction is a process or an outcome (Parker & Mathews, 2001). More precisely, satisfaction definitions have either emphasized an evaluation process (e.g., (Fornell, 1992; H. K. Hunt, 1977; R.L. Oliver, 1981)) or a response to an evaluation process (e.g., (Halstead, et al., 1994; J. A. Howard & Sheth, 1969; R.L. Oliver, 1981; R. L. Oliver, 1997; Tse & Wilton, 1988; R. Westbrook & Reilly, 1983)). Satisfaction as an evaluation process: Historically, the earliest attempts to capture the phenomenon of satisfaction were directed at a conceptual model which postulated a direct causal link between the performances of products attributes and overall state of satisfaction (Tan, 2004). By looking at satisfaction as a process (R. L. Day, 1984; J. F. Engel & Blackwell, 1982; H. K. Hunt, 1977), these definitions concentrate on the antecedents to satisfaction rather than satisfaction itself. Consequently, much research effort has been directed at understanding the cognitive processes involved in satisfaction evaluations.

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Satisfaction was described as an evaluation process that occurs during the service delivery process and that takes the form of a comparison between the actual performance of a product and the customer's prior expectations (e.g., (R.L. Oliver, 1981; Tse & Wilton, 1988)). This strand of theory appears to have origins in discrepancy theory (L. W. Porter, 1961), and a number of authors have, over the years, used some form of comparison to model satisfaction (e.g. (Olson & Dover, 1979)). Satisfaction as an outcome to an evaluation process In the literature, there is a dominant view of satisfaction as an end state or a summary response to an evaluation process (i.e., a fulfillment response (R. L. Oliver, 1997); affective response (Halstead, et al., 1994); overall evaluation (C. Fornell, 1992); non observable psychological state (Aurier & Evrard, 1998; J. A. Howard & Sheth, 1969); global evaluative judgment (R. A. Westbrook, 1987); summary attribute phenomenon (Richard L. Oliver, 1992); or evaluative response (R. L. Day, 1984)). While this view focus on the nature (not cause) of satisfaction, it acknowledges the input of comparative cognitive processes but goes further by stating that these may be just one of the determinants of the affective state satisfaction (Parker & Mathews, 2001). The status of satisfaction in the context of this study For the purpose of this study, a choice must be made between these two approaches to satisfaction. Evidences from the literature show that patient satisfaction is a multi-dimensional concept, which derive from an evaluation of varied features of the care experience (Crowe, et al.,

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2002). Patients evaluate their healthcare experience to give a single global summary outcome or response (C. Lin, 1996).

Accordingly, in the current study satisfaction will be considered as an outcome to an evaluation process. 1.1.4.3 The Nature of the Satisfaction Outcome

While most researchers have sustained the idea of satisfaction as an outcome to an evaluation process, they disagree on the nature of this response. In fact, they portray satisfaction as either a cognitive response (e.g., (R. N. Bolton & J. H. Drew, 1991; J. A. Howard & Sheth, 1969; Tse & Wilton, 1988)) or an affective response (e.g., (Cadotte, Woodruff, & Jenkins, 1987; Halstead, et al., 1994; R. Westbrook & Reilly, 1983)) or both cognitive and affective response to an evaluation process (R. L. Oliver, 1997). Satisfaction as exclusively cognitive response to an evaluation process Historically, satisfaction was conceptualized as a cognitive construct (Robert A. Westbrook, 1989). In this case, satisfaction results from a comparison between the customers perception of product performance and their expectation level. For example, Engel and Blackwell refer to An evaluation that the chosen alternative is consistent with prior beliefs with respect to that alternative (Engel & Blackwell, 1982). The most well-known descendent of this cognitive approach is the expectation-disconfirmation paradigm (Fournier & Mick, 1999; Halstead, et al., 1994) which is analyzed hereafter.

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Having roots in social psychology (Weaver & Brickman, 1974) and organizational behavior (Ilgen, 1971), expectancy disconfirmation is actually two processes consisting of the formation of expectations and the disconfirmation of those expectations. Assuming that the customer is capable of evaluating the product performance, the result is compared to expectations prior to purchase or consumption. Any discrepancy leads to disconfirmation; i.e. positive disconfirmation increases or maintains satisfaction and negative disconfirmation creates dissatisfaction (review Figure 2) (R. Oliver, 1980). Even though positive disconfirmation and negative disconfirmation are both clearly related to a subsequent level of satisfaction, the outcome is more confusing for zero disconfirmation. Many authors consider that zero disconfirmation refers to a "zone of indifference" (R. Woodruff, Cadotte, & Jenkins, 1983). This zone of indifference surrounds a performance range that is acceptable to the consumer. Notwithstanding the fact that the concept is intuitively appealing; Oliver noted that "unfortunately, little research exists to guide researchers on identifying the existence and limits of indifference zone" (R. L. Oliver, 1997). Thus, such a concept will not be considered in this study.

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Figure 2: Expectancy Disconfirmation Paradigm. Source: adapted from Oliver (R. Oliver, 1980)

Satisfaction as exclusively affective response to an evaluation process In the mid 1990s, research had started to not only criticize the overwhelming dominance of the expectation-disconfirmation paradigm (H. Keith. Hunt, 1993) but also increasingly investigated affective antecedents of satisfaction (e.g. (Brockman, 1998; Dube-Rioux, 1990; Yves. Evrard & Aurier, 1994; Mano & Oliver, 1993; R.L. Oliver, 1989; Richard L. Oliver, 1992, 1994; Robert A. Westbrook, 1989; R. A. Westbrook & Oliver, 1991; Wirtz, Mattila, & Tan, 2000)). Fournier and Mick declared that: "Research within customer satisfaction paradigm has probably underrepresented the emotional aspects of satisfaction and that the further study of affective satisfaction modes could play a promising corrective role" (Fournier & Mick, 1999). Cadotte et al. referred to a feeling developed from an evaluation of the use experience (Cadotte, et al., 1987). Westbrook examined customer affective responses to consumption experience and established that good and bad feelings represent two dimensions of affective response to products in use (R. A. Westbrook, 1987) . The author also demonstrated that these two dimensions relate directly, and in the expected direction, to product satisfaction judgments.

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Giese and Cote proposed a general definitional framework for satisfaction and also asserted that satisfaction is an affective construct (Giese & Cote, 2000). Their definition is a result of thirteen group interviews and twenty-three personal interviews with consumers. Giese and Cote observed during these interviews that 77,3% of group interview responses and 64% of individual interviews responses specifically used affective terms to describe satisfaction(Giese & Cote, 2000). Thus, Giese and Cote proposed to define satisfaction as "a summary affective response of varying intensity"(Giese & Cote, 2000). Satisfaction as both cognitive and affective response to an evaluation process There has been an increasing recognition among satisfaction researchers that a purely cognitive or a purely affective approach may be inadequate in modeling satisfaction evaluations (e.g., (Garbarino & Johnson, 1999; Martnez Caro & Martnez Garca, 2007). It is now generally accepted that customers' evaluative judgments are based partly on cognition and partly on affective responses to a product stimulus (Oliver, 1997). Fournier observed that: Our cases reveal satisfaction as technical and artful, cognitive and affective, purposeful and spontaneous, and interlaced with meanings of many kinds" (Fournier & Mick, 1999). It is noteworthy that if satisfaction results from both cognitive and affective processes, no clear consensus exists on the relationships between both dimensions. For instance, Oliver observed that the "hybrid cognition-emotion" is not well described in the literature (R. L. Oliver, 1997). The status of satisfaction in the context of this study In the context of this study, the question of whether the satisfaction response relies on cognitive, affective or cognitive-affective processes should be discussed. The marketing approach to

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conceptualizing of satisfaction draws heavily on the work of Fishbein and Ajzen (Fishbein & Ajzen, 1975b) into beliefs and attitudes (Newsome & Wright, 1999). Central to this approach is the notion that satisfaction arises out of an interplay between cognitive and affective processes. According to Fishbein and Ajzen perceptions, including beliefs, are cognitive in nature (referring to the process of knowing or thinking) and represent the information an individual has about the object in question while attitudes, on the other hand, are affective in nature (referring to the process of emotion) and are characterized by a general evaluation or feeling of favorableness or un-favorableness toward the object (Fishbein & Ajzen, 1975b). As far as satisfaction is concerned, the expectation formation process, the comparison of performance to expectations or desires, and judgments based on equity and attributions are mostly conscious, overt activities and therefore primarily cognitive in nature. The role that affective responses, not under conscious control, play in the satisfaction process is less well developed. However, it is now accepted that a variety of emotional responses, including such affects as joy, excitement, pride, anger, sadness and guilt do play a significant, complimentary, role in determining satisfaction (R.L. Oliver, 1993a). Thus, in the current study satisfaction will be considered as a cognitive - affective response. 1.1.4.4 The Scope of the Evaluative Judgment

Two perspectives are considered in the literature: transaction-specific satisfaction and cumulative satisfaction: Transaction- specific satisfaction

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From a transaction-specific perspective, satisfaction is viewed as a post-choice evaluative judgment of a particular purchase/consumption occasion (R.L. Oliver, 1993a). Behavioral researchers in marketing have developed a rich body of literature investigating the antecedents and consequences of this type of satisfaction at the individual level (E. W. Anderson, et al., 1994). Distinctive reasons justify the advantages of the analysis of transaction-specific satisfaction. First, the analysis of a specific transaction is necessary to understand the satisfaction formation process (Johnson, 1995). Then, satisfaction is a function that comes from the discrepancy between the consumer's prior expectations and his/her perceived consumption experience. As expectations can evolve over time, the analysis should take place over a short period (Iacobucci & Grayson, 1994). For these different reasons, the transactional vision of satisfaction has been largely adopted, even in longitudinal studies (e.g., (R. N. Bolton & J. H. Drew, 1991; LaBarbera & Mazursky, 1983; Mittal, et al., 1999; Richins & Bloch, 1991)). Cumulative satisfaction By comparison, cumulative satisfaction is an overall evaluation based on the total purchase/consumption experiences with a good or service over time (Bitner & Hubbert, 1994). Since overall satisfaction is based on information from all previous experiences with the service provider, overall satisfaction can be viewed as a function of all previous transaction-specific satisfactions (Parasuraman & Zeithaml, 1994; Teas, 1993). Overall satisfaction may be based on many transactions or just a few, depending on the number of times the customer has used a particular provider. In essence, overall customer satisfaction is an aggregation of all previous transaction-specific evaluations and is updated after each specific transaction much like expectations of overall service quality are updated after each transaction (Boulding, Kalra,

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Staelin, & Zeithaml, 1993). It should be noted that although overall satisfaction at time t-1 will have an impact on the expectations which produce transaction-specific satisfaction at time t, this transaction-specific satisfaction will only be influenced indirectly by overall satisfaction (through expectations) and not completely reflect or subsume the overall satisfaction construct. Overall customer satisfaction at time t will then be based on overall satisfaction at time t-1 (which reflects all previous transaction-specific satisfactions), as well as the transaction-specific customer satisfaction that resulted from the information collected from the most recent service transaction produced at time t (Boulding, et al., 1993). In general, transaction-specific satisfaction may not be perfectly correlated with overall satisfaction since service quality is likely to vary from experience to experience, causing varying levels of transaction-specific satisfaction. Overall satisfaction, on the other hand, can be viewed as a moving average that is relatively stable and more similar to an overall attitude (Parasuraman & Zeithaml, 1994). For example, a customer may have a dissatisfying experience because of lost baggage on a single airline flight (i.e. low transaction-specific satisfaction) yet still be satisfied with the airline (i.e. overall satisfaction) due to multiple previous satisfactory encounters. The status of satisfaction in the context of this study As this study refers to the analysis of potential antecedents of outpatient satisfaction and their impacts on the satisfaction formation process, the focus is clearly on transaction specific satisfaction. 1.1.4.5 Distinction between the Operationalization of Satisfaction and Other Closed Concepts

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Satisfaction being a problematical and multi-dimensional construct, Yi observed that: another issue that needs further attention is whether or not customer satisfaction is conceptually distinct from other concepts (Yi, 1990). Actually, the risks of confusing satisfaction and three related constructs - attitude, perceived quality and perceived value - are demonstrated in the literature. Henceforward, satisfaction and each of the abovementioned concepts are accordingly contrasted.

Satisfaction and Attitude The concept of attitude has been called the most distinctive and indispensable concept in contemporary American social psychology. In fact several writers define social psychology as the scientific study of attitudes (Allport, 1967). Nonetheless, attitudes have been defined in many, often conflicting ways. There is general agreement on the meaning of attitudes with respect to one characteristic, namely, persistent affect: "Attitudes refer to persistent and affectively charged psychological states that enable individuals to relate to their surroundings and to 'objects' (people and/or things) that comprise their surroundings in ways that make for behavioral consistency" (Allport, 1967). In reviewing the satisfaction literature, we can notice that few researchers have spread suspicions on the discriminant validity of the satisfaction construct: "Given that attitude and satisfaction are both evaluative responses to products, it is not clear whether there are any substantive differences between the two. In fact, it may be more parsimonious to consider satisfaction measures as post-consumption attitude measures" (LaTour & Peat, 1979).

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"Consumer satisfaction is an attitude in the sense that it is an evaluative orientation which can be measured. It is a special kind of attitude because by definition it cannot exist prior to the purchase or consumption of the attitude object" (Czepiel & Rosenberg, 1977). Another sources of perplexity arises from the nature (involve both a cognitive and an emotional component) and relative character (being an evaluation) of satisfaction has sometimes led some researchers to assimilate this concept to a form of attitude (R. L. Day, 1984; Evrard, 1993). Although the logic of the two concepts seems relatively close, three differences have been highlighted in the literature: Firstly, satisfaction is related to a (or to several) consumption experience(s), which is not necessarily the case for attitude (Evrard, 1993). The second difference is related to the formation process. Satisfaction relies on comparison between a consumer's prior expectation and the actual performance of a product (Oliver, 1980). Oppositely, attitude is not related to comparative judgments. Finally, Oliver suggested another conceptual difference by defining satisfaction as an evaluation of the surprise inherent in a product acquisition and/or consumption experience, the surprise or excitement is of finite duration, so that satisfaction soon decays into attitude toward purchase (R. Oliver & Linda, 1981). This is the reason why an immediate measure of

satisfaction after consumption/purchase is the one that offers the highest discriminant validity (Vanhamme, 2002). Satisfaction and Service Quality

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Although there seems to be a consensus in the literature that satisfaction and service quality are two different constructs, distinctions in their definitions have not always been made clear (Tomiuk, 2000). An important source of confounding between these two constructs has been the use of the expectancy disconfirmation model in defining both concepts conceptually and operationally (Gronroos, 1982; R.L. Oliver, 1993b; R. L. Oliver, 1997; Parasuraman, Zeithaml, & Berry, 1985). In an attempt to provide clarity to the distinction between these two constructs, two different types of standards have been proposedone reflecting a desired state and the other an ideal state. Boulding proposed that the ideal expectation (or should) be used as the referent in the expectancy disconfirmation involving service quality and the desirable expectation (or will) as a referent in the case of satisfaction (Boulding, et al., 1993). Oliver treated this issue noticeably in his book and presented some key variations which one finds between the two concepts (R. L. Oliver, 1997). He suggests that quality is a judgment or evaluation that concerns performance pattern, which involves several service dimensions specific to the service delivered. Quality is believed to be determined more by external cues. Satisfaction, however, is perceived as a global consumer response in which consumers reflect on their pleasure level. Satisfaction is based on service delivery predictions/norms that depend on past experiences, driven by conceptual cues (e.g., equity, regret). Although service quality may be updated at each specific transaction or service experience, it tends to last longer than satisfaction, which is understood as being transitory and merely reflecting a specific service experience. These variations are presented in Table 2.

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Table 2: Differences between service quality & satisfaction

Comparison dimension Quality2


Experience dependency Perception of quality may come from external mediation rather than experience of service/product (e.g., interpersonal communication). Dimensions Results only from specific quality characteristics of products/services

Satisfaction
Experiencing the product/service is required (we have to eat at the restaurant to define if we are dis/satisfied toward it). Potentially it results from all attributes of the product or service (some are related to quality while (e.g., the freshness of a fish) others are not). Can be judged according to others standards then the ideal one, such as predictions, product category norms, needs (related or not to quality).

Expectation / standard

Is judged according to an ideal standard of quality

Even if not clearly mentioned in this table, the term quality refers, according to the author, to perceived quality (Oliver, 1997: 165).

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Cognitive / affective Conceptual antecedents

Primarily cognitive Service quality is influenced by a very few variables (e.g., external cues like price, reputation, and various

Cognitive & Affective Satisfaction is influenced by numerous cognitive and affective causes (e.g., equity, attribution, and emotion). Primarily short term

Temporal focus

communication sources). Primarily long term

Source: adapted from (R. L. Oliver, 1997)

Satisfaction and Perceived Value While reviewing the literature, we can notice that the existent definitions of perceived value may lead to potential confusions with satisfaction. For instance, customer perceived value has been defined as the "consumers' overall assessment of the utility of a product based on perceptions of what is received and what is given" (Valarie A. Zeithaml, 1988). Oliver defined the same concept as "a judgment comparing what was received (e. g. performance) to the acquisition costs (e. g. financial, psychological, effort)" (R. L. Oliver, 1997). Although the two concepts seem relatively close, four discrepancies have been highlighted in the literature. First, value is the result of a cognitive comparison process. The concept has been described as a cognitive based construct which captures any benefits sacrifice discrepancy in much the same way disconfirmation does for variations between expectations and perceived performance (Patterson & Spreng, 1997). In contrast to the purely cognitive value construct, satisfaction may encompass an affective evaluative response (R. L. Oliver, 1997).

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Second, while satisfaction is considered as a post purchase construct, customer perceived value, in turn, is independent of the timing of the use of a market offering (R. B. Woodruff & Gardial, 1996) and can be considered as a pre- or post purchase construct. Consequently, it is not related to any purchase/consumption experience (Vanhamme, 2002). Third, although the two constructs rely on comparisons, the standards are different. Many authors summarized customer perceived value as a trade-off between perceived benefits and costs (P. Kotler, 2002). Finally, although the two constructs have directions, they have different aims. In fact, while customer satisfaction measures how well a supplier is doing with his/her present market offering, as perceived by existing customers. Such a tactical orientation provides guidelines of action for improving current products. The customer value construct, in turn, points at future directions. Its strategic orientation aims at assessing how value can be created for customers and by which means a suppliers market offering can best meet customers requirements. Table 3 provides an overview of major conceptual differences between customer satisfaction and customer perceived value.
Table 3: Differences between perceived value & satisfaction Satisfaction Affective and/ or cognitive Post purchase perspective Tactical orientation Present customers Suppliers offerings Comparison between expectations and perceived performance Customer Perceived Value Purely cognitive construct Pre / post purchase perspective Strategic orientation Present and potential customers Suppliers offerings and competitors offerings Comparison between perceived benefits and perceived costs

Source: adapted from (Eggert, 2002).

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To conclude, satisfaction has been clearly distinguished from attitude, perceived quality and perceived value. These distinctions justify the discriminant validity of the satisfaction construct. The following sections will review the way in which the concept of satisfaction is conceptualized and measured in the healthcare environment where patient satisfaction counterpart customer satisfaction (Otani, Herrmann, & Kurz, 2010). 1.2 Conceptualization of Patient Satisfaction

1.2.1 Introduction to Healthcare and Patient Satisfaction

Between about 1850 and 1950 there was a fundamental shift in the role of clinicians (R. Porter, 1997). Their role changed from being one of helping patients through their sickness (where the determinants of the outcomes were largely a function of the natural course of the condition) to one where the clinician was expected to either cure the patient or alleviate the symptoms of a chronic condition (where the determinants of the outcomes were perceived to be largely a function of the efficacy of the medical intervention, or the clinicians expertise). Consequent upon this change in perceived role was accountability, first defined around 1900 as assessing the value of the care provided (Ezekiel, 1996 ). Two broad areas of value assessment were developed. First was the search to find ever better clinical outcomes through improved interventions (Campanella, Campanella, & Grayson, 2000). This in turn gave rise, from the 1960s onwards, to the patient rights movement (B. Williams, 1994) a movement that led directly to management concerns with service quality, and the assessment of that quality by those using the services; hence patient or consumer satisfaction. By the late 1960s, then, the debate

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over the relationship between patient satisfaction as an assessment of the value of the technical care versus the process of care was well established (Donabedian, 1966, 1979, 1980). 1.2.2 A Patient or a Consumer

Usually, words as patient, user and consumer are indistinctly used as synonyms, even though they differ for the nature of relationships between health professionals and citizens. While the patient is a person who has an illness and comes to doctors and nurses asking for advice and treatment, the user may identify people who used, use or could use health care services. Instead, the consumer reminds us of a person who purchases goods and services for his needs or a person who consumes something (Herxheimer & Goodare, 1999). According to McIver in the 1980s a general shift towards consumerism, evident in UK National Health System, increased the promotion of a customer service-oriented culture (McIver, 1991). Thus, even though the use of consumer concept in health care mainly received a wide opposition from the medical establishment (Wassersug, 1986) because of its strong commercial connotation (Blaxter, 1995; Leavy, Wilkin, & Metcalfe, 1989; Normand, 1991), the consumerism movement introduced in health systems the issue of the protection of the consumers interests. Patient becomes a consumer when he looks for health services after having collected all information helpful to make the best choice (Shackley & Ryan, 1994). In this regard, researchers questioned: Can patient fulfill the role of consumer? and more, Does patient wish to fulfill it? (Owens & Batchelor, 1996). In 2002 a study conducted in eight European countries (Germany, Italy, Poland, Slovenia, Spain, Sweden, Switzerland and UK) highlighted that patients ask for a more autonomous role in the health care decision-making process and, then, for more information, equitable access, freedom of choice, prompt attention, respect and quality of amenities (Coulter

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& Jenkinson, 2005). Nonetheless, consumers of health care still are often not well and sufficiently informed. This information asymmetry causes an imbalance in the relationship between who asks for health services and who provides them. Even though much effort has been put into these issues, the healthcare systems still have to work in order to move away from the idea of patient as a passive and dependent stakeholder.

In the context of this study, which occurs at a primary care setting, both the words patient and outpatient refers to a consumer of healthcare services due to the fact that ambulatory settings usually treat cold cases that correspond to patients who possess the characteristics associated with consumers in the private sector; i.e., enough time, ability and freedom to search, inquire about and as a result choose the service provider that best fulfill their needs and expectations (Carr-Hill, 1992). 1.2.3 Defining Patient Satisfaction Despite its large use, the patient satisfaction was initially considered as a difficult concept to be measured and interpreted (Fitzpatrick & Hopkins, 1983; B. Williams, 1994). A common consensus on the definition of satisfaction with healthcare is not already fully achieved (review Table 4) due to the multidimensional and subjective nature of this concept, which is affected by individuals expectations, needs or desires (Avis, Bond, & Arthur, 1995; R. Baker, 1997; Gill & White, 2009). For example, when users have limited knowledge of opportunities and low expectations of service quality, high satisfaction scores may be recorded even though poor standards of care have been ensured.

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Factors influencing dissatisfaction could be somewhat different from factors generating satisfaction. While on one side an adequate or acceptable standard of quality might be considered as necessary, on the other, a feeling of satisfaction might result from a high quality service. Moreover, when something negative happens consumers might be satisfied or not; for instance, this depends on whether the negative event is caused by the health professionals or it is not due to their behavior (B. Williams, Coyle, & Healy, 1998). Thus, it is possible that what makes one person satisfied might make another one dis-satisfied (Avis, et al., 1995; Greeneich, 1993).

- Working definition of patient satisfaction The current study will define patient satisfaction as: The patients global judgment, that derives from a subjective evaluation of a received healthcare service, and where the evaluation contains both cognitive and affective reactions. The present definition derived from the definition of consumer satisfaction discussed in the preceding part of this chapter not only clearly states the disposition (global judgment that derives from an evaluation), the nature (cognitive and affective), and the scope (a received healthcare service) of patient satisfaction; but, it also explicitly argues that it is the patients subjective perspective that is central to patient satisfaction. Consequently, this new definition is detached from the vagueness or drawbacks of previous definitions.

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Table 4: Key definitions of patient satisfaction that are considered as references in the literature Disposition of References (B. Hulka, Zyzanski, Cassel, & Thompson, 1970) (Linder-Pelz, 1982) The patient's attitudes toward physicians and medical care. Individuals positive evaluations of distinct dimensions of the health care. It is an expectancyvalue attitude that is based on two distinct pieces of information: belief strength and attribute evaluations. Specifically, measures of belief strength (B) about attributes and An outcome to an evaluation process An evaluation process Affective Cognitive Definition satisfaction satisfaction This definition is a general statement that provided little guidance regarding its precise meaning. A fundamental problem exists in Linder-Pelz conceptualization of satisfaction as an expectancy-value attitude. Satisfaction may partially include a broad domain represented by prior expectations and general values. However, satisfaction with the services an individual actually receives may be more influenced by the Nature of Comment

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measures of evaluation (E) of those attributes are multiplied and the products summed. (1982b, pp. 578-579) (J. J. Ware, Snyder, Wright, & Davies, 1983) A personal evaluation

reaction of the patient to their immediate experience than by his or her general values and expectations regarding the medical enterprise. This definition is a general statement that An evaluation Cognitive provided little guidance regarding its precise meaning. process

of healthcare services and providers.

A healthcare recipients reaction to salient aspects of the Pascoe, 1983 context, process, and result of their service experience. Restricting patient satisfaction to evaluations The patients on the quality of care judgment on the received is an inherent quality of care in all (Donabedian, its aspects, but 1988) particularly as concerns the been found in several interpersonal process. empirical studies (e.g. A special form of (A. Woodside & Frey, 1989) consumer attitude reflecting how much An outcome to an evaluation process Cognitive and Affective Ross et. al., 1987). The authors use of the word satisfied in their definition of the patient process unhappy" patients has an evaluation Affective segment of "healthy but An outcome to Cognitive and weakness. In fact, a process Affective the nature of patient satisfaction. An evaluation Cognitive and This definition does not clarify the disposition nor

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patients are satisfied satisfaction concept which with the healthcare is illogical (defining service after something by itself). experiencing it. This definition is a The extent to which An outcome to (Carr-Hill, 1992) aspirations are met an evaluation given self-perceived process status. meaning. Fitzpatrick definition emphasizes the psychological aspects of A cognitive (Fitzpatrick, 1993) evaluation of an emotional reaction to healthcare. An evaluation process Cognitive and Affective the patient, which can fluctuate a lot as it relies much on the mind and mentality of the patient at the time when the patient satisfaction study is conducted. Restricting patient A relative concept; it is a reflection of consumers Crowe et al. (2002) evaluations of the quality of care they receive, compared with a subjective standard. An outcome to an evaluation process Cognitive and Affective satisfaction to evaluations on the quality of care received is an inherent weakness. In fact, a segment of "healthy but unhappy" patients has been found in several empirical studies (e.g. Ross et. al., 1987). Affective regarding its precise Cognitive and provided little guidance general statement that

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1.2.4 From Healthcare Service Quality to Patient Satisfaction

One concept frequently encountered when discussing patient satisfaction is that of quality of care. Patient perceptions of healthcare quality are critical to healthcare organizations success because of its influence on patient satisfaction (Donabedian, 1966; Koska, 1990; S. J. Williams & Calnan, 1991a). Accordingly, it is worthwhile discussing what constitutes healthcare quality and its relationship with patient satisfaction.

1.2.4.1 Defining Healthcare Service Quality

Unlike products, where quality can be easily assessed, most researchers agree that service quality is an elusive and abstract construct that is difficult to define and measure (J.M. Carman, 1990; Cronin & Taylor, 1992; Lee, Delene, Bunda, & Kim, 2000). This proclamation is definitely right in the healthcare service industry where a standard definition of healthcare quality is difficult to achieve because providers and consumers see the issue from distinct perspectives (Turner & Pol, 1995). Physicians and nurses define quality of care differently than patients (Backhouse & Brown, 2000; Donabedian, 1980; Stichler & Weiss, 2000). To doctors and nurses, quality care refers to how well they treat patients (Donabedian, 1980). However, patients are known to consider various medical care dimensions to evaluate healthcare quality (Choi, Cho, Lee, Lee, & Kim, 2004; J. Hall & Dornan, 1988; G. C. Pascoe, Attkisson, & Roberts, 1983). Accordingly,

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each definition of the Table 5 below is both possible and legitimate, depending on where we are located in the system of care and on what the nature and extent of our responsibilities are.

Researchers in the healthcare industry suggest two forms of quality: technical quality and functional quality (Chapko, et al., 1985; De Friese, 1985; J. J. Ware, Davies-Avery, & Stewart, 1978). The distinction between these two forms is extensively accepted although diverse terminology is occasionally used (DiMatteo & DiNicola, 1986). Technical quality in healthcare industry refers to the accuracy of diagnostic and therapeutic processes; whereas functional quality refers to the manner and behavior of the health care providers during the service delivery process (Babakus & Mangold, 1992; J. M. Carman, 2000).

Most of the studies are only focusing on the functional dimension in the healthcare literature (Choi, Lee, Kim, & Lee, 2005). One reason is that patients are considered lack of the ability and the required knowledge to evaluate the technical aspect of the healthcare (Donabedian, 1982). Bopp argues that most patients cant differentiate between the technical and functional performance of the health care providers (Bopp, 1990). Another reason for the ignorance of technical dimension is the time lag between the provision of the medical care and the recognition of the technical outcomes (Choi, Cho, Lee, Lee, & Kim, 2004). Finally, more variability is associated with the process quality rather than the outcome of healthcare (Ostrom, 1995). As a consequence, patients base their perceptions of the healthcare quality primarily on the expressive interpersonal attitudes and environmental factors during the health care delivery process (V.A. Zeithaml, Berry, & Parasuraman, 1996). Healthcare providers therefore focus much more

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attention on the encounter dimensions rather than on the outcome of the health service (J. M. Carman, 2000). However, some prior studies substantiate that the technical dimension such as physicians competence and the environment of the health care delivery process is also critical; whereas the functional dimension, for instance, personal interaction with physicians is the most important to patient perceptions of healthcare quality (Brown & Swartz, 1989). Both dimensions are an integral part of the health care quality in spite of their different importance (Phillips & Hokans, 1994).

The interaction between the technical dimension and the functional dimension has been tested by previous research. Ruyter and Wetzels find the significance of this interaction (Ruyter & Wetzels, 1998). Specifically, their finding shows a favorable process can increase the positive evaluation of the service encounters, and this effect is more positive in a favorable outcome than in an unfavorable outcome. Carman found no significance interaction within or between these two dimensions (J. M. Carman, 2000). These findings support the argument that consumers are able to differentiate the technical dimension of a service from the functional dimension.

- Working Definition of Healthcare Quality

This study will adopt Carmans definition of healthcare quality as a working definition: An attitude that is a function of some combination of attributes that a patient considers to be components of quality (J. M. Carman, 2000). This definition is shared by several scholars in the

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field (e.g., (Hazilah, 2009; Marley, Collier, & Goldstein, 2004)). Consequently, it is deemed to be appropriate.

Table 5: Key definitions of healthcare quality that are considered as references in the literature Author / Definition Organization Quality of care is the kind of care which is expected to maximize an inclusive measure of Donabedian patient welfare, after one has taken account of the balance of expected gains and losses that (1980) attend the process of care in all its parts. American Medical Care which consistently contributes to the improvement or maintenance of quality and/or Association duration of life. (1984) US Office of The degree to which the process of care increases the probability of outcomes desired by Technology patients and reduces the probability of undesired outcomes, given the state of medical Assessment knowledge. (1988) Quality of care is the degree to which health services for individuals and populations increase Institute of the likelihood of desired health outcomes and are consistent with current professional Medicine (1990) knowledge. Quality of care is: Department of doing the right things (what) Health Care (UK) to the right people (to whom) (1997) at the right time (when) and doing things right first time. Quality of care is the degree to which the treatment dispensed increases the patients chances of Council of Europe achieving the desired results and diminishes the chances of undesirable results, having regard to (1998) the current state of knowledge.

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World Health Quality of care is the level of attainment of health systems intrinsic goals for health Organization improvement and responsiveness to legitimate expectations of the population. (2000)

1.2.4.2 Service Quality and Perceived Service Quality

The real quality of a product or service is not necessarily reflected in the customers perceptions (Marr, 1986). In healthcare as in many other products and services, it is perceived quality that is important, not objective quality. For consumers, perception is reality (Roland T. Rust, Zahorik, & Keiningham, 1994; R. B. Woodruff & Gardial, 1996), and it is this perceived quality, as opposed to actual or absolute quality, that is important for healthcare professionals to manage (Singh, Wood, & Goolsby, 1991 ).

It is noteworthy that some authors define service quality (e.g. (Gronroos, 1982; Parasuraman, Zeithaml, & Berry, 1988)) while others add the word perceived to service quality (e.g. (Boulding, et al., 1993; Valarie A. Zeithaml, 1988)). Based on the assumption that quality is defined / assessed from a customers perspective, as recommended by Meffert and Bruhn, service quality / perceived service quality represent the same thing (Meffert & Bruhn, 2006). Previous definitions clearly indicate that it is used interchangeably and that definitions defining service quality usually incorporate the word consumer perception. Due to this fact and in line with the previously listed scholars, the word service quality is used in this paper when referring to either service quality or perceived service quality.

1.2.4.3 The Causal Order of the Service QualitySatisfaction Relationship

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The lack of clarity in the definitions of service quality and satisfaction is further linked to the ongoing controversy surrounding the causal order of service quality and satisfaction (Bitner, 1990; R. Bolton & J. Drew, 1991). This debate over which comes first has many similarities to the cognition-emotion debate (Tomiuk, 2000). Distinguishing between service quality as a cognitive construct and satisfaction as an affective construct suggests a causal order that positions service quality as an antecedent to satisfaction. This is consistent with the attitude theoretical framework proposed by Fishbein and Ajzen, and refined further by Bagozzi (Richard P. Bagozzi, 1992; Fishbein & Ajzen, 1975a). Although not absolute, much evidence has been documented for the service quality to satisfaction link in recent consumer satisfaction studies including those in the area of healthcare marketing (e.g. (Andaleeb, 2001; Brady & Robertson, 2001)). 1.2.5 Patient Satisfaction Research in Lebanon

Very few previous patient satisfaction investigations have been conducted in Lebanon. For instance, in 2008, an exploratory research conducted in Beirut was published by the International Journal of Pharmaceutical and Healthcare Marketing. The study aimed to provide insight and support for the strategic use of hospital secondary support functions as an initial strategy for marketing healthcare, increasing patient volume, and expanding patient satisfaction. However, the questionnaire was designed without conducting solid psychometric tests which disallowed accurate results (Baalbaki & Zafar, 2008). Unfortunately, all the investigations were exclusively inpatient studies. We couldnt find any published literature on the outpatient satisfaction topic. Accordingly, this is the first attempt to conduct such a study in Lebanon, even if its primary focus is not to compare Lebanon to other countries.

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1.3 Measurement of Patient Satisfaction

In order to have a comprehensive view of the related literature, the methodologies that have been used in the past to measure patient satisfaction was reviewed as well. 1.3.1 Instruments to Measure Patient Satisfaction in Healthcare The work of Hulka et al. began the initial steps to measure patient satisfaction in the healthcare area with the development of the Satisfaction with Physician and Primary Care Scale (B. Hulka, et al., 1970). This was followed by Ware and Snyder with their Patient Satisfaction Questionnaire, aimed at assisting with the planning, administration and evaluation of health service delivery programs (J. J. Ware, Wright, Snyder, & Chu, 1975). At the end of the 1970s, the Client Satisfaction Questionnaire was developed by Larsen et al. as an eight-item scale for assessing general patient satisfaction with healthcare services, and was superseded by their Patient Satisfaction Scale (D. L. Larsen, Attkisson, Hargreaves, & Nguyen, 1979; MurphyCullen & Larsen, 1984). Since that time, numerous instruments have been developed but the question remains as to how valid and reliable those instruments really are (Gill & White, 2009). Further, the measurement of satisfaction varies depending on the assumptions that are made as to what satisfaction means and a number of approaches to measurement can be identified: expectancy-disconfirmation; performance only; technical-functional split; satisfaction versus service quality; and attribute importance (Gilbert & Veloutsou, 2006; Gilbert, Veloutsou, Goode,

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& Moutinho, 2004). Nguyen et al. indicated that, in the absence of standardized instruments as well as satisfaction scores across studies being so high, it was almost impossible to make meaningful comparisons between different patient satisfaction scale scores (Nguyen, Attkisson, & Stegner, 1983). Over the course of years, a number of meta-analyses of patient satisfaction studies have been conducted. These authors reported that most researchers designed their own questionnaire to measure patient satisfaction without conducting any psychometric tests, or if they have the results were not acceptable (Crowe, et al., 2002; Hawthorne, 2006; Pascoe, 1983; Sitzia, 1999; van Campen, Sixma, Friele, Kerssens, & Peters, 1995). Table 6 provides a summary of these meta-analyses.

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Table 6: Meta analysis of patient satisfaction

Study Details

Pascoe (1983)

Sample Size (No. of Studies)

Not specified

Study Authors Van Sitzia (1999) Campen et al (1995) 165 195

Crowe et. al (2002) 176 (139 determinants of satisfaction; 37 methodological) 7% Qualitative; 82% Quantitative and 11% Mixed method Not addressed Recognized not fully established16% based on theory Quantitative studies superficial, simplistic and reductionist

Hawthorne (2006) 130

Data From

All quantitative

Quantitative

93 % Quantitative ; 7% Qualitative 11% Only few studies were based on theory 81% used new instrument; of which 61% no psychometric data. 10% modified existing instrument. Poor validity, problems with reliability

All quantitative

Inclusion patient satisfaction views Key Findings Theory/Construct

Not addressed Only few studies were based on theory

Only one study None based on theory

Not addressed Unresolved; no agreed theoretical model No psychometric data; lack of standardization

Methodology

Lack of standardization; simple ad hoc instruments

Five of 113 sound methodology (meet at least three study requirement)

Validity & Reliability

Poor validity, problems with reliability

Eight of 165 reported validity and reliability

Many possible sources of measurement and interpretation error

Poor, little sustained evidence of validity; some problems with reliability

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Conclusion

Measurement should follow from well developed models of satisfaction

None of the instruments met all five of the study requirements

Little evidence of reliability or validity, plus poor research practice

Use alternative methods to record patient evaluations of healthcare

Unacceptable research practice

Adapted from: A critical review of patient satisfaction, Liz Gill & Lesley White, 2009, Leadership in Health Services, Vol. 22 Iss: 1, pp.8 - 19

1.3.2 Biases Issues The format of the instrument and type of data collection may also affect the validity of patient satisfaction studies. There are a number of possible biases. Their effects on the accuracy of the results are considered hereafter:

Non-response bias

There are two views towards non-response bias. Some researchers suggested that non respondents may be less satisfied than those who respond to patient satisfaction surveys (Ley, 1976), while Ware found that patients who are more satisfied are less likely to return questionnaires (Aharony & Strasser, 1993; J. J. Ware, et al., 1983). This type of bias is difficult to avoid as it is difficult to reach the non-response population.

Acquiescence response bias

It is defined as the tendency to agree on statements of opinion regardless of content, and arises from the agree-disagree response scale used in questionnaires (J. J. Ware, et al., 1978). This does not only create equivocal responses, but may also result in response sets, which means a respondent chooses the same answer to every question regardless of what the question is asking

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(Yellen, Davis, & Ricard, 2002). Items of the questionnaire should be worded both positively and negatively to minimize the bias.

Selection bias

It was discovered that dissatisfied patients tend to withdraw from the healthcare facility midway before they end their treatments or before their satisfaction levels are measured (Hudak & Wright, 2000). As a result, this type of patient is under-represented in the sample of respondents, leading to a higher than average satisfaction levels than in reality. For general hospitals or clinics, this type of bias can be avoided by administering patient satisfaction surveys mid-way before the patient finishes his/her treatment (Ferris & Williams, 1992).

Social desirability

Social desirability is one of the potential confounders that lead to higher levels of satisfaction than the reality (Pascoe, 1983). If respondents are strongly motivated to present themselves in a way that the society regards as positive, they may tend to report greater satisfaction than they actually feel, as they believe positive comments are more acceptable to researchers (Le May, Hardy, Taillefer, & Dupuis, 1999; Sitzia & Wood, 1997). This bias can be avoided by increasing the anonymity of the respondents, such as using a central deposit box for completed selfadministered questionnaires (K. Miles, Penny, Power, & Mercey, 2003).

Halo effect

Patients feelings towards one aspect of care can affect their judgment of another aspect (Beck, et al., 1999). For example, patients who find their doctors friendly and respectful (interpersonal

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aspect) tend to judge their technical competence (technical aspect) favorably (Roberts, 2002). This type of bias is again difficult to eliminate as it is rarely possible to estimate its effect on the true satisfaction level.

Other types of bias

Social-psychosocial artefacts such as self-interest bias, gratitude effect and simple indifference can affect patient satisfaction levels. For self-interest bias, patients ingratiate themselves with the healthcare facility, as they believe that expressions of satisfaction will contribute to the continuation of the service, which will benefit them eventually (Sitzia & Wood, 1997). For gratitude effect, Williams proposed that dissatisfaction is only expressed when an extreme negative event occurs, which is normally associated with elderly populations (B. Williams, 1994). For simple indifference, patients may feel that problems are too trivial and cannot be remedied, so they tend not to comment during the surveys (Sitzia & Wood, 1997). With the concerns above, Yellen et al. concluded that questionnaires must include reliable, standardized items measuring the defined concept to make patient satisfaction truly indicative (Yellen, et al., 2002).

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1.4 Patient Satisfaction: Conclusion

- Defining patient satisfaction for the purposes of this research

The review of the literature allowed addressing the issue of defining and measuring the broad concept of satisfaction and its specific interpretation for the customers of health related services. It has been argued that defining satisfaction is problematic (R. Day, 1980). A key reason is that meaning is influenced by context. The concept often differs according to the particular setting and purpose of the theory (Giese & Cote, 2000). One consequence of this situation is the presence of a plethora of patient satisfaction definitions (Gill & White, 2009). Hence, a working definition, which is consistent with our approach to patient satisfaction, was proposed in this study: The patients global judgment, that derives from a subjective evaluation of a received healthcare service, and where the evaluation contains both cognitive and affective reactions.

- Defining healthcare quality for the purposes of this research

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The review of the literature allowed addressing the issue of defining the broad concept of service quality and its specific interpretation for healthcare customers. It has been argued that defining healthcare quality is complex and controversial because of the different stakeholders' views (Turner & Pol, 1995). Providers and consumers see the issue from distinct perspectives (Backhouse & Brown, 2000). One consequence of this situation is the presence of an overabundance of healthcare quality definitions (Barker, 2009). Hence, Carman definition, which is shared by several scholars in the field, was adopted in this study: An attitude that is a function of some combination of attributes that a patient considers to be components of quality (J. M. Carman, 2000).

- Implications of the results for the research question:

The first chapter of the literature review helped to sharpen the research question. Definitely, it has been established in the literature review that there is a need: (1) to prioritize research on outpatient satisfaction in the Lebanese context (2) to clarify the relationship between patients satisfaction and their perceptions of the quality of their healthcare service (3) to better understand the mechanisms by which a patient becomes satisfied or dissatisfied.

A consequence of such a research orientation is the need to identify those drivers and factors which contribute most to patients satisfaction. In the second chapter of the literature review, this topic is explored. Each driver and its role in the process of patient satisfaction formation is examined.

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Chapter 2: Drivers of Patient Satisfaction


-------------------------------------------------------------------------------------------------

It does not matter whether the degree of patient satisfaction reflects the competence of the physician or the quality of care. The most important thing is that if patients are dissatisfied, healthcare has not achieved its goal- (Vuori, 1991).

Determining the drivers associated with patient satisfaction is a significant issue for healthcare providers to understand what is valued by patients and to know where service changes should be focused (J. L. Tucker, 2002). Ware, an authority of behavioral sciences in the field of medical care, is credited for his significant distinction between objective satisfaction reports about the major characteristics of providers and care (waiting time, for instance), and satisfaction ratings, which "attempt to capture a personal evaluation of care that cannot be known by observing care directly" (J. J. Ware, et al., 1983). Satisfaction ratings, it was argued, reflect three variables: the personal preferences of the patient, the patient's expectations, and the realities of the care received, satisfaction with the last affected by many different components of that care. In this way satisfaction ratings, being both a reflection of the patient and a measure of care, do not reflect

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objective reality (J. J. Ware, et al., 1983). Sitzia and Wood distinguish between care variables and patient variables (Sitzia & Wood, 1997).

In line with previous studies in primary care settings and the literature (e.g. (Hutchison, et al., 2003; Marian, et al., 2008; Sitzia & Wood, 1997), the present study addressed these two categories of variables. 2.1 Care Variables

Several researchers acknowledged the impossibility of effectively defining patient satisfaction drivers by a single dimension (e.g., (B. Lin & Kelly, 1995; Rubin, 1990; J. Tucker & Adams, 2001)). Ware et al. (1983) reported that the concept of patient satisfaction encompasses several contributory antecedents that are reflective of the caregivers and of the care that is provided (J. J. Ware, et al., 1983). Sixma et al. reported that patients tend to assess distinct dimensions of their care when making an overall evaluation of (parts of) the healthcare system (Sixma, Spreeuwenberg, & van der Pasch, 1998).

Numerous classifications of care variables have been proposed. While some propose specific dimensions regarding particular healthcare situations (e.g. (Auquier & Blache, 1999; Brand & Cronin, 1997; Garland & Saltzman, 2000; Kolb & Race, 2000), others were aiming at broad applicability (e.g. (F. G. Abdellah & Levine, 1965; Risser, 1975; J. E. Ware & Snyder, 1975). Abdellah and Levine attempted an early identification of key dimensions, proposing the following: adequacy of the facilities; effectiveness of the organizational structure; professional qualifications and competency of personnel; and the effect of care on the consumers (F. G.

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Abdellah & Levine, 1965). Reviewing U.S. patient satisfaction research conducted from 1957 to 1974, Risser reported that four dimensions emerged: cost; convenience; the provider's personal qualities and the nature of the interpersonal relationship; and the provider's professional competence and the perceived quality of care received (Risser, 1975). Ware's classification of care variables which includes eight dimensions that constitute the major sources of satisfaction and dissatisfaction with healthcare (interpersonal manner, technical quality,

accessibility/convenience, finances, efficacy/outcomes, continuity, physical environment, and availability) is broadly accepted in the literature, as it is explicit, exhaustive and accurately presents what patients are concerned about during their visits at health care facilities (Chow, 2008; J. J. Ware, et al., 1978). However, as many satisfaction studies are conducted in very specific contexts it is understandable that any standard classification never seems entirely appropriate (Sitzia & Wood, 1997).

In primary care settings, care variables showing association with patient satisfaction include: interpersonal manner, technical quality of care, accessibility, finances, physical environment, and continuity of care (Mclver, 1991; Rees, 1994): 2.1.1 Interpersonal Manner / Functional Quality of Care

The interpersonal manner of care features the way in which providers interact personally with their patients (J. J. Ware, et al., 1983). It is regarded as the principal component of satisfaction as illustrated by Blanchard et al. (Blanchard, Labrecque, Ruckdeschel, & Blanchard, 1990). Two factors of this component are considered as particularly important: communication and empathy as described by Mclver (Mclver, 1991).

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2.1.2 Technical Quality of Care

The technical quality of care refers to the providers competence of and his adherence to high standards of diagnosis and treatment (J. J. Ware, et al., 1983). This aspect of the provider has been linked to patient satisfaction. For instance, an index of technical performance based on chart review by physician judges was positively related to satisfaction in a study of hypertension treatment (Shortell, Richardson, & LoGerfo, 1977). Also, Needle found that female students perception of their gynecologists competence was positively related to satisfaction, indexed by self-report of willingness to return to that physician (Needle, 1976). Furthermore, and in another study, data from both male and female students indicated that the providers perceived technical competence was the best predictor of students satisfaction (Gillette, Byrne, & Cranston, 1982). 2.1.3 Accessibility / Access to Care

Anderson, an authority on access-to-care issues, defined access to healthcare as those factors which describe the potential and actual entry for a given population group to the healthcare delivery system (Andersen & Aday, 1983). Access is one of the key issues that affect a patients perception of satisfaction with healthcare delivery (Dougall, Russell, Rubin, & Ling, 2000; Grandinetti, 2000; Marquis, Davies, & Ware, 1983; M. Murray & Tantau, 1999; Pascoe, 1983; J. J. Ware, et al., 1983). 2.1.4 Finances / Price of Care

Price is a subtle variable that depends on a number of different factors, many of them difficult to pin down exactly. Kotler and Armstrong defined price as the amount of money charged for a product or service or the sum of the values that consumers exchange for the benefits of having or

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using the product or service (P. Kotler, 2010). In healthcare, the price charged by the provider is a perennial concern among those seeking healthcare service especially in case they do not have an health insurance coverage (Andaleeb, et al., 2007). Studies examining the cost of care have found that the higher the cost the lower the level of patient satisfaction and that persons in prepaid plans tend to be more satisfied with financial aspects of care (P. D. Cleary & McNeil, 1988). It is important to notice that in the literature there is a general agreement that what actually influences consumer behavior, especially final consumers' behaviors, is not the objective price (real price) but the perceived price which was defined as the customer perception about what is sacrificed to obtain a product or service (Lichtenstein, Ridgway, & Netemeyer, 1993; Valarie A. Zeithaml, 1988). Due to this fact and in line with the previously listed scholars, the word price of care is used in this paper when referring to the perceived price of care. 2.1.5 Physical Environment / Atmospheric of Care

Atmospherics" refers to the tangible or physical aspects in a service environment that influence customers purchasing intentions. Physical evidence comprises the environment in which the service is delivered - as well as any tangible cues, such as the appearance of the building, interior decoration, uniforms, equipment and facilities (Boshoff & Du Plessis, 2009). In healthcare, there seems to be agreement in the literature that atmospheric factors play a critical role in patients satisfaction. For example, Woodside found that location, equipment, and facility were important factors that hospital patients sought to optimize (A. G. Woodside, 1988). For dental offices, organization, neatness, comfort of seating, magazine selection, and music all had a significant impact on dental service satisfaction (Andrus & Buchheister, 1985; Chakraborty, Gaeth, &

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Cunningham, 1993). Gotlieb found that patients' perceptions of their hospital rooms could influence patients' satisfaction (J. Gotlieb, 2000). 2.1.6 Continuity of Care

Although not all findings concur, the bulk of the research evidence indicates that having a regular source of care and seeing the same provider is directly associated with satisfaction in primary care settings (Fan, Burman, McDonell, & Fihn, 2005). This longitudinal relationship ideally leads to a bond between clinician and patient, characterized by trust and a sense of responsibility (Saultz, 2003).There is evidence that continuity of care is associated with improved outcomes such as fewer emergency department visits (Christakis, Mell, Koepsell, Zimmerman, & Connell, 2001) and hospitalizations (Mainous, 1998), improved management of chronic diseases such as diabetes (Parchman, Pugh, Noel, & Larme, 2002), and use of preventive services (O'Malley, Mandelblatt, Gold, Cagney, & Kerner, 1997).

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2.2 Patient Variables Although the existing literature on patient satisfaction solely present one type of patient variables (patients sociodemographic characteristics), the current study propose to investigate a new one (patients perception of interpersonal equity) due to its significant role in the formation of the satisfaction response (Sitzia & Wood, 1997; Vinagre & Neves, 2010; J. J. Ware, et al., 1983). 2.2.1 Patients Sociodemographic Characteristics

The results of associations between patient satisfaction and sociodemographic factors are contradictory and have limited predictive power (P. D. Cleary & McNeil, 1988; J. Tucker & Munchus, 1998). More often, studies find conflicting results for the same socio-demographic variables they purport to measure (review Table 7). The disparate and inconclusive findings depicted in these studies suggest that these and other patient specific variables may moderate the relationship between healthcare attributes and patient satisfaction. The impact of such variables may be influenced to some extent by the health care system, for instance, if health care services are provided by governmental funding, insurance or out-of-pocket payment (Bjrngaard, 2008). To date, the strength and specifics of these patients factors continue to be unclear.

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Socio-demographic variables showing association with patient satisfaction Include: age, education, gender, ethnic origin, health Status, and income (Mummalaneni & Gopalakrishna, 1995; Naidu, 2009).

2.2.1.1 Age

The impact of age on patient satisfaction levels is questionable and, according to Lin and Kelly the relationship between age and patient satisfaction was complex (B. Lin & Kelly, 1995). Crow et al. reported age was the only demographic that exerted influence on satisfaction levels (Crowe, et al., 2002). Contrarily, several studies demonstrated a positive effect (F. Abdellah & Levine, 1957; Otani, Kurz, & Harris, 2005; J. L. Tucker, 2002), in which an increase in patient age coincided with an increase in the level of patient satisfaction. Findings in other studies demonstrated varied relationships.

Crowe et al. reported that 70.7% of studies demonstrated the linear relationship between age and patient satisfaction (Crowe, et al., 2002). Rahmqvist demonstrated individuals within the highest age bracket did not have the highest levels of satisfaction. Rahmqvist also demonstrated the individuals in the lowest age bracket had satisfaction levels that exceeded that of individuals within the next higher age group (Rahmqvist, 2001). Mangelsdorff and Finstuen also noted the importance of age as an influencing variable (Mangelsdorff & Finstuen, 2003).

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No specific defining relationship between age and patient satisfaction permeates the literature. Jaipaul and Rosenthal reported that age is frequently found to influence patient satisfaction significantly (Jaipaul & Rosenthal, 2003). In contrast, OHolleran et al., study concluded age did not affect the level of patient satisfaction reported (O'Holleran, Kocher, Horan, Briggs, & Hawkins, 2005). Thus, our study will add knowledge by showing how age moderates the link between care variables and satisfaction in the Lebanese primary care settings. 2.2.1.2 Education

The relationship between educational attainment and patient satisfaction is ambiguous. Germinal research by Ware et al. reported lower educational levels might negatively affect patient satisfaction (J. J. Ware, et al., 1978). Mattsson et al., who noted increased educational attainment led to higher levels of patient satisfaction, reported the same relationship between educational attainment and satisfaction (Mattsson, et al., 2005). Similarly, some studies indicated a positive correlation between educational attainment and some components of patient satisfaction (Baker (R. Baker, Mainous, Gray, & Love, 2003; Lantz, et al., 2005).

There are studies that do not demonstrate a positive effect on patient satisfaction related to increased educational attainment levels (Alasad & Ahmad, 2003; Chang, Weng, Chang, & Hsu, 2006; Johansson, Oleni, & Fridlund, 2002). Specifically, a study by Franchignoni et al. demonstrated no relationship between educational attainment and satisfaction (Franchignoni, Ottonello, Benevolo, & Tesio, 2002). In total contrast to the positive relationship between educational attainment and patient satisfaction, studies by Alasad and Ahmad, Chang et al., and

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Johansson et al. indicated individuals with lower educational attainment levels might have increased levels of patient satisfaction.

The attainment levels can be used for control purposes (Jaipaul & Rosenthal, 2003) or as an independent variable, as often done for other sociodemographic data (Oermann, Masserang, Maxey, & Lange, 2002). The influences of increased educational attainment may be multifactorial because of various influences that may manifest in other aspects of the patient satisfaction process. 2.2.1.3 Gender

It has usually been discovered that patient gender does not affect satisfaction values (Doering, 1983; Hopton, et al., 1993; Wallin, 2000), a conclusion attained also in Hall and Dornan's meta analysis (J. A. Hall & Dornan, 1990). However, few nonconforming papers have appeared. For instance, while Saila and Woods reported that significantly more men than women were satisfied with their healthcare experience (Saila, 2008; Woods & Heidari, 2003), Strasser and Burke reported that women were associated with higher levels of satisfaction (Aharony & Strasser, 1993; Burke, 2003). Thus, our study will add knowledge by showing how gender moderates the link between care variables and satisfaction in the Lebanese primary care settings. 2.2.1.4 Ethnic Origin

Ethnic origin is perhaps one of the most complicated determinant characteristics. In the U.S., there is evidence that whites on the whole are more satisfied than Asian/Pacific Islanders,

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Hispanics and African Americans (Bakewell & Higgins, 2001). In the U.K., the consumer healthcare surveys in the late 1970 s and 1980 s identified as key problems language difficulties, principally with general practitioners, hospitals' staff attitudes to Asian patients, and hospital catering (Jones, Leneman, & Maclean, 1987). The cultural standards and expectations of women from Asian communities are prominent in these studies; in particular, the examination of Muslim women by male doctors was highlighted as a source of distress. Recent evidences from both U.K. and U.S. suggest these problems persist (Haviland, Morales, Dial, & Pincus, 2005; van Zanten, Boulet, & McKinley, 2004; Woods, Bivins, Oteng, & Engel, 2005). However, an unlike deduction was presented by Jain who discovered that choice of doctor was determined more by the proximity of the patient's home to the practice premises than by ethnic considerations (Jain, et al., 1985). 2.2.1.5 Health Status

In general, there is evidence that poorer physical health is associated with dissatisfaction. For instance, Zapka showed that people with poor health had stronger feelings in either direction and that the most satisfied groups were those with good health or those suffering chronic diseases (Zapka, et al., 1995). Glynn et al. indicated that patients with lower physical and mental health scores were significantly less likely to be satisfied with their out-of-hours care (Glynn, Byrne, Newell, & Murphy, 2004). Among inpatients, poorer health is generally associated with lower satisfaction and complaints (P. Cleary, et al., 1991; P. Cleary, Keroy, Karapanos, & McMullen, 1989; P.D. Cleary, Edgeman-Levitan, & McMullen, 1992; Krupat, et al., 2000). However, an unlike deduction was presented by Beck et al. who discovered that there is no significant association between the patients health status and his satisfaction (Beck, et al., 1999).

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2.2.1.6 Income

While some researchers consider that poor income people have poorer health, get poorer healthcare, have less continuous relations with doctors, and have harder times getting appointments. They are also treated differently from privately insured patients to some degree. Consequently, they tend to be less satisfied (M. Calnan, 1988; Patrick, Scrivens, & Charlton, 1983). Other researchers argued that the patients income correlated negatively with global satisfaction with care (Theodosopoulou, 2007 ) or even not having any correlation (J. A. Hall & Dornan, 1990). Thus, our study will add knowledge by showing how income moderates the link between care variables and satisfaction in the Lebanese primary care settings.

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Table 7: Observed impact of socio-demographics variables on patient satisfaction


Findings on the Influence on patient Variable Study status of the satisfaction levels variable Conclusion General

(J. Hall & Dornan, 1988) (Aharony & Strasser, 1993) (Katz, 1997) (Tsasis, Tsoukas, Age & Deutsch, 2000) (Bodenlos, 2004) (Beck, et al., 1999) (Dykeman, 1998) (K. Miles, et al., Education 2003) (J. Hall & Dornan, 1988)

Moderator between healthcare attributes and patient satisfaction Older patients were associated with higher levels of satisfaction Conflicting data

No significant association with patient satisfaction Moderator between Less educated patients were

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healthcare attributes and (Canales, 1998) patient satisfaction Moderator

associated with higher levels of satisfaction

Less educated between patients were healthcare (Thiedke, 2007) attributes and Education lower levels of patient satisfaction satisfaction (Katz, 1997) (Erwin, 2000) (K. Miles, et al., 2003) (Aharony & Strasser, 1993) (Burke, 2003) (Saila, 2008) Gender (Woods & Heidari, 2003) (Wallin, 2000) (Erwin, 2000) (J. A. Hall & Dornan, 1990) (Marx, 2001) Ethnic Origin (Jones, et al., 1987) No significant association with patient satisfaction Moderator between healthcare attributes and patient satisfaction Women were associated with higher levels of satisfaction Men were associated with higher levels of satisfaction Conflicting data associated with Conflicting data

No significant association with patient satisfaction

Moderator between

White persons are more satisfied than

Conflicting data 79

healthcare Asian/Pacific (Haviland, et al., 2005) (Beck, et al., 1999) (Erwin, 2000) (Marx, 2001) (K. Miles, et al., 2003) (Jain, et al., 1985) (Zapka, et al., 1995) (Glynn, et al., 2004) (Krupat, et al., Health Status 2000) (Burke, 2003) (Beck, et al., satisfaction 1999) Income (B. S. Hulka, Kupper, B., Cassel, & Schoen, 1975) (Patrick, et al., 1983) (M. Calnan, 1988) Moderator between healthcare attributes and patient satisfaction Patients income correlated positively with global satisfaction with care Conflicting data No significant association with patient satisfaction attributes and Islanders, Hispanics patient and Africans satisfaction

Moderator Patients with more between severe symptoms healthcare were associated with attributes and lower levels of patient satisfaction satisfaction No significant association with patient Conflicting data

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Patients income (Theodosopoulou, 2007 ) correlated negatively with global satisfaction with care

(J. A. Hall & Dornan, 1990)

No significant association with patient satisfaction

2.2.2 Patients Perception of Interpersonal Equity/ Distributive Justice

Popular in social psychology (Walster, Walster, & Berscheid, 1978), sociology (G. Jasso, 1980) and organizational behavior (Pritchard, 1969), equity theory has received little attention in the patient satisfaction literature. Apart from the works done by Betancourt, Vinagre and Neves, and Fondacaro et al., few if any studies have discuss the relationship between equity and patient satisfaction (Betancourt, 2006; Fondacaro, Frogner, & Moos, 2005; Vinagre & Neves, 2010).

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Generally, equity theory suggests that parties involved in an exchange feel equitably treated and thus satisfied if their amount of input to the exchange is somewhat in balance with their output of the exchange. Both equity and disconfirmation are processes of comparison, which can be taken as being conceptually different and with complementary effects on the prediction of satisfaction (R.L. Oliver & DeSarbo, 1988; R. L. Oliver & J. E. Swan, 1989). To assess disconfirmation, results are compared with predictive expectations one has. To assess equity, the personal results are compared with other peoples results and with some sort of normative standards (Adams, 1963, 1965; Blodgett, Hill, & Tax, 1997). When compared to other paradigms of satisfaction with intrapersonal characteristics, equity takes into account the outcomes for both parties: user and supplier, thus adding an interpersonal dimension. First, the consumer compares his outcome to his input; second, he performs a relative comparison of this to the other exchange party (Homans, 1961). Satisfaction or dissatisfaction judgment is believed to be formed as a summary of equity/inequity of one's own outcome relative to the other party's outcome, given input. Key to this comparison is the perception of fairness as it explicitly implies a form of distributive justice whereby individuals get what they deserve based on their inputs (Cook & Messick, 1983; G. Jasso & Rossi, 1977). Seen from the patients point of view the outcome may be perceived as fair or unfair. An unfavorable outcome will be perceived as unfair and create low satisfaction with the received service. A favorable outcome will be perceived as fair and thus create positive satisfaction with the received service (Vinagre & Neves, 2010).

Based on the above, we consider that the patients perception of interpersonal equity may have a significant impact on patients satisfaction; therefore, there is an interest in investigating its role in the present study.

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2.3 Drivers of Patient Satisfaction: Conclusion

The literature review makes a twofold contribution towards understanding and conceptualizing the different drivers of patient satisfaction.

1- The different drivers of patient satisfaction have been identified and defined. Two categories of causal variables have been highlighted. The first refers to the care variables. The second

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refers to the patient variables. Furthermore, distributive justice was proposed as a new antecedent by the present study.

2- The current state of research on the relationships between patient satisfaction and its drivers has been highlighted. The variables that must be taken into account in any effort to measure the patient satisfaction concept may differ according to the specific healthcare situation (hospital/primary care setting/lab) and societal level (geographical context,). These variables should reflect the concerns of the healthcare users rather than the provider (M. Calnan, 1988).

These findings as well as findings from the first part of the literature review allow proposing, in the next section, a global conclusion in which the perspectives for the further steps of this study are exposed.

CONCLUSION LITERATURE REVIEW

Although, patient satisfaction has been studied for long, yet some significant limitations can be identified in the literature.

- Theoretical Gaps

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Previous studies in the healthcare literature did not explicitly investigate the role of distributive justice in the formation of the patient satisfaction response.

This theoretical gap will be overcome by providing evidences that distributive justice should play the role of a mediating variable in the relationship between price of care and patient satisfaction.

There is no consensus on how to best conceptualize the relationship between patients satisfaction and their perceptions of the quality of their healthcare service. Accordingly, there is a need for additional investigation on this issue.

This theoretical gap will be overcome by providing evidences that healthcare service quality is just an antecedent factor driving patient satisfaction.

There is no consensus on how to best conceptualize the relationship between patients sociodemographic characteristics and patient satisfaction. Accordingly, there is a need for additional investigation on this issue.

This theoretical gap will be overcome by providing evidences that the patients sociodemographic variables should be incorporated as moderators between healthcare attributes and patient satisfaction.

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- Methodological Gaps

Most researchers designed their own questionnaire to measure patient satisfaction without conducting solid psychometric tests, or if they have the results were not acceptable.

This methodological gap will be overcome by providing sustained evidences of validity and reliability of measurement scales used to count data.

Most researchers have been using healthcare providers agendas or common templates to identify the key drivers of patient satisfaction.

This methodological gap will be overcome by conducting a qualitative pilot study in the second part of this dissertation (chapter 3). Through face to face interviews, the patients (the ultimate beneficiaries of healthcare) will be involved in the final integration of these key drivers. Such approach will improve our measurement of the patient satisfaction construct (Tarantino, 2004) especially that it was argued that any standard classification never seems entirely appropriate (Sitzia & Wood, 1997) and that research on outpatient satisfaction were never conducted in the Lebanese context before (review section 1.2.5).

- Managerial Gap

No previous research on outpatient satisfaction was conducted in the Lebanese context.

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Although a large number of outpatient satisfaction researches were conducted in the U.S. and the Western countries (Hawthorne, 2006), results from these studies cannot be simply generalized and applied to Lebanon. A key reason is that people vary in what they perceive to be a health condition worthy of health care and in their health literacy (Jorm, et al., 1997; Suchman, 1965). There is also variation in what people want from the healthcare system, and what they expect from any particular encounter with healthcare providers (Fox & Storms, 1981; Locker & Dunt, 1978). These differences operate at both the individual as well as at the societal level with the consequence that there may be differences of such magnitude as to render what is important in one context relatively unimportant in another (Hawthorne, 2006). Moreover, even if studies are conducted in similar social contexts, results of patient satisfaction studies cannot be compared easily. This is because researchers tend to devise their own instruments for measurement (e.g. questionnaires) due to different study objectives, nature of the facilities, and composition of clients (Chow, 2008). This implies that operational variables can be different, which may not yield meaningful comparisons between studies conducted within the country, not to mention those in other countries.

The current academic research overcomes this managerial gap in the sense that it is the first to be conducted on outpatient satisfaction in Lebanon.

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PART 2: HYPOTHESES, METHODOLOGIES AND OUTCOMES


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Introduction

The findings of the literature review brought to design the framework of this research. Actually, the theoretical shortcomings identified in the literature concern (1) the absence of any research study on outpatient satisfaction in the Lebanese context (2) the absence of an explicit 88

investigation on the relationship between distributive justice and patient satisfaction (3) the absence of an agreement on the best conceptualization of the relationship between perceived healthcare quality and patient satisfaction (4) the absence of an agreement on the best conceptualization of the relationship between patients sociodemographic characteristics and patient satisfaction

In order to bridge those gaps, the second part of this work is devoted to formulating the research hypotheses and carrying out two empirical investigations (qualitative and quantitative). It is divided into three chapters (chapters 3, 4, and 5).

Chapter 3 presents the characteristics of the qualitative research, the research model, and the hypotheses that are based on theoretical considerations. These hypotheses investigate the different mechanisms of outpatient satisfaction.

Chapter 4 explains how the quantitative research was carried out, which measures were undertaken and what the results were. Details are provided on the data collection procedure. Then, the development and/or validation of the used scales are detailed. Finally, the results of the hypothesis-testing are presented.

Chapter 5 describes the practical consequences of the empirical results. The discussion centers on direct management implications and an advanced process of patient satisfaction.

The organization of the second part is presented in figure 3.

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Figure 3: Organization of Part 2

PART 2: HYPOTHESES, METHODOLOGIES AND OUTCOMES


Part 2 fills the gap identified in the literature review on patient satisfaction: The absence of any empirical evaluation to identify the key factors of primary care dimensions that have the most impact on patient satisfaction.
RESEARCH MODEL & HYPOTHESES (CHAPTER 3)

Framework:
Characteristics of the qualitative study Design of the research model Research hypotheses

Contributions of chapter 3: -The research model and twenty research hypotheses are formulated.

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-The hypotheses describe the different mechanisms of the satisfaction antecedents - patient satisfaction relationships and specify the role of (1) service quality (2) distributive justice and (3) patients sociodemographics.
METHODOLOGIES & OUTCOMES (CHAPTER 4)

Framework:
Scales development and validation

Characteristics of the quantitative study

Hypotheses tests

Contributions of chapter 4: - The hypotheses are tested that confirm and complete the initial assumptions made on the impact of physician care, access to care, price of care, atmospherics of care, service quality and distributive justice on patient satisfaction. - Identification of the key dimensions and factors of healthcare that have the most impact on patient satisfaction in primary care settings.
MANAGERIAL CONTRIBUTIONS (CHAPTER 5)

Framework:
Implications of the empirical results on daily activities
Process to be followed by care providers to improve patient satisfaction

Contributions of chapter 5: - The results of the hypotheses sections are reviewed in light of management practice. - A holistic process for the management of patient satisfaction is proposed.

The findings of PART 2 bring new knowledge on patient satisfaction and its drivers.

Chapter 3: Research Model and Hypotheses


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For 2000 years medicine was an art, for 200 years a science, and for the last twenty years its been a business. - Irwin Press.

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In order to build the research model and develop the corresponding research hypotheses, the literature review is completed by a qualitative study. Actually, the fact that no previous model of outpatient satisfaction was specifically elaborated or tested in Lebanon makes it indispensable to perform an exploratory qualitative study to identify the most appropriate constructs for this environment in formulating and finalizing our conceptual research model.

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3.1 The Qualitative Pilot Study

In social science research, the term pilot study is used in two different ways. It can refer to socalled feasibility studies which are "small scale version[s], or trial run[s], done in preparation for the major study" (Polit, Beck, & Hungler, 2001). However, a pilot study can also be the pretesting or trying out of a particular research instrument (T. L. Baker, 1994). One of the advantages of conducting a pilot study is that it might give advance warning about where the main research project could fail, where research protocols may not be followed, or whether proposed methods or instruments are inappropriate or too complicated. In the words of De Vaus Do not take the risk. Pilot test first" (De Vaus, 1993).

Pilot studies can be based on quantitative and/or qualitative methods and large-scale studies might employ a number of pilot studies before the main survey is conducted. Thus researchers may start with "qualitative data collection and analysis on a relatively unexplored topic, using the results to design a subsequent quantitative phase of the study" (Tashakkori & Teddlie, 1998). When the term pilot study is used in the context of exploratory research, the data collection methods are informal because standards are relaxed (Zikmund, 2000). Thus, probing interviews were used to collect data. 3.1.1 Study Objectives

As explained throughout this thesis, there is a lack of scientifically proven research on outpatient satisfaction in developing countries, and notably in Lebanon. This was confirmed in the literature review. Therefore, in order to customize the research model and to ensure that it covers most of

the important elements of outpatient satisfaction in Lebanon, an exploratory qualitative study must be undertaken. The specific objectives of the study were more precisely: (1) to identify the key healthcare dimensions that improve patient satisfaction with primary care services in Lebanon (2) to complete the findings of the literature review. 3.1.2 Study Setting

Our research area is Mount Lebanon Clinic (MLC) activities and its interactions with its patients. MLC is kind of community based care at a level that falls between the current general practitioner practice and the traditional general hospital. It offers a greater range of diagnostic services than currently offered in general practitioners practices (e.g., X-Rays, ultrasounds, blood tests, cardiac stress test, video endoscope...),whilst being more accessible and less medicalised than hospitals. MLC acts as a first point of consultation for all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with multiple chronic diseases.

Unlike the hospital setting, MLC has a short amount of time to create a positive experience for patients. Accordingly, an earliest services mistake can have a major negative impact on the last patients overall perception since the first impressions are likely to be vivid and not easily erased. The building, equipment and facilities in the clinic may impress to some extent at the first sight, but mainly the care provided with the human touch, promptness, attitude and behavior are going to leave a lasting impression on the outpatient. For this, the importance of patient satisfaction assumes great significance for the MLC administration (which I represent) in particular and the public in general. 94

3.1.3 Data Collection

In order to collect primary data, twenty structured face to face interviews were conducted with patients attending MLC where a judgmental sampling approach was used. Judd et al. defined judgmental sampling or purposive sampling as picking cases that are judged to be typical of the population in which we are interested, assuming that errors of judgment in the selection will tend to counterbalance one another (Judd, Smith, & Kidder, 1991). To conduct the discussion, an interview guide which was developed in English and translated into Arabic, was followed (review Appendix 1). Following the recommendations made by Giannelloni and Vernette , each interview was divided in four phases (Giannelloni & Vernette, 2001). In phase one "introduction", questions were related to: (1) history of contact and use of ambulatory care services, (2) patients' actual experiences. In phase two "subject centring", questions concerned: (3) patients needs (4) provider-patient relationships. In phase three, dedicated to giving deeper insight to the key topic, questions were about (5) patients meaning of satisfaction with a healthcare experience (6) satisfying & dissatisfying circumstances (7) patients expectations and their role in developing satisfaction with healthcare (8) factors that most contribute to patients satisfaction. Finally, in phase four "conclusion", the interview was closed by discussing the patients perspective on healthcare providers in general and the major barriers that stand in the way of increasing patients satisfaction levels. All the questions were developed based on the literature review information that was discovered by other authors. Before starting the interviews, the respondents were clearly informed that the interviews will be recorded and that they may stop at any time without holding any responsibility. Moreover, interviewees were guaranteed that their personalities will remain anonymous. The interviews 95

were conducted at the 3rd, 4th, 5th, 6th, and 8th of April 2010 between 10 AM and 2 PM (on the basis of 4 consecutive interviews /day). During the interviews that were conducted in Arabic in order to avoid any misunderstanding, I basically asked the opening questions, and used notes taking. The estimated time for each interview lasted approximately 30 minutes. No incentives were given to respondents. 3.1.4 Data Analysis

After collecting all the data the process of analysis begins. To summarize and rearrange the data several interrelated procedure are performed during the data analysis stage (Zikmund, 2000). The data was analyzed based on words frequencies and also, gathered data from patients was compared with the service provider data.

Data analysis is consisting of some flows of activity (B. M. Miles & Huberman, 1994):

a) Data reduction To appear data in transcriptions form data reduction process involves the selecting, focusing, simplifying, abstracting and transforming the collected data. There are several ways that can be used to reduced and transformed qualitative data - through selection, through summary or paraphrase, through being subsumed in a larger pattern and so on. Data reduction is a form of analysis that sharpens shorts, focuses, discards and organizes data that helps to draw and verify final conclusion (B. M. Miles & Huberman, 1994).

b) Conclusion Drawing/Verification

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Conclusion drawing and verification is the other stream of analysis activity where researcher need to decide meaning of things by noting regularities, patterns, explanations, possible configurations, causal flows and propositions (M. B. Miles & Hurberman, 1994). While much work in the analysis process consists of consolidating the data into smaller pieces, the final goal is the emergence of a larger, consolidated picture (Tesch, 1990). The information was consolidated and certain patterns appeared. The patterns that emerged from this consolidated picture enabled the researcher to identify new variables for the research model. 3.1.5 Profile of Respondents

A total of 20 respondents were interviewed. 40% of them were male and 60% were female. All respondents were aged 16 or above. The mean age of the respondents was 37. Table 8 below presents an overview of the interviewees3. In general, the demographic data of the sample and that of the population were almost similar.

Table 8: Overview of the Interviewees

Comparison of sample profile and population profile by sex Sample No. Male Female Mean age Base: All respondents 20 8 12 37 100 10690 % 40 60 Population (aged 16 and above) No. 4062 6628 % 38 62 35 100

Comparison of sample profile and population profile by age

MLCs database includes only basic information on its patients profiles. Thus, the analysis was limited to gender and age.

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3.1.6 Outcomes of the Pilot Study

The analysis of the qualitative study showed the analogy in the answers of the different respondents. All the patients stated that they are mainly influenced by four dimensions of healthcare, namely physician care, atmospherics of care, access to care, and price of care. The specific results are detailed below.

1. Physician Care This dimension breaks down into two sub dimensions:

Interpersonal performance of the physician The interpersonal performance of the physician refers to the manner in which the physician interacts with the patient (Ginzberg, 1991).

b)

Technical performance of the physician The technical performance of the physician refers to whether a physician, given the preference of the patient, is using the most appropriate intervention available (Ginzberg, 1991).

Physician care is a dimension to which exceptional attention is usually given by patients who do not only expect doctors to competently diagnose the disease, correctly interpret laboratory reports, and provide appropriate explanations to queries; but primarily to behave and

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communicate in a compassionate manner: The doctor is someone who validates my pain, listens to my problem and treats me with professional courtesy. In this dimension, five factors were identified as most relevant for MLCs patients. These factors were: 1) Empathy Empathy was described as an accurate understanding of another person's inner experience -the attitude of comprehending their feelings and emotions and seeing things from their point of view (Anfossi & Numico, 2004). This factor was identified due to patients verbatims such as: The doctor really cares and understands how much pain I am feeling every day. I am loyal to my empathic doctor. He always supports me. My doctor recognizes my fear.

2) Competence Competence was described as having the skills and knowledge needed to perform the service (John, 1992). This factor was identified due to patients verbatims such as: There are many unskilled physicians. Therefore, I always check about the physicians credentials and competences. An unskilled doctor may do more harm than good. A specialist should have up-to-date knowledge about illness and treatment. My doctor is very competent and well trained.

3) Courtesy

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Courtesy was described as the respect, consideration, politeness, and friendliness of the personnel with whom the patient comes into contact (John, 1992). This factor was identified due to patients verbatims such as: My doctor always treats me with the highest respect. The doctor was very arrogant and rude, I hated him. Dr. Haddad always shakes my hand and asks me how I have been. If I am willing to pay his hefty fees, then surely he should be responsible for actually doing his job both correctly and politely.

4) Communication Communication was described as the degree to which the patient is heard, kept informed through understandable terms, afforded social interaction and time during consultation and provided psychological and non-technical information (J. L. Tucker, 2002). This factor was identified due to patients verbatims such as: My doctor always listens carefully before diagnosing the problem. My doctor explains things to me in a way that I understand. The doctor should tell me what he will do and why. I have helped to choose my treatment.

5) Accuracy The present study defined accuracy as the degree of adherence to high standards of medical diagnosis. This factor was identified due to patients verbatims such as: The doctor always performs an accurate diagnosis of the case. An accurate diagnosis is half the cure. 100

An accurate diagnosis and timely medical diagnosis can make the difference between life and death.

When the diagnosis is inaccurate, we cant expect to heal.

2. Atmospheric of Care

Kotler claims that "one of the mixed blessings of human history is that man increasingly lives, works, and plays in artificial environment (P. Kotler, 1973). Obviously, then, marketing exchanges take place in artificial environments that are controllable by people. Furthermore, people's purchasing decisions include the "total product (Bitner, 1990). This total product affects buyers since everything associated with the product influences the desire to make an exchange. The place is a part of the total product and the atmosphere is a part of the place. Commonly, outpatients are influenced by the physical and controllable environmental components of their medical provider since they consider that these features provides to some extent tangible cues about the quality of the services that they can expect. In this dimension, five factors were identified as most relevant for MLCs patients. These factors were:

1) Physical appearance of the setting: The present study defined physical appearance of the setting as the patients perception about the design of the facility. This factor was identified due to patients verbatims such as: They provide outstanding care in a good-looking setting. The doctors office looked unappealing and chaotic, I was very disappointed. 101

The setting was beautiful and relaxing like being at a spa.

2) Air freshness The present study defined air freshness as the patients perception about the presence of cool air in the facility. This factor was identified due to patients verbatims such as: There was no air conditioning it was hot as hell! If the setting has poor or unclean air flow it will be exposed to infections diseases.

3) Equipments' modernity The present study defined equipments modernity as the patients perception about the modernity of the medical equipments in the facility. This factor was identified due to patients verbatims such as: With such modern equipments, they can easily diagnose and treat my condition. Even doctors are weak and feeble without the help of these modern equipments. My doctors office has the needed equipments to provide complete medical care.

4) Sounds The present study defined sounds as the patients perception about the sound level in the facility. This factor was identified due to patients verbatims such as: The experience was very bad since we were disturbed and distracted mainly due to noise from non-clinically relevant events. Music off. I hate music. Ha!

5) Cleanness 102

The present study defined cleanness as the patients perception about purity of the facility. This factor was identified due to patients verbatims such as: As a woman, I can quickly remark if they adopt hygienic and safe practices. I always check the cleanness. One child had severe diarrhea and the place was a mess. The toilet was shinny.

3. Access to Care

Access to care is also an important concern for outpatients in every feature of it: phone access (wait time), front desk personnels responsiveness, access to physicians for questions, access to results reporting (laboratory tests, imaging...), timelines of referrals, and office waiting time.

Outpatients want access to care to be effective, efficient and equitable. While they like to be able to closely park near the facility, easily secure an appointment with a physician, and quickly access their paramedical tests results, they hate waiting in the rest room when they show up for an appointment especially if they are in pain.

In this dimension, five factors were identified as most relevant for MLCs patients. These factors were:

1) Waiting time: Waiting time was defined as the amount of time the patient waited before being seen by the physician for a scheduled appointment (R. T. Anderson, Camacho, & Balkrishnan, 2007). It is the length of perceived waiting time by the patient which is important not the real time. This factor was identified due to patients verbatims such as: 103

I was frustrated for waiting so long. Since I have money, I will be most welcomed elsewhere. For someone in my age, waiting time is a huge annoyance especially that I have a disk pain. When you arrive for your appointment, you don't wait more than 5-10 minutes. I couldnt wait anymore! 2) Operating hours The present study defined operating hours as the patients perception about the adequacy of the operation hours. This factor was identified due to patients verbatims such as: The operating hours of the clinic are not suitable for me. The operating hours should be increased. I have to do the blood test around 7 am, so I will not be late on my work at 8 am. You should open overnight.

3) Parking convenience The present study defined parking convenience as the patients perception about the easiness of finding a convenient parking. This factor was identified due to patients verbatims such as: I asked about the parking because I cant easily walk with a broken leg. There was no car parking facility available near the clinic; and we had to park the car elsewhere, and walk in from there. The parking is free for disabled badge holders and there are designated parking spaces for disabled visitors.

4) Effort required to get an appointment 104

The present study defined effort required to get an appointment as the patients perception about the easiness to get an appointment. This factor was identified due to patients verbatims such as: I had to wait on hold for 5 minutes. It was impossible to get a fast appointment without paying a tip. There, you don't need to make an appointment to consult a general practitioner.

5) Receptionists personnel behavior The present study defined receptionists personnel behavior as the patients perception about the responsiveness of the receptionist. This factor was identified due to patients verbatims such as: Although I couldnt get a quick appointment, the receptionist was very lovely and friendly which removed my disappointment. The courtesy and helpfulness of the office receptionist was just excellent. Moreover, the receptionist had a negative attitude.

4. Price of Care

The expensive price of care is a major concern for those seeking healthcare services in general and ambulatory care in particular since most patients barely have an inpatient insurance coverage (may not be used for primary care services). This price might include financial charges (e.g. consultation fees) and non financial charges (e.g. time costs, energy costs): As you may know, many patients ask the pharmacist to prescribe their medications because they cannot easily afford the consultation fees of a specialist.

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In this dimension, two factors were identified as most relevant for MLCs patients. These factors were:

1) Perceived monetary price The present study defined perceived monetary price as the perceived out-of-pocket expenses that the patient bore to obtain the needed service. This factor was identified due to patients verbatims such as: I have to pay for my medical care more than I can afford. Sometimes I go without the medical care I need because it is too costly. The medical fees are usually expensive and I do not have an outpatient insurance coverage. Sometimes it is a problem to cover my share of the cost for a medical care visit.

2) Perceived non monetary price The present study defined perceived non monetary price as the other costs than the monetary price that the patient bore to obtain the needed service (e.g., time costs, energy costs, and psychic costs). This factor was identified due to patients verbatims such as:

Every time I have to come here, there is a hassle. We wasted a lot of time before reaching the correct diagnosis.

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3.1.7 Conclusion on the Pilot Study

The findings of the pilot study were helpful in that they assisted the researcher in:

a)

Identifying the main constructs that should be included in the research model. These

constructs represent the key healthcare dimensions that impact patient satisfaction with primary care services in the Lebanese context.

b) Identifying what factors of these healthcare dimensions are most significant to improve patient satisfaction with primary care services in the Lebanese context. Based on these factors we will afterward develop the formative scales (review section 4.2.2) and some managerial implications of the present study (review Chapter 5).

It is important to note that although the identified four dimensions and their corresponding factors were very close to those traditionally recognized in the literature for this type of medical settings that MLC represents (R. Baker, 1991; Ernst & Bergus, 2003; Mclver, 1991; Olusoji, 2009), the study findings revealed that the Lebanese patients have two distinctive attitudes:

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1) Surpassing their foreign counterparts, Lebanese patients accord an exceptional attention to the competency of their doctors. This is mainly due to the fact that many doctors working in the Lebanese territory are graduated from eastern European universities which are locally reputed for their low academic standards, and the relatively low level of governmental supervision (Kassak & Ghomraw, 2006).

2) Surpassing their foreign counterparts, Lebanese patients accord an exceptional attention to the price of care. This is mainly due to the fact that in the Lebanese medical system, ambulatory care costs are entirely paid for by the patients, which isnt the case in many foreign countries where those treatment costs are paid for (partially or entirely) by the states (Kronfol, 2006).

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3.2 Design of the Research Model

Conceptual models help us to understand complex phenomena, and they are frequently used to illustrate research questions under investigation. They typically depict causal relationships among several variables for the purpose of explaining when, how, and why human phenomena occur (Lindley & Walker, 1993). While such models relies on the definition of mediating variables and moderating variables which further clarify the relationships between the predictors and the criterion construct, the terms moderating and mediating effects in causal models can be problematic (Baron & Kenny, 1986; Cooper & Schindler, 2008). Thus, distinctions of their respective roles and properties are specified hereafter.

A moderating variable is one which systematically modifies either the form and or strength of the relationship between a predictor and a criterion variable (S. Sharma, Durand, & Gur-Arie, 1981). It specifies when or under what conditions a predictor variable influences a dependent variable (Holmbeck, 1997). Moderator variables which can be either quantitative or qualitative do not correlate strongly either with the criterion variable or the predictor, but they may change the direction of the causal relationship between the predictor and the criterion variable from positive to negative or visa versa (Lindley & Walker, 1993). Complete moderation would occur 109

in the case in which the causal effect of (X) on (Y) would go to zero when (M) took on a particular value (Baron & Kenny, 1986).

In marketing literature, moderators began to arouse interest when researchers observed that traditional validation models, which only take mediation into account, did not provide a comprehensive understanding of the phenomenon studied (S. Sharma, et al., 1981). A moderator variable can be considered when the relationship between a predictor variable and a dependent variable is strong, but most often it is considered when there is an unexpectedly weak or inconsistent relationship between a predictor and a dependent variable (Holmbeck, 1997). The moderating effect is typically expressed as an interaction between predictor and moderator variable (Aldwin, 1994). The role of the moderator variables is to restrict, refine, and elaborate generalizations in such a way as to describe its precise impact on the relationship between the independent variable and the dependent variable (Kenny, 1979). It should be noted that, unlike the mediator-predictor relation (where the predictor is causally antecedent to the mediator), moderators and predictors are at the same level in regard to their role as causal variables antecedent or exogenous to certain criterion effects. That is, moderator variables always function as independent variables, whereas mediating events shift roles from effects to causes, depending on the focus of the analysis (Kim, Kaye, & Wright, 2001).

A mediator variable, which is often an attribute or an intrinsic characteristic of individuals, represents an intervening variable through which an independent variable is able to influence a dependent variable (Peyrot, 1996). It can be defined as a factor that theoretically affects the dependent variable but cannot be observed or has not been measured; its effects must be inferred from the effects of the independent and moderator variables on the observed phenomenon 110

(Cooper & Schindler, 2008). Mediation is said to occur when the causal effect of an independent variable (X) on a dependent variable (Y) is transmitted by a mediator (M). In other words, (X) is correlated with (Y) not because (X) exerts some direct effect upon (Y), but because (X) causes changes in an intervening or mediating variable (M), and then the mediating variable causes changes in (Y) (Baron & Kenny, 1986). The mediator variable, then, serves to clarify the nature of the relationship between the independent and dependent variables (MacKinnon, 2008). Accordingly, whereas moderator variables specify when certain effects will hold, mediators speak to how or why such effects occur (Holmbeck, 1997). In contrast to moderating effects which are most commonly introduced when there is an unexpected weak relationship between predictor and dependent variable, there must be a significant relationship between the predictor and the dependent variable before testing for a mediating effect (Baron & Kenny, 1986).

Now that these issues have been clarified, the existence and role of the different variables in our model will be discussed. 3.2.1 Dependent Variable of the Model Zikmund defined dependent variable as a criterion or a variable that is to be predicted or explained (Zikmund, 2000). In our research model presented in figure 4 below, the dependent variable is the patient's overall satisfaction with the services provided. 3.2.2 Independent Variables of the Model Zikmund defined independent variable as a variable that is expected to influence the dependent variable (Zikmund, 2000). In our research model presented in figure 4 below, the four independent variables are physician care, access to care, atmospherics of care, and price of care. 3.2.3 Mediating Variables of the Model 111

The findings drawn from the literature review bring to suggest that two variables can mediate the relationships in the hypothesized model. One of the mediators concerns distributive justice. The second mediating variable refers to perceived healthcare service quality.

a) Distributive justice Oliver & Swan argued that distributive justice is posited to intervene between inputs and outcomes from one side and satisfaction from the other. Theoretically, the implication is that individuals perceive specific meaning in outcome/input comparisons that cannot be interpreted as satisfaction, but which mediate satisfaction (R. Oliver & J. Swan, 1989; R. L. Oliver & J. E. Swan, 1989).

b) Healthcare Service Quality Although, there is no consensus on how to best conceptualize the relationship between patient satisfaction and their perceptions of the quality of their healthcare (Andaleeb, 2001; Gill & White, 2009), the findings of many studies provide evidences that perceived healthcare quality mediate patient satisfaction (e.g. (Badri, Attia, & Ustadi, 2009; Elleuch, 2008; J. B. Gotlieb, Grewal, & Brown, 1994)). 3.2.4 Moderating Variables of the Model Based on the findings of the literature review, we suggest that the patients socio-demographics characteristics should be regarded as moderators of the relationship between healthcare attributes and patients satisfaction.

Further to proposing the research model, comes the research hypotheses formulation. However, and for the sake of building a common foundation, we will proceed by reviewing the definitions 112

of the different variables used in the research hypotheses and model. These are presented in Table 9 below.

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Table 9: Definitions & Operationalization of the different variables, included in the research model Nature of the Variable Physician Care Definition & Operationalization of the variable in the study measure The components that constitute the physicians performance toward the patient (working definition). In the physician care dimension, five distinct factors will be measured: 1-Empathy: An accurate understanding of another person's inner experience - the attitude of comprehending their feelings and emotions and seeing things from their point of view (Anfossi & Numico, 2004). 2-Competence: Having the skills and knowledge needed to perform the service (John, 1992). 3- Courtesy: The respect, consideration, politeness, and friendliness of the personnel with whom the patient comes into contact (John, 1992). 4- Communication: The degree to which the patient is heard, kept informed through understandable terms, afforded social interaction and time during consultation and provided psychological and non-technical information (J. L. Tucker, 2002). Price of care 5- Accuracy: Adherence to high standards of medical diagnosis (working definition). The patients overall evaluation of the sacrifices that were given up to obtain the needed service from the healthcare institution (working definition). In the price of care dimension, two distinct factors will be measured: 1-Perceived monetary price: The perceived out-of-pocket expenses that the patient bore to obtain the needed service (working definition). 2- Perceived non monetary price: The other costs than the monetary price that the patient bore to obtain the needed service (e.g., time costs, energy costs, and psychic costs) Access to Care (working definition). Those factors which describe the potential and actual entry for a given population group to the healthcare delivery system (Andersen & Aday). In the access to care dimension, five distinct factors will be measured: 1- Waiting time: The amount of time the patient waited before being seen by the physician for a scheduled appointment (R. T. Anderson, et al., 2007). It is the length of perceived Subjective Subjective Subjective Subjective Subjective Subjective Subjective Subjective

waiting time by the patient which is important not the real time. 2- Operating hours: It is the patients perception about the adequacy of the operation hours (working definition). 3- Parking convenience: It is the patients perception about the easiness of finding a convenient parking (working definition). 4- Effort required to get an appointment: It is the patients perception about the easiness to get an appointment (working definition). 5- Receptionists personnel behavior: It is the patients perception about the responsiveness of the receptionist (working definition). Atmospheri c of Care The physical and controllable environmental components affecting the patient's attitude and/or behavior (working definition). In the atmospheric of care dimension, five distinct factors will be measured: 1- Physical appearance of the setting: It is the patients perception about the design of the facility (working definition). 2-Air freshness: It is the patients perception about the presence of cool air in the facility (working definition). 3- Equipments' modernity: It is the patients perception about the modernity of the medical equipments in the facility (working definition). 4-Sound: It is the patients perception about the sound level in the facility (working definition). Healthcare Quality Distributive Justice Patient Satisfaction 5-Cleanness: It is the patients perception about purity of the facility (working definition). An attitude that is a function of some combination of attributes that a patient considers to be components of quality (J. M. Carman, 2000). The patients overall perception of whether his outcomes are just given the amount of his individual contributions and compared to the outcomes and contributions of the physician (working definition). The patients global judgment, that derives from a subjective evaluation of a received healthcare service, and where the evaluation contains both cognitive and affective reactions Subjective Subjective Subjective Subjective Subjective Subjective Subjective Subjective Subjective Subjective Subjective Subjective

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3.3 Research Hypotheses

3.3.1 Hypotheses Concerning the Relationships between Physician Care, Service Quality and Patient Satisfaction - Physician Care and Patient Satisfaction

Patient perceptions of the physician care attribute can play a significant role in predicting its satisfaction judgment. In fact, previous studies conducted in primary care settings have shown that the patients' first concern is their doctor (e.g., (D. E. Larsen & Rootman, 1976; Tung & Chang, 2009)); hence, any aspect (technical or interpersonal) of the physicians performance becomes an important element in the patients evaluation of the received service. This finding is consistent with the primary provider theory which suggests that, at its core, patient satisfaction (or dissatisfaction) springs forth from the interrelationship between patients expectations and their interactions with their primary providers (Aragon & Gesell, 2003). The theory posits that primary providers have the greatest clinical utility or value to patients; they likewise have the greatest influence on outcomes such as satisfaction. Accordingly, and in line with previous finding and theory, we hypothesize that:

H1: The better the patients perception of the physician care, the greater will be its satisfaction with the services provided. - Physician Care and Service Quality This study adopted Carman definition of healthcare quality as an attitude that is a function of some combination of attributes that a patient considers to be components of quality (review 116

section 1.2.4.1). Previous studies showed that physician care is such a relevant attribute (e.g., (Cho, Lee, Kim, Lee, & Choi, 2004; Tso & Chan, 2006). In fact, Donabedian, the father of quality improvement in healthcare, consider physician care as the core element that constitutes healthcare quality (Donabedian, 1980, 1988, 2005). Accordingly, and in line with previous definition and findings, we hypothesize that:

H2: The better the patients perception of the physician care, the better will be its perception of the service quality.

-Service Quality and Patient Satisfaction

The role of customer perceptions of service quality as an antecedent of overall customer satisfaction has been extensively researched and is widely accepted in the services marketing literature (E. W. Anderson, et al., 1994; G.A Churchill & Surprenant, 1982; Cronin & Taylor, 1992; R.T. Rust & Oliver, 1994). More recently, evidence has emerged supporting the existence of a causal connection between service quality perceptions and patient satisfaction judgments in the healthcare context (Bigne, Moliner, & Sanchez, 2003; Marley, et al., 2004; Woo, Lee, Kim, Lee, & Choi, 2004). As a result, there is ample theoretical and empirical justification to hypothesize affirmative links between perceived service quality and patient satisfaction. Thus, we hypothesize that:

H3: The better the patients perception of service quality, the greater will be its satisfaction with the services provided.

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3.3.2 Hypotheses Concerning the Relationships between Access to Care and Patient Satisfaction

- Access to care and patient satisfaction

Access to medical care which is traditionally viewed as one of the three sides (cost, quality, and access) of the healthcare triangle (Fuchs, 1974) have been found to significantly affect patient overall satisfaction more than quality of care (Rutledge & Nascimento, 1996). Patients usually want the timely provision of appropriate care to meet their health needs and are frustrated by any individual, social, financial or organizational barriers to access (Gulliford, 2001; Pechansky & Thomas, 1981). Therefore, it is assumed that when a primary care setting has easy physical access, convenient operating hours, responsiveness staff, patients will be more satisfied. In other words, and in line with previous findings, we hypothesize that:

H4: The better the patients perception of the access to care, the greater will be its satisfaction with the services provided. 3.3.3 Hypotheses Concerning the Relationships between Atmospheric of Care and Patient Satisfaction

- Atmospheric of care and patient satisfaction

Early works in the services marketing literature exemplify the discipline's interest in how the servicescape affects consumers service evaluations. These studies indicate that it is a fundamental factor that influences consumer satisfaction (e.g. (Bitner, 1992; Kaplan, 1987; P. Kotler, 1973)). Similar results have also been reported for patients evaluations (Reidenbach & 118

Sandifer-Smallwood, 1990; J. E. Swan, Richardson, & Hutton, 2003). Hence, the environment in which the service is delivered, the appearance of the buildings, uniforms, and the appearance of the equipments can enhance patient satisfaction. Accordingly, and in line with previous findings, we hypothesize that:

H5: The better the patients perception of the atmospheric of care, the greater will be its satisfaction with the services provided. 3.3.4 Hypotheses Concerning the Relationships between Price of Care, Distributive Justice and Patient Satisfaction

- Price of care and patient satisfaction

Patient satisfaction should also be influenced by perceived treatment costs. Even with insurance coverage, patients may perceive some costs to be excessive. In fact, with insurance companies challenging what they feel are unnecessary claims, costs, and operating procedures (Schlossberg, 1990), and employers requiring larger employee contributions to offset rising insurance premiums (W. K. Wong, 1990), healthcare beneficiaries may have become much more sensitive to the price issue. Wong also predicts that consumers will shop for the best value. Accordingly, and in line with previous findings, we hypothesize that:
.

H6: The better the patients perception of the price of care, the greater will be its satisfaction with the services provided.

- Price of Care and Distributive justice

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Consumers tend to consider the relative relationship between price and their expectations about the performance of the product they want to purchase (Voss, Parasuraman, & Grewal, 1998). Hence, an initial price quote from the healthcare provider will be compared with a patients previous experience or an expectation of an acceptable or fair price for the service. If patients perceptions of performance of the healthcare service exceed their expectations and the service represents good value for money, then they will be more likely to perceive that the services price is fair which will systematically increase their levels of distributive justice due to the fact that the fairness dimension of equity has the dominant influence in distributive justice (R. L. Oliver & J. E. Swan, 1989). Thus, we hypothesize that:

H7: The better the patients perception of the price of care, the better will be its perception of distributive justice.

- Distributive justice and Patient Satisfaction

Findings from previous research regarding equity suggest that changes must be made in the conceptual representation on the effect of equity and increase the ability to predict satisfaction (R. L. Oliver, 1997). A meta-analysis of the empirical research on customer satisfaction found that equity exhibited a dominant effect on satisfaction judgments with a correlation between equity and satisfaction of 0.50 (Szymanski & Henard, 2001). Satisfaction or dissatisfaction judgment is believed to be formed as a summary of equity/inequity of one's own outcome relative to the other party's outcome, given input (Guillermina, 1980). Key to this comparison is the perception of fairness as it explicitly implies a form of distributive justice whereby individuals get what they deserve based on their inputs (Cook & Messick, 1983). Accordingly, and in line with previous findings, we hypothesize that: 120

H8: The better the patients perception of distributive justice, the greater will be its satisfaction with the services provided. 3.3.5 Hypotheses Concerning Moderating Variables

A premise of social psychological theory strongly suggests that patients' differences influence their attitudes (B. Williams, et al., 1998). The underlying premise is that people differ in their orientations towards care because of social, cultural, and otherwise distinct orientations to which they associate themselves (Fox & Storms, 1981). According to social identity theory, attitudes are moderated by demographic, situational, environmental, and psychosocial factors (Haslam, McGarty, & Oakes, 1993; Jackson & Hodge, 1996; Platow, et al., 1997). Further, interpretations of these factors are moderated by individual beliefs, perceptions, and frames of reference that are affected by cultural orientations (Carr-Hill, 1992; Cothern & Collins, 1992 ). Patients attitudes towards the care that they receive are potentially complex and multifaceted. As a result, discernible social and psychological differences between patients and providers, as well as physiological differences, can be expected to influence variations in patients attitudes (J. L. Tucker, 2002). This dissertation proposes a model of satisfaction in which patients sociodemographic characteristics do not influence patients satisfaction directly but can affect the form of the relationship between the delivery system attributes and satisfaction. The present study will focus on the moderating roles of three patients sociodemographic characteristics that have the most consistent relationship with patient satisfaction, namely: age, income and gender (J. L. Tucker, 2002; J. L. Tucker & Kelley, 2000). Accordingly, and in line with previous argumentation and findings, we hypothesize that:

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H9a: The impact of physician care on patient satisfaction will be higher for older patients than for younger patients. H9b: The impact of access to care on patient satisfaction will be higher for older patients than for younger patients. H9c: The impact of atmospherics of care on patient satisfaction will be lower for older patients than for younger patients. H9d: The impact of price of care on patient satisfaction will be lower for older patients than for younger patients. H10a: The impact of physician care on patient satisfaction will be lower for upper income patients than for lower income patients. H10b: The impact of access to care on patient satisfaction will be higher for upper income patients than for lower income patients. H10c: The impact of atmospherics of care on patient satisfaction will be higher for upper income patients than for lower income patients. H10d: The impact of price of care on patient satisfaction will be lower for upper income patients than for lower income patients. H11a: The impact of physician care on patient satisfaction will be lower for male patients than for female patients. H11b: The impact of access to care on patient satisfaction will be higher for male patients than for female patients. H11c: The impact of atmospherics of care on patient satisfaction will be lower for male patients than for female patients. H11d: The impact of price of care on patient satisfaction will be lower for male patients than for female patients. 122

3.4 Research Model and Hypotheses: Conclusion

Figure 4 presents the global overview of the research model and the research hypotheses.

Figure 4: Research Model and the Hypotheses

The value of the research model and proposed hypotheses is twofold. First, although comparable models exist in the literature, the research model represents the first model of outpatient 123

satisfaction to be elaborated and tested in the Lebanese context. In this new model, we underscore the impact of some key elements of healthcare on the formation of the patient satisfaction response; specifically, we emphasize the impact of distributive justice, something that has not been done previously. Second, although the majority of the proposed hypotheses were tested in previous studies in healthcare service environment, hypotheses (H7, H8) are empirically examined for the first time.

Table 10 presents the summary of the research hypotheses.

Table 10: Hypotheses of the present study Relationship Studied in the Hypothesis Hypothesis Formulation of the Hypothesis

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The better the patients perception of the physician care, Impact of physician care on patient H1 satisfaction with the services provided. Impact of physician care on service H2 quality Impact of service quality on patient H3 satisfaction with the services provided. Impact of access to care on patient H4 satisfaction with the services provided. Impact of atmospherics of care on H5 patient satisfaction with the services provided. Impact of price of care on patient H6 satisfaction with the services provided. Impact of price of care on distributive H7 justice Impact of distributive justice on patient H8 satisfaction with the services provided. provided. Moderating role of age on the The impact of physician care on patient satisfaction will relationship between physician care and H9a patient satisfaction with the services provided. Moderating role of age on the relationship between access to care and H9b patient satisfaction with the services provided. Moderating role of age on the The impact of atmospherics of care on patient relationship between atmospherics of H9c care and patient satisfaction with the younger patients. H9d services provided Moderating role of age on the The impact of price of care on patient satisfaction will be satisfaction will be lower for older patients than for be higher for older patients than for younger patients. The impact of access to care on patient satisfaction will be higher for older patients than for younger patients. the greater will be its satisfaction with the services the better will be its perception of distributive justice. The better the patients perception of distributive justice, provided. The better the patients perception of the price of care, the greater will be its satisfaction with the services provided. The better the patients perception of the atmospheric of care, the greater will be its satisfaction with the services provided. The better the patients perception of the price of care, the greater will be its satisfaction with the services greater will be its satisfaction with the services provided. The better the patients perception of the access to care, the better will be its perception of the service quality. The better the patients perception of service quality, the provided. The better the patients perception of the physician care, the greater will be its satisfaction with the services

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relationship between price of care and patient satisfaction with the services provided. Moderating role of income on the The impact of physician care on patient satisfaction will relationship between physician care and H10a patient satisfaction with the services income patients. provided. Moderating role of income on the The impact of access to care on patient satisfaction will relationship between access to care and H10b patient satisfaction with the services income patients. provided. Moderating role of income on the The impact of atmospherics of care on patient relationship between atmospherics of H10c care and patient satisfaction with the for lower income patients. services provided. Moderating role of income on the The impact of price of care on patient satisfaction will be relationship between price of care and H10d patient satisfaction with the services patients. provided. Moderating role of gender on the relationship between physician care and H11a patient satisfaction with the services provided. Moderating role of gender on the relationship between access to care and H11b patient satisfaction with the services provided. Moderating role of gender on the The impact of atmospherics of care on patient relationship between atmospherics of H11c care and patient satisfaction with the female patients. H11d services provided. Moderating role of gender on the relationship between price of care and The impact of price of care on patient satisfaction will be lower for male patients than for female patients. satisfaction will be lower for male patients than for be higher for male patients than for female patients. The impact of access to care on patient satisfaction will be lower for male patients than for female patients. The impact of physician care on patient satisfaction will lower for upper income patients than for lower income satisfaction will be higher for upper income patients than be higher for upper income patients than for lower be lower for upper income patients than for lower lower for older patients than for younger patients.

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patient satisfaction with the services provided.

Chapter 4: Methodologies & Outcomes


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Patient satisfaction, once considered a soft indicator used primarily by marketing departments, has become an integral component of strategic organization and healthcare quality management - Urden (2002). Now that the research framework has been presented, the different variables defined and the research hypotheses introduced, the data analysis and the statistical validation of the hypotheses will be addressed in Chapter 4. An overview of the quantitative study is first proposed in section 4.1. More specifically, an explanation and justifications of choices followed during the research project are introduced. Then, the different measurement scales of the modeled variables are presented in section 4.2. Methodological and/or statistical evidence of the relevance of the 127

different scales used in the study were provided in section 4.3. In section 4.4 the hypotheses are tested and results discussed. Finally, the chapter is concluded in section 4.5.

4.1 Characteristics of the Quantitative Study

In order to test the research hypotheses, a quantitative survey was carried out in MLC. 4.1.1 Questionnaire Design To collate the right data a questionnaire was designed. Objectives of questionnaires are to provide an answerable set of questions, encourage participation while keeping the response error (inaccurate answers, misrecordings and misanalysis) to a minimum (Malhotra & Birks, 2006). Hence, great care was given to the wording, ordering of the questions, instructions, perception of anonymity and confidential treatment of responses. It was also important to avoid implicit assumptions, generalizations and estimations. The questionnaire was made up of different parts each fulfilling a special purpose and containing the subsequently described measuring scales. 4.1.2 Test of the Questionnaire 128

According to Malhotra, a pre-test of a questionnaire should always be done to control its quality (Malhotra & Birks, 2006). Ideally pre-tests should be done through personal interviews, with a pool of test candidates that should be a fair representation of the overall sample and typically ranging from 15-30 candidates (Malhotra & Birks, 2006). As the survey instrument was originally in English, translation to Arabic was performed by the researcher and then checked and corrected by two instructors: an Arabic language teacher and a marketing professor. An initial pre-test on 15 interviewees was carried out. The actual conditions of the data collection were reproduced. Interviewers were asked to highlight any problems they found in the questionnaire. Following this test, the formulation of 3 items, which appeared to be imprecise or equivocal, was modified. The new version of the questionnaire was tested on 15 other interviewees in order to verify the relevance of these modifications. Respondents confirmed questions clarity and understandability. The questionnaire is presented in appendix 3. 4.1.3 Selecting the Appropriate Sampling Design

Sampling was defined as a process of selecting a subset of randomized number of members of the population of a study and collecting data about their attributes. The limited members of the population selected for sampling are called as sampling units. Based on the data of the sample, the analyst will draw inference about the population (Panneerselvam, 2004 ).

A. Identification of the Target Population At the outset of the sampling process, it is vitally important to carefully define in the first stage the target population so the proper source from which the data are to be collected can be identified (Zikmund, 2000). In research methods, a target population was defined as a specific, complete group of entities sharing some common set of characteristics and relevant to the 129

research project (Zikmund, 2000). In this study, the target population consisted of all outpatients whose ages were 16 and above (because respondents at this age were mature enough to answer questions independently), and who attended MLC between July 22, 2011 August 23, 2011 for a physician consultation.

B. Selecting of a Sampling Method The second sampling decision requires the researcher to choose how the sampling units are to be selected (Zikmund, 2000). Sampling techniques could be classified into probability sampling technique and nonprobability sampling technique (Panneerselvam, 2004 ).

1) Non Probability Sampling Technique Non probability sampling technique is a judgment sampling in which the units are selected on the advice of some experts or by the intuition / opinion of the researcher himself (e.g., a test plant is selected because it appears to be typical) (Panneerselvam, 2004 ). In this sampling method, there is more chance of personal biases than in the probability sampling technique. Moreover, there are no appropriate statistical techniques for measuring random sampling error from a non probability sample. Thus projecting the data beyond the sample is statistically inappropriate. Examples of non probability sampling include: Convenience Sampling, Judgment Sampling, Purposive Sampling, Quota Sampling, Snowball Sampling, etc (Zikmund, 2000).

2) Probability Sampling Technique In probability sampling, each unit of the population has an equal and non zero probability of being selected as a unit of the chosen sample (Panneerselvam, 2004 ). The advantage of probability sampling is that it allows the researcher to calculate the likely degree of error in 130

extrapolating findings from the study sample to the wider population. Examples of probability sampling include: cluster sampling, stratified sampling, simple random sampling, multistage sampling, and systematic sampling (Zikmund, 2000). Given that, in this study we need to calculate the likely degree of error in extrapolating findings from the study sample to the wider population, it leaves us no other choice than to choose the probability sampling technique (simple random sampling) as the appropriate sampling procedure for this study. In simple random sampling, each individual is chosen randomly and entirely by chance, such that each individual has the same probability of being chosen at any stage during the sampling process, and each subset of k individuals has the same probability of being chosen for the sample as any other subset of k individuals (Yates, Moore, & Starnes, 2008). 4.1.4 Sampling In order to guarantee the collection of a minimum of n =385 usable responses (3.60% of the total population4 of N=10690), the researcher distributed 600 copies of the questionnaire. This size seemed appropriate for multiple linear regression (a statistical technique that shall be further employed for hypothesis-testing) and avoid the statistical bias of small samples (Green, 1991; Joseph F. Hair, Black, Babin, Anderson, & Tatham, 2006). To ensure consistency in the administration of the survey, the survey was given to all attendees in the following way: one new employee who was recruited as data collector (he was properly briefed about the study objective and the questionnaire) handled the survey to each patient at the end of his visit, and asked him/her if he/she would voluntarily accept to complete the questionnaire before leaving MLC premises. After completeness, each questionnaire was given back to the employee.

Aged 16 and above

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All the respondents were clearly informed that the focus of this study was specifically related to the visit they just had. Accordingly, they were instructed to ignore any form of responses (cognitive/affective/behavioral) they might have previously developed toward an earlier visit to MLC. The researcher supervised the data collecting employee who was present at all times when the participants completed the questionnaires, and assisted him in responding to patients inquiries. A total of 600 questionnaire copies were distributed, and 447 responses collected.

The descriptive statistics of the sample showed that it was truly representative of the main characteristic of actual patients profiles existing in MLCs database (review Appendix 4)5. 4.1.5 Survey Fieldwork The field study took place between July 22, 2011 and August 23, 2011. One employee, who was supervised on a daily basis during the whole period of the data collection process, was full time recruited and trained to collect the data. The employee handled the questionnaire to each patient at the end of his visit, and asked him/her if he/she would voluntarily accept to complete the questionnaire before leaving MLC premises. After completing the questionnaire, the patient handled it back to the new employee who will check its whole completeness. In the event of missing data or unclear information, the questionnaire was rejected. All participants in the survey were given a covering letter (review Appendix 2) including information such as the organization behind the study, the contact name and telephone number of the researcher, details of how and why the respondent was selected, the aims of the study, and

MLCs database includes only basic information on its patients profiles. Thus, the analysis is limited to age and gender.

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what will happen to the information provided. Furthermore, it was clearly expressed that the respondents names and identities will remain anonymous.

4.2 Measurement and Scaling

A researcher who needs scales for his/her study has two options. The first approach consists in using a scale which has already been validated by previous research. When this is not possible or inappropriate, the second option is to develop and validate a specific scale. This study exclusively leveraged previously validated scales, principally for measuring distributive justice and healthcare service quality. 4.2.1 Reflective Scales

4.2.1.1 Measuring Distributive Justice

Over the years, different measures were used to capture distributive justice within various context e.g. ((Kumar, Scheer, & Steenkamp, 1995; R.L. Oliver & Swan, 1985; R. L. Oliver & J. 133

E. Swan, 1989; Ramaswami & Singh, 2003; Tax, 1993; Tax, Brown, & Chandrashekaran, 1998)). This dissertation utilized the multi-item subjective scale of McCollough (review Appendix 3) to measure distributive justice (McCollough, Berry, & Yadav, 2000). The reasons were twofold:

First, this scale was developed in a service context (airline travel); thus, it is possible to apply it to another sector of the service industry (healthcare) with minor modifications. Second, since both the fairness interpretation of equity and the preference interpretation of advantageous inequity were hypothesized specifically as intervening constructs in the satisfaction framework, efforts were made to develop straightforward elementary scales of each and hence a potential confounding between the domains of fairness/preference and satisfaction. Accordingly, the construct was operationalized using four items measured on a seven-point Likert scale ranging from (1) strongly disagree to (7) strongly agree (review Appendix 3). The items are summed to arrive at an individuals overall perceptions of the fairness of the distribution of outcomes, with higher scores reflecting better perception of distributive fairness. Words of the individual items were adapted to go well with the healthcare services of this research project. Parasuraman et al. pointed out that such adaptations are common and do not represent difficulties regarding reliability and validity of the survey instrument (Parasuraman, et al., 1988). 4.2.1.2 Measuring Healthcare Service Quality: The Choice of SERVPERF To measure healthcare service quality we referred to the premiere instruments used by researchers to measure perceived service quality i. e., SERVQUAL and SERVPERF (Van Dyke, Prybutok, & Kappelman, 1999; Whitten, 2004). They have a rich tradition in the marketing 134

literature and have been validated numerous times in subsequent studies of healthcare quality across different developed and developing countries of the world (e.g., (E. Anderson, 1995; Hibbard, Sofaer, & Jewett, 1996; McAlexander, Kaldenburg, & Koenig, 1994) in the USA; (Lam, 1997) in Hong Kong; (Martinez Fuentes, 1999) in Spain; (Lim & Tang, 2000) in Singapore; (Jabnoun & Chaker, 2003) in the UEA; (Sohail, 2003) in Malaysia; (Mostafa, 2005) in Egypt).

The SERVQUAL (Service Quality) scale was build up based on a marketing perspective with the support of the Marketing Science Institute (Parasuraman, Zeithaml, & Berry, 1986). Its purpose was to provide an instrument for measuring service quality that would apply across a broad range of services with minor modifications in the scale. The developers of the scale contend that, while each service industry is unique in some aspects, there are five dimensions of service quality that are applicable to service-providing organizations in general (A. Parasuraman, V. A. Zeithaml, & L. L. Berry, 1988). These dimensions are:

(1) Tangibles- appearance of physical facilities, equipments, personnel and communication materials (4 items). (2) Reliability -ability to perform the promised service dependably and accurately (5 items). (3) Responsiveness willingness to help customers and provide prompt service (4 items). (4) Assurance-knowledge and courtesy of employees and their ability to inspire trust and confidence (4 items). (5) Empathy -caring, the individualized attention the firm provides its customers (5 items).

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In its final form, SERVQUAL contains 22 pairs of items. Half of these items are intended to measure consumers) expected level of service for a particular industry (expectations). The other 22 matching items are intended to measure consumer perceptions of the present level of service provided by a particular organization (perceptions). Both sets of items are presented in seven point Likert response format, with the anchors "strongly agree" and "strongly disagree." Service quality is measured on the basis of the difference scores by subtracting expectation scores from the corresponding perception scores (on the basis of the expectancy-disconfirmation paradigm).

The preceding aspect of the administration of SERVQUAL has been criticized on the grounds that there is little if any theoretical or empirical evidence supporting the expectation-performance gap as a predictive measure of service quality (Babakus & Boiler, 1992; R. N. Bolton & J. H. Drew, 1991; J.M. Carman, 1990). For instance, Cronin and Taylor asserted that some features (such as pleasure, for example) could not be measured by the simple arithmetic difference between perceptions and expectations (Cronin & Taylor, 1994). Cronin and Taylor asserted that the use of the performance battery of SERVQUAL would be a richer construct in measuring the multifaceted nature of service quality (Cronin & Taylor, 1992, 1994). This scale called SERVPERF (Service Performance) would measure service quality of an organization using the following equation: [Q= P, x]. Where (Q) represents consumers perceived service quality and (P) consumers performance rating of x statement (x=1 22). Using a 7 point Likert scale, with ends anchored by the labels Strongly Disagree (value 1) and Strongly Agree (value 7), Cronin and Taylor conclude that SERVPERF out-performed SERVQUAL in terms of reliabilities, and it reduces by 50% the number of items that must be measured (from 44 items to 22 items).

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In deciding whether to use SERVQUAL or SERVPERF, one must consider the selection of the most appropriate one. The perceptions-only operationalization is appropriate if the primary purpose of measuring service quality is to attempt to explain the variance in some dependent construct, while the perceptions-minus-expectations difference score measure is appropriate if the primary purpose is to diagnose accurately service shortfalls (V.A. Zeithaml, et al., 1996). Since the purpose of this research is to examine the variance in the patients satisfaction outcomes, therefore the perceptions only measure is used. Hence, the SERVPERF instrument proposed and validated by Saxena (Saxena, 2009) is used in this study (review Appendix 3). The only deviation from the Saxena modified SERVPERF instrument was the change of the term Hospital to Clinic. It is worth mentioning that in the current study service quality is measured broadly as a second order factor (not at dimension level). Although this approach reflects a relatively new direction in service quality research that differs from the traditional Servqual / Servperf conceptualization which dominated service quality research (Janda, Trocchia, & Gwinner, 2002 ), it seemed to be a more appropriate to follow since the service quality construct is hierarchical in nature (Brady & Cronin, 2001) and comprises three levels (from top to bottom): customers overall perceptions of service quality, primary dimensions, and sub-dimensions (Dabholkar, Thorpe, & Rentz, 1996). Furthermore, this treatment of the service quality measure is consistent with earlier studies in healthcare literature (e.g. (Akter & Hani, 2011; H. Wong & Chang, 2012 )). 4.2.2 Formative Scales

Management scholars often identify structural relationships among latent, unobserved constructs by statistically relating covariation between the latent constructs and the observed variables or indicators of the latent constructs (Borsboom, Mellenbergh, & Heerden, 2003, 2004). This 137

allows scholars to argue that if variation in an indicator X is associated with variation in a latent construct Y, then exogenous interventions that change Y can be detected in the indicator X. Most scholars assume this relationship between construct and indicator is reflective. In other words, the change in X reflects the change in the latent construct Y. With reflective (or effect) measurement models, causality flows from the latent construct to the indicator. However, not all latent constructs are entities that are measurable with a battery of positively correlated items (Edwards & Bagozzi, 2000). A less common, but equally plausible approach is to combine a number of indicators to form a construct without any assumptions as to the patterns of intercorrelation between these items. A formative or causal index results (Diamantopoulos & Winklhofer, 2001), where causality flows in the opposite direction, from the indicator to the construct (review Figure 5). In this case, the change in the latent construct (Y) reflects the change in the formative indicator (X) (Jarvis, MacKenzie, & Podsakoff, 2003). The formative items cause the index rather than the other way around (Rossiter, 2002).

Figure 5: Diagram of Reflective and Formative Measurement Models

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Source: Bollen & Lennox, Conventional Wisdom on Measurement: A Structural Equation Perspective, Psychological Bulletin (110:2), 1991, pp 305-314.

Constructs themselves are inherently neither formative nor reflective, the researcher often has a choice between formative and reflective measurement (Wilcox, Howell, & Breivik, 2008). It is the final goal of the researcher that determines which operationalization approach should be adopted (Jarvis, et al., 2003; Petter, Straub, & Rai, 2007). For instance, in case a researcher wants to test theories with respect to satisfaction, the reflective approach should be adopted. On the other hand, in managerially oriented business studies where we want to find out what are most important drivers of satisfaction that ultimately lead to the retention of a customer, the formative approach should be adopted (Albers & Hildebrandt, 2006). In either case, it is critical that the conceptualization and operationalization of a construct match if it is conceptualized formatively, then it is measured formatively and vice versa (C. Fornell & Bookstein, 1982). Based on all the above, the constructs that represent the four dimensions of the healthcare experience that were identified in the qualitative pilot study as key drivers of patient satisfaction were conceptualized and measured formatively as well. Accordingly, for each of the four dimensions, an index that is made up by calculating the average score of items that operationalize the corresponding dimension was created. Each factor (facet) of the corresponding dimension was measured with a single item of the index (review Table 11). Respondents were asked to respond to these items on a seven-point Likert-type scale ranging from strongly disagree (1) to strongly agree (7). Thus, the higher numbers indicated higher attribute reactions (better perception of the healthcare attribute).

This treatment for measuring the patients perception of the healthcare attributes is identical with earlier studies (e.g. (Oswald, Turner, Snipes, & Butler, 1998; Otani, et al., 2005)). In other 139

words, creating an index for each of the healthcare dimensions seems to be common practice. Otani attributed a composite index for each attribute as the mean of the items that measure that attribute. Thus, the method is considered to be appropriate.

Table 11: Measurement of formative scales Healthcare Service Dimensions Factors Item Description

Receptionist Personal Behavior

Access to Care

The receptionist employee was courteous Waiting Time I did not wait for a long period before being seen by the physician for my scheduled appointment Convenience of the operating hours The operation hours are convenient for me. Effort Required to Get an It was easy to schedule an appointment for the outpatient visit. Appointment Parking convenience The clinic provides appropriate car parking facilities. 5

Total number of items

140

Competence Accuracy Empathy Physician Care Courtesy Communication Total number of items Price of Care Total number of items 5 Perceived Monetary Price Perceived Non Monetary Price 2 Cleanness Equipments' modernity Atmospheric of Care

The physician has the needed knowledge to take care of me. The physician was attentive to the details of my medical condition. The physician considered my individual feelings when treating my condition. The physician has a friendly attitude. I received adequate information, so I know what to do when I get home. The monetary price I paid for the service is cheap. The non monetary price I paid for the service is inexpensive. The waiting room was clean. The apparatus in the clinic are modern. The clinics landscape design is visually appealing. There was a fresh air in the clinic. The hearing environment was controllable.

Physical appearance of the setting Air freshness Sounds

Total number of items

4.2.3 Mono Item Scales

4.2.3.1 Measuring Age The moderating variable age was measured on a continuous scale by one item in the questionnaire. Patients were asked to state their age in completed years as of their last birthday before the survey date. As per survey inclusion criteria, all respondents were at least 16 years of age. 4.2.3.2 Measuring Income The moderating variable income was measured on a continuous scale by one item in the questionnaire. Patients were asked to state their monthly household income in US dollars. 141

4.2.3.3 Measuring Gender The moderating variable gender was measured on a nominal scale by one item in the questionnaire. Patients were asked to indicate their gender (Male or Female). 4.2.3.4 Measuring Patient Satisfaction The literature review revealed that many definitions of patient satisfaction have been put forward (Gill & White, 2009; Hawthorne, 2006). Especially, satisfaction has been defined as both a cognitive and an affective concept. Transaction-specific and cumulative visions of satisfaction have also been debated. In the present study, patient satisfaction is considered as a cognitive affective response (review section 1.2.3); also, the patient is considered as a consumer of healthcare services (review section 1.2.2). Consequently, the cognitive - affective measure of consumer satisfaction proposed by Ladhari was used in this study (Ladhari, Ladhari, & Morales, 2011). The satisfaction variable included one item in the questionnaire that asked the patient's overall satisfaction with the services provided (review Table 12).
Table 12: Measurement of patient satisfaction

Overall, I am satisfied with the services provided


Strongly Disagree (1) Disagree (2) Somewhat Disagree (3) Undecided (4) Somewhat Agree (5) Agree (6) Strongly Agree (7)

Although debates in the literature support multi-item scales, because they have better psychometric qualities (G. A. Churchill, 1979). However, researchers in the field of satisfaction have shown that mono-item scales present sufficient psychometric properties (Kekre, Krishnan, & Srinivasan, 1995; LaBarbera & Mazursky, 1983; Yi, 1990). Moreover, this treatment of the overall patient satisfaction measure is consistent with earlier studies in healthcare literature (e.g.

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(Dolinsky & Caputo, 1990; Hansen, Peters, & Viswanathan, 2008; Otani & Kurz, 2004)). In other words, this method is considered to be appropriate.

4.3 Scales Validation Multi-item scales need to be checked for accuracy and applicability. Due to the utilization of a previously validated scale, the upcoming section sticks to the fundamentals of scales validation 6. To verify quality of adjustment to data various indices based on recommendations of Hu and Bentler, and Jreskog and Srbom are presented (L. Hu & Bentler, 1999; L. T. Hu & Bentler, 1998; Jreskog & Srbom, 1989). To assess the reliability of the SERVPERF and distributive justice scales, Cronbachs Alpha and Jreskogs Rh are shown (Cronbach, 1951, 1960; Jreskog, 1971). While in-depth validity assessment is beyond the scope of this project and was examined by scholars previously, content, criterion and construct validity are briefly checked
6

Depending on the statistic either SPSS 17 or AMOS 16 was used in this study.

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(for SERVPERF and distributive justice). Diamantopoulos and Winklhofers guidelines for index construction are followed for the access to care, atmospheric of care, physician care and price of care indexes (Diamantopoulos & Winklhofer, 2001). 4.3.1 Reflective Scales

-First and Second Order Confirmatory Factor Analyses

If a scale has been used previously, then a testable a priori measurement model can reasonably be presumed to exist, and a confirmatory approach is the preferred analysis (Hunter & Gerbing, 1982). Accordingly, confirmatory factor analyses were conducted using AMOS (version 16) to verify whether the earlier established factor structures fits to the data. The program adopted the maximum likelihood estimation to generate estimates in the measurement model. A key assumption for this method is multivariate normality for the exogenous variables (Byrne, 2001). Model fit is statistically calculated and represented through indices which show how well the underlying factor structure explains pattern of correlations or covariances. In other words, it tests if there is an association between latent variable and the measured items that it is supposed to be related to (Byrne, 2001).

While in the first order CFA models, the researcher specifies just one level of factors that are correlated and assumes that the factors, although correlated, are separate constructs (Millan & Esteban, 2004 ); in the second order CFA, the researcher assumes that the first-order factors estimated are actually sub-dimensions of a broader and more encompassing second-order factor (J.F. Hair, Babin, Money, & Samouel, 2003). This second-order factor is completely latent and unobservable. There are two unique characteristics of the second-order model: first, the second144

order factor becomes the exogenous construct, whereas the first-order factors are endogenous; second, there are no indicators of the second-order factor (Byrne, 2001).

The first of the indices is the root mean square error of approximation (RMSEA) which dates back to Steiger and Lind (1980). It ranges from 0 to 1. Smaller values indicate better fit. According to Browne and Cudeck (1993) a value below 0.08 is acceptable. Usually though a stricter heuristic, of lower 0.06, is applied. The standardized root mean square residual (SRMR) is the second of the indices. It ranges from 0 to 1. A value below 0.10 shows satisfactory model fit (Kline, 1998). A more stringent cut-off below 0.05 is however recommendable. The Bentler and Bonetts (1980) non normed fit index (NNFI) and the comparative fit index (CFI) were also calculated. Both indices have similar thresholds for indicating acceptable model fit. Larger values are better. The resulting value should be close to 1 and ideally above 0.950. Kline (1998) considers a (CFI) value above 0.900 as fair. Due to popularity and despite possible limitations those indices were complemented by the goodness of fit index (GFI) and the adjusted goodness of fit index (AGFI) (Jreskog and Srbom, 1989). Both should be higher than .900 (Jreskog and Srbom, 1989). Values that meet the described constrains are viewed as satisfactory, although a convergence of the different indicators is considered to be beneficial.

Table 13: Results of the first order confirmatory factor analysis (distributive justice) Results Distributive Justice (First Order CFA ) 0.038 0.052 0.893 0.913 0.923 0.919

Indices RMSEA SRMR NNFI CFI GFI AGFI

Standard Heuristics < 0.05 < 0.1 > 0.9 >0.9 >0.9 >0.9

Table 14: Results of the first and second order confirmatory factor analysis (SERVPERF)

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Model With 5 Factors (First order CFA) RMSEA SRMR NNFI CFI GFI AGFI
0.048

Model With 6 Factors (Second order CFA)


0.023

Standard Heuristics

< 0.05
< 0.1 > 0.9 > 0.9 >0.9 >0.9

0.023 0.785 0.910 0.850 0.810

0.014 0.910 0.977 0.925 0.910

While the results summarized in Table 13 showed a highly acceptable quality of adjustment for distributive justice, those in Table 14 showed that it was possible to improve the model fit for service quality by considering service quality as a second order construct composed of five primary dimensional factors which is in line the recommendations of Brady and Dabholkar (Brady & Cronin, 2001; Dabholkar, et al., 1996). Further model modification was not necessary, as the second-order confirmatory factor analysis model for service quality had model fit indices that were more than satisfactory.

- The Assessment of Reliability

Reliability is about the degree to which measures (scales) are free from error and therefore yield consistent results over time and situations (Malhotra & Birks, 2006). A scale is internally consistent to the extent that its items are highly inter-correlated (DeVellis, 1991). Higher consistency in responses among the items forming a scale and / or dimension leads to a higher coefficient alpha. Cronbachs alpha, is one method to measure internal consistency of different items forming a scale. It is the average of all possible split-half coefficients (Malhotra & Birks, 2006). Values of the coefficient alpha range from 0 to 1, the higher the score the higher the consistency. There are different thresholds indicating a sufficient Cronbachs alpha. Nunnally started out recommending a score above .50 (Nunnally, 1967). The scholar increased it to .70 146

several years later (Nunnally, 1978). Malhotra recently commented that a value of .60 or less is not considered to be satisfactory at large (Malhotra & Birks, 2006). Thus the internal consistency gate of this research was set according to Nunnally (1978) at .70. One of the weaknesses of the coefficient alpha is that it tends to rise as the number of items in the scale increase (Malhotra & Birks, 2006). For this contingency Jreskogs Rh was also calculated (Jreskog, 1971). It is known to overcome described limitations. Akin with the previous method a value close to 1 indicates that the scale is reliable.

Table 15: Reliability of the distributive justice & SERVPERF scales


Scales Results Coefficient Cronbachs alpha Jreskogs rho Distributive Justice 0.811 0.828 SERVPERF 0.702 0.809 Standard Heuristics > 0.7 1

The distributive justice and SERVPERF scales reliability coefficients are acceptable. The Cronbachs alpha of distributive justice is in accord with the Cronbachs alphas of earlier studies, for example 0.83 (McCollough, et al., 2000). Similarly, SERVPERF outcomes are in line with the Cronbachs alphas of earlier studies, for example 0.74 to 0.83 (Fogarty, Catts, & Forlin, 2000) and 0.703 to 0.854 (Vazifedost & Taghipouryan, 2011).

- The Assessment of Validity

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While reliability is a necessary condition for validity; the proof of reliability in itself is not sufficient: an instrument needs to be valid as well (G. A. Churchill, 1979; Nunnally, 1967). Validity refers to whether were really measuring the concept that we intended to measure (Malhotra & Birks, 2006). In its truest sense, validity refers to how well were measuring some underlying construct. Are we measuring what we think that were measuring? The validity of the construct is explored by investigating its relationship with other constructs, both related (convergent validity) and unrelated (discriminant validity), and collecting empirical evidence on the validity of the context, criterion and construct (Pallant, 2007).

Content Validity

Content validity (or face validity) as defined by Malhotra and Birks is a subjective but systematic evaluation of the representativeness of the content of a scale for the measuring task at hand (Malhotra & Birks, 2006). It refers to extent of the measures representation of the concept of information system usage, or in other words the samples representativeness of the population (Pallant, 2007). This validity may not be measured by statistical indicators. Usually, the researcher herself / himself evaluates whether the items proposed cover the entire domain of the construct (Malhotra & Birks, 2006). In this dissertation, only validated scales (distributive justice and SERVPERF), already used in several studies and checked by several scholars, were applied (review all previous sections). Furthermore, the researcher and a marketing scholar qualitatively double-checked the appropriateness and completeness of adapted items. On this basis, it is concluded that content validity was adequately established. 148

Criterion Validity

Criterion validity examines whether a measurement scale performs as expected in relation to other variables selected as meaningful criteria (Malhotra & Birks, 2006). Other variables might include all other scales, demographic and psychographic information (Malhotra & Birks, 2006). It is commonly assured at the hypotheses testing stage. It implies that variables behave as theoretically expected which they do in this dissertation mostly (review chapter 3 hypotheses and section 4.4 hypotheses testing).

Construct Validity

Construct validity addresses the question of what construct or characteristic the scale is, in fact, measuring (Malhotra & Birks, 2006). In other terms, construct validity refers to the evidence that a particular construct or measure, adequately accounts for what it is built to measure. Campbell and Fiske recommend analyzing discriminant and convergent validity when examining construct validity (Campbell & Fiske, 1959). Discriminant validity is the degree to which measures of different concepts are distinct while convergent validity is the degree to which multiple attempts to measure the same concept are in agreement (R. P. Bagozzi & Yi, 1991). The objective of this dissertation was not to re-validate established scales. Measures at hand were already successfully examined for construct validity (e.g. (Cronin & Taylor, 1994; Parasuraman & Zeithaml, 1994)) and re-tests were performed in the field typically (e.g. (Yoo, 2005)). Hence, efforts regarding construct validity were kept to a minimum.

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a) Discriminant validity Malhotra and Birks suggested that discriminant validity is useful in assessing "the extent to which a measure does not correlate with other constructs from which it is supposed to differ" (Malhotra & Birks, 2006). Since the purpose of this study is not to better understand challenges between either distributive justice or SERVPERF and their closely related constructs from which they should differ, there was no need to analyze discriminant validity.

b) Convergent validity With regard to the assessment of convergent validity, Bagozzi and Yi suggested to analyze two levels of evidence. Those are complementary methods. The first is named weak evidence of convergent validity. The second is called strong evidence of convergent validity. Weak evidence for convergent validity results when the factor loading on a measure of interest is statistically significant. Strong evidence for convergent validity is achieved when at least half of the total variation is due to traits (R. P. Bagozzi & Yi, 1991). Table 16 highlights that weak evidence of convergent validity for the distributive justice and SERVPERF scales are provided significantly (p < 0.001).

Table 16: Distributive Justice and SERVPERF models estimates Parameter Estimate Distributive Justice SERVPERF 0.558 0.679 Standard Error 0.058 0.051 T Statistic 9.597 13.281 p-value 0.000 0.000

Fornell and Larcker suggested an approach that is usually used to assess the strong evidence for convergent validity (C. Fornell & Larcker, 1981). The method consists in calculating the

variance shared by the measured concept with its items. This indicator is typically termed the p 150

cv (Joreskog rho). If the p cv is inferior to 50%, it means that the latent variable (the concept) shares less than 50% of its variance with its items. In this case, measurement errors explain the greater part of the variance. Oppositely, if the p cv is superior to 50%, the latent variable shares more than 50% of its variance with the items. Measurement errors explain less than 50% of the variance. Thus, it is considered that strong evidence for convergent validity is ensured when the p cv is superior to 50%. Table 17 highlights that Strong evidence of convergent validity can be attested.

Table 17: Strong evidence of convergent validity

Joreskog rho (Rho VC)

Scales Results Distributive Justice SERVPERF 0.543 0.517

Standard Heuristics > 0.5

In consideration of the weak evidence findings, convergent validity of the constructs are established adequately.

4.3.2 Formative Scales

The traditional approaches of reliability and validity assessment are not meaningful for indexes (Petter, et al., 2007). Thus, the guiding principles for construing indexes of Diamantopoulos and Winklhofers (2001) which involve content and indicator specification, indicator collinearity and external validity were executed. 151

- Content and Indicator Specification Content specification is about the scope of the latent variable e.g. physician care. It needs to be defined holistically to avoid the exclusion of parts (Diamantopoulos and Winklhofer, 2001). This part is closely linked with the specification of the items forming the index. Including all important items is essential as exclusion would lead to missing parts of the construct itself (Diamantopoulos and Winklhofer, 2001). The literature review clearly discussed each determinant and its framework. Consequently, the parameters of content and indicator specification are considered to be sufficiently met.

- Indicator Collinearity Before creating the index, it has to be checked that no problems with multicollinearity exist. The maximum variance inflation factor (VIF) of 1.39 of this study is far below the common cut-off threshold of 10 (Kleinbaum, Kupper, & K.E., 1988); thus, showing the absence of multicollinearity (review Table 18). Hence, all items per dimension are retained.

Table 18: Multicollinearity of items measuring patient satisfaction with healthcare dimensions

Physician Care unadjusted R2 1- R2 VIF= 1/(1- R2) PHC 1 0.058 0.942 1.061 PHC 2 0.166 0.834 1.199 PHC 3 0.022 0.978 1.022 PHC 4 0.279 0.721 1.386 PHC 5 0.132 0.868 1.152 2 2 NOTE: R is the unadjusted R when we regress PHCi against all the other explanatory variables (items) in the model. Access to Care ACC 1 unadjusted R2 0.092 1- R2 0.908 VIF= 1/(1- R2) 1.101 152

ACC 2 ACC 3 ACC 4 ACC 5 Atmospheric of Care ATC 1 ATC 2 ATC 3 ATC 4 ATC 5 Price of Care PRC 1 PRC 2

0.004 0.128 0.011 0.117 unadjusted R2 0.055 0.243 0.095 0.012 0.085 unadjusted R2 0.052 0.190

1.004 0.872 1.011 0.883 1- R2 0.945 0.757 0.905 0.988 0.915 1- R2 0.948 0.810

0.996 1.147 0.989 1.133 VIF= 1/(1- R2) 1.058 1.321 1.105 1.012 1.093 VIF= 1/(1- R2) 1.055 1.235

- External Validity

The final point to be checked is external validity. It is about how items and / or the index relate to other variables. According to Diamantopoulos and Winklhofer one option is to link the index to at least one other and reflective construct with which an association is expected and can be theoretically explained (Diamantopoulos & Winklhofer, 2001). The hypothesized relationships between the four dimensions / indexes (i.e. access to care, physician care, price of care, and atmospheric of care) and the reflective SERVPERF and distributive justice dimensions were provided in the hypotheses section and are validated in the data analysis section. All guidelines of proper index construction were followed. Consequently, for each of the patient satisfaction dimensions an index centered on the mean was created and used for the data analysis. 4.3.3 Conclusion Scales Validation 153

Previously developed scales have sound properties in this study too. Indices reveal that the SERVPERF and distributive justice factor structure has adequate model fit. Service quality and distributive justice constructs are confirmed to have appropriate internal consistency. Content, criterion and construct validity for those two constructs is established. Index creation, for the measurement of patient satisfaction dimensions, is justifiable. Thus, scales and the indexes are eligible and suitable for testing the research hypotheses of this dissertation.

4.4 Testing the Hypotheses

This part, which includes six sections, aims to measure whether the research model and the research hypotheses are valid. The first section (4.4.1) presents the statistical modeling techniques, namely multiple linear regression; the second (4.4.2) covers the overall fit of the research model; and the third (4.4.3) the validation of the hypotheses which deal with the "satisfaction antecedents - patient satisfaction" relationships. The fourth (4.4.4) covers the validation of the mediating roles of service quality and distributive justice and the fifth (4.4.5) the validation of the moderating roles of income, age and gender. Finally, the results are synthesized and discussed in the sixth section (4.4.6). 4.4.1 Statistical Methodology: Multiple Linear Regression

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A Multiple Regression Model is a probabilistic model which is based on correlation, and which includes more than one independent variable, where the dependent variable is a function of k independent variables, using a mathematical equation, x1, x2, , xk. The random error term is added to make the model probabilistic rather than deterministic. The value of the coefficient i determines the contribution of the independent variable xi, and 0 is the y-intercept (Pallant, 2007). In a multiple regression model, relationships may be nonlinear, independent variables may be quantitative or qualitative, and one can examine the effects of a single variable or multiple variables with or without the effects of other variables taken into account (J. Cohen, Cohen, West, & Aiken, 2003). Since correlation does not imply causation, what makes regression different from correlation is that regression assumes that the independent variable (x) is, at least in part, a cause or a predictor of the dependent (y) variable. Hence, regression is a version of General Linear Model that allows us to test hypotheses in which causality is asserted (R. Miller & Acton, 2009). In multiple linear regression, the true model contains the true coefficients for the input variables and the random error term (residual), which is introduced to account for the effect of all omitted variables:

y= 0+ 1x1+ + pxp + Where (y) is dependent variable, 0 is the intercept, 1, 2, , p are regression coefficients that represent population parameters and are usually unknown, () is the residual (equal to the difference between observed and predicted values of the dependent variable), and x1, x2, , xn are independent variables in the model. We also have a prediction (estimation) model which has the estimated coefficients for the input variables and does not contain an error term: 155

y= 0+ 1x1+ + pxp In hierarchical multiple regression analysis, the researcher determines the order that variables are entered into the regression equation. The researcher may want to control for some variable or group of variables. The researcher would perform a multiple regression with these variables as the independent variables. From this first multiple regression analysis, the researcher has the variance accounted for this corresponding group of independent variables. The researcher will run another multiple regression analysis including the original independent variables and a new set of independent variables. This allows the researcher to examine the contribution above and beyond the first group of independent variables (Eugene & Patrick, 2004).

The p-value for all hypotheses was calculated through SPSS 17 which automatically resulted in a bilateral coefficient. Since a unilateral coefficient is sufficient, the resultant p-value was divided by two (p/2). According to Norusis this adjustment to a one-tailed test is acceptable, if the direction of the effect is known or expected (Norusis, 2008).

- The Sample Size

The sample size is a crucial aspect of multiple linear regression implementation that must be discussed because it can bias the results. In fact, without an adequately large sample size, a research study may not possess sufficient statistical power to detect a significant effect. When this happens, a researcher may erroneously conclude that no significant effect exists in their study when, in fact, the sample size was simply not large enough to detect the hypothesized effect (J. Cohen, et al., 2003). Several rule-of-thumb sample size recommendations for a multiple regression analysis have been proposed over the years, for example: Green recommended N > 156

(50 + 8k) when testing R2 and N > (104 + k) when testing individual Bj. where (k) is the number of independent predictors (Green, 1991); also Hair et al. recommended that the minimum ratio of observations to variables is 5 to 1 (Joseph F. Hair, et al., 2006). In the present study, the sample size was estimated based on the assumption that 50% of the patients attending health facilities are satisfied (standard deviation of the population= 50%), a 5% margin of error, and a 95% confidence level. Accordingly, the sample size was equal to 385 = (Z.S/E) 2 = [(1.96*0.5)/0.05] 2 which complied with all the above recommendations.

4.4.2 The Overall fit of the Model

In order to assess the overall fit of our research model, we conducted a multiple regression analysis predicting patient satisfaction based on the four independent variables: physician care, access to care, price of care, and atmospherics of care.

The adjusted R Square of our research model was equal to 0.647 (review Table 19) which indicates that the model is supported by the collected data (Aiken & West, 1991). Also, the regressors, taken together, are significantly associated with the dependent variable (Fisher F =176.731 and Sig = 0.000).

This result is important in the context of the research: it provides clear evidence that the theoretical model of the antecedents of patient satisfaction drawn from the literature review and the pilot study fits the empirical data. From an analytical point of view, the fact that the overall 157

goodness-of-fit of the model to the data is satisfactory, means that the relationships (i. e.: the hypotheses) are, on the whole, relevant to reproduce the initial data.

Table 19: Multiple regression analysis results (All predictors)

Unstandardized Model Coefficients


B Std. Error

Standardized Coefficients
Beta

Sig.

(Constant) 1 AVERAGEACCESSTOCARE AVERAGEPHYSICIANCARE AVERAGEPERCEIVEDPRICEOFCARE AVERAGEATMOSPHERICSOFCARE

-1.220 .313 .496 .341 .069

.219 .050 .061 .061 .043 .232 .378 .281 .063

-5.571 6.303 8.148 5.570 1.597

.000 .000 .000 .000 .011

a. Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale Std. Error of the Estimate 1.10058

Model 1

R .806a

R Square .650

Adjusted R Square .647

a. Predictors: (Constant), AVERAGEATMOSPHERICSOFCARE, AVERAGEACCESSTOCARE, AVERAGEPHYSICIANCARE, AVERAGEPERCEIVEDPRICEOFCARE Model Sum of Squares df Mean Square F Sig.

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Regression 1 Residual Total

856.284 460.287 1316.571

4 380 384

214.071 1.211

176.731

.000

4.4.3 Validation of the Hypotheses Linking Care Variables to Patient Satisfaction (H1, H4, H5, H6) The suggested model in Chapter 3 (Figure 4) presents a number of variables and relationships. To validate these different relationships within the research model, two categories of results must be analyzed and presented. The first, referring to the statistical significance of the relationships in question, and the second pertaining to the practical significance of these relationships in explaining the variations of the models factors or variables (Bakan, 1966).

To satisfy the first requirement, we used the standardized regression coefficients (Beta) which indicate how a change in one of the independent variables affects the values taken by the dependent variable , when all the other independent variables are held constant (Wonnacott & Wonnacott, 1981). This coefficient is associated with its significance level (alpha level) which was set at 0.05.

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The second requirement is assessed using the effect size indicator (r) coefficient of determination, which measures the part of the models dependent variable which is actually explained by the model presented and being tested (J. W. Cohen, 1988). The coefficient of determination (r) varies from 0 to 1.

4.4.3.1 Impact of Physician Care on Patient Satisfaction Hypothesis 1 stipulates that there is a positive relationship between the patients perception of the physician care and patients satisfaction. The results of the multiple regression analysis show that this proposition is sustainable (Beta = 0.378; Sig. = 0.000; review Table 19) (J. W. Cohen, 1988). Thus: Hypothesis 1 is supported. 4.4.3.2 Impact of Access to Care on Patient Satisfaction Hypothesis 4 stipulates that there is a positive relationship between the patients perception of the access to care and patients satisfaction. The results of the multiple regression analysis show that this proposition is sustainable (Beta = 0.232; Sig. = 0.000; review Table 19) (J. W. Cohen, 1988). Thus: Hypothesis 4 is supported.

4.4.3.3 Impact of Atmospheric of Care on Patient Satisfaction Hypothesis 5 stipulates that there is a positive relationship between the patients perception of the atmospheric of care and patients satisfaction. The results of the multiple regression analysis show that this proposition is sustainable even if the effect is pretty low compared to the others care variables (Beta = 0. 063; Sig. = 0.000; review Table 19) (J. W. Cohen, 1988). Thus: 160

Hypothesis 5 is supported.

4.4.3.4 Impact of Price of Care on Patient Satisfaction Hypothesis 6 stipulates that there is a positive relationship between the patients perception of the price of care and patients satisfaction. The results of the multiple regression analysis show that this proposition is sustainable (Beta = 0. 281; Sig. = 0.000; review Table 19) (J. W. Cohen, 1988). Thus: Hypothesis 6 is supported.

4.4.4 Validation of Hypotheses Referring to Mediation Roles (H2, H3, H7, H8)

The central idea in a mediation relationship revolves around an active organism intervenes between stimulus and response [] the effects of stimuli on behavior are mediated by various transformation processes internal to the organism (Baron & Kenny, 1986). This concept set forth by Baron and Kenny is in line with what Woodworth (Woodworth, 1928) suggested on the role of the mediating variables that intervene between both variables stimulus and response (review Figure 6 and Figure 7).

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Figure 6: An Unmediated Model

Reference: David A. Kenny, 2011

Figure 7: A Mediated Model

Reference: David A. Kenny, 2011 The mediated model presents two relationships with three variables. It includes one direct relationship (XY) and another causal (XMY) that depicts the existence of a mediating factor. In this linear model the total effect is the sum of the direct and indirect effects of the independent variable X on the dependent variable Y (Total effect = c'+ a*b), where the direct effect is the coefficient (c) and the indirect (or mediated) effect is the product of paths coefficients (a*b). Accordingly, the independent variable has a direct effect on the dependent variable and an indirect effect through the mediator (Kenny, 1979) . Mediating effects are often tested using hierarchical multiple regression (HMR) procedures. Typical of the HMR-based strategies is the very frequently cited and widely used procedure described by Baron and Kenny (Baron & Kenny, 1986): 162

- Step 1: This step establishes that there is an effect that may be mediated. In other words, it tests if the independent variable (X) is correlated with the dependent variable (Y). Accordingly, it estimates and tests (path c) in figure 6. The effect of the independent variable (X) in this model must be significant. If there is no direct effect of (X) on (Y), then there is no relationship to mediate.

- Step 2: This step essentially involves treating the mediator as if it was a dependent variable. It tests if the independent variable (X) is correlated with the mediator (M). Accordingly, it estimates and tests (path a) in figure 7. The effect of the independent variable (X) in this model must be significant. If the independent variable (X) does not reliably affect the mediator (M), the mediator (M) cannot be responsible for the relationship observed between (X) and (Y).

Step 3: This step essentially involves treating the mediator (M) as if it was an independent variable. It tests if the mediator (M) is correlated with the dependent variable (Y). Accordingly, it estimates and tests (path b) in figure 7. The effect of the independent variable (M) in this model must be significant. If the independent variable (M) does not reliably affect the dependent variable (Y), the mediator cannot be responsible for the relationship observed between (X) and (Y).

Step 4: this step simultaneously predicts the value of the dependent variable (Y) from both the independent variable (X) and the mediating variable (M). It is not sufficient just to correlate the mediator (M) with the dependent variable (Y); the mediator and the dependent variable may be correlated because they are both caused by the independent variable (X). Thus, the independent 163

variable (X) must be controlled in establishing the effect of the mediator (M) on the dependent variable (Y). Accordingly, this step estimates and tests (path c) in figure 7.

One of three different outputs might arise:

a) Complete Mediation: it is the case in which the independent variable (X) no longer affects the dependent variable (Y) after controlling the mediator variable (M) and so (path c') is zero. The effect of the mediating variable (M) is significant while the effect of the independent variable (X) became insignificant.

b) Partial Mediation: it is the case in which the (path c') is reduced in absolute size but is still different from zero when the mediator (M) is controlled. Both the mediating variable (M) and the independent variable (X) are significant.

c) The effect of the mediating variable (M) became insignificant while the effect of the independent variable (X) is significant we dont have a mediating effect.

Our research model includes two suggested mediator factors. The first is service quality which mediates the relationship between physician care and patient satisfaction and the second is distributive justice who mediates the relationship between price of care and patient satisfaction. These mediating factors were measured from the field by computing the mean of a number of items for each variable (review Table 20).

Table 20: Items used for measuring the mediating variables of the model Variable Items

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Service Quality Distributive Justice

V2 V23 V25V28

4.4.4.1 Service quality mediating the relationship between physician care and patient satisfaction

The tests as suggested by Baron and Kenny (1986) were conducted for the factor of service quality mediating the relationship between the independent variable (physician care) and the dependent variable (patient satisfaction). The results of the paths mediation tests are summarized in Table 21. The results of the mediation tests clearly reveal the presence of a mediation effect (partial mediation). The magnitude of this mediation effect is fair. In fact, while R2 of Path c (Step 1) is 0.543, R2 of path c' (Step 4) is 0.660 (R2 = 0.117= 11.7 %). Thus, we can say with 95% confidence that service quality explains 11.7 % of the variance in patient satisfaction in primary care settings. Furthermore, we can state that both: H2 and H3 are supported.
Table 21: Regression results of service quality mediating the relationship between physician care and patient satisfaction

Standardized Unstandardized Regression Variables Regression Coefficient Coefficient (B) (Beta) Step 1 DV: Patient 0.965 0.737 0.045 0.543 21.321 0.000 Error Standard R Square statistic T Sig

satisfaction IV: Physician Care Step 2 DV: Service

Quality IV: Physician Care Step 3

0.920

0.846

0.30

0.716

31.061

0.000

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DV:

Patient 0.806 0.036 0.649 26.619 0.000

Satisfaction IV: Service Quality 0.971 Step 4 DV: Patient

Satisfaction IV: Service Quality 0.774 IV: Physician Care 0.254

0.642 0.194

0.067 0.073

0.660 0.660

11.465 3.459

0.000 0.001

4.4.4.2 Distributive justice mediating the relationship between price of care and patient satisfaction

The tests as suggested by Baron and Kenny (1986) were conducted for the factor of distributive justice mediating the relationship between the independent variable (price of care) and the dependent variable (patient satisfaction). The results of the paths mediation tests are summarized in Table 22. The results of the mediation tests clearly reveal the presence of a mediation effect (partial mediation). The magnitude of this mediation effect is fair. In fact, while R2 of Path c (Step 1) is 0.656, R2 of path c' (Step 4) is 0.508 (R2 = + 0.148= 14.8 %). Thus, we can say with 95% confidence that distributive justice explains 14.8 % of the variance in patient satisfaction in the Lebanese primary care settings. Furthermore, we can state that both: H7 and H8 are supported.

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Table 22: Regression results of distributive justice mediating the relationship between price of care and patient satisfaction

Standardized Unstandardized Regression Variables Regression Coefficient Coefficient (B) (Beta) Step 1 DV: Patient 0.713 0.043 0.508 19.874 0.000 Error Standard R Square statistic T Sig

satisfaction IV: Price of Care 0.863 Step 2 DV: Distributive Justice IV: Price of Care 0.989 Step 3 DV: Patient Satisfaction IV: Distributive 0.789 Justice Step 4 DV:

0.804

0.037

0.647

26.485

0.000

0.802

0.030

0.643

26.241

0.000

Patient 0.647 0.050 0.656 12.809 0.000

Satisfaction IV: Distributive 0.637

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Justice IV: Price of Care

0.233

0.192

0.061

0.656

3.801

0.000

4.4.5 Validation of Hypotheses Referring to the Moderating Role of Age (H9a, H9b, H9c, H9d)

A moderator model (review Figure 8) is operative when the strength or direction of a relation between two variables varies as a function of a third variable called the moderator (MacKinnon, 2008).

Figure 8: A Moderator Model

Reference: Baron& Kenny, 1986 The process of testing a moderating effect is of four stages (Frazier, Barron, & Tix, 2004):

Stage 1: If either the predictor or moderator variable is categorical, the first stage is to represent this variable with code variables. The number of code variables needed depends on the number of levels of the categorical variable, equaling the number of levels of the variable minus one.

Stage 2: The second stage in formulating the regression equation involves centering or standardizing predictor and moderator variables that are measured on a continuous scale.

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Stage 3: The third stage in formulating the regression equation involves creating the product terms that represent the interaction between the predictor and moderator. To form product terms, one simply multiplies together the predictor and moderator variables using the newly coded categorical variables or centered/standardized continuous variables. A product term needs to be created for each coded variable (e.g., if there is one coded variable for a categorical variable with two levels, there is one interaction term; if there are two coded variables for a categorical variable with three levels, there are two interaction terms). This product term does not need to be centered or standardized.

Stage 4: After product terms have been created, everything should be in place to structure a hierarchical multiple regression equation using standard statistical software to test for moderator effects. To do this, one enters variables into the regression equation through a series of specified steps. The first step generally includes the code variables and centered/standardized variables representing the predictor and the moderator variables. All individual variables contained in the interaction term(s) must be included in the model. Product terms must be entered into the regression equation after the predictor and moderator variables from which they were created. If two or more product terms have been created because a categorical variable has more than two levels, all of the product terms should be included in the same step.

To interpret the output, we should examine:

a) The column labeled "sig" in the Coefficients output, which represents the significance or (p) values that pertain to each independent variable. We have a moderation effect only if the interaction term is statistically significant (p/2< 0.05).

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b) The R square change in the Model Summary output. If the change in R square is statistically significant, it would bring more evidence in favor of the moderator effect.

c) The direction of the moderator effect. The above mentioned regression statistical procedure of moderation was followed to validate each sub-hypothesis referring to the moderating roles of age, income (continuous variables) and gender (categorical variable).

Age, as reported by Katz (1997) and Bodenlos (2004), is expected to be related to patient satisfaction. The reason behind this expected relationship is based on social identity theory which proposes that attitudes such as patient satisfaction are moderated by demographic, situational, environmental, and psychosocial factors (Haslam, et al., 1993; Jackson & Hodge, 1996; Platow, et al., 1997). Our hypotheses derived from the literature and presented in the model under test, suggests that age is a moderator of the relationships between patient satisfaction and each of the four healthcare attributes, namely physician care (H9a), access to care (H9b), atmospherics of care (H9c), and price of care (H9d).

4.4.5.1 Moderation of the relationship between physician care and patient satisfaction

In the current study, H9a was initially formulated as follows: The impact of physician care on patient satisfaction will be higher for older patients than for younger patients.

The results summarized in Table 23 indicate that the interaction term between physician care and age is not significant (p/2 > 0.05) suggesting that the effect of physician care on patients

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satisfaction doesnt depend on the age level. Accordingly, we do not have a moderating effect. Thus: H9a is not supported.

Table 23: Regression results testing the moderating effect of age


Coefficients Model (Constant) PHYSICIANCENT 1 ACCESSCENT ATMOSPHERICCENT PRICECENT AGECENT (Constant) PHYSICIANCENT ACCESSCENT ATMOSPHERICCENT 2 PRICECENT AGECENT PHCENTXAGECENT ACCCENTXAGECENT ATMOCENTXAGECENT PRICENTXAGECENT Unstandardized Coefficients B 4.286 .482 .284 .095 .330 .019 4.260 .512 .266 .075 .306 .020 .008 .009 .000 -.010 Std. Error .055 .060 .049 .043 .060 .004 .056 .061 .055 .046 .063 .005 .005 .004 .003 .005 .390 .197 .069 .252 .134 .068 .078 -.011 -.099 .368 .211 .087 .273 .130 Standardized Coefficients Beta t 78.121 8.089 5.796 2.225 5.520 4.271 76.268 8.433 4.869 1.654 4.881 4.313 1.529 2.025 -.284 -1.937 Sig. .000 .000 .000 .027 .000 .000 .000 .000 .000 .099 .000 .000 .127 .056 .777 .054

Model Summary Adjusted Model R R Square R Square 1 2 .816a .821


b

Std. Error of the Estimate 1.07644 1.06943 R Square Change .666 .008

Change Statistics F Change 151.447 2.245 df1 5 4 df2 379 375 P<0.05 Sig. F Change .000 .064

.666 .674

.662 .666

Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale

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4.4.5.2 Moderation of the relationship between access to care and patient satisfaction In the current study, H9b was initially formulated as follows: The impact of access to care on patient satisfaction will be higher for older patients than for younger patients.

The results summarized in Table 23 indicate that the interaction term between access to care and age is not significant (p/2 > 0.05), suggesting that the effect of access to care on patients satisfaction doesnt depend on the age level. Accordingly, we do not have a moderating effect. Thus: H9b is not supported. 4.4.5.3 Moderation of the relationship between atmospheric of care and patient satisfaction In the current study, H9c was initially formulated as follows: The impact of atmospherics of care on patient satisfaction will be lower for older patients than for younger patients.

The results summarized in Table 23 indicate that the interaction term between atmospherics of care and age is not significant (p/2 > 0.05), suggesting that the effect of atmospherics of care on patients satisfaction doesnt depend on the age level. Accordingly, we do not have a moderating effect. Thus: H9c is not supported. 4.4.5.4 Moderation of the relationship between price of care and patient satisfaction

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In the current study, H9d was initially formulated as follows: The impact of price of care on patient satisfaction will be lower for older patients than for younger patients.

The results summarized in Table 23 indicate that the interaction term between price of care and age is not significant (p/2 > 0.05), suggesting that the effect of price of care on patients satisfaction doesnt depend on the age level. Accordingly, we do not have a moderating effect. Thus: H9d is not supported. 4.4.6 Validation of Hypotheses Referring to the Moderating Role of Income (H10a, H10b, H10c, H10d)

Income, as reported by Calnan (1988) and Theodosopoulou (2007), is expected to be related to patient satisfaction. The reason behind this expected relationship is based on social identity theory which proposes that attitudes such as patient satisfaction are moderated by demographic, situational, environmental, and psychosocial factors (Haslam, et al., 1993; Jackson & Hodge, 1996; Platow, et al., 1997). Our hypotheses derived from the literature and presented in the model under test, suggests that income is a moderator of the relationships between patient satisfaction and each of the four healthcare attributes, namely physician care (H10a), access to care (H10b), atmospherics of care (H10c), and price of care (H10d). 4.4.6.1 Moderation of the relationship between physician care and patient satisfaction

In the current study, H10a was initially formulated as follows: The impact of physician care on patient satisfaction will be lower for upper income patients than for lower income patients.

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The results summarized in Table 24 indicate that the interaction term between physician care and income is not significant (p/2 > 0.05), suggesting that the effect of physician care on patients satisfaction doesnt depend on the income level. Accordingly, we do not have a moderating effect. Thus: H10a is not supported.

Table 24: Regression results testing the moderation effect of income


Coefficientsa Model Unstandardized Coefficients B (Constant) PHYSICIANCENT 1 ACCESSCENT ATMOSPHERICCENT PRICECENT INCOMECENT (Constant) PHYSICIANCENT ACCESSCENT ATMOSPHERICCENT 2 PRICECENT INCOMECENT PHYCENTXINCCENT ACCCENTXINCCENT ATMOCENTXINCCENT PRICENTXINCCENT 4.286 .488 .298 .073 .325 .000 4.225 .448 .286 .039 .342 .000 .000 5.576E-5 4.249E-5 .000 Model Summary Std. Model R R Square Adjusted R Square .654 .681 Error of the Estimate 1 2 .811a .830
b

Standardize d Coefficients Beta

t 77.163

Sig. .000 .000 .000 .090 .000 .004 .000 .000 .000 .345 .000 .000 .151 .041 .346 .058

Std. Error .056 .060 .049 .043 .061 .000 .056 .060 .048 .042 .060 .000 .000 .000 .000 .000

.372 .221 .067 .268 -.091

8.090 6.019 1.700 5.340 -2.925 75.273

.342 .212 .036 .283 -.357 -.161 .084 .029 -.236 Change Statistics

7.514 6.002 .945 5.744 -6.445 -1.440 1.149 .944 -1.900

R Square Change .658 .030 145.907 9.034 5 4 379 375 P<0.05 F Change df1 df2

Sig. F Change .000 .000

.658 .688

1.08980 1.04634

Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale

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4.4.6.2 Moderation of the relationship between access to care and patient satisfaction

In the current study, H10b was initially formulated as follows: The impact of access to care on patient satisfaction will be higher for upper income patients than for lower income patients.

The results summarized in Table 24 indicate that while access to care correlates positively with patients satisfaction (standardized coefficient Beta is positive; p/2 < 0.05), patients income correlates negatively (standardized coefficient Beta is negative; p/2 < 0.05). The interaction term between access to care and income is significant (p/2 < 0.05), suggesting that the effect of access to care on patients satisfaction depends on the income level. The change in R square (0.03) is also statistically significant (F = 9.034; p/2 < 0.05), which brings more evidence in favor of the moderator effect. In order to verify whether the significant moderator effect is in the predicted direction, we looked at patients with the highest and lowest incomes. The descriptive statistic of the patients income variable shows that the upper quartile is at about 1900$, and the lower is about 1000$ (review Appendix 9). A comparison of the results for the correlations and plots between patient satisfaction and access to care for these two groups of patients reveals that the relationship is stronger for upper income patients (review Table 25 and Figure 9). 175

Based on all the above evidences, we can claim that hypothesis H10b is supported.

Table 25: Correlations between access to care and patient satisfaction for both groups Correlations Groups Pearson Correlation 0.648 ** Group 1 (income >1900) Group 2 (income <1000) 0.487** **. Correlation is significant at the 0.01 level (2-tailed).

Sig 0.000 0.000

Number of Cases 95 92

Plot for the cases with Income > 1900$

Plot for the cases with Income < 1000$

Figure 9: Plots of correlations between access to care and satisfaction for both groups

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4.4.6.3 Moderation of the relationship between atmospheric of care and patient satisfaction

In the current study, H10c was initially formulated as follows: The impact of atmospherics of care on patient satisfaction will be higher for upper income patients than for lower income patients.

The results summarized in Table 24 indicate that the interaction term between price of care and income is not significant (p > 0.05), suggesting that the effect of price of care on patients satisfaction doesnt depend on the income level. Accordingly, we do not have a moderating effect. Thus: H10c is not supported. 4.4.6.4 Moderation of the relationship between price of care and patient satisfaction In the current study, H10d was initially formulated as follows: The impact of price of care on patient satisfaction will be lower for upper income patients than for lower income patients.

The results summarized in Table 24 indicate that the interaction term between price of care and income is not significant (p/2 > 0.05), suggesting that the effect of price of care on patients satisfaction doesnt depend on the income level. Accordingly, we do not have a moderating effect. Thus: H10d is not supported. 177

4.4.7 Validation of Hypotheses Referring to the Moderating Role of Gender (H11a, H11b, H11c, H11d) Gender, as reported in the literature reviewed by Burke (1994) and Saila (2008), is expected to be related to patient satisfaction. The reason behind this expected relationship is based on social identity theory which proposes that attitudes such as patient satisfaction are moderated by demographic, situational, environmental, and psychosocial factors (Haslam, et al., 1993; Jackson & Hodge, 1996; Platow, et al., 1997). Our hypotheses derived from the literature and presented in the model under test, suggests that gender is a moderator of the relationships between patient satisfaction and each of the four healthcare attributes, namely physician care (H11a), access to care (H11b), atmospherics of care (H11c), and price of care (H11d). As with the previous other moderator variables, we used the same process to validate the hypotheses referring to the moderating role of gender. However, since in this case the moderator is categorical in nature, we needed to represent this variable with dummy code variables. Accordingly, we created a two-group categorical independent variable (Male = 0; Female =1) and we have chosen the male group as the reference group, that's the group that is not represented in the coding. 4.4.7.1 Moderation of the relationship between physician care and patient satisfaction In the current study, H11a was initially formulated as follows: The impact of physician care on patient satisfaction will be lower for male patients than for female patients.

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The results summarized in Table 26 indicate that the interaction term between physician care and gender is not significant (p/2 > 0.05), suggesting that the effect of physician care on patients satisfaction doesnt depend on the gender of the patient. Accordingly, we do not have a moderating effect. Thus: H11a is not supported.
Table 26: Regression results of testing the moderating effect of gender
Coefficientsa Model Unstandardized Coefficients B (Constant) PHYSICIANCENT 1 ACCESSCENT ATMOSPHERICCENT PRICECENT GENDER RECODED (Constant) PHYSICIANCENT ACCESSCENT ATMOSPHERICCENT 2 PRICECENT GENDER RECODED PHYCENTXGENDUM ACCCENTXGENDUM ATMOCENTXGENDUM PRICENTXGENDUM 4.334 .499 .308 .072 .336 -.073 4.332 .536 .361 .021 .242 -.068 -.046 -.062 .043 .142 Model Summary Std. Model R R Square Adjusted R Square .646 .644 Error of the Estimate 1 2 .807a .808b .651 .653 1.10152 1.10440 R Square Change .651 .002 141.215 .506 5 4 379 375 P<0.05 F Change df1 df2 Change Statistics Sig. F Change .000 .732 Std. Error .098 .061 .051 .044 .062 .122 .100 .108 .074 .090 .102 .122 .134 .109 .106 .132 .409 .267 .019 .200 -.017 -.028 -.030 .035 .092 .381 .228 .066 .278 -.019 Standardize d Coefficients Beta 44.162 8.162 6.078 1.660 5.454 -.595 43.510 4.945 4.903 .232 2.361 -.553 -.346 -.575 .402 1.072 .000 .000 .000 .098 .000 .552 .000 .000 .000 .817 .019 .581 .730 .566 .688 .284 t Sig.

Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale

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4.4.7.2 Moderation of the relationship between access to care and patient satisfaction

In the current study, H11b was initially formulated as follows: The impact of access to care on patient satisfaction will be higher for male patients than for female patients.

The results summarized in Table 26 indicate that the interaction term between access to care and gender is not significant (p/2 > 0.05), suggesting that the effect of access to care on patients satisfaction doesnt depend on the gender of the patient. Accordingly, we do not have a moderating effect. Thus: H11b is not supported. 4.4.7.3 Moderation of the relationship between atmospheric of care and patient satisfaction

In the current study, H11c was initially formulated as follows: The impact of atmospherics of care on patient satisfaction will be lower for male patients than for female patients.

The results summarized in Table 26 indicate that the interaction term between atmospherics of care and gender is not significant (p/2 > 0.05), suggesting that the effect of atmospherics of care on patients satisfaction doesnt depend on the gender of the patient. Accordingly, we do not have a moderating effect. Thus: H11c is not supported. 180

4.4.7.4 Moderation of the relationship between price of care and patient satisfaction

In the current study, H11d was initially formulated as follows: The impact of price of care on patient satisfaction will be lower for male patients than for female patients.

The results summarized in Table 26 indicate that the interaction term between price of care and gender is not significant (p/2 > 0.05), suggesting that the effect of price of care on patients satisfaction doesnt depend on the gender of the patient. Accordingly, we do not have a moderating effect. Thus: H11d is not supported.

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4.4.8 Summary and Discussion

In this last section, the results of the hypothesis-testing will be discussed. From the twenty hypotheses that were proposed in chapter 3, only nine were validated.

The results of the hypothesis-testing are summarized in Table 27 below.

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Table 27: Summary of hypotheses testing results. Hypothesis H1 satisfaction with the services provided. The better the patients perception of the physician care, the better will be its H2 perception of the service quality. The better the patients perception of service quality, the greater will be its H3 satisfaction with the services provided. The better the patients perception of the access to care, the greater will be its H4 satisfaction with the services provided. The better the patients perception of the atmospheric of care, the greater will be its H5 satisfaction with the services provided. The better the patients perception of the price of care, the greater will be its H6 satisfaction with the services provided. The better the patients perception of the price of care, the better will be its H7 perception of distributive justice. The better the patients perception of distributive justice, the greater will be its H8 satisfaction with the services provided. The impact of physician care on patient satisfaction will be higher for older patients H9a than for younger patients. The impact of access to care on patient satisfaction will be higher for older patients H9b than for younger patients. The impact of atmospherics of care on patient satisfaction will be lower for older H9c patients than for younger patients. The impact of price of care on patient satisfaction will be lower for older patients H9d than for younger patients. The impact of physician care on patient satisfaction will be lower for upper income H10a patients than for lower income patients. The impact of access to care on patient satisfaction will be higher for upper income H10b H10c patients than for lower income patients. The impact of atmospherics of care on patient satisfaction will be higher for upper Supported Supported Not Supported Not Supported Not Supported Not Supported Not Supported Not Supported Supported Supported Supported Supported Supported Formulation of the Hypothesis The better the patients perception of the physician care, the greater will be its Result Supported

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income patients than for lower income patients. The impact of price of care on patient satisfaction will be lower for upper income H10d patients than for lower income patients. The impact of physician care on patient satisfaction will be lower for male patients H11a than for female patients. The impact of access to care on patient satisfaction will be higher for male patients H11b than for female patients. The impact of atmospherics of care on patient satisfaction will be lower for male H11c patients than for female patients. The impact of price of care on patient satisfaction will be lower for male patients H11d than for female patients.

Supported Not Supported Not Supported Not Supported Not Supported Not Supported

In the present study, the mean score for patient satisfaction was 4.28 points out of 7 (review Appendix 4). This indicates generally speaking that patients are satisfied, yet not very satisfied with MLC services. The relatively low overall satisfaction may be explained by the patients high expectation levels or perhaps the incompetent management system at MLC. However, as

184

this type of survey is new in Lebanon, we cannot compare our results to similar cases. Thus, it is difficult to conclude definitely on the main cause.

The testing of the complete suggested model in Figure 4 above, using the data collected from 385 respondents among a population of 10690 patients revealed the following:

Results regarding the physician care dimension

Patients perception of the physician care attribute is positively correlated with its satisfaction with the services provided (Beta = 0.378, p/2 < 0.01). This finding is consistent with prior studies conducted in outpatient settings (e.g. (Lytle & Mokwa, 1992; R. Sharma & Chahal, 1999)), all of whom confirm this positive relationship.

The comparison of the standardized regression coefficients for the four independent variables used in this study shows that physician care is the strongest factor influencing patient satisfaction (review Table 19). We can infer from such finding which is consistent with other studies conducted in ambulatory settings abroad (e.g., (D. E. Larsen & Rootman, 1976; Tung & Chang, 2009)) that the physician care dimension is equally important to Lebanese and foreign outpatients. This result can be explained by outpatients' interest that is generally focused on the core service and the way it is provided. We assume that most outpatients are anxious about their uncertain conditions when they visit doctors. They expect the physician to make the right diagnosis and provide the right treatment. However, they are not able to directly assess whether the physician's diagnosis and treatment options are correct. Thus, outpatients probably rely on other factors that they can assess, and they believe those factors are related to the correct diagnosis and treatment option. Our results clearly support this assumption. Patients in the study 185

were most influenced by the very reason that they visited their physiciansthat is, to receive care from the physician.

With regard to the physician care dimension, the most influential factor was communication (review Appendix 5) since patients were mostly interested in acquiring medical knowledge and advises concerning their specific health condition and the variety of approaches to treat it. The second influential factor was accuracy which implied that within the visit timeframe the doctor did everything needed to get an accurate diagnosis of the patients condition; thus, the patient would be led to believe that the diagnosis and treatment must be correct. The third factor, competency", was also likely to be viewed by patients as directly related to correct diagnosis and treatment. Patients frequently appraise physicians competency based on peripheral clues such as where the physician received his/her degree, affiliations with medical schools, and promotional material (Yavas & Shemwell, 1996).

The less influential factors of the physician dimension are associated with features that may be described in general as bedside manner. Although these factors did influence patient satisfaction in our study, their impact was smaller than for factors related to the reason for the visitto receive the right diagnosis and treatment.

Table 28: Classification of factors related to the physician care dimension along with their impacts on patient satisfaction Factors Communication Accuracy Competence Courtesy Empathy Position First Second Third Fourth Fifth 186

Results regarding the price of care dimension

Patients perception of the price of care is positively correlated with its satisfaction with the services provided (Beta= 0.281; p/2 < 0.01). This finding is consistent with prior studies conducted in outpatient settings (e.g., (Biswas, Lloyd-Sherlock, & Zaman, 2006; Oladapo & Lyaniwura, 2008)) all of whom confirm this positive relationship.

The comparison of the standardized regression coefficients for the four independent variables used in this study shows that the price of care dimension has the second largest parameter estimate (review Table 19). This result can be explained by the fact that in many developing countries such is Lebanon, primary healthcare services are not freely provided, employees pensions are inadequate relative to basic livelihood needs such as healthcare (UNDP, 2006); consequently, the price becomes a perennial interest among most patients who scarcely have inpatient care insurance coverage.

Our examination of both factors of this dimension also produced an important result: the perceived monetary price has more impact on patient satisfaction than the perceived non monetary price (review Appendix 6) which indicated that for most patients, money is a more important asset than any other non monetary resource. Table 29: Classification of factors related to the price of care dimension along with their impacts on patient satisfaction Factors Perceived monetary price Perceived non monetary price Results regarding the access to care dimension 187 Position First Second

Patients perception of the access to care attribute is positively correlated with its satisfaction with the services provided (Beta = 0.232, p/2 < 0.01). This finding is consistent with prior studies conducted in outpatient settings (e.g., (Davis & Hobbs, 1989; Otani, et al., 2005)) all of whom confirm this positive relationship.

The comparison of the standardized regression coefficients for the four independent variables used in this study shows that the access to care dimension has the third largest parameter estimate (review Table 19). This result can be traced to the fact that the ease of access to care is a common interest for most patients who wish to receive the needed medical care in a timely way (M. Porter & Guth, 2010).

With regard to the access to care dimension, the most influential factor was waiting time (review Appendix 7). This result is not surprising as waiting time is known to be a common importance for patients around the world (e.g. (Bar-dayan, Leiba, Weiss, Carroll, & Benedek, 2002; R. S. Kurz & Scharff, 2003). The second receptionist personal behavior and the third "effort required to get an appointment factors were also important. They both indicate the importance of the receptionists interaction with the patients. To visit physicians, outpatients typically make a phone call for an appointment. Our results suggest that patients pay attention to the way that the person in charge of scheduling appointments responds to their personal needs first on the telephone and later at the site. Actually, patients who are usually anxious and dependent probably seek caring and compassionate behaviors from the reception staff before entering to the examination room (Otani, et al., 2005). The less influential factors of the access to care dimension are associated with features that may be described in general as availability of the services (operating hours and parking). 188

Table 30: Classification of factors related to the access to care dimension along with their impacts on patient satisfaction Factors Waiting time Receptionist personal behavior Effort required to get an appointment Convenience of operating hours Parking convenience Position First Second Third Fourth Fifth

Results regarding the atmospheric of care dimension Patients perception of the atmospheric of care attribute is positively correlated with its satisfaction with the services provided (Beta = 0.063; p/2 < 0.01). This finding is consistent with prior studies conducted in outpatient settings (e.g., (Andrus & Buchheister, 1985; Elleuch, 2008)) all of whom confirm this positive relationship.

The comparison of the standardized regression coefficients for the four independent variables used in this study shows that the atmospheric of care dimension is the fourth most influential on overall patient satisfaction, but its impact was much smaller than the other three attributes (review Table 19). This result can be explained by the outpatients' interest that is generally focused on core service and the way it is provided rather than the environment in which the outpatient does not stay long. With regard to the atmospheric of care dimension, the most influential factor was cleanness (review Appendix 8) which indicated that patients were mostly interested in hygiene. In fact, whenever patients visit a healthcare setting they expect a certain standard of cleanliness, if the settings standard is lower than that which they are accustomed to, the patients will be very dissatisfied. The second influential factor was equipments' modernity which implied that 189

patients were also interested in the medical apparatus that was present in the treatment room. This isnt to suggest that patients can accurately judge the true technical / medical value of that equipment. Rather, they form an impression of whether or not these items appear to be modern and state of the art. These perceptions are as well, in part, driven by previous expectations that are built by medical external marketing, wherein advertisements may make claims of various scientific and not- so- scientific equipment representing the elusive concept of state of the art.

Table 31: Classification of factors related to the atmospherics of care dimension along with their impacts on patient satisfaction Factors Cleanness Equipments' modernity Physical appearance Air freshness Sounds Position First Second Third Fourth Fifth

Results regarding the service quality dimension Service quality is a direct mediator between physician care and patient satisfaction. Physician care has a significant impact on the perception of service quality (Beta = 0.737, p/2 < 0.01). The perception of service quality has a strong and significant impact (Beta = 0.806, p/2 < 0.01) on satisfaction.

The empirical results are good news in one sense. They suggest that service quality interventions can be initiated as a means of improving patient satisfaction. The problem is that healthcare services are high in credence properties (Butler, et al., 1996). That is, the patient in many cases does not have enough knowledge, training, or skill to make a logical, rational, supraliminal service quality evaluation. In other service domains, the issue is much simpler because service 190

providers can raise consumers perceptions of service quality by making an actual improvement in service quality delivery. Thus, to improve patients service quality perceptions, healthcare providers should focus on improving the how it is done or functional aspects of service quality rather than the what is done or technical aspects of service quality.

Results regarding the distributive justice dimension Distributive Justice is a direct mediator between the perceived price of care and patient satisfaction. The perceived price of care has a significant impact on the perception of distributive justice (Beta = 0.804, p/2 < 0.01). The perception of distributive justice has a strong and significant impact (Beta = 0.802, p/2 < 0.01) on satisfaction.

Although this finding is new in patient satisfaction studies, it is consistent with prior consumer satisfaction research (e.g. (R. L. Oliver & J. E. Swan, 1989; J. Swan & Trawick, 1980)). This result can be explained by the equity theory (review section 2.2.2). This result suggests that interventions with the objective of enhancing distributive justice perceptions can be initiated as a means of improving patient satisfaction. Accordingly, it proposes that improving the price of care leads to higher distributive justice perceptions and ultimately, to a higher levels of patient satisfaction. The problem is that many primary care setting do not have a scientific pricing approach that constantly take into consideration issues such as customers' subjective willingness to pay, price communication, price awareness, and the economic situation.

Results regarding the moderating role of age

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Age proved not to be a moderator of any relationship between healthcare attributes and overall patient satisfaction with services provided. This finding runs contrary to social identity theory and is conflicting with most prior studies conducted in healthcare settings e.g. ((Bodenlos, 2004; Tsasis, et al., 2000)). A possible explanation for this unexpected finding is that patients are willing to articulate their dissatisfaction with the service provided whatever is their age (since all MLCs patients pay for the service, they can easily select an alternative provider).

Results regarding the moderating role of income Income proved to be a moderator of a single relationship between healthcare attributes and overall patient satisfaction with services provided, i.e. between access to care and patient satisfaction. This finding is consistent with some studies conducted in healthcare settings (e.g. (Brach & Chevarley, 2008; Mummalaneni & Gopalakrishna, 1995)). One possible explanation of this finding is that Lebanese affluent patients have higher levels of expectations regarding access to care than the less privileged patients. In fact, my work experience at MLC showed me that this particular category of patients is very demanding when it comes to the access issue: they began nagging after waiting more than three minutes!

Results regarding the moderating role of gender Gender proved not to be a moderator of any relationship between healthcare attributes and overall patient satisfaction with services provided. This finding runs contrary to social identity

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theory and is conflicting with prior studies conducted in healthcare settings (e.g. (Saila, 2008; Woods & Heidari, 2003)). One possible explanation for this unexpected finding is the overwhelmingly female (66 percent) characteristic of the surveyed patients (review Appendix 4). As only 34 percent of the population is male, there may not be enough interpretable variance in gender to reflect a significant association.

4.5 Methodologies and Outcomes: Conclusion The fourth chapter of this study started with an explanation of the research context and a justification of choices pursued. Later it presented the procedures followed in conducting the 193

quantitative research and the hypotheses testing. While confirmatory factor analysis (CFA) technique and Diamantopoulos and Winklhofers guidelines for index construction were used to validate the research instruments, correlation and linear regression analysis were used in testing the hypotheses. The implementation of regression analysis enabled the evaluation of the overall adjustment of the model to the data. The statistical index recommended in the literature was used to show that the model-fit was satisfactory in the study. This result means that the hypothesized relationships were relevant to reproduce the data. Then, the last step consisted in validating the research hypotheses. Nine out of twenty hypotheses were supported.

The results of the survey conducted in MLC also revealed that the mean overall satisfaction level of the patients in this study was barely equal to 61.2 % which strongly suggest that more could be done to assure that services provided are more patient centered.

This study has shown that physician care affect outpatient satisfaction in Lebanon more than other attributes of care do. The physician is the focus of the patient's experience. Thus, he becomes key to patients, and those factors of physician care that most directly affect the patient's medical concern are most influential on patient satisfaction. This study also specifically examined the factors of the physician care attribute that had the most positive impact on patient satisfaction. Two items, Satisfaction toward information received and Satisfaction toward physician accuracy were found to be the most important and influential factors in the physician care attribute. Other factors that may be described in general as bedside manner, did influence patient satisfaction, but their impact was much smaller. Thus, it seems that outpatients are rational consumers. They look for surrogate indicators of correct diagnosis and treatment options, which were the only measures of satisfaction they could use. The results from this study 194

indicate that outpatients may find these surrogate indicators in their perceptions of the feedback they receive from their physicians.

The price of care dimension, showed the second largest impact on outpatient satisfaction in Lebanon. Even though this dimension only placed second, its difference from the leading dimension of physician care was not large; thus, it is worth investigating and improving by establishing a clear relationship between the perceived price and the value received by the patients/customers. In this dimension, the most influential factor was the perceived monetary price.

The third most influential dimension was access to care. In this dimension, the most influential factor waiting time highlighted the influence of patient wait time on satisfaction with primary care. Process improvement in this aspects of the visit have been addressed by experts (M. Murray & Berwick, 2003; Nolan, Schall, Berwick, & Roessner, 1996); thus, models for immediate interventions by the managers of primary care practices are available and can be implemented in Lebanon without extensive research. Changing the workflow or reducing the waiting time is difficult, but informing patients of the reasons for the wait can improve patients' perception. The second receptionist personal behavior and the third "effort required to get an appointment influential factors, focused on the positive interaction between outpatients and reception staff. Thus, it seems that outpatients were influenced by the willingness and compassionate behaviors of the staff members. With this in mind, the appropriate training of the reception personnel may be warranted. Developing and using a protocol and providing guidelines regarding these factors would help staff members work more efficiently.

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The least influential dimension was atmospheric of care. Although this dimension played a less significant role in outpatient satisfaction, it nonetheless requires attention. In this dimension, the most influential factor was Cleanness. For most patients, cleanliness is a prerequisite for any satisfactory outcome. After all, and from a patient's perspective, if a medical setting cannot maintain the cleanliness of its facilities, it can not be trusted to perform well on other factors that the patient is unequipped to notice or unable to assess such as the technical quality of care. The second influential factor equipments' modernity highlighted the patients interest in the novelty of the medical equipments that was present in the clinic. They consider that these equipments provide to some extent tangible cues about the quality of the services that they can expect. Armed with such understanding, atmospherical factors can be strategically planned to correctly communicate the firm's image to its patients.

Chapter 5: Managerial Contributions


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Patient satisfaction is a process, not some panacea or magic elixir- Jeff Peters

In the previous chapter, the impact of different variables was assessed and it was shown that the modeled variables have either direct or indirect effects on outpatient satisfaction in Lebanon. The managerial chapter builds on these findings. Knowing what patients consider to be important is essential, yet certainly only the beginning. It does not suggest what to do with it. This chapter is split in two parts. Section 5.1 reconsiders the findings of the hypotheses section in the light of management implications. Consequences of the impact of the different influencing factors are discussed in the sub-sections. Disadvantages of previous approaches to improve patient satisfaction and a holistic process for its management are discussed and developed in section 5.2. The concluding section (5.3) rounds up the facts of chapter 5.

5.1 Direct Implications for Primary Care Providers

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This section is about different practical implications based on the results of the hypotheses tests. Each category of the practical implications is handled consecutively.

5.1.1 Practical implications related to the four healthcare attributes findings The explanatory power of the independent variables underscores that Lebanese healthcare providers should be aware of the importance of the selected variables. Strategy formulation should focus on these specific attributes of healthcare which is much more cost efficient manner than attempting to improve all influential variables simultaneously. Such approach will concurrently encourage patients to choose those facilities with which they are most satisfied and enlarge the return on assets since limited resources will be deployed in the most effective way. Moreover, our findings enable primary care providers to rank order the organizational objectives that pertain to the healthcare attributes we studied and to determine the extent to which those organizational objectives should be emphasized.

5.1.2 Practical implications related to the factors findings

The factors of the four explanatory variables can be readily acted on and incorporated in a settings tactical stance. For example, the detailed analysis of the physician care attribute revealed that the communication between the physician and the patient has a strong impact on patient satisfaction. Accordingly, physicians in Lebanese primary care settings should (1) listen carefully to what patients have to say (2) explain comprehensively any concern that is related to their conditions and treatments (3) involve patients in decisions about the best treatment options 198

for them (4) provide adequate visit time to answer any important questions the patient might have about his condition or treatment (5) give patients a second opportunity to communicate (provide e-mail address for instance). Moreover, the detailed analysis of the price of care attribute revealed that the perceived monetary price of care has a strong impact on patients satisfaction. Accordingly, Lebanese primary care providers must be careful that their bills do not appear as more expensive than what the customer expects to pay. In other words, if primary care settings bills provoke the reaction that they are inordinately high, it will lead to patient dissatisfaction. Primary care settings can, perhaps, work with patient expectations, as well as with their education to help them deal with potential cost shock. On the expectation front, some research may be undertaken by the settings to assess what patients expect to pay for certain services. If these patients have done some comparative shopping, bills that are significantly higher than the prices at comparable institutions will not confirm their expectations, leading to dissatisfaction. Where there is flexibility, and apparently there is quite a bit of this, primary care settings must conform as closely as possible to patients expectations if they are to build long-term relationships. For patients who do not expect to pay much, primary care settings can introduce a form of education by including, with the bill, comparative prices based on country wide statistics. These figures should be shown next to the settings charges and the savings, if any, highlighted. Where there are discrepancies, these must be clearly explained, to reduce any dissonance whatsoever.

Furthermore, the detailed analysis of the access to care attribute revealed that the waiting time has a strong impact on outpatients satisfaction. Studies in the healthcare sector have shown that delays perceived to be unreasonable or unnecessary by the patients could result in not just

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dissatisfaction, but also anger. Patients don't like the fact that the office does not respect their valuable time. A successful approach to decrease patients waiting times might include: (1) Reducing the mean and standard deviation of consultation times by assuring physician access to clinical information at the time of the appointment, such as radiograph reports, laboratory reports, and other consultants reports. At institutions without a computer-based patient record, coordinated efforts can successfully assure that a patients internal paper medical record will be available. Charts should be screened for necessary information before the patients appointment. (2) Providing activities for patients as they wait. Simple practices can alleviate the apparent lack of respect or concern evident to patients in being forced to wait in a clinic. Accordingly, the provider may: - Apologize for the delay. -Provide an accurate estimate of the waiting time. -Offer the patient the option of leaving and returning later for another appointment. -Provide an estimate of the minimum time the patient will need to wait, to provide the patient with flexibility (e.g., to get lunch). -Provide ample reading material, drinks, snacks, a quiet waiting area, and a television area. - Acknowledge periodically that the patient has not been forgotten.

Finally, the detailed analysis of the atmospheric of care attribute revealed that the hygiene of the setting has a strong impact on outpatients satisfaction. If the Lebanese primary care provider wants to ensure patients satisfaction, he should ask the housekeeper to check the holistic environment and the restrooms regularly in order to keep them neat, well manicured, and pleasant smelling. After all, patients visit a clinic to get rid of germs and bacteria not to pick them up. 200

5.1.3 Practical implications related to the moderators findings

An additional significant finding of our study is the minimal predictive power of patients' sociodemographic characteristics. Income was the only sociodemographic variable that appeared to have much influence on patient satisfaction, but that would have relevance only if Lebanese providers are targeting a specific income group. If that is the case, it might be more useful to segment on the basis of psychological variables or benefits sought by consumers. Accordingly, healthcare providers shouldn't concern themselves with consumers' sociodemographic characteristics when trying to improve satisfaction with health care. Instead, their focus should be on the delivery of those services. 5.1.4 Practical implications related to the mediators findings

This study showed that healthcare service quality is an antecedent of satisfaction. Accordingly, some factors such as price may influence satisfaction while not affecting customers' perceptions of service quality (Cronin & Taylor, 1992; R. L. Oliver, 1997). Consequently, healthcare providers and managers should try not only to improve service quality but also to find and manage factors, which may not be related to service quality but related to satisfaction per se.

In addition, this study confirmed the important role of distributive justice as an antecedent of satisfaction. Hence Lebanese healthcare providers and managers should attempt to provide an environment wherein patients will feel that they have received high levels of tangible (e.g., a better health status) and intangible (e.g., information) outcomes in return to their financial and non financial inputs.

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5.2 A Holistic Process of Patient Satisfaction

The present section broadens the scope of the discussion even further. Earlier sections presented hypotheses related consequences, provided and validated some guidelines to increase outpatient satisfaction in Lebanon. However, this is only part of the overall patient satisfaction picture. It needs to be embedded in an overall process of patient satisfaction management. After all, achieving exceptional patient satisfaction is a process, not the result of random acts (Otani, et al., 2005). A process that must be planned, controlled, and manipulated to produce high levels of satisfaction (Finley, 2001).

Although dozens of different initiatives to improve patient satisfaction (e.g., nurse rounding, huddles, brief, quality improvement techniques) have been proposed in the healthcare literature (Tea, Ellison, & Feghali, 2008; Torres & Guo, 2004), these approaches tend to be tactics and dont often tackle neither the core areas that need to be addressed prior to their implementations nor the management principles that should guide them. For example, its essential that the whole staff understand how well they perform in the measurements of patient satisfaction before implementing tactics such as rounding and huddles. Furthermore, each operational unit must be able to function effectively and be responsive to the customers needs before embarking on specific initiatives to improve patient satisfaction.

On the other hand, even if the processes are well-planned and structured, we believe that they should be guided by management principles such as accountability. In fact, horizontal accountability which refers to communication and problem solving among all employees across the organization (Ray & Elder, 2007), has been reported by a variety of references to improve patient satisfaction (Conners, Smith, & Hickman, 1994; Studer, 2000). In this form of 202

accountability, employees hold themselves jointly accountable for an organizational goal. There is no chain of command or reporting relationship. The focus is on committing efforts toward a principle that all employees support rather than focusing on the performance of each individual (O'Donnell, 1999). Horizontal accountability appeals to an individuals personal commitment or passion rather than their duty to serve their report. Their personal involvement allows them to feel empowered and propagates grassroots engagement of employees throughout an organization.

Taking into consideration the abovementioned weakening features, we propose the following process (review Figure 10) that includes seven steps:

Step One: Measurement of patient satisfaction Healthcare settings can't know where they want to go until they know where they are. They must have an ongoing, valid, and reliable system of measurement for determining how well they are satisfying their patients. The improvement process begins with a baseline of performance. The best managers know how to assimilate this baseline satisfaction measurement with other measurement systems. For instance, a best-practice emergency department director does not simply know that her patients are dissatisfied with waiting times. She also knows the current average wait times for various steps in the process at different times of day. Good lab managers know the average time it takes from the submission of an order to receipt of results by the ordering physician.

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Step Two: Share Data It is not enough for the manager alone to be familiar with patient satisfaction results. All employees must know their current level of performance. Managers must post patient satisfaction results for the entire staff to see and hold ongoing discussions on performance and expectations for improving scores. Step Three: Prioritization/Focus Developing 10 or 20 separate action plans for different areas of improvement is not feasible, so those areas must be prioritized and those that have the most impact must receive the lion's share of focus. Step Four: Action Plan Stepping on a scale every morning does not constitute a diet. The same goes for measuring patient satisfaction. One must measure and take action to achieve results. The actions taken to improve patient satisfaction must be specific, measurable, actionable, and timely. Simply saying "we will do a better job" is not enough. Staff members, as well as managers, should prioritize and develop action plans. Some behaviors that need to be implemented may seem simple; however, if such scripts, protocols, and procedures are imposed from above, rather than developed by staff members at the workgroup level, employees may be less likely to follow them.

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Step Five: Implement Planning has no impact if it does not result in actions carried out by everyone. Implementation is a task for the entire workgroup, not only the manager. If not everyone buys in and participates, the action plans are doomed to failure. Step Six: Stay the Course Improvement that lasts for one week, one month, or even one quarter does not constitute true success. Success is long-term, sustainable improvement. Once they establish their priorities, the whole staff needs to maintain focus on them. A common factor in failures is tendency of managers to change priorities each time they receive bad patient satisfaction results or to blame their own failings on subordinates. Hence, no action plan is ever seen through to completion. Workgroups should pick their top priorities, maintain focus until they achieve success, and only then identify the next area for improvement. Step Seven: Measure and Adjust Workgroups must have specific, measurable objectives and ongoing measurement to determine if they are achieving these objectives over time. Continuous patient satisfaction measurement provides trended data showing change over time, which allows workgroups to modify their strategies as needed.

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Figure 10: A Holistic Process of Patient Satisfaction

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5.3 Managerial Contributions: Conclusion

Performance in patient satisfaction is primarily driven by an organizations ability to meet the patients needs and deliver excellent service, which in turn are dependent upon operational efficiency, responsiveness, and accountability. Once these basic operational components are achieved, a set of core principles can be used to improve patient satisfaction.

Our understanding of these core principles permitted the development of a holistic process of patient satisfaction.

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CONCLUSION HYPOTHESES, METHODOLOGIES AND OUTCOMES

The first part of the research aimed to provide a better conceptual understanding of patient satisfaction and its drivers. One important limitation drawn from the literature review was the absence of any methodological study on outpatient satisfaction in Lebanon. Thus, it was proposed to fill this gap in the second part of this study identifying and ranking the key drivers of patient satisfaction with primary care services in Lebanon

Specifically, in the third chapter, the research model was build and twenty hypotheses were formulated. The fourth chapter outlined the deployed methodologies and data analysis strategy. Research instruments were validated and results of the statistical tests were presented. In the fifth chapter, the practical consequences of the empirical results were described. A holistic process of patient satisfaction was also proposed.

The empirical findings of the study can be classified in two classes. One class refers to questionnaire development the other to the definition of a model of the antecedents of patient satisfaction with primary care services in Lebanon.

The questionnaire developed by the researcher to collect the data from the field was mostly new. The questionnaire revealed strong psychometric properties and may be used in future research on outpatient satisfaction in Lebanon or abroad.

The definition of the model of antecedents to satisfaction with healthcare services brings an important contribution to research on patient satisfaction. Specifically, it highlights the importance of distributive justice as a mediating variable between price of care and patient 208

satisfaction. The results also reveal the importance of income as a moderator in the relationship between healthcare attributes and patient satisfaction.

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CONCLUSION
-------------------------------------------------------------------------------------------------------------------Healthcare is like any other business; if we do not take care of our customers, they will take their business elsewhere- Author unknown.

Patient satisfaction is critical to any health-care provider's success and survival (Esa, Rajah, & Abdul Razak, 2006 ). Although, substantial research attention has been directed toward the conceptualization and operationalization of the patient satisfaction concept; much more studies are still needed (Gill & White, 2009). Keeping this in mind, this study was the first to identify the key dimensions and factors of healthcare that affect patient satisfaction with primary care services in Lebanon.

In an ever more globalized world, where patients have become more conscious about their rights, healthcare providers need to show the community that patients and their satisfaction are considered first and foremost at every point in the planning, implementation, and evaluation of service delivery. Patient preferences should guide every aspect of service delivery, from clinic hours to counseling techniques to contraceptive decision-making. Patients satisfaction is created through a combination of responsiveness to the patient's views and needs, as well as a continuous improvement of the healthcare services.

The key contributions of the research are presented hereafter. Then, the limitations of the work are stressed. Finally, the directions for further research on patient satisfaction are explored.

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CONTRIBUTIONS OF THE RESEARCH The contributions of this research are of theoretical and managerial nature. Theoretical Contributions

Identifying the key dimensions of healthcare that improve outpatient satisfaction in Lebanon

This study was the first to identify the key dimensions and factors of healthcare that affect patient satisfaction with primary care services in Lebanon.

This work enables future researchers to have a better conceptual understanding of the drivers of outpatient satisfaction in general and, most specifically, in Lebanon.

Verification of the causal order between healthcare service quality and patient satisfaction While the literature on service quality and patient satisfaction does not appear to be in agreement regarding the causal order between these two constructs (Gill & White, 2009), the findings of this study show that healthcare quality leads to patient satisfaction. This result is significant since it predicts an attitudinal approach where cognitive evaluation precedes the formation of the associated affect. An example of this approach is the research on evaluations of telephone service (R. Bolton & J. Drew, 1991) where cognitions appear to be formed first regarding the quality of the service and where the customer then decides whether s/he is happy with the service.

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Investigating the role of distributive justice in patients satisfaction While the role of distributive justice has been often advanced to explain consumers satisfaction / dissatisfaction with various types of services (e.g., (R.L. Oliver & Swan, 1985; R. L. Oliver & J. E. Swan, 1989)), this role hasnt been investigated to better understand patients satisfaction with healthcare. The findings from this study show that distributive justice should be regarded as a mediator in the relationship between price of care and patients satisfaction.

Managerial Contributions

From a management point of view, Chapter 5 described the practical consequences of the empirical results. It showed how organizations and practitioners can transfer this knowledge into their daily work. Furthermore, it was shown that former approaches to patient satisfaction implementation were incomprehensive. A holistic process was proposed. Those procedures can assist primary care providers in allocating resources more efficiently and effectively.

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LIMITATIONS OF THE RESEARCH

No research study is devoid of limitations and this study is not an exception. Some of these limitations pertain to the research design, others to the sampling design and its process, yet some others to the model tested in this study.

The first set of limitations is related to the research design. First, the data collected was completed in a one phase, cross-sectional, study design. This limits the ability to draw causal inferences between the modeled variables. Second, the study was restricted to one particular primary care setting located in the capital Beirut. Only the specific case of Mount Lebanon Clinics patients was analyzed, which presents a limitation as to the generalization of the results to other primary care settings.

A second set of limitations pertains to the sampling design and its process. First, the size of the sample selected for collecting data from respondents can always be challenged because it was not a census. The actual number of questionnaires used in the research was 385, from a total population of 10690, which represents only 3.6%. Although statistically speaking a 3.6% sample is generally accepted, a census remains of higher value. Second, like any study that is based on consumer survey through a predesigned questionnaire, this study suffers from the basic limitation of the possibility of difference between what is recorded and what is the truth. This is because the patients may not deliberately report their true preferences and even if they want to do so, there are bound to be differences owing to problems in filters of communication process.

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The third set of limitations is related to the model tested in the research study. First, although the research model is original, it was not the intention of this research exercise to build a model that include every driver of outpatient satisfaction in Lebanon, knowing that there may be more than the four drivers presented in this research model itself. Second, while a compensatory model (Fishbein & Ajzen, 1975a) was used in this study (positive attribute reactions can compensate for weak or poor attribute reactions) to evaluate patient satisfaction, the non compensatory models (Ganzach, 1993; Kahneman & Tversky, 1979) which do not admit trade-offs among attributes were not considered even though several studies have used them in healthcare and found that they provide valuable information [e.g., (Otani, 2006; Otani & Harris, 2004; Otani, Harris, & Tierney, 2003; Otani, Kurz, Burroughs, & Waterman, 2003)]. IMPLICATIONS FOR FUTURE RESEARCH

The current research can be enhanced through new studies. Especially presented limitations provide opportunities of further research. Generally, future research might either aim to consolidate the most recent knowledge or extend existing frames of mind.

Consolidation

The first approach would be to consolidate the research model proposed in the study. It should disguise the limitations presented above. Accordingly, future research could support the research model proposed in this study by replicating the study in other primary care settings in order to validate the causal relationships in it. The model can also be reinforced by identifying complementary mediating/moderating variables.

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Extension

This section is about broadening the scope of focus. Extension efforts are supposed to go beyond the already researched. It could involve testing a completely new model in which more variables are entered in order to have a more comprehensive study for the factors that affect patient satisfaction, such as patients expectations. It could also consist in analyzing the consequences of patient satisfaction on other dimensions of corporate performance, for instance patient loyalty and patient trust.

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Glossary of Statistical and Technical Terms


Association: Two variables are associated if some of the variability of one can be accounted for by the other. Attribute: An attribute is a constant characteristic which belongs to an object, person, situation or variable. Causal relation: Two variables are causally related if changes in the value of one cause the other to change. Two variables can be associated without having any causal relation, and even if two variables have a causal relation, their correlation can be small or zero. Coefficient of correlation or Pearson correlation coefficient (r): To quantify the strength of the relationship between two variables, we can calculate the correlation coefficient symbolized by (r). The value of (r) always lies between -1 and +1. A value of the correlation coefficient

close to +1 indicates a strong positive linear relationship. A value close to -1 indicates a strong negative linear relationship. A value close to 0 indicates no linear relationship. Coefficient of determination (r2): It is a statistical coefficient that explains how much of the variability of a variable can be caused or explained by its relationship to another variable. In regression, the coefficient of determination (R2) is a statistic that will give some information about the goodness of fit of a model. (R2) indicates the proportion of the variance in the criterion variable which is accounted for by the set of predictor variables present in the model. The coefficient of determination (R2) varies between 0 and 1 which indicates that the regression line perfectly fits the data. Constrained parameters: Constrained parameters are coefficients set equal to one another by the researcher prior to model estimation. Construct (or Concept): An abstract or general idea that describe a phenomenon of theoretical interest. Constructs can not be measured directly; they should be operationalized first in order to 216

be measured. It is therefore important for constructs to be converted into variables as they can be subjected to measurements though the degree of precision with which they can be measured varies from scale to scale. Continuous Variable: A variable that can take on any value and therefore is not discrete. Content Analysis: Any technique for making inferences by objectively and systematically identifying specified characteristics of messages. Control variable: is that factor which is controlled (kept constant) by the experimenter to cancel out or neutralize any effect it might otherwise has on the observed phenomenon. The role of the control variable is usually confined to merely restricting generalizations. It proclaims that the observed relationship between the independent variable and the dependent variable can be generalized on condition that the controlled variable is neutralized. Correlation: A correlation is a single statistic that describes the degree of relationship between two variables. Two variables can be strongly correlated without having any causal relationship, and two variables can have a causal relationship and yet be uncorrelated. Covariance: Is a measure of the strength of the link between two (numerical) random variables. The covariance of a variable with itself is the variable's variance. Cross Sectional: one time study Dependent variable: is that variable which is observed and measured to determine the effect of the independent variable. It is also called criterion variable or factor. Discrete Variable: A discrete variable is one that cannot take on all values within the limits of the variable. For example, responses to a five-point rating scale can only take on the values 1, 2, 3, 4, and 5. The variable cannot have the value 1.7

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Diploma mill: A diploma mill is an organization that awards academic degrees and diplomas with substandard or no academic study and without recognition by official educational accrediting bodies. Effect Size Indicator: An effect size indicator is a statistical measure of the strength of a relationship. Effect-size indicators are important aids when we are making a judgment about practical significance. The coefficient of determination (R2) is one of the many effect size indicators. Element: An element is the basic unit that is selected from the population Endogenous variables: A dependent variable in at least one linear equation in the equation system under consideration. In a path diagram, endogenous variables have at least one arrow pointing to them. Note that an endogenous variable may also cause another endogenous variable in the model. Estimator: An estimator is a rule for "guessing" the value of a population parameter based on a random sample from the population. An estimator is a random variable, because its value depends on which particular sample is obtained, which is random. A canonical example of an estimator is the sample mean, which is an estimator of the population mean. Exogenous variable: An independent variable that is not caused by another variable in the model. Usually this variable causes one or more variables in the model. Falsifiable: designating or of a statement, theory, etc. that is so formulated as to permit empirical testing and, therefore, can be shown to be false. Fixed parameter: coefficient set equal to a particular value by the researcher prior to model estimation. Free parameter: unknown coefficient estimated by a SEM model. Geneticist: a biologist who specializes in genetics (branch of biology that deals with heredity). 218

Hypothesis: A hypothesis is an unproven proposition that is scientifically testable through quantitative or qualitative measures and which tentatively explains certain facts or phenomena. Hypothesis Testing: Hypothesis testing is a method that is used to draw conclusions about a population using data obtained from a sample. Hypothesis testing is therefore classified under inferential statistics. Independent variable: is that variable which is measured, manipulated or selected by the experimenter to determine its relationship to an observed phenomenon. It is also called predictor variable or factor. Inpatient: Inpatient means that the procedure requires the patient to be admitted to the hospital, primarily so that he or she can be closely monitored during the procedure and afterwards, during recovery. If the patient comes in for diagnostic tests and leaves the hospital in less than 24 hours that is considered outpatient. Instrument: An instrument is the formal language used to describe the descriptive system of a measure. It usually comprises several scales, each of which contains several items. Intervening variable: is that variable which theoretically affects the observed phenomenon but cannot be seen, measured or manipulated; its effect must be inferred from the effects of the independent and moderator variables on the observed phenomenon, i.e. that conceptual variable which is being affected by the independent, moderator and control variables, and in turn affects the dependent variable. Item: Is the term used to describe a single question, where the psychometric properties of the question are known. A question has no formally known measurement properties. Items consist of two parts: the item stem is the question part, and the item response is the response part. Latent variable: A variable of interest that cannot be directly measured but has to be estimated through procedures such as factor analysis applied to a number of manifest variables deemed to 219

be caused by the latent variable. Latent variables are pure unidimensional concepts or constructs and they are also known as factors, constructs or unobserved variables. Likert scale: A Likert scale is a psychometric scale commonly used in survey where respondents specify their level of agreement or disagreement with Likert items. An important distinction must be made between a Likert scale and a Likert item. The Likert scale is the sum of responses on several Likert items which are often accompanied by a visual analog scale (e.g., a horizontal line, on which a subject indicates his or her response by circling or checking tick-marks). Linear Regression: In statistics, linear regression is an approach to modeling the relationship between a scalar variable y and one or more variables denoted X. Linear Model: Statistical model in which the value of a parameter for a given value of a factor (y) is assumed to be equal to a+ bx+ e, where (a), (b) are constants and (e) is the residual. The model predicts a linear regression. Matrix: A matrix is a rectangular array of numbers arranged in rows and columns. Numbers that appear in the rows and columns of a matrix are called elements of the matrix. Measures (indicators, items): observable, quantifiable scores obtained through self-report, interview, observation or other empirical means. Measured variable: A measured variable is a variable that can be observed directly and is measurable. Measured variables are also known as observed variables, indicators or manifest variables. Model Fit: The ability of an over-identified model to reproduce the variables' correlation or covariance matrix. Model Parameter: A coefficient (mean/ variance/ covariance/ regression coefficient) of a model. The parameters of a SEM model are the variances, regression coefficients and covariances among variables. 220

Multicollinearity: is a statistical phenomenon in which two or more predictor variables in a multiple regression model are highly correlated. Multiple Linear Regression: Multiple Linear Regression aims is to find a linear relationship between a response variable and several possible predictor variables. Non Recursive Model: A model that include bi-directional causal relationships (two or more variables that influence each other) and/or correlations between two or more error terms. One-tailed hypothesis: One-tailed hypothesis is one that specifies the direction of a difference or correlation. Operationalization: Operationalization is the process of defining a fuzzy concept so as to make the concept clearly distinguishable (in humanities) or measurable (in physicality sciences) and to understand it in terms of empirical observations. Outpatient: Outpatient means that the procedure does not require hospital admission and may also be performed outside the premises of a hospital. If the patient exceeds 24 hours of stay in a hospital, that is already inpatient. Parameter: Parameters are numerical characteristics of a population that describe the relationships between variables when such a relationship would be difficult to explicate with an equation. Parameters are often estimated since their value is generally unknown, especially when the population is large enough that it is impossible or impractical to obtain measurements for all people. Path Analysis: Path Analysis which is a special case of SEM, is the statistical technique used to examine causal relationships between two or more variables and it is based upon a linear equation system. In path analysis mediated pathways (those acting through a mediating variable, i.e., Y, in the pathway X Y Z) can be examined. Pathways in path models represent

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hypotheses of researchers, and can never be statistically tested for directionality. Path analysis deals only with measured variables (no latent variables). Path coefficient: Path coefficient is the standardized versions of linear regression weight which can be used in examining the possible causal linkage between statistical variables in the structural equation modeling approach. Path diagram: A structural equations model represented according to graphical conventions. Performance: The results of activities of an organization or investment over a given period of time. Population: The population is all the individuals in whom we are interested. A population does not always consist of individuals. Sometimes, it may be geographical areas such as all cities with populations of 100,000 or more. Practical Significance: Practical significance is concerned with whether the result is useful in the real world. Primary care: Primary care is the term that refers to the health services offered by providers who act as the principal point of consultation for patients within a healthcare system (World Health Organization). Probability Value: The probability value (also called the p-value) is the probability of the observed result found in your research study of occurring, under the assumption that the null hypothesis is true (i.e., if the null were true). Basically in hypothesis testing the goal is to see if the probability value is less than or equal to the significance level (i.e., is p alpha). Psychometrics: This is the discipline of measurement, where psychometric refers to the formal measurement properties of an item, scale or instrument. Random Error: Random error is caused by any factors that randomly affect measurement of the variable across the sample. Random error does not have any consistent effects across the entire 222

sample. Instead, it pushes observed scores up or down randomly. This means that if we could see all of the random errors in a distribution they would have to sum to zero. The important property of random error is that it adds variability to the data but does not affect average performance for the group. Because of this, random error is sometimes considered to be noise in measurement. Recursive Models: Models in which causality goes in one direction only and error terms are uncorrelated. Redundancy: Refers to items that are not needed in a scale, i.e. their presence does not contribute to the scale, and the scale is as reliable and valid with these items removed. Regression: A regression is a statistical analysis assessing the association between two variables. It is used to find the relationship between two variables. Regression Weights (Unstandardized Regression Coefficients- B) - Represent the average amount of change in the dependent variable for a single raw score unit increase in the predictor variable (controlling for the other predictors in the model). When the regression line is linear (y = ax + b +e) the regression weight (unstandardized regression coefficient) is the constant (a) that represents the rate of change of one variable (y) as a function of changes in the other (x); it is the slope of the regression line. Residual (Error): Residual represents unexplained variation after fitting a regression model. The actual cases in the data will not correspond exactly to what the equation predicts. The predicted values are the fit to the data that the regression has produced. The difference between the values of the dependent variable that are predicted by that fit and the actual observed values are the residuals, that which is not fit. Response Scale: Items often use a response scale on which the respondent selects the response that best describes his/her position.

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Scale: Refers to a collection of items that, between them, measure a construct. It is accepted that the items within a scale should be homogenous. Several scales may be included in an instrument. Significant: In statistics, a result is called statistically significant if it is unlikely to have occurred by chance only. Significance level: The significance level (also called the alpha level) is the cutoff value the researcher selects and then uses to decide when to reject the null hypothesis. Most researchers select the significance or alpha level of .05 to use in their research; hence, they reject the null hypothesis when the p-value (which is obtained from the computer printout) is less than or equal to .05. Simple Linear Regression: Simple Linear Regression aims to find a linear relationship between a response variable and a possible predictor variable by the method of least squares. Statistic: A statistic is a numerical characteristic of a sample. Statistics: Statistics refers to methods and rules for organizing and interpreting quantitative observations. Statistical Error: A statistical error is the amount by which an observation differs from its expected value, the latter being based on the whole population from which the statistical unit was chosen randomly. Statistical Significance: Statistical significance means that the observed mean differences are not likely due to sampling error. The term statistically significant is used to describe results for which there is a 5% or less probability that the results occurred by chance. A high significance does not mean a strong relationship. Standardized Regression Weights (Standardized Regression Coefficients- Beta) - represent the average amount of change in the dependent variable (Y) in Y standard deviations, given a

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standard deviation unit change in the predictor variable (controlling for the other predictors in the model). Statistic: A statistic is a quantity, calculated from a sample of data, used to estimate a parameter. For example, the average of the data in a sample is used to give information about the overall average in the population from which that sample was drawn. Statistical Model: A set of mathematical equations which describe the behavior of an object of study in terms of random variables and their associated probability distributions. Structural Model: A set of structural equations. Systematic Error: Systematic error is caused by any factors that systematically affect measurement of the variable across the sample. Unlike random error, systematic errors tend to be consistently either positive or negative. The important property of systematic error is that it not only adds variability to the data but also affect average performance for the group - because of this; systematic error is sometimes considered to be bias in measurement. Systematic Disturbance: Error term for a latent variable. Theory: In confirmatory factor analysis (CFA), theory is a systematic set of causal relationships that provide the comprehensive explanation of a phenomenon. Two-tailed hypothesis: Two-tailed hypothesis is one that does not specify the direction of a difference or correlation. For example, if we were correlating people's heights with their income, we might have no good reason for expecting that the correlation would be positive (income increasing with height) or negative (income decreasing with height). We might just want to find out if there were any relationship at all, and that's a two-tailed hypothesis. Variable: A variable is a conceptual entity, an invention based on reality that exists in the minds of people. Variables are so called because they can assume any one of a range of values.

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Measurability is the main difference between a variable and a concept. A variable can be measured while concepts can not. Variance: A measure of the amount of diversity or variation in the scores received for a question. The variance is a very good index of the degree of dispersion. It will be equal to zero if and only if each and every observation in the distribution is the same as the mean. The variance will grow larger as the observations tend to differ increasingly from each other and from the mean. Variance-Covariance Matrix: Variance and covariance are often displayed together in a variance-covariance matrix. The variances appear along the diagonal and covariances appear in the off-diagonal elements.

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Appendix 1
The Interview Guide

Interviewer reads preamble: Todays interview is intended to clarify how MLCs patients interpret the concept of satisfaction. Its specific objective is to identify the dimensions and aspects that are most relevant for these patients. This interview may take up to 30 minutes and with your permission it will be recorded to ensure your views are accurately reflected. Please, keep in mind that your personality will stay anonymous and that you may stop this interview at any time without holding any kind of responsibility. Phase 1: Introduction 1) Is it your first visit to MLC and what services do you want from it? 2) Do you often visit primary care settings? Phase 2: Subject centering 3) For which medical reason you may visit a primary care setting? 4) How do you describe your relationship with MLCs staff? Why? Phase 3: Insights on the key topic 5) Are you satisfied with the outcomes of this visit? Why? 6) Can you describe a satisfying or dissatisfying incident that happened during this visit? 7) Have your expectations been met? To what extent? 8) What were your main concerns before and during your visit?

Phase 4: Conclusion 9) What is your perception on healthcare providers in general? 10) From your perspective, what are the major barriers that stand in the way of increasing patients satisfaction levels?

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Appendix 2
Cover Letter MOUNT LEBANON CLINIC

Dear Patient, At Mount Lebanon Clinic, our mission is to dedicate our skills, energies and resources to providing you with individual and sensitive care in a safe, comfortable and well-equipped environment. We are always looking for ways to improve our service; therefore, we would like to request your assistance by asking you to complete this questionnaire on the services you have received whilst in our care. By completing this form, you will help make a real difference to our clinic. We ensure that we take note of all comments received and review your feedback as part of our commitment to continuous improvement. All observations will be treated with the strictest of confidence unless you indicate otherwise. We can assure you that the collected data will be kept anonymous even though it will be used as well in a research paper that will be available for any stakeholder on Grenoble School of Management website following the school approval. Once completed, please give back the form to the employee who gave it to you in the first place. In case you have any suggestions or inquiries regarding this questionnaire, do please fill free to contact me at the following number: 961-70- 132 131. Thank you for helping us to better serving you.

Karim Kobeissi. Administrative Manager 253

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Appendix 3
The Final Instrument
V1- Respondent number The following set of statements relate to your feelings about MLC. For each statement, please show the extent to which you believe MLC has the feature described by the statement. Circling a seven on the line means you strongly agree that MLC has that feature, and a one means you strongly disagree. You may circle any of the numbers in the middle as well to show how strong your feelings are. There are no right or wrong answersall we are interested in is a number that best shows your perceptions about MLC. Healthcare Service Quality Scale Strongly Agree V2- The physical facilities in the clinic are visually appealing. V3- The clinic has modern looking equipments. V4- Materials associated with the service (such as pamphlets or statements) are visually appealing. V5- Personnel in the clinic are neat in appearance. V6- When the clinic promises to do something by a certain time it does so. V7- The clinic provides its services at the time it promises to do so. V8- When you have a problem, the clinic shows a sincere interest in solving it. V9-The clinic insists on error-free records. V10- The clinic gets things right the first time. V11- The personnel in the clinic tell you exactly when services will be performed. V12- Personnel in the clinic give you prompt service. V13-Personnel in the clinic are always willing to help you. V14- Personnel in the clinic are never too busy to respond to your requests. V15- The behaviour of personnel in the clinic instills confidence in you. V16- You feel safe in your dealings with the clinic. V17- Personnel in the clinic are consistently courteous with you. V18- Personnel in the clinic have the knowledge to answer your questions. V19- The clinic has personnel who give you personal attention. V20- The clinic gives you individual attention. Strongly Disagree 1---------------2---------------3-------------- 4---------------5---------------6------------7 1---------------2---------------3-------------- 4---------------5---------------6------------7 1---------------2---------------3-------------- 4---------------5---------------6------------7 1---------------2---------------3-------------- 4---------------5---------------6------------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7

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V21- The clinic has your best interests at heart. V22- The clinic has operating hours convenient to all its patients. V23- The personnel of the clinic understand your specific needs. V24- Calculated Mean Global Service Quality on the SERVPERF scale for the clinic Distributive Justice Scale V25- This primary care visit resulted in a very positive outcome for me. V26- I was more than compensated for any out-of-pocket expenses I might have incurred. V27- I was more than compensated for any frustration. V28- I got more out of this transaction than the physician. V29- Calculated Mean Score for the Distributive Justice scale Access to Care Index V30- The clinic provides appropriate car parking facilities. V31- The receptionist employee was responsive. V32- The operation hours are convenient for me. V33- It was easy to schedule an appointment for the outpatient visit. V34- I did not wait for a long period before being seen by the physician for my scheduled appointment. V35- Composite Index Access to Care (Mean) Physician Care Index V36- The physician has a friendly attitude. V37- The physician has the needed knowledge to take care of me. V38- The physician considered my individual needs when treating my condition. V39- I received adequate information, so I know what to do when I get home. V40- The physician was attentive to the details of my medical condition. V41- Composite Index Physician Care (Mean)

1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7

1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7

1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7

1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7

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Price of Care Index V42- The monetary price I paid for the service is cheap. V43- The non monetary price I paid for the service is economical. V44- Composite Index Perceived Price of Care (Mean) Atmospherics of Care Index V45- The waiting room was clean. V46- There was a fresh air in the clinic V47- The clinics landscape design is visually appealing. V48- The apparatus in the clinic are modern. V49- The hearing environment was controllable. V50- Composite Index Atmospherics of Care (Mean) V51- What is your overall degree of satisfaction toward the service that you had received during this visit to Mount Lebanon Clinic. PATIENT PROFILE V52- Gender Male -------------- Years V54- Average monthly household income (US $) is: ----------------Female V53- At my last birthday, my age was: 1---------------2---------------3-------------- 4--------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7 1---------------2---------------3-------------- 4---------------5---------------6-----------7

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Appendix 4
Descriptive Statistics of the Quantitative Study

Descriptive Statistics N AVERAGE PERCEIVED SERVICE QUALITY AVERAGE DISTRIBUTIVE JUSTICE AVERAGEACCESSTOCARE AVERAGEPHYSICIANCARE AVERAGEPERCEIVEDPRICEOFCARE AVERAGEATMOSPHERICSOFCARE Overall patient satisfaction score on a 1 to 7 scale Patient age Patient monthly household income in US $ Valid N (list wise) 385 385 385 385 385 385 385 385 385 385 Minimum 1.45 1.00 1.40 1.00 1.00 1.00 1.00 17.00 500.00 Maximum 6.77 7.00 6.80 6.80 7.00 7.00 7.00 72.00 21000.00 Mean 4.6166 4.6494 4.4208 4.5003 4.6844 4.2608 4.2857 38.1351 1553.3117 Median 5.0000 5.5000 4.2000 4.8000 5.0000 4.2000 5.0000 37.0000 1300.0000 Std. Deviation 1.53595 1.88092 1.37264 1.41304 1.52915 1.69440 1.85164 12.59929 1209.08712

Comparison of sample profile and population profile by sex Sample Population (aged 16 and above) No. % No. % Male 4062 38 131 34.0 Female 6628 62 254 66.0 Comparison of sample profile and population profile by age Mean age 38.1351 35 Base: All respondents 385 100 10690 100

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Appendix 5
Results of the Physician Care Attribute Analysis

Coefficientsa Standardized Unstandardized Coefficients Model 1 (Constant) Patient sex Patient age Patient monthly household income in US $ 2 (Constant) Patient sex Patient age Patient monthly household income in US $ Satisfaction toward physician attitude on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward physician competence on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward considering individual needs on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward information received on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward physician accuracy on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied a. Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale .181 .057 .216 3.166 .002 .300 .053 .263 5.626 .000 .114 .060 .092 1.900 .048 .181 .053 .191 3.386 .001 .145 .066 .139 2.182 .030 .119 -.156 .020 .000 .422 .136 .005 .000 -.040 .138 -.148 .282 -1.152 3.990 -4.417 .778 .250 .000 .000 B 4.224 -.302 .035 .000 Std. Error .514 .195 .007 .000 -.077 .238 -.324 Coefficients Beta t 8.212 -1.549 4.778 -6.826 Sig. .000 .122 .000 .000

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Appendix 6
Results of the Price of Care Attribute Analysis

Coefficientsa Standardized Unstandardized Coefficients Model 1 (Constant) Patient sex Patient age Patient monthly household income in US $ 2 (Constant) Patient sex Patient age Patient monthly household income in US $ Satisfaction toward monetary price paid on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward non monetary costs incurred on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied a. Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale .209 .060 .160 3.486 .001 .531 .044 .553 11.972 .000 .019 .065 .029 .000 .438 .142 .005 .000 .017 .198 -.157 .043 .457 5.516 -4.476 .966 .648 .000 .000 B 4.224 -.302 .035 .000 Std. Error .514 .195 .007 .000 -.077 .238 -.324 Coefficients Beta t 8.212 -1.549 4.778 -6.826 Sig. .000 .122 .000 .000

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Appendix 7
Results of the Access to Care Attribute Analysis

Coefficientsa Standardized Unstandardized Coefficients Model 1 (Constant) Patient sex Patient age Patient monthly household income in US $ 2 (Constant) Patient sex Patient age Patient monthly household income in US $ Satisfaction toward parking convenience on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward receptionist responsiveness on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward operating hours convenience on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward appointment scheduling on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward waiting time before been seen on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied a. Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale .339 .047 .381 7.250 .000 .115 .055 .102 2.074 .039 .113 .063 .099 1.796 .043 .151 .054 .155 2.811 .005 .074 .065 .071 1.132 .258 .327 .061 .017 .000 .461 .146 .006 .000 .016 .117 -.157 .710 .419 3.113 -4.212 .478 .675 .002 .000 B 4.224 -.302 .035 .000 Std. Error .514 .195 .007 .000 -.077 .238 -.324 Coefficients Beta t 8.212 -1.549 4.778 -6.826 Sig. .000 .122 .000 .000

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Appendix 8
Results of the Atmospherics of Care Attribute Analysis

Coefficientsa Standardized Unstandardized Coefficients Model 1 (Constant) Patient sex Patient age Patient monthly household income in US $ 2 (Constant) Patient sex Patient age Patient monthly household income in US $ Satisfaction toward cleanness of the setting on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward presence of fresh air on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward landscape design on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward modernism of the used equipments on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied Satisfaction toward hearing environment on a 1 to 7 scale from 1 =strongly dissatisfied to 7 = strongly satisfied a. Dependent Variable: Overall patient satisfaction score on a 1 to 7 scale .003 .060 .003 .049 .048 .149 .061 .151 2.439 .015 .100 .061 .111 1.629 .104 .046 .067 .048 .682 .045 .339 .041 .417 8.323 .000 1.423 -.350 .025 .000 .431 .147 .005 .000 -.090 .169 -.185 3.301 -2.382 4.521 -5.084 .001 .018 .000 .000 B 4.224 -.302 .035 .000 Std. Error .514 .195 .007 .000 -.077 .238 -.324 Coefficients Beta t 8.212 -1.549 4.778 -6.826 Sig. .000 .122 .000 .000

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Appendix 9

Statistics Patient monthly household income in US $ N Valid Missing Percentiles 25 50 75 385 0 1000.0000 1300.0000 1900.0000

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