value co-creation in social marketing wellness services · 2013-07-04 · value co-creation in...

Value Co-Creation in Social Marketing Wellness Services

A thesis submitted to Queensland University of Technology in fulfilment of the

requirements for the degree of Doctor of Philosophy, 2011 by

Nadia Zainuddin

B Bus (Marketing) (Hons) QUT

School of Advertising, Marketing and Public Relations

QUT Business School, Queensland University of Technology

Supervisory Panel Members

Professor Boris Kabanoff (Panel Chair)

School of Management


Professor Rebekah Russell-Bennett (Principal Supervisor)

School of Advertising, Marketing and Public Relations


Dr Josephine Previte (Associate Supervisor)

UQ Business School

Faculty of Business, Economics and Law, University of Queensland

Associate Professor Anne Pisarski (Faculty Representative)

School of Management


1 October 2011

STATEMENT OF ORGINAL AUTHORSHIP

The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any other higher education institution. To the

best of my knowledge and belief, the thesis contains no material previously

published or written by another person except where due reference is made.

______________________________

Nadia Zainuddin

on 1 October 2011

“Great discoveries and improvements invariably involve the co-operation of many

minds. I may be given credit for having blazed the trail but when I look at the

subsequent developments I feel the credit is due to others rather than to myself”

Alexander Graham Bell

ACKNOWLEDGEMENTS

I would first like to acknowledge the contributions of my supervisors; Professor Rebekah

Russell-Bennett and Dr Josephine Previte. I am lucky to have had the opportunity to be

supervised by two incredibly talented, knowledgeable, and high-achieving women; who have

such complimentary skill sets and supervision styles from which I felt that I was able to

benefit most greatly. Rebekah, I‟ve come to deeply admire and respect you as an academic,

but am also deeply appreciative of you as a mentor. I feel as ready as I can be for this next

adventure because of you. Jo, I truly admire your passion for what you do and your

commitment to the endeavours that you take on. Your enthusiasm for research is contagious

and now I feel a sense of excitement for things to come.

The support I received from the School of Advertising, Marketing and Public Relations has

also been invaluable. I would like to thank the Head of School, Associate Professor Robina

Xavier, for providing me with support and access to the resources that were necessary in

supporting the completion of my PhD. My appreciation also goes to my panel members;

Professor Boris Kabanoff and Associate Professor Anne Pisarski for lending their

expertise to the development of the final version of this thesis. Thank you to Ms Trina

Robbie from the Research Students Support Centre for looking after me during my

candidature.

I would also like to acknowledge my appreciation for every academic who has ever given me

advice on the various aspects of my research. In particular, I am grateful for the contributions

of Associate Professor Ian Lings and Dr Larry Neale. Thank you, Ian, for being so kind in

my panic-stricken moments. I‟m glad that generosity, talent, pragmatism, and the ability to

face a crying girl have found their way into someone like you! I always felt a sense of relief

after seeking your advice and you have made a huge difference to my experiences with

research. Larry, I have never met another academic who is always happy like you! Your

easy-going attitude, humour and ability to seemingly take everything in your stride are

qualities that I appreciate and hope to emulate. The laws of emotional contagion are true!

Thank you for teaching me about the “softer” side of life as an academic.

This research was conducted with the support of Queensland Health‟s BreastScreen

Queensland and in particular, I would like to thank Ms Jennifer Muller and Ms Michelle

Tornabene. Their enthusiasm for my research has made me feel incredibly valued as a

researcher and I am glad that my research findings have been able to make a positive impact

on the community so far.

FINAL THANKS

My final thanks go to my friends and loved ones; I would not have been able to navigate my

way around this endeavour as gracefully as I would‟ve liked without all of you!

For the many years of support that I have received from Mr Damien McDonald, I am

incredibly grateful. Thank you for your friendship, encouragement, and patience (especially

your patience) over the many years of our friendship. You are the original inspiration for my

own wellness paradigm, which has shaped me as a researcher and as a person.

To my friend, Ms Lindsay Lim, who epitomises wellness and inspires me on this journey of

living well and being well, thank you also for always being real and keeping me grounded.

I am grateful to Ms Lisa Wessels who is one of the kindest friends that I have had the good

fortune of knowing. Your compassion, enthusiasm and sincerity are qualities that I

appreciate and I am blessed to have a wonderful friend in you.

To an incredible role model, Dr Cheryl Leo, thank you for sharing your own journey with

me. Your pragmatism has allowed me to keep perspective despite my many bleary moments

and for that, I am grateful. I look forward to navigating my way around this next journey

with you, my friend!

To another incredible role model, Dr Dominique Greer, for whom I have deep admiration

of her talent, determination and grace, I could only hope to be as naturally talented a

researcher as you!

For being the sort of friend who is like family, thank you to Mr Bernard Li. I am glad for

having a friend like you around whom I can really be myself.

My heartfelt thanks and gratitude also go to Joe & Michelle McDonald for looking after me

and making me feel truly cared for; your kindness and generosity will never be forgotten.

Most importantly, I would like to thank my family for all their love and support, as well as

their undying belief in me despite the distance and despite my absence over the many years;

my parents Zainuddin & Latifah, and my brother Azri. Undertaking such monumental

challenges are never easy without one‟s family, but in the end, such endeavours only serve to

develop character and build resilience. In the end, this journey has been about living well,

being well, and doing well, and the development of the strength necessary to achieve this. As

such, I would like to dedicate this thesis to my Mother. Who is the strongest person I know.

ABSTRACT

Customer perceived value is concerned with the experiences of consumers when

using a service and is often referred to in the context of service provision or on the

basis of service quality (Auh, et al., 2007; Chang, 2008; Jackson, 2007; Laukkanen,

2007; Padgett & Mulvey, 2007; Shamdasani, Mukherjee & Malhotra, 2008).

Understanding customer perceived value has benefits for social marketing and allows

scholars and practitioners alike to identify why consumers engage in positive social

behaviours through the use of services. Understanding consumers‟ use of wellness

services in particular is important, because the use of wellness services demonstrates

the fulfilment of social marketing aims; performing pro-active, positive social

behaviours that are of benefit to the individual and to society (Andreasen, 1994). As

consumers typically act out of self-interest (Rothschild, 1999), this research posits

that a value proposition must be made to consumers in order to encourage

behavioural change. Thus, this research seeks to identify how value is created for

consumers of wellness services in social marketing. This results in the overall

research question of this research:

How is value created in social marketing wellness services?

A traditional method towards understanding value has been the adoption of an

economic approach, which considers the utility gained and where value is a direct

outcome of a cost-benefit analysis (Payne & Holt, 1999). However, there has since

been a shift towards the adoption of an experiential approach in understanding value.

This experiential approach considers the consumption experience of the consumer

which extends beyond the service exchange and includes pre- and post-consumption

stages (Russell-Bennett, Previte & Zainuddin, 2009). As such, this research uses an

experiential approach to identify the value that exists in social marketing wellness

services. Four dimensions of value have been commonly conceptualised and

identified in the commercial marketing literature; functional, emotional, social, and

altruistic value (Holbrook, 1994; Sheth, Newman & Gross, 1991; Sweeney & Soutar,

2001). It is not known if these value dimensions also exist in social marketing.

In addition, sources of value said to influence value dimensions have been

conceptualised in the literature. Sources of value such as information, interaction,

environment, service, customer co-creation, and social mandate have been

conceptually identified both in the commercial and social marketing literature

(Russell-Bennet, Previte & Zainuddin, 2009; Smith & Colgate, 2007). However, it is

not clear which sources of value contribute to the creation of value for users of

wellness services. Thus, this research seeks to explore these relationships.

This research was conducted using a wellness service context, specifically breast

cancer screening services. The primary target consumer of these services is women

aged 50 to 69 years old (inclusive) who have never been diagnosed with breast

cancer. It is recommended that women in this target group have a breast screen every

2 years in order to achieve the most effective medical outcomes from screening.

A two-study mixed method approach was utilised. Study 1 was a qualitative

exploratory study that analysed individual-depth interviews with 25 information-rich

respondents. The interviews were transcribed verbatim and analysed using NVivo 8

software. The qualitative results provided evidence of the existence of the four value

dimensions in social marketing. The results also allowed for the development of a

typology of experiential value by synthesising current understanding of the value

dimensions, with the activity aspects of experiential value identified by Holbrook

(1994) and Mathwick, Malhotra and Rigdon (2001). The qualitative results also

provided evidence for the existence of sources of value in social marketing, namely

information, interaction, environment and consumer participation. In particular, a

categorisation of sources of value was developed as a result of the findings from

Study 1, which identify organisational, consumer, and third party sources of value. A

proposed model of value co-creation and a set of hypotheses were developed based

on the results of Study 1 for further testing in Study 2.

Study 2 was a large-scale quantitative confirmatory study that sought to test the

proposed model of value co-creation and the hypotheses developed. An online-

survey was administered Australia-wide to women in the target audience. A response

rate of 20.1% was achieved, resulting in a final sample of 797 useable responses after

removing ineligible respondents. Reliability and validity analyses were conducted on

the data, followed by Exploratory Factor Analysis (EFA) in PASW18, followed by

Confirmatory Factor Analysis (CFA) in AMOS18. Following the preliminary

analyses, the data was subject to Structural Equation Modelling (SEM) in AMOS18

to test the path relationships hypothesised in the proposed model of value creation.

The SEM output revealed that all hypotheses were supported, with the exception of

one relationship which was non-significant. In addition, post hoc tests revealed seven

further significant non-hypothesised relationships in the model. The quantitative

results show that organisational sources of value as well as consumer participation

sources of value influence both functional and emotional dimensions of value. The

experience of both functional and emotional value in wellness services leads to

satisfaction with the experience, followed by behavioural intentions to perform the

behaviour and use the service again. One of the significant non-hypothesised

relationships revealed that emotional value leads to functional value in wellness

services, providing further empirical evidence that emotional value features more

prominently than functional value for users of wellness services.

This research offers several contributions to theory and practice. Theoretically, this

research addresses a gap in the literature by using social marketing theory to provide

an alternative method of understanding individual behaviour in a domain that has

been predominantly investigated in public health. This research also clarifies the

concept of value and offers empirical evidence to show that value is a multi-

dimensional construct with separate and distinct dimensions. Empirical evidence for

a typology of experiential value, as well as a categorisation of sources of value is

also provided. In its practical contributions, this research identifies a framework that

is the value creation process and offers health services organisations a diagnostic tool

to identify aspects of the service process that facilitate the value creation process.

Keywords: social marketing, experiential value, value co-creation, wellness

services.

Table of Contents

CHAPTER 1 INTRODUCTION .................................................................................................... 1

1.1 INTRODUCTION........................................................................................................................ 1 1.2 MARKETING THEORETICAL FRAMEWORKS ........................................................................... 3 1.3 PURPOSE OF RESEARCH .......................................................................................................... 5 1.4 RESEARCH QUESTIONS AND OBJECTIVES ............................................................................... 6 1.5 OVERVIEW OF RESEARCH PROGRAM ................................................................................... 11

1.5.1 Study 1: Qualitative ..................................................................................................... 14 1.5.2 Study 2: Quantitative ................................................................................................... 15

1.6 CONTRIBUTIONS TO THEORY AND PRACTICE ....................................................................... 15 1.6.1 Theoretical contributions ............................................................................................ 15 1.6.2 Practical contributions ................................................................................................ 18

1.7 STRUCTURE OF THESIS .......................................................................................................... 19 1.8 CONCLUSION ......................................................................................................................... 21

CHAPTER 2 LITERATURE REVIEW ...................................................................................... 22

2.1 INTRODUCTION...................................................................................................................... 22 2.2 PREVENTIVE HEALTH AND A WELLNESS PARADIGM ............................................................ 22

2.2.2 The role of government in preventive health .............................................................. 23 2.2.3 Using marketing theory in preventive health and wellness ........................................ 24

2.3 SOCIAL MARKETING AND PREVENTION ................................................................................ 27 2.3.1 Justification for use of social marketing .................................................................... 30 2.3.2 Typology of social marketing activities ...................................................................... 31

2.4 PREVENTIVE HEALTH AND WELLNESS SERVICES ................................................................. 33 2.4.1 Significance of health services .................................................................................... 34 2.4.2 Service quality and health services ............................................................................. 35

2.5 VALUE .................................................................................................................................... 37 2.5.1 Perspectives on value ................................................................................................... 37 2.5.2 Experiential value: moving away from an economic approach ................................. 38 2.5.3 Dimensions of value .................................................................................................... 41 2.5.4 Experiential value in wellness services ....................................................................... 44

2.6 VALUE CREATION .................................................................................................................. 45 2.6.1 Value co-creation and service-dominant (S-D) logic ................................................. 46 2.6.2 Value co-creation in social marketing ........................................................................ 47 2.6.3 Sources of value ........................................................................................................... 48 2.6.4 Consumer participation as a source of value ............................................................. 51

2.7 SUMMARY OF GAPS AND PROPOSITIONS ............................................................................... 54 2.8 CONCLUSION ......................................................................................................................... 55

CHAPTER 3 METHODOLOGY ................................................................................................. 56

3.1 INTRODUCTION...................................................................................................................... 56 3.2 PHILOSOPHICAL PERSPECTIVES ........................................................................................... 58 3.3 RESEARCH CONTEXT: BREAST CANCER SCREENING SERVICES ........................................... 59 3.4 OVERALL RESEARCH PROGRAM ........................................................................................... 63

3.4.1 Multi-method approach ............................................................................................... 65 3.4.2 Objectives of qualitative Study 1 ................................................................................. 65 3.4.3 Objectives of Quantitative Study 2 .............................................................................. 67 3.5.1 Justification for individual in-depth interviews .......................................................... 68 3.5.2 Sample and unit of analysis ........................................................................................ 69 3.5.3 Interview procedure ..................................................................................................... 70 3.5.4 Analysis of qualitative data ......................................................................................... 72

3.6 RESEARCH DESIGN OF QUANTITATIVE STUDY 2 .................................................................. 76 3.6.1 Reliability and validity ................................................................................................. 76 3.6.2 Sampling ...................................................................................................................... 79

3.6.3 Survey design and measures ....................................................................................... 80 3.6.4 Analysis of quantitative data ....................................................................................... 97

3.7 ETHICAL CONSIDERATIONS ................................................................................................ 100 3.8 CONCLUSION ....................................................................................................................... 101

CHAPTER 4 RESULTS OF QUALITATIVE STUDY 1 .......................................................... 103

4.1 INTRODUCTION.................................................................................................................... 103 4.2 SAMPLE OF STUDY 1 ............................................................................................................ 103

4.2.1 Sampling criteria ....................................................................................................... 105 4.2.2 Sample characteristics ............................................................................................... 105

4.3 DIMENSIONS OF VALUE ....................................................................................................... 108 4.3.1 Dimensions of customer perceived value .................................................................. 109 4.3.2 Activity aspects of experiential value ........................................................................ 113 4.3.3 New conceptualisation of value in wellness services using social marketing ......... 115

4.4 SOURCES OF VALUE ............................................................................................................. 120 4.4.1 Organisational sources of value ................................................................................ 122 4.4.2 Consumer participation sources of value ................................................................. 130 4.4.3 Third party sources of value ...................................................................................... 133 4.4.4 New categorisation of sources of value and stages of consumption ........................ 135

4.5 CONSUMER GOALS & RELATIONSHIPS BETWEEN VALUE DIMENSIONS AND SOURCES ...... 137 4.5.1 Consumer goals ......................................................................................................... 137 4.5.2 Relationships between dimensions and sources explained by consumer goals ....... 147

4.6 CONCLUSION ....................................................................................................................... 150

CHAPTER 5 THEORETICAL MODEL AND HYPOTHESES ............................................... 153

5.1 INTRODUCTION.................................................................................................................... 153 5.2 PROPOSED MODEL AND HYPOTHESES ................................................................................. 157 5.3 VALUE IN WELLNESS SERVICES .......................................................................................... 158

5.3.1 Functional value in wellness services ....................................................................... 158 5.3.2 Emotional value in wellness services ........................................................................ 158

5.4 INTERACTION IN WELLNESS SERVICES ............................................................................... 159 5.4.1 Administrative quality ............................................................................................... 160 5.4.2 Technical quality ....................................................................................................... 160 5.4.3 Interpersonal quality ................................................................................................. 161

5.5 CONSUMER PARTICIPATION IN WELLNESS SERVICES ........................................................ 161 5.5.1 Motivational direction ............................................................................................... 162 5.5.2 Co-production ............................................................................................................ 163 5.5.3 Stress tolerance .......................................................................................................... 164

5.6 RELATIONSHIP BETWEEN INTERACTION AND VALUE ........................................................ 165 5.6.1 Administrative quality and functional value............................................................. 166 5.6.2 Technical quality and functional value .................................................................... 167 5.6.3 Interpersonal quality and emotional value ............................................................... 168

5.7 RELATIONSHIP BETWEEN MOTIVATIONAL DIRECTION AND FUNCTIONAL VALUE ............ 169 5.8 RELATIONSHIP BETWEEN CO-PRODUCTION AND FUNCTIONAL VALUE ............................. 170 5.9 RELATIONSHIP BETWEEN STRESS TOLERANCE AND EMOTIONAL VALUE ......................... 171 5.10 MARKETING OUTCOMES OF VALUE CREATION IN WELLNESS SERVICES ...................... 172 5.11 RELATIONSHIP BETWEEN VALUE AND MARKETING OUTCOMES: SATISFACTION AND

BEHAVIOURAL INTENTIONS................................................................................................. 173 5.11.1 Relationship between value and satisfaction ....................................................... 173 5.11.2 Relationship between satisfaction and behavioural intentions ........................... 174

5.12 SUMMARY OF PROPOSITIONS, HYPOTHESES AND MODEL TO BE TESTED ...................... 175 5.13 CONCLUSION .................................................................................................................. 177

CHAPTER 6 RESULTS OF QUANTITATIVE STUDY 2........................................................ 178

6.1 INTRODUCTION ............................................................................................................... 178 6.2 SAMPLE AND RESPONSE RATE ........................................................................................ 178 6.3 TESTS FOR NON-RESPONSE BIAS, MISSING DATA AND COMMON-METHOD BIAS ........... 182

6.4 SAMPLE CHARACTERISTICS ........................................................................................... 182 6.5 CONSTRUCT RELIABILITY ............................................................................................. 185 6.6 CONSTRUCT VALIDATION – EXPLORATORY FACTOR ANALYSIS .................................. 187 6.7 CONSTRUCT VALIDATION – CONFIRMATORY FACTOR ANALYSIS ............................... 192 6.8 DESCRIPTIVE ANALYSIS OF CONSTRUCTS ...................................................................... 196 6.9 THEORY ASSUMPTIONS .................................................................................................. 199 6.10 HYPOTHESIS TESTING OUTPUTS .................................................................................... 202 6.11 POST HOC TESTS ............................................................................................................ 204

6.11.1 Non-hypothesised relationships between sources and dimensions of value ....... 204 6.11.2 Non-hypothesised relationships between the dimensions of value ...................... 204 6.11.3 Non-hypothesised relationships between sources of value and satisfaction ....... 205 6.11.4 Non-hypothesised relationships between sources of value and behavioural

intentions ............................................................................................................... 205 6.11.5 Non-hypothesised relationships between dimensions of value and behavioural

intentions ............................................................................................................... 205 6.11.6 Mediated relationships in the model .................................................................... 206 6.11.7 Summary of SEM output for hypothesised and non-hypothesised relationships 208

6.12 SUMMARY ....................................................................................................................... 210

CHAPTER 7 DISCUSSION AND CONCLUSION ................................................................... 211

7.1 INTRODUCTION ............................................................................................................... 211 7.2 VALUE DIMENSIONS IN WELLNESS SERVICES ................................................................ 212

7.2.1 Value dimensions in wellness: the prominence of functional and emotional value

and the diminished role of social and altruistic value .............................................. 212 7.2.2 Experiential value in wellness: incorporating new understanding of consumer goals .................................................................................................................................... 214 7.2.3 Experiential value in wellness: the prominence of reactive over active value ........ 214 7.2.4 Experiential value in wellness services: the development of a new typology of value .. .................................................................................................................................... 215 7.2.5 Summary of findings for RQ1 ................................................................................... 216

7.3 VALUE SOURCES IN WELLNESS SERVICES ...................................................................... 217 7.3.1 Providing empirical evidence for sources of value in wellness services .................. 217 7.3.2 A new development of categorisation of sources of value in wellness services ....... 218 7.3.3 Summary of findings for RQ2 ................................................................................... 222

7.4 INTER-RELATIONSHIPS OF VALUE SOURCES AND DIMENSIONS IN WELLNESS .............. 223 7.4.1 Organisational sources of value and the value dimensions ..................................... 223 7.4.2 Consumer participation sources and the value dimensions ..................................... 223 7.4.3 Summary of findings ................................................................................................. 224

7.5 ADDITIONAL FINDINGS ................................................................................................... 224 7.5.1 The influence of emotional value over functional value in wellness ....................... 225 7.5.2 The influence of emotional value on behavioural intentions .................................. 225 7.5.3 The curious case of co-production ............................................................................ 226 7.5.4 Consumers co-create value through motivational direction and stress tolerance ... 227 7.5.5 The direct influence of technical quality on satisfaction ......................................... 228 7.5.6 Summary of findings ................................................................................................. 229

7.6 THEORETICAL CONTRIBUTIONS..................................................................................... 230 7.6.1 Contributions to service quality ................................................................................ 230 7.6.2 Contributions to consumer value .............................................................................. 231 7.6.3 Contributions to S-D logic ......................................................................................... 232

7.7 PRACTICAL CONTRIBUTIONS ......................................................................................... 233 7.8 LIMITATIONS AND FUTURE RESEARCH .......................................................................... 235

7.8.1 The context of secondary prevention ........................................................................ 235 7.8.2 The nature of women................................................................................................. 235 7.8.3 The nature of Baby Boomer women ......................................................................... 236 7.8.4 The context of an Australian study ........................................................................... 236 7.8.5 The selection of current users of the service ............................................................ 236 7.8.6 The focus on functional and emotional value .......................................................... 237

7.8.7 The exclusion of environment and third parties....................................................... 237 7.8.8 A consideration of other social marketing activities ................................................ 238

7.9 CONCLUSION .................................................................................................................. 239

REFERENCES ........................................................................................................................... 240

APPENDIX A: EXPLORATORY FOCUS GROUP GUIDE & PROCESS ............................. 259

APPENDIX B: INDIVIDUAL-DEPTH INTERVIEW GUIDE & PROCESS .......................... 264

APPENDIX C: EMAIL INVITATION TO PARTICIPATE IN SURVEY ............................... 270

APPENDIX D: ONLINE SURVEY – FRONT PAGE ............................................................... 271

APPENDIX E: ONLINE SURVEY – SCREENING QUESTION 1 .......................................... 272

APPENDIX F: ONLINE SURVEY – NEGATIVE RESPONSE TO SCREENING QUESTION 1

..................................................................................................................................................... 273

APPENDIX G: ONLINE SURVEY – SCREENING QUESTION 2 ......................................... 274

APPENDIX H: ONLINE SURVEY – POSITIVE RESPONSE TO SCREENING QUESTION 2

..................................................................................................................................................... 275

APPENDIX I: ONLINE SURVEY – SECTION 1: BREASTSCREEN PROVIDERS ............. 276

APPENDIX J: ONLINE SURVEY – SECTION 2: FUNCTIONAL AND EMOTIONAL

VALUE ....................................................................................................................................... 277

APPENDIX K: ONLINE SURVEY – SECTION 3: ORGANISATIONAL SOURCES OF

VALUE ....................................................................................................................................... 278

APPENDIX L: ONLINE SURVEY – SECTION 4: CONSUMER PARTICIPATION (CO-

PRODUCTION & MOTIVATIONAL DIRECTION) ............................................................... 279

APPENDIX M: ONLINE SURVEY – SECTION 5: CONSUMER PARTICIPATION (STRESS

TOLERANCE) ........................................................................................................................... 280

APPENDIX N: ONLINE SURVEY – SECTION 6: SATISFACTION AND BEHAVIOURAL

INTENTIONS ............................................................................................................................. 281

APPENDIX O: ONLINE SURVEY – SECTION 7: DEMOGRAPHIC QUESTIONS ............. 282

APPENDIX P: ONLINE SURVEY – CONCLUDING PAGE .................................................. 285

APPENDIX Q: PARTICIPANT INFORMATION SHEET & INTERVIEW CONSENT ....... 286

APPENDIX R: CODEBOOK FOR CUSTOMER PERCEIVED VALUE CONSTRUCTS ..... 289

APPENDIX S: CODEBOOK FOR EXPERIENTIAL VALUE DIMENSIONS ....................... 290

APPENDIX T: CODEBOOK FOR SOURCES OF VALUE ..................................................... 291

List of Tables

TABLE 1. 1 OVERVIEW OF RESEARCH PROGRAM ............................................................................................... 13

TABLE 2. 1 TYPOLOGY OF SOCIAL MARKETING ACTIVITIES ................................................................................... 32

TABLE 2. 2 SUMMARY COMPARISON TABLE BETWEEN ECONOMIC AND EXPERIENTIAL PERSPECTIVES OF VALUE .............. 40

TABLE 2. 3 COMPARISONS OF CONCEPTUALISATIONS OF VALUE ........................................................................... 41

TABLE 2. 4 HOLBROOK’S TYPOLOGY OF VALUE ................................................................................................. 42

TABLE 2. 5 TYPOLOGY OF EXPERIENTIAL VALUE ................................................................................................ 48

TABLE 3. 1 OVERVIEW OF RESEARCH PROGRAM ............................................................................................... 64

TABLE 3. 2 SUMMARY OF RESEARCH PROCEDURE UNDERTAKEN IN STUDY 1 ........................................................... 75

TABLE 3. 3 ITEMS FOR FUNCTIONAL VALUE ...................................................................................................... 85

TABLE 3. 4 ITEMS FOR EMOTIONAL VALUE ....................................................................................................... 85

TABLE 3. 5 ITEMS FOR ADMINISTRATIVE QUALITY .............................................................................................. 86

TABLE 3. 6 ITEMS FOR TECHNICAL QUALITY...................................................................................................... 87

TABLE 3. 7 ITEMS FOR INTERPERSONAL QUALITY ............................................................................................... 88

TABLE 3. 8 ITEMS FOR MOTIVATIONAL DIRECTION ............................................................................................. 90

TABLE 3. 9 ITEMS FOR CO-PRODUCTION ......................................................................................................... 91

TABLE 3. 10 ITEMS FOR STRESS TOLERANCE ..................................................................................................... 92

TABLE 3. 11 ITEMS FOR SATISFACTION ........................................................................................................... 93

TABLE 3. 12 ITEMS FOR BEHAVIOURAL INTENTIONS........................................................................................... 94

TABLE 4. 1 SUMMARY OF SAMPLE DESCRIPTION ............................................................................................. 106

TABLE 4. 2 SAMPLE DESCRIPTIVE AT COMMENCEMENT OF BREAST SCREENING BEHAVIOUR ..................................... 107

TABLE 4. 3 CONCEPTUALISATION OF VALUE IN WELLNESS SERVICES USING SOCIAL MARKETING ................................. 115

TABLE 4. 4 SUMMARY OF SOURCES OF VALUE CATEGORISATION WITH STAGES OF CONSUMPTION ............................. 136

TABLE 4. 5 RELATIONSHIPS BETWEEN ORGANISATIONAL SOURCES OF VALUE AND DIMENSIONS OF VALUE EXPLAINED BY

CONSUMER GOALS ........................................................................................................................... 147

TABLE 4. 6 RELATIONSHIPS BETWEEN CONSUMER PARTICIPATION SOURCES OF VALUE AND DIMENSIONS OF VALUE

EXPLAINED BY CONSUMER GOALS ........................................................................................................ 148

TABLE 4. 7 RELATIONSHIPS BETWEEN THIRD PARTY SOURCES OF VALUE AND DIMENSIONS OF VALUE EXPLAINED BY

CONSUMER GOALS ........................................................................................................................... 149

TABLE 5. 1 SUMMARY OF PROPOSITIONS, HYPOTHESES AND RESEARCH QUESTIONS ............................................... 156

TABLE 5. 2 SUMMARY OF PROPOSITIONS & HYPOTHESES TO BE TESTED IN STUDY 2 AND RELEVANT GOALS ................ 176

TABLE 6. 1 SAMPLE CHARACTERISTICS – DEMOGRAPHIC INFORMATION ............................................................... 183

TABLE 6. 2 SAMPLE CHARACTERISTICS – FAMILY BACKGROUND ......................................................................... 183

TABLE 6. 3 SAMPLE CHARACTERISTICS – BREAST SCREENING HISTORY ................................................................. 184

TABLE 6. 4 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR FUNCTIONAL VALUE ..................................... 185

TABLE 6. 5 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR EMOTIONAL VALUE ...................................... 185

TABLE 6. 6 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR ADMINISTRATIVE QUALITY ............................. 185

TABLE 6. 7 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR TECHNICAL QUALITY ..................................... 186

TABLE 6. 8 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR INTERPERSONAL QUALITY .............................. 186

TABLE 6. 9 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR MOTIVATIONAL DIRECTION ............................ 186

TABLE 6. 10 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR CO-PRODUCTION ....................................... 186

TABLE 6. 11 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR STRESS TOLERANCE .................................... 187

TABLE 6. 12 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR SATISFACTION ........................................... 187

TABLE 6. 13 CRONBACH’S ALPHA AND ITEM-TO-TOTAL STATISTICS FOR BEHAVIOURAL INTENTIONS .......................... 187

TABLE 6. 14 SUMMARY OF INITIAL ITEMS FOR FUNCTIONAL VALUE ..................................................................... 189

TABLE 6. 15 SUMMARY OF INITIAL ITEMS FOR EMOTIONAL VALUE ...................................................................... 189

TABLE 6. 16 SUMMARY OF INITIAL ITEMS FOR SERVICE QUALITY ........................................................................ 189

TABLE 6. 17 SUMMARY OF INITIAL ITEMS FOR MOTIVATIONAL DIRECTION ........................................................... 190

TABLE 6. 18 SUMMARY OF INITIAL ITEMS FOR CO-PRODUCTION ........................................................................ 190

TABLE 6. 19 SUMMARY OF INITIAL ITEMS FOR STRESS TOLERANCE ...................................................................... 191

TABLE 6. 20 SUMMARY OF INITIAL ITEMS FOR SATISFACTION ............................................................................ 191

TABLE 6. 21 SUMMARY OF INITIAL ITEMS FOR BEHAVIOURAL INTENTIONS ........................................................... 192

TABLE 6. 22 FACTOR LOADINGS FOR ALL INDICATORS ...................................................................................... 193

TABLE 6. 23 SQUARES OF PARAMETER ESTIMATE BETWEEN FACTORS (Ø2) AND AVERAGE VARIANCE EXTRACTED FOR

PAIRS OF FACTORS ........................................................................................................................... 195

TABLE 6. 24 LATENT VARIABLE INDICATORS AND DESCRIPTIVES ......................................................................... 196

TABLE 6. 25 BIVARIATE CORRELATIONS MATRIX ............................................................................................. 198

TABLE 6. 26 SAMPLE SKEWNESS AND KURTOSIS ............................................................................................. 200

TABLE 6. 27 SEM OUTPUT FOR HYPOTHESISED PATH RELATIONSHIPS IN THE PROPOSED MODEL ............................... 203

TABLE 7. 1 SUMMARY OF DIMENSIONS OF VALUE AND AIMS WITH CORRESPONDING GOALS AND ACTIVITY DIMENSIONS 216

List of Figures

FIGURE 2. 1 HEALTH CONTINUUM ................................................................................................................. 26

FIGURE 3. 1 SERVICE OPERATING PROCESS OF BSQ AND CORRESPONDING STAGES OF CONSUMPTION ......................... 61

FIGURE 4. 1 CATEGORISATION OF SOURCES OF VALUE IN WELLNESS SERVICES ....................................................... 121

FIGURE 4. 2 CONCEPTUAL MODEL FOR QUALITATIVE FINDINGS OF STUDY 1 ......................................................... 151

FIGURE 5. 1 PROPOSED MODEL OF VALUE CREATION FOR TESTING IN STUDY 2 ..................................................... 157

FIGURE 6. 1 SUMMARY OF ONLINE RESPONSES TO EMAIL INVITATION TO PARTICIPATE IN STUDY 2 ........................... 179

FIGURE 6. 2 SAMPLE SCREENING PROCESS..................................................................................................... 181

FIGURE 6. 3 BASIC MEDIATIONAL MODEL ...................................................................................................... 206

FIGURE 6. 4 MEDIATIONAL MODEL FOR TECHNICAL QUALITY, SATISFACTION, AND FUNCTIONAL VALUE ...................... 206

FIGURE 6. 5 MEDIATIONAL MODEL FOR CO-PRODUCTION, BEHAVIOURAL INTENTIONS, AND SATISFACTION ................ 207

FIGURE 6. 6 FULL PATH MODEL WITH ALL RELATIONSHIPS ................................................................................. 209

Chapter 1: Introduction 1

CHAPTER 1 INTRODUCTION

“Since ancient times humans have wondered about what makes a good life.

Scientists who study subjective well-being assume that an essential ingredient

of the good life is that the person herself likes her life”

Ed Diener, Richard E. Lucas & Shigehiro Oishi

1.1 Introduction

In recent years, members of developed societies have entered a “postmaterialistic”

era where their concerns have moved beyond issues of economic prosperity towards

issues of quality of life (Diener, Lucas & Oishi, 2002, p.484). One important aspect

of quality of life is the adoption of a proactive approach in managing one‟s own

health. This can be characterised by preventive health behaviours undertaken

willingly and performed regularly such as daily exercise at the gym, or occasionally

such as yearly routine visits to the dentist. These behaviours describe actions that are

undertaken by individuals to enhance or maintain health either within or outside the

medical care system and medical authority (Kirscht, 1983). In societies such as

Australia, preventive health has gained newfound attention in recent years, evidenced

by the Australian Federal Government‟s establishment of a Preventative Health

Taskforce in 2008 (Preventative Health Taskforce, 2009b) (Preventative Health

Taskforce, 2009b), demonstrating its importance and significance. As such, in

focussing on preventive health, this thesis follows a “wellness paradigm” which

emphasises the importance of health prevention and maintenance rather than health

treatment (Zainuddin, Previte, & Russell-Bennett, 2011).

Much of the early literature on preventive health is represented from a biomedical

perspective (Kirscht, 1983). However, the area of health psychology has since been

able to provide an alternative, psychosocial view into this area. Specifically,

preventive health issues have been typically investigated using a public health

approach. Public health focuses predominantly on population-level changes (Hoek &


Jones, 2011) and utilises approaches that target public policy and the development of

a supportive environment to facilitate behaviour change. These approaches are seen

as higher order priorities than those focussed at the individual-level (World Health

Organisation, 1989). The development of appropriate public policy and a supportive

environment enables individuals with necessary information, motivation, and skills

in prevention and self-management, which are all essential in achieving effective

prevention in society (World Health Organisation, 2002).

However, part of the responsibility of ensuring that preventive health behaviours are

undertaken is borne by individuals themselves. While public health research does not

discount the importance of individual-level interventions, its philosophy is one that

believes a greater overall change can be achieved through population-level

interventions (Hoek & Jones, 2011). In contrast, marketing research is an area driven

by the identification, segmentation, and subsequent targeting of a section of the

population (see Smith, 1956). This is geared towards the maximisation of profits – or

in the case of preventive health and wellness, the maximisation of successful

behaviour change. The sub-discipline of social marketing is a suitable approach in

investigating preventive health and wellness behaviours, with the aim of maximising

success in behaviour change strategies in specific segments of the population.

Social marketing concerns itself with influencing voluntary behaviours for the

benefit of individuals themselves, groups, or society as a whole (Kotler, Roberto, &

Lee, 2002). Specifically, social marketing is concerned with „„the application of

commercial marketing technologies to the analysis, planning, execution, and

evaluation of programs designed to influence the voluntary behaviour of target

audiences in order to improve their personal welfare and that of their society‟‟

(Andreasen, 1995, p.7). The performance of preventive health or wellness behaviours

has benefits for the individual as the purpose of undertaking this behaviour would be

to prevent or detect disease in an asymptomatic state (Kasl & Cobb, 1966). These

individual prevention efforts collectively ease the burden of disease on societies by

reducing the negative economic impact on countries (World Health Organisation,

2002). This demonstrates the improvement of personal welfare, as well as that of

society and as such, the use of social marketing is appropriate in this research

enquiry.


1.2 Marketing theoretical frameworks

This research is informed by three marketing frameworks; service quality, consumer

value, and Service-Dominant (S-D) logic. In this thesis, these three marketing

frameworks are applied to social marketing, which formed the basis of this research

inquiry, situated in the context of preventive health.

Service quality is a subjective evaluation of an individual‟s experience with a service

and is not just made on the basis of the outcomes of the service, but also the process

of the service delivery (Zeithaml, Parasuraman & Berry, 1985). Many preventive

health behaviours are supported by the health care system through the provision of

preventive health or wellness services. Steele and McBroom (1972) define

preventive behaviour as the use of professional services in an asymptomatic state to

avoid illness. The provision of such services provides “behavioural opportunities”

(Kirscht, 1983, p. 282) for individuals to engage in preventive health behaviours

through their use. Preventive health services are those aimed at secondary

prevention, which revolves around issues of detection and early treatment (Fielding,

1978). As such, the use of a services (and subsequently, service quality) approach is

also appropriate for this inquiry.

Social Marketing

Service quality

Consumer value

S-D logic


Social and health behaviours have much in common with services marketing

(Hastings, 2003) as they share similar issues and challenges compared to the

commercial marketing of tangible goods. Aspects of the service such as competence

of staff, interactions, and administrative elements all have an impact on the

individual‟s experience with performing preventive health behaviours through the

use of a service. This demonstrates the relevance of service quality as a theoretical

framework in this investigation. The service quality theoretical framework utilises a

customer-orientation approach in understanding individuals‟ service experiences,

which is useful in determining future use of the service again, resulting in long-term

maintenance of the desired behaviour.

Consumers typically continue to use services because of the value that they

subjectively evaluate and derive from the service experience. This leads to the

second theoretical framework, which is consumer value. Consumer value is derived

from an interactive relativistic preference consumption experience (Holbrook, 2006).

In order to incentivise individuals into action (i.e. using preventive health services), it

is necessary to provide them with a value proposition (Dann, 2008; Kotler & Lee,

2008). Individuals often act out of self-interest (Rothschild, 1999), and a value

proposition will encourage their use of preventive health services due to the value

they derive and self-interest they fulfil. The continued use of these services can be

achieved through ensuring that users derive value from their experiences as

consumers seek satisfying experiences (Abbott, 1995) rather than simply outcomes

alone.

In light of the need for individuals to be proactive in managing their health, this

coincides with the need to recognise the increasing importance and significance of

the role of the consumer in a service consumption experience. As such, a third

theoretical framework is used to guide this research; Service-Dominant (S-D) logic.

S-D logic recognises the role of customers as operant resources in a service setting

(Vargo & Lusch, 2004) such as in preventive health services. The skills and

knowledge of the consumer are considered to be useful, important, and necessary

resources in the co-creation of value in a service consumption experience and

consumers are seen as operant resources which are dynamic and produce effects

(Vargo & Lusch, 2004). Consumers using preventive health services are not only


proactive participants in the value that is created for them, but they are also

empowered in determining the type of value they seek.

These three marketing frameworks have been used separately in much of the existing

consumer research. However they have never been integrated and used in

combination in a single research inquiry. This research integrates and combines the

use of these three theoretical frameworks by situating these theories in social

marketing. As social marketing considers the voluntary nature of behaviour

performed by individuals (Andreasen, 1995), it requires a need for relational thinking

and customer orientation and the use of the three theoretical frameworks of service

quality, consumer value, and S-D logic fulfils this need.

1.3 Purpose of research

The purpose of this research is to understand how value can be created in social

marketing wellness services for the achievement of maintaining quality of life

through sustained wellness behaviour. Specifically, this research seeks to investigate

individuals‟ use of government-provided wellness services. The selection of

government-provided services is justified by two reasons. First, it is the role of

government to shape the nature of society (Ryan, Parker & Brown, 2003) and one

way of doing so is through the provision of basic health services to members of

society regardless of socioeconomic status. This shapes the nature of society by

ensuring the good health of its citizens. Second, governments often use social

marketing in targeting individual behaviour to seek societal gain (e.g. the

establishment of the Preventative Health Taskforce by the Australian Government).

As such, a government-provided wellness services would be an appropriate context

for this research enquiry.

A core aim of this research is to identify the consumer value that is experienced

during the use of government-provided wellness services. Examining the service

experience through service quality indicators as well as incorporating an

understanding of S-D logic will offer insights into understanding why individuals

perform wellness behaviours through the use of services and how their continued


performance of wellness behaviours can be sustained. This is achieved through the

identification of the value experienced during the use of these services, and the

various factors that influence the creation and experience of this value. As such, this

leads to the development of the overall research question of this thesis:

Overall RQ: How is value created in social marketing wellness services?

The offer of a value proposition is critical in encouraging the uptake and

maintenance of wellness behaviours in individuals. As such, there is a need to

determine what value consumers seek and how it can be created. Examples of a value

proposition in wellness not only include the promise of feeling good, looking good,

and enjoying better quality of life, but can also include the ease and convenience of

achieving these outcomes. In spite of the lack of research demonstrating how

customer value is created in wellness services, there is great importance in

understanding the nature of value in this context. Consumer value perceptions

influence satisfaction with the service (Day & Crash, 2000) and consequently,

satisfaction with the service influences consumers‟ decisions to use the service again

in the future (Bolton & Lemon, 1999). In the context of wellness services and social

marketing, this affects the long-term maintenance of wellness behaviours through

individuals‟ continued use of wellness services.

1.4 Research questions and objectives

To address the overall research question, there were three research objectives that

this thesis sought to achieve. First, this thesis sought to understand the nature of

value in a social marketing wellness services context as most of the existing research

in value has been undertaken in the commercial marketing treatment services

context. Second, this thesis sought to identify the factors that influence this value in a

wellness services context. Third, this thesis sought to understand the relationships

between these factors and the value experienced by consumers in order to understand

value co-creation in wellness services.


There are two alternate approaches that can be taken in the investigation of value;

economic or experiential. Although the economic approach is traditionally utilised,

the experiential approach was undertaken in this thesis. This experiential approach

has started to gain more attention in marketing research in recent years. This

approach defines value as an interactive relativistic preference experience (Holbrook,

2006) which considers the subjective experience of an individual with a consumption

experience. This approach acknowledges that value can vary for different individuals

who use the same service, and accepts that the consumer is very much involved in

the determination and creation of value sought through the consumption experience.

An example of a subjectively determined value preference experience for an

individual can include convenience, which is a functional type of value. This is

subjectively determined and experienced through the consumption process and is not

experienced by all individuals, only those who seek it.

In comparison, the economic approach sees a greater focus on the outcomes of the

consumption experience rather than the process, and the utilitarian aspect of using a

service is emphasised, rather than the experiential aspect. An example of a utilitarian

outcome of a wellness service consumption experience can include the avoidance of

illness, which is consistent across all individuals. This is not a subjectively

determined outcome, and is one that is experienced by all individuals.

The economic approach is the more commonly used approach in value research,

whereby value is an outcome of an evaluation of costs against benefits (Zeithaml,

1988). This is often based on a utilitarian outcome and has been the more common

value approach thus far as it relates to the economic heritage of marketing (Sheth &

Uslay, 2007). Despite this, the economic approach has become an insufficient means

in ensuring long-term continuation of behaviour as consumers are now active

participants in the consumption process and are empowered to determine the value

that they seek. As such, consumers now seek satisfying experiences that are

subjectively determined, in addition to the utilitarian outcomes of their consumption

experiences. The current dominance of an economic approach signifies a gap in the

research where an experiential approach is under-used but is relevant.


It is important to address this gap because individuals‟ decisions to perform wellness

behaviours are complex and not limited to a utilitarian outcome alone. A common

utilitarian outcome measured using the economic approach in value is financial cost.

However, with a number of government-provided wellness services provided at no

cost (i.e. free) or at a subsidy, the importance of financial cost is minimised and other

indicators become increasingly significant in consumers‟ considerations to use

wellness services. Other considerations such as the smooth transaction in the

consumption process become more important indicators in consumers‟ decision-

making. Such aspects of the service in delivering social marketing programs

highlights that the service experience is an important influence on consumers‟

likelihood to perform the behaviour again. Thus, it is important to use the

experiential approach in this value investigation as it allows for an understanding of

why individuals‟ make decisions to behave beyond economically rational reasons.

Value is conceptualised as a multi-dimensional construct, commonly made up of four

dimensions; functional value, emotional value, social value, and altruistic value

(Holbrook, 2006). These four dimensions can co-occur for consumers as an

individual can experience multiple dimensions of value from the same consumption

experience. For example, an individual can experience functional value from going

to the gym because they experience health benefits, but at the same time they also

experience social value because they could have friends who go to the same gym and

they exercise together. Individuals seek satisfying experiences which are attained

through activities (Abbott, 1995) and experiential value is derived as a result.

Experiential value is important in social marketing because if consumers derive

experiential value from performing social marketing activities, then they are likely to

also derive satisfaction. Subsequently, there is an increased likelihood of their

continuation with these activities in the future. In social marketing, this is important

as sustained wellness behaviour is then achieved. These value dimensions have been

conceptualised and tested in commercial marketing, but there is limited empirical

evidence for these value dimensions in social marketing. Thus, this leads to the first

sub-research question:

RQ1: What are the dimensions of value experienced by users of wellness

services in social marketing?


Upon understanding the nature of value in a social marketing wellness services

context, the next step is to understand the various factors that can influence this

experiential value for users of a wellness service. As value creation is considered to

be contextual (Hilliard, 1950; Holbrook, 1994), it can be influenced by different

factors or sources where there is currently limited empirical understanding of these

sources. It has been conceptually proposed that some sources, known as sources of

value, include sources such as information, interaction, environment, service,

customer co-creation, and social mandate (Prahalad & Ramaswamy, 2004; Russell-

Bennett et al., 2009; Smith & Colgate, 2007).

Some of these sources of value refer to activities and processes within and between

organisations that create value for customers in a commercial marketing context such

as information, interaction, and environment (Smith & Colgate, 2007). These sources

of value refer to those that are generated by the organisation and as such, service

quality is used as a framework to guide this inquiry. Service quality includes aspects

of the service such as the technical skills (i.e. technical quality) and interpersonal

skills (i.e. interpersonal quality) possessed by staff members, the environment quality

(Brady & Cronin, 2001; Rust & Oliver, 1994), and the administrative processes (i.e.

administrative quality) of the service (McDougall & Levesque, 1994). Some of the

sources of value conceptualised by Smith and Colgate such as information and

interaction are derived through consumers‟ interactions with staff members and as

such, service quality dimensions such as technical quality and interpersonal quality

are important sources of value. On the other hand, other conceptualised sources of

value such as environment are derived through consumers‟ assessment of the service

quality dimension of environment quality.

In contrast, other sources of value such as customer co-creation are generated by the

customers themselves and not the service organisation. Customer co-creation is

driven by consumers‟ increasing knowledge and skills, resulting in their desire and

ability to interact with organisations in order to “co-create” value (Prahalad &

Ramaswamy, 2004). This relates to the S-D logic framework, which considers

consumers to be co-creators of value (Vargo & Lusch, 2004). As this research seeks

to understand why consumers voluntarily use wellness services as opposed to being

mandated into using them, the use of S-D logic allows for the consideration of


consumers of wellness services as proactive co-creators of value. Aspects of

customer co-creation of value include motivational direction, which refers to the

activities to which an individual directs and maintains effort (Katerberg & Blau,

1983). For example in wellness, this can refer to understanding the importance of

using a specific wellness service and ensuring that it is used. Another aspect of

customer co-creation includes co-production, which refers to the participation of the

consumer in the service process to produce the core service offering with the service

provider (Bendapudi & Leone, 2003). This can include physical or behavioural

contributions of the consumer that are essential to produce the core service offering,

such as removing any items of clothing so that the consumer may be examined or

keeping still during physical examination if required. Additionally, stress tolerance is

another aspect of customer co-creation which involves the management of emotions

for the attainment of a specific goal (Mayer & Salovey, 1997). This is likely to be

important in a wellness context due to the highly personal nature of health and the

stress that this can create for many people.

The notion of sources of value can be applied to a social marketing context. It is

equally important in social marketing to understand the various influences on

consumers‟ experience of value since this is likely to impact their decisions to

perform wellness behaviours again in the future. However, as these sources of value

have only been conceptualised in the existing literature, there is no empirical

evidence in commercial marketing or in social marketing for them, which represents

the next gap in the research. Thus, this leads to the second sub-research question:

RQ2: What are the sources of value that exist in wellness services in social

marketing?

Upon identifying and understanding the value dimensions present in a social

marketing wellness services context, as well as the sources of value, it is necessary to

determine how the dimensions and sources of value relate. An understanding of the

relationship between the value dimensions and sources will provide health service

organisations with a framework for identifying the various aspects of the

consumption experience that can influence experiential value for consumers. This


understanding will provide insight as to how value can be created for users of

wellness services. Currently, no research has addressed how the sources of value

specifically influence the dimensions of value in a wellness services context. It is

important to address this gap because this will provide social marketers and health

organisations with specific knowledge as to how to create specific dimensions of

value for individuals who use the service. For example, advertising messages

(information) can use statements that illicit positive emotions (emotional value) in

target audiences. This knowledge can provide wellness services with a framework

that will allow them to tailor their services marketing mix in order to provide the

specific value that their users seek. As such, a third sub-research question was

proposed:

RQ3: What is the relationship between the sources and dimensions of value

in wellness services?

In summary, this research sought to understand how value can be created in wellness

services that use social marketing and the inquiry was guided by three theoretical

frameworks; service quality, customer value, and S-D logic. In determining how

value can be created in wellness services, three sub-research questions were

developed to address the gaps inherent in the literature. The following section

provides an overview of the research program that was used to answer the three sub-

research questions.

1.5 Overview of research program

In investigating wellness services, the research investigation was situated in the

context of breast cancer screening services in Australia. This type of service

represented a wellness service provided by the government that recommends women

in the target age group of 50 to 69 years to have a breast screen once every two years.

Breast cancer screening services are services aimed at secondary prevention, which

revolves around detection and early treatment (Fielding, 1978). Breast cancer

screening services are provided to Australian women in the target age group free by

the government, making this service available to all women who voluntarily choose


to use it. However, despite the government agenda for this service to available to all

in the target segment, this research acknowledges that there are still disadvantaged

groups (e.g. on the basis of location or ethnicity) who may still be unable to access

these services.

In order to answer the three sub-research questions, a multi-method two-study

research program was developed. A multi-method approach is advantageous as it

allowed for the ability to use a more comprehensive approach to the research inquiry

and to triangulate results, allowing for a broader set of research questions to be asked,

and enabling discovery (Gil-Garcia & Pardo, 2006). The process of discovery was

pertinent in this research as the use of the three theoretical frameworks of service

quality, customer value, and S-D logic had never been previously undertaken in a

single research enquiry based in social marketing. Multi-method approaches

typically use a combination of both qualitative and quantitative methodology

(Creswell, 2003), which was the approach used in this research.

Study 1 was a qualitative exploratory study, while Study 2 was a quantitative

confirmatory study and both studies sought to address each of the three sub-research

questions. Study 1 sought to qualitatively determine the dimensions and sources of

value present in a wellness service, addressing RQ1 and RQ2. It also sought to

provide insight into the possible relationships between these dimensions and sources,

addressing RQ3. A theoretical model describing the value co-creation process was

then developed as an outcome of the qualitative analysis, which was then tested in

the second study. This theoretical model described a proposed model of value co-

creation in breast cancer screening services, identifying the specific constructs

present in the model as well as the various hypothesised relationships within this

model.

Subsequently, Study 2 sought to quantitatively confirm the dimensions and sources

of value present in a wellness service that were identified qualitatively in the

previous study through the testing of the proposed theoretical model. This

empirically addressed RQ1 and RQ2. Additionally, it sought to provide empirical

evidence for the relationships that were qualitatively derived from the results of the

first study, through the use of a large-scale online survey. This empirically addressed


RQ3. A detailed description of the methodology is provided in Chapter 3; however a

summary of the overall research design is presented here in Table 1.1.

Table 1. 1 Overview of research program

Research Questions

Gaps Addressed

Study that addresses

RQs

Objectives of Research

Research Method

Analysis

RQ1: What are the dimensions of value experienced by users of wellness services?

GAP 1: Lack of

empirical evidence for dimensions of value in social marketing wellness service context

Study 1

To identify the dimensions of value experienced by individuals when performing wellness behaviours To identify the sources of value experienced by individuals when performing wellness behaviours To identify the constructs necessary for value co-creation in wellness

Qualitative

1. Use of 1 focus group discussion (n=5) for the development and refinement of an individual-depth interview guide 2. Semi-structured individual-depth interviews (n=25)

Thematic analysis using NVivo

RQ2: What are the sources of value that exist in wellness services?

GAP 2: Lack of

empirical evidence for sources of value in social marketing wellness services

Study 1

RQ3: What is the relationship between the sources and dimensions of value in wellness services?

GAP 3: Limited

empirical evidence demonstrating the relationship between value dimensions and sources in a social marketing wellness service context

Study 1

and Study 2

To understand the relationships between the individual dimensions and sources of value in wellness

Quantitative

Survey 1. Initial validation sample (n=397) 3. Final sample (n=400)

Reliability analysis, exploratory factor analysis (EFA) using PASW18 Confirmatory factor analysis (CFA) using PASW 18 Structural equation modelling (SEM) using AMOS 18


1.5.1 Study 1: Qualitative

Study 1 was a qualitative exploratory study which sought to determine the value

dimensions experienced by individuals who use breast cancer screening services, as

well as the sources of value that influence the dimensions of value experienced. This

was achieved through the use of individual in-depth interviews. A focus group was

first conducted to develop and refine the instrument, which was an interview guide.

Upon refinement of the interview guide, individual in-depth interviews with 25

participants who were users of government-provided breast cancer screening services

were interviewed. Thematic analysis was undertaken to reveal themes which

reflected four dimensions of value; functional, emotional, social, and altruistic. Also

revealed were three categories of sources of value; organisational, consumer, and

third parties. Detailed findings of these results are presented in Chapter 4.

As a consequence of the qualitative analysis, a theoretical model of value creation

was developed for testing in Study 2. It was determined that Study 2 would limit its

focus on empirically testing functional and emotional value only as these were

determined to be the most important value dimensions to the women interviewed.

Furthermore, the study limited its focus to the interaction between the organisation

and consumer, as these were determined to be the most important value sources in

breast cancer screening services. As such, this limited the focus to organisational and

consumer sources of value only. The theoretical model included 10 constructs used

for hypotheses testing. This included 2 value dimension constructs (functional value

and emotional value), 3 organisational sources of value constructs (technical quality,

interpersonal quality, and administrative quality), 3 consumer sources of value

constructs (motivational direction, co-production, and stress tolerance), and 2

outcome variables (satisfaction and behavioural intentions). A detailed description of

the theoretical model and the hypotheses developed for testing are presented in

Chapter 5.


1.5.2 Study 2: Quantitative

Study 2 sought to test the relationships between the sources of value and dimensions

of value in a social marketing wellness service using the constructs identified in the

theoretical model of value co-creation. The measures used for the model testing were

taken from existing, established scales in the literature. However, the scale measures

were modified to reflect more appropriate scale items for the specified context of

breast cancer screening. These items were tested with a pilot sample of n=397

through exploratory factor analysis (EFA) and reliability analysis using PASW 18

software program. Then, the model was tested through the use of a large-scale

quantitative online survey with a sample of n=400. Confirmatory factor analysis

(CFA) was conducted using PASW 18 software program as well as regression

analysis through structural equation modelling (SEM) using AMOS 18 software

program. Detailed findings of these results are presented in Chapter 6.

1.6 Contributions to theory and practice

In conducting this research enquiry, this research provides several contributions to

both theory and practice, which are described in the following sections.

1.6.1 Theoretical contributions

The major theoretical contribution of this research is that this inquiry has

demonstrated the dynamism and complexity of value co-creation in social marketing

wellness services. The findings of this research add to the existing knowledge on

consumer value by showing that value is a dynamic construct that changes

throughout the consumption process and is determined, created, and experienced

differently by different individuals. These results show that the context of value co-

creation is important as its complexities suggest that its nature is likely to change in

different consumption situations. A significant gap in the literature was addressed by

situating three marketing theoretical frameworks (service quality, consumer value,

and S-D logic) in social marketing and in doing so, an alternative means for


understanding individual consumer behaviour in a domain that has been traditionally

focussed in public health, psychology and medicine was provided.

The following theoretical contributions were made to the area of service quality:

Service quality dimensions that are keys to value co-creation in wellness

services were identified. Empirical evidence for the service quality

dimensions of interaction quality, technical quality, and administrative

quality were provided by both the qualitative and quantitative studies of this

research, while empirical evidence for the service quality dimension of

environment quality was provided by the data from the qualitative study only.

The development of a value co-creation model in wellness identifies specific

service quality constructs that lead to specific dimensions of value. Empirical

evidence was provided to show that the service quality dimensions of

administrative quality, and technical quality specifically led to the creation of

functional value, while interpersonal quality specifically led to the creation of

emotional value.

The following theoretical contributions were made to the area of consumer value:

The use of the experiential approach to investigating value reflects the current

academic shift from the traditional and often-used economic approach in

understanding consumer value. This acknowledges the growing importance

of an experiential perspective in academic inquiry into value co-creation.

Empirical evidence for experiential value dimensions was provided through

the development of a typology of experiential value in wellness. This

typology identifies the various types of value present in the value co-creation

process, and through the use of social marketing, clarifies the concept of

value in government wellness services.

Empirical evidence for sources of value was provided through the

development of a categorisation of the sources of value. This categorisation


identified the sources of value that are present in wellness services using

social marketing and explains the influences of the different sources of value

on the dimensions of value in social marketing wellness services.

And understanding of how the value dimensions and sources relate was

provided through both the qualitative and quantitative studies identifying the

specific relationships between the experiential value dimensions with the

identified sources of value. The nature of these relationships is explained by

consumer goals identified from the qualitative study.

Empirical evidence was also provided to show that in the context of wellness

services in social marketing, emotional value has a positive and significant

influence over the experience of functional value. This demonstrates that the

different dimensions of value in social marketing are inter-related and are not

separate and distinct.

The following theoretical contributions were made to the area of S-D logic:

The identification of consumer participation as one of the categories of

sources of value provides empirical evidence for S-D logic, showing that

consumers are co-creators of value in wellness. Empirical evidence for this

was provided in both the qualitative and quantitative studies.

Consumer participation was delineated further to identify motivational

direction, co-production, and stress tolerance as aspects of participation that

lead to value co-creation. This demonstrates that while consumers are co-

creators of value in wellness, they are able to co-create this value in multiple

ways. It demonstrates that consumers are not just empowered in their

determination of the type of value that they seek, but also in how they choose

to create it with the service.

The development of a model of value co-creation identifies how the different

aspects of consumer participation create value. Specifically, consumer

participation aspects of motivational direction and stress tolerance led to both


functional and emotional value. However, while the consumer participation

aspect of co-production did not lead to value, it led directly to the outcome

variables of satisfaction with the service and behavioural intentions to use the

service again.

The qualitative data provided further empirical evidence for S-D logic

through demonstrating the complexity of the role of the consumer in the co-

creation of value and showing that the consumer plays a key role in value co-

creation.

1.6.2 Practical contributions

This research also provided a number of practical contributions that are beneficial to

wellness services, social marketers, governments and other policy makers in the area

of wellness. Specifically, this research has provided the following practical

contributions:

This research outlines the expectations of value that consumers have from

free wellness services provided by the government and makes these

expectations clearly identifiable to service organisations, governments, and

social marketers who seek to target users of wellness services. This

knowledge is useful for wellness services in their planning and allows for the

setting of more realistic targets to achieving consumer satisfaction through

the provision of customer value.

A diagnostic tool for improving organisational competences was provided by

the value co-creation model developed in this research. This diagnostic tool

can be utilised by wellness service organisations in identifying the different

factors within the service experience that have an impact on consumers‟

determination of value when using the service. This provides wellness service

organisations with an understanding of how to manage these various factors

in order to maximise the desired positive outcomes and minimise negative

outcomes.


A more practical understanding of the causes of behaviour change in

consumers engaging in health prevention is also provided by this research

through the identification of the sources and dimensions of value in wellness.

This research also provides wellness services with insights into consumers‟

consumption experiences that would allow for the identification of areas of

strengths, weaknesses, as well as opportunities. This would lead to a greater

likelihood of achieving organisational strategies and objectives, as well as

greater consumer satisfaction and repeat usage, through more effective

delivery of the service and provision of value to consumers. Additionally,

these insights can aid in the development of more effective organisational

strategies revolving around service provision and social marketing efforts.

1.7 Structure of thesis

This thesis is comprised of seven chapters. Following this introductory chapter, a

review of the literature is provided in Chapter Two. This chapter provides a detailed

discussion of the current literature on preventive health, social marketing, health

services, and consumer value. The chapter also identifies the research gaps inherent

in the literature and the subsequent research questions developed in order to address

those gaps.

Chapter Three then describes the philosophical underpinnings of this research and

follows with the research methodology for this thesis. This chapter provides a

justification for the use of a two-study multi-method approach, utilising a qualitative

exploratory study (Study 1), followed by a quantitative confirmatory study (Study 2).

A justification for the use of a qualitative approach through the use of individual in-

depth interviewing technique for Study 1 is provided, as well as a justification for the

use of a quantitative approach through the use of an online survey for Study 2. The

research procedures for both studies are outlined in this chapter, which then

concludes with a discussion of the ethical considerations of this research.


Chapter Four follows with a report of the qualitative findings of Study 1. This

chapter reports the evidence provided for four dimensions of value in a social

marketing wellness service context by describing six themes that reflect the

functional, emotional, social, and altruistic dimensions of value. It also provides

evidence for three categories of sources of value in wellness services, which are

organisational sources, consumer sources, and third party sources of value.

Chapter Five then presents a proposed model of value co-creation that identifies the

constructs for testing in Study 2. This model identifies and describes the

hypothesised relationships between the constructs in value co-creation. This chapter

provides a set of propositions and justifications and presents nine hypothesised

relationships for testing in Study 2.

Chapter Six reports the analysis procedure and results of the model testing in Study

2. This chapter reports the response rate as well as sample characteristics of the

respondents who participated in the online survey used for this study. The results of

construct reliability and validity tests are also presented, with a descriptive analysis

of the constructs and a discussion of the theory assumptions. The hypothesis testing

outputs are then presented, identifying the supported and non-supported hypotheses.

This is followed by a report of the post hoc tests, which identify the non-

hypothesised significant relationships evident in the data, as well as mediated

relationships evident in the data.

Chapter Seven then discusses the key findings of the overall investigation by

drawing upon the findings of both Studies 1 and 2. The theoretical and managerial

contributions of this research are discussed, as well as the limitations of the current

study. Suggestions for future research are then presented, which not only seek to

overcome the existing limitations of the current study, but also to expand the current

scope of understanding as a result of this research enquiry.


1.8 Conclusion

In summary, this chapter has provided an overview of this thesis. It outlines the

research background as well as significance and justification for the research. A

summary of the research program is presented, showing the research gaps as well as

research questions developed to address these gaps. Theoretical and practical

contributions are also provided and an overview of the structure of the thesis is

presented. The following chapter offers a discussion of the relevant literature that

forms the basis of this investigation and explains the research gaps in detail as well

as demonstrating the derivation of the research questions.

Chapter 2: Literature review 22

CHAPTER 2 LITERATURE REVIEW

“No longer do the dominant theories view the individual as a passive vessel

„responding‟ to „stimuli‟; rather, individuals now are seen as decision

makers, with choices, preferences, and the possibility of becoming masterful,

efficacious, or, in malignant circumstances, helpless and hopeless”

Martin E.P. Seligman

2.1 Introduction

This chapter provides a review of the literature on social marketing wellness services

and the role of value in facilitating behaviour maintenance. This review begins by

demonstrating the emergence of preventive health efforts within a wellness

paradigm, followed by a review of social marketing and its use in preventive health.

Next, a justification for the use of a services marketing framework is provided,

followed by a review of the literature on the area of consumer value. Additionally,

three research gaps inherent in the literature are identified and subsequently, research

questions developed to address these gaps are presented.

2.2 Preventive health and a wellness paradigm

In Australia, there is a great focus on public health issues and the provision of health

services by the government. The Preventative Health Taskforce was launched by the

Minister for Health and Ageing on 9 April 2008 with the objective of providing

evidence-based advice to governments and health providers on preventive health

issues (Preventative Health Taskforce, 2009b). Subsequently, a National Preventative

Health Strategy was launched on 1 September 2009 outlining strategies to achieve

the broad objective of achieving the status of healthiest country by 2010

(Preventative Health Taskforce, 2009a). This demonstrates the importance and

prominence of preventive health issues in Australian society.


2.2.1 Preventive health

Preventive health behaviour refers to activities undertaken by individuals who

believe themselves to be healthy, in an attempt to prevent disease or detect disease in

an asymptomatic state (Kasl & Cobb, 1966). Health prevention involves the

interference of the processes of disease or trauma (Kirscht, 1983) and includes

multiple types of prevention. Primary prevention focuses on the prevention of the

occurrence of a condition, secondary prevention focuses on detection and early

treatment, while tertiary prevention focuses on the alleviation of the effects of a

condition after its occurrence (Fielding, 1978). Prevention behaviours are comprised

of the seeking of positive, healthy behaviours (e.g. exercising) or the avoidance of

negative, unhealthy behaviours (e.g. smoking) and preventive health behaviours can

be undertaken by individuals outside of the medical care system or within the

medical care system. This demonstrates the complexity and multi-faceted

characteristic of preventive health behaviours and the most appropriate strategy in

achieving behavioural change is contingent on the specific type of prevention effort

(primary, secondary, or tertiary; starting positive behaviour, or stopping negative

behaviour; operating within the medical care system, or operating outside the

medical care system). This thesis focuses its enquiry on secondary prevention efforts,

for the achievement of positive, healthy behaviours among the target audience,

within the medical care system.

2.2.2 The role of government in preventive health

The establishment of the Preventative Health Taskforce demonstrates the

significance of preventive health issues to government. The role of government is

typically seen as one that provides a variety of public services to its citizens, such as

transport, criminal justice, and public health. Many public health services are

provided by the government as the role of government lies in its responsibility for

shaping the nature of society (Ryan, Parker & Brown, 2003). This would include

ensuring that adequate public health services are available to all citizens in order to

maintain reasonable quality of life. The provision of these public services is made on

the basis of equality and community (Laing, 2003) and thus the government agenda


is that no individual citizen is excluded from the ability to benefit from such services.

Despite these efforts, there are still disadvantaged citizens that exist in any society

who may still experience exclusion from the use of these services.

Health services represent a type of public service that is of great importance to

society. Government-provided health services represent a focus of this research as

these public services are provided to target populations on the basis of social justice

and equity (Van der Hart, 1991), rather than economic or financial ability to use

these services. This is in contrast to the provision of health services by non-

government or private health services, which target consumers on their ability to pay

for such services. This excludes populations that do not have the means to afford or

access these services. Government public health services are provided on the basis of

a collectivist philosophy, whereby the needs of society and social justice are

emphasised over the needs of an individual. The use of government-provided public

health services, while fulfils the needs of the individual who uses them, also fulfils

the broad needs of society. The achievement of community goals is a typical

objective held by many government public health services. Despite this agenda, as

mentioned previously, this research acknowledges that disadvantaged groups that are

unable to access such services will continue to exist in society despite government

effort to make public health services accessible to all.

2.2.3 Using marketing theory in preventive health and wellness

In terms of resource allocation by government to public health services, there is a

predominance of health treatment services over health prevention services. This is

evidenced by the large proportion of government expenditure on treatment services

comparative to preventive services. For example, from 2000 to 2001, the health

expenditure in Australia on cancer treatment accounted for 90% of the total

expenditure on disease and injury, while in comparison the expenditure on cancer

prevention was 1.8% (Australian Institute of Health and Welfare, 2005b).

A possible reason for the lower emphasis on prevention (in terms of resource

allocation) thus far could be that negative situations and experiences may be


perceived to be more urgent and override positive situations and experiences

(Seligman, 2002). There is greater urgency experienced by an individual who is

feeling unwell to get treated to feel better again. In response, an individual may

respond in a reactive manner (seeking treatment) as they are behaving in response to

an external stimulus (falling ill). Furthermore, the burden of disease poses a

significant threat to society and represents a pertinent problem that governments are

required to address appropriately and urgently.

In the marketing area, little research exists in the examination of preventive health

services, while more occurs in the context of health treatment services (e.g. Dagger,

Sweeney & Johnson, 2007). There is an opportunity for a marketing approach

towards understanding preventive health behaviours through the use of consumer

behaviour theories. This approach can be used to compliment the work that exists in

public health research, as a marketing approach offers insights into specific target

segments, rather than a population-level approach which public health research

appears to favour (see Hoek & Jones, 2011).

A marketing approach in a research investigation of health services allows for the

consideration of users of such services as customers or consumers of the service.

This has the potential to provide insight into consumers‟ attitudes and how these

attitudes influence their decisions to use these services. This responds to a call by

Maddux (2002) who highlights the need for new ways of thinking about human

behaviour in health psychology, as it adds an alternative perspective of thinking of

preventive health behaviour that is complimentary to the existing biomedical and

public health perspectives that are typically used in this area of investigation.

In the pursuit of health, as discussed previously, there are many different types of

health behaviours that can be undertaken in a variety of situations and contexts. The

quest for good health from a current state of poor health can be seen as activity

within health treatment, while the quest to maintain or enhance good health can be

seen as activity within health prevention. The quest for good health from a current

state of poor health can be described as a function of an illness paradigm, whereby

activities undertaken by individuals to reach their goal are reactive and in response to

an existing problem or issue. In contrast, the quest to maintain or enhance good


health can be described as a function of a wellness paradigm (Zainuddin et al., 2001),

whereby activities undertaken by individuals to achieve these goals are proactive and

not in response to any existing health problems or issues. Activities undertaken in a

wellness paradigm are inclusive of preventive health behaviours as individuals can

be motivated by the desire to prevent disease or detect it (among other possible

motivations).

Figure 2.1 provides an illustration of the health continuum which summarises the two

paradigms of illness and wellness and identifies examples of different activities

involved in both the illness and wellness paradigms. The specific points on which

individuals find themselves on the continuum depend on their current health status.

The activities described are placed along the continuum in order of the extent of an

individual‟s poor health or good health. As shown in the continuum, activities within

the illness paradigm reflect reactive behaviours that individuals engage in to improve

their poor health, while activities at the wellness paradigm reflect the opposite. These

activities reflect proactive behaviours that individuals engage in anticipation of

potential future issues as well as to maintain their already good health.

Figure 2. 1 Health

continuum

Some of the activities within health prevention and the wellness paradigm are

activities that individuals can undertake on their own, outside of the medical care

system as discussed previously. Similarly, other activities require the use of health

Chemotherapy

Hospitalisation

Dialysis

Basic GP

services

Diet & Exercise

Sun-smart

practices

Regular health

checks

Cancer

screening

WELLNESS

PARADIGM

ILLNESS

PARADIGM

Health

Treatment

Health

Prevention

Source: Zainuddin, Previte and Russell-Bennett (2011)


care providers, such as cancer screening services in the case of secondary prevention

efforts. The provision of preventive health services by governments or the medical

care system offer behavioural opportunities for individuals to undertake health

prevention efforts. The use of preventive health, or wellness, services is an example

of a socially desirable behaviour that individuals can engage in. This results in

benefits for the individual, and subsequently, benefits for society. These outcomes

are consistent with the goals of social marketing, which are to improve the personal

welfare of a target audience, as well as that of their society through the successful

influencing of their behaviour in a voluntary fashion (Andreasen, 1995). As such, it

would be appropriate to investigate consumers‟ use of wellness services using social

marketing to guide the inquiry.

2.3 Social marketing and prevention

The origins of social marketing are found in sociology in the early 1950s by G.D.

Wiebe (1951-52) who examined social campaigns to determine the conditions that

led to their success. Wiebe (1951-52) asked, “Why can‟t you sell brotherhood like

you sell soap?” referring to the effectiveness of selling commodities (goods) and the

relative ineffectiveness of selling social causes or ideas. Social marketing is “the

application of commercial marketing technologies to the analysis, planning,

execution and evaluation of programs designed to influence the voluntary behaviour

of target audiences in order to improve their personal welfare and that of society of

which they are a part” (Andreasen, 1994) and is can be described as a process that

creates and delivers value to individuals in an effort to influence their behaviour

(Kotler, Lee, & Rothschild, 2006 cited in Kotler & Lee, 2008, p.7). Thus, social

marketing is a useful technique in influencing individuals‟ wellness behaviours.

The academic roots of social marketing are found in work by Kotler and Levy (1969)

who suggest that marketing can be a socially useful activity, expanded beyond the

marketing of goods towards the marketing of services, people, and subsequently

ideas. The concept of social marketing was more formally defined and described by

Kotler and Zaltman (1971) as the design, implementation, and control of programs

calculated to influence the acceptability of social ideas and involving considerations


of product planning, pricing, communication, distribution, and marketing research.

Essentially this definition refers to the use of the marketing mix to influence

consumers‟ uptake of ideas (and subsequently behaviour). There have since been

many definitions for social marketing, but what is consistent across many definitions

is that social marketing is the application of commercial marketing understanding,

for the achievement of individual benefit, as well as societal benefit (Dann, 2008).

The achievement of these benefits centres on some form of behaviour change or

modification that is mutually beneficial to the individual who performs the behaviour

as well as the society that they live in including other people within that society.

Aspects of social marketing that form the social marketing theoretical framework for

this thesis include a customer-centred focus (Kotler & Lee, 2008), voluntary

behaviour of individuals (Kotler et al., 2002), and motivation, opportunity and ability

(MOA model) (MacInnis, Moorman, & Jaworski, 1991).

Some of the more contemporary issues facing social marketing include common

myths and misconceptions as to what social marketing constitutes. The Australian

Association of Social Marketing (AASM) considers social marketing as a lens in

which the world can be viewed in terms of its social problems and that through a

combination of academic techniques, policy, strategy, and social management can be

developed and achieved to address these problems (AASM, 2010). The AASM also

makes not that social marketing is not social media marketing (i.e. the use of social

media communications), nor is it solely a communication or education strategy, or

legislation (AASM, 2010).

Social marketing is known to have been utilised by governments to influence public

opinion or educate the public (Kotler & Roberto, 1989) in many instances in the past

in social issues such as the HIV or AIDS campaigns in the 1990s or in war

propaganda in the 1940s (Donovan & Henley, 2003). The government plays a critical

role in ensuring that citizens act collectively in order to achieve community goals

(Ryan et al., 2003). If citizens do not perform the desired behaviours, government

has the authority to develop strategies that will result in positive behavioural change

of its citizens.


These strategies can either be implemented as policy (law), education, or through the

implementation of social marketing programs (marketing). These three approaches

are described by Rothschild (1999) as strategies that are effective in public health

management. However, there has been heavy reliance on education and law in order

to achieve community goals and in contrast, a neglect of the use of social marketing

(Rothschild, 1999). Some disagreement exists among scholars over the place of

legislation in social marketing interventions. While Rothschild views a distinction

between legislation and social marketing, others advocate for its appropriateness and

use as part of an integrated social marketing intervention effort (e.g. Hoek & Jones,

2011).

Similarly, there is debate over whether behaviour change in social marketing should

occur voluntarily. Some scholars argue that social change should occur voluntarily

(e.g. Andreasen, 1995; Kotler et al., 2002; Maibach, Rothschild, & Novelli, 2002),

while others feel that this imposes limitations on what social marketing interventions

can achieve (e.g. Donovan, 2011). The AASM appears to find a compromise in

stating that behaviour change should not occur involuntarily, under duress (AASM,

2010).

Education is also useful in improving consumer knowledge and influencing attitudes

(Rasmuson, Seidel, Smith, & Booth, 1988), individuals still need to initiate action on

their own. It is necessary to develop tactics using each of the strategies in order to

develop an integrated strategy to behaviour change and maintenance. In some

situations, education campaigns can be seen as insufficient and the use of education

in a holistic social marketing intervention is regarded by some as being more

effective (than education alone) (e.g. Donovan, 2011).

The motivation, opportunity and ability model (MOA model) provided by MacInnis,

Moorman and Jawarski (1991) describes the process of information processing in an

advertising context, which has relevance in social marketing. Rothschild (1999)

believes that this MOA model can be suitably applied in social marketing to achieve

behaviour change in individuals, specifically in the context of public health.

Individuals‟ motivation to perform a wellness behaviours can be influenced by

offering a value proposition, as individuals are often motivated to act out of self-


interest (Rothschild, 1999). In addition, the provision of a social marketing service

creates the opportunity for the individual to act. Ability, in MacInnis et al.‟s (1991)

advertising context, refers to a consumer‟s ability to interpret brand information in an

advertisement. Rothschild (1999) again believes that this is also applicable to an

individual‟s ability to perform a behaviour, particularly in public health. An

individual‟s ability to perform an act can be related to self-efficacy theory (Bandura,

1977) and suggests that the individual has the potential to play a significant role in

the value creation process when they perform social behaviours.

2.3.1 Justification for use of social marketing

Social marketing is an appropriate theoretical framework to use in this research

because the current use of marketing theories is rampant in the commercial context

(Laing, 2003). While marketing theories are also used in researching public services,

the theories are used from a commercial perspective (Caruana, Ramaseshan, &

Ewing, 1997; Walsh, 1991). This demonstrates a lack of use of marketing theories in

public services research from a non-commercial, social marketing perspective.

It is necessary to use marketing theories from a social marketing perspective to

research public services because public-sector organisations such as public

government services (including public health services) are seen as agents of social

change in society (Laing, 2003, p.428). Governments play an important role in

shaping society (Ryan et al., 2003) and in the area of population health, government

provision of public health services is one such way to shape society. It has been

acknowledged that public services like health services provide direct benefits to the

users of these services in addition to providing wider social benefits to the

community (Laing, 2003). This is in contrast with private health services, which are

less concerned with societal outcomes and more concerned with the consumers who

use their services. For example, “for-profit” hospitals only cater to some segments of

the population willing to pay for additional amenities (Poullier, 1986, p.27), rather

than the entire population regardless of willingness or ability to pay.


The ability of public health services that provide benefits to the individuals who use

them as well as the wider community is consistent with the objectives of social

marketing, which seeks to encourage behaviour in individuals that provide not only a

benefit to the individual, but to the wider community as well. Furthermore, the public

sector literature recognises the increasing significance of the consumers in the policy

planning processes and their level of influence over the decision-making processes of

public organisations (Caruana et al., 1997; McNulty, Whipp, Whitington, &

Kitchener, 1994). This suggests and increasing need for a consumer-centric approach

in investigating public health services, which social marketing provides.

Furthermore, social marketing is often used in developing solutions to problems in

public health (Grier & Bryant, 2005; Helmig & Thaler, 2010) and as such, is

appropriate for this research.

2.3.2 Typology of social marketing activities

In social marketing, there are many different types of social behaviours that

individuals can perform. Social marketing programs are often used by governments

seeking to create behavioural change in society that would result in a socially

desirable outcome, such as a healthier, happier or more productive society. This in

turn, is likely to result in an improved standard of living, or the maintenance of good

quality of life. Examples of government adoption of social marketing strategies

include bodies such as the U.S. Department of Agriculture and the Centres for

Disease Control and Prevention, as well as state and local governments (Andreasen,

2002). In Australia, examples of social marketing programs include the “Find your

30” campaign about achieving 30 minutes of exercise daily (Queensland

Government, 2009), the “Target 140” campaign about water conservation

(Queensland Water Commission, 2007), and the “Do something special” campaign

about blood donation (Australian Red Cross Blood Service, 2008).

The examples above demonstrate that there are many different social behaviours that

an individual can perform which are beneficial to themselves, to other people, and to

society. Kotler and Zaltman (1971) categorise these behaviours into three different

categories of social marketing causes; altruistic causes, social betterment causes, and


personal health causes. Within each of the causes, the behaviour performed by an

individual can be directed at their self, at others, or at society. Subsequently, there

are direct and indirect benefits as a result of these behaviours. Table 2.1 summarises

the three categories of social marketing causes and describes the direction of the

behaviour and subsequent directness or indirectness of the benefit experienced by the

individual, by others, and by society.

Table 2. 1 Typology of social marketing activities

Type of cause Altruistic causes Social betterment

causes

Personal health

causes

Direction of behaviour Towards others Towards society Towards self

Benefit to others Direct Indirect Indirect

Benefit to self Indirect Indirect Direct

Benefit to society Indirect Direct Indirect

Examples

Blood donation

Volunteering

Charity giving

Recycling

Energy conservation

Water saving

Nutrition

Exercise

Health screens

Altruistic causes include blood donation and charity giving (Kotler & Zaltman,

1971). These describe social marketing activities that are performed by an individual

for other people. Behaviours within altruistic causes provide a direct benefit to the

recipient and an indirect benefit to the individual and society.

Social betterment causes include better environment and civil rights (Kotler &

Zaltman, 1971). These describe social marketing activities that are performed by an

individual for society. Behaviours within social betterment causes provide a direct

benefit to society and an indirect benefit to the individual and other people.

Finally, personal health causes include non-smoking and better nutrition (Kotler &

Zaltman, 1971). These describe social marketing activities that are performed by an

individual for themselves. Behaviours within personal health causes provide a direct

benefit to the individual and an indirect benefit to other people and society.

As the focus of this research is on understanding individuals‟ wellness behaviours,

this falls within the personal health causes category. It is unsurprising that there is a

dominance of personal health problems as being the focus of social marketing

(Andreasen, 2006; Hastings, 2003) as the use of social marketing to address health

problems is well-researched and accepted in the field. As described in the health


continuum in Figure 2.1, behaviours within personal health causes can either be

undertaken independently by the individual, or facilitated through the provision and

use of health care services.

Within the Australian context it is the responsibility of the government to ensure that

all basic health care services are provided for access by all members of society

regardless of age, income, or social status as part of the public health system. These

health services are provided because as mentioned previously, the government has a

duty of care to all its citizens to ensure that every individual has access to adequate

personal health services. As such, it is appropriate to focus on public, wellness

services rather than private, wellness services. This answers calls by Seligman

(2002), Maddux (2002) and Rothschild (1999) for increased attention on the issue of

health and lifestyle maintenance through prevention (i.e. wellness paradigm).

2.4 Preventive health and wellness services

Health care is an important sector in Australia, with total expenditure by both

government and private sectors accounting for approximately 9.8% of the GDP in

Australia (Department of Foreign Affairs and Trade, 2008). In 2000-01, the

expenditure on disease and injury by the health system accounted for $50.1 billion in

total (Australian Institute of Health and Welfare, 2005a). Within this expenditure on

disease and injury, 90% of the expenditure was for cancer treatment and in

comparison the expenditure for cancer prevention was 1.8% (Australian Institute of

Health and Welfare, 2005b).

In investigating wellness behaviours of individuals through their use of wellness

services, it would be appropriate to situate the investigation in cancer prevention

services. At least one in three cancer cases are preventable (Cancer Council

Australia, 2009a) which indicates that prevention and preventive behaviours are

extremely important in minimising the cancer risk for individuals. The Cancer

Council of Australia has provided fact sheets for individuals interested in engaging in

wellness behaviours to minimise their risk of cancers (Cancer Council Australia,

2009b). These fact sheets are most likely to be used by individuals who are proactive


about protecting their health and voluntarily take steps to maintain their quality of

life. The Cancer Council has also developed a National Cancer Prevention Policy

2007-09 which outlines recommendations for government and non-government

organisations to reduce the estimated 106,000 new cases of cancer diagnosed every

year (Cancer Council Australia, 2009c). The policy outlines three broad areas to

address; preventable risk factors, cancer screening, and immunisation. The

preventable risk factors section describes issues such as nutrition, physical activity,

and moderate alcohol consumption, which are all behaviours that can be undertaken

independently by individuals themselves. The cancer screening section outlines

cancer screening efforts, which are only achievable through the use of cancer

screening services. Finally, the immunisation section discusses the importance of

immunisations, however these tend to be discreet behaviours as it is unnecessary to

be immunised against the same disease repeatedly (outside of the recommended

number of doses needed).

Within cancer screening, there are three government cancer screening programs in

Australia; BreastScreen Australia, the National Cervical Screening program, and the

National Bowel Screening program (Department of Health and Ageing, 2009).

BreastScreen Australia is the only cancer screening program of the three that offers a

free government-provided service. Other cancer screening services such as cervical

and bowel cancer screening are mostly provided by GPs or specialists. It is important

to ensure that all individuals have access to health services (Gruskin, Plafker, &

Smith-Estelle, 2001) so they may have the opportunity to reach their potential by

performing social marketing behaviours (Donovan & Henley, 2003). As such, breast

screening services provided by the government is a suitable context to situate this

research investigation as this service is readily available to all eligible members of

society, thus enabling individuals to perform social marketing behaviours through

use of this service.

2.4.1 Significance of health services

Health services are an important area of investigation as health care is a service

sector that is fast growing (Andaleeb, 2001). Services can be described as acts,


performances or experiences (McColl-Kennedy, 2003), which are acted out or

performed by a service provider for a customer. Lovelock (1983) describes the nature

of services as having two elements; at whom the act is directed and the tangibility of

the actions. This results in four types of services; services directed at people‟s bodies,

services directed at people‟s minds, services directed at physical possessions, and

services directed at intangible assets. Health services are categorised as services

directed at people‟s bodies and the value created in these services are likely to be

different from the value created in the other service categories.

Within health services, there are many factors that influence consumers‟ perceptions

of a service. These include perceptions of technical quality (McDougall & Levesque,

1994), interpersonal quality (Brady & Cronin, 2001), environment quality (Gotlieb,

Grewal, & Brown, 1994), and administrative quality (Grönroos, 1990; McDougall &

Levesque, 1994). However, health services are often evaluated within an illness

paradigm and as such, are outcomes-oriented. This means that the quality of health

services is very often measured by economic standards like mortality and morbidity,

while more subjective assessments of measuring quality are neglected (Dagger,

Sweeney, & Johnson, 2007). Thus there is a need for an approach that has a customer

orientation and uses relational thinking in social marketing wellness services.

2.4.2 Service quality and health services

Perceived service quality often refers to consumers‟ evaluations of the performance

of a service entity based on its overall excellence or superiority (Cronin & Taylor,

1992; Zeithaml, Parasuraman & Berry, 1985). There are two approaches in

investigating service quality, which are the two-factor Nordic model (Grönroos,

1984) and the five-factor American SERVQUAL model (Parasuraman et al., 1988).

These models are based on the disconfirmation paradigm, which was employed in

the tangible goods area (e.g. Cardozo, 1965; Churchill & Suprenant, 1982; Howard

& Sheth, 1969; Oliver, 1977, 1980; Olshavsky & Miller, 1972; Olson & Dover,

1976).


The Nordic model conceptualises service quality as a comparison of perceived

service against expected service (Grönroos, 1984). This perspective identifies two

service quality dimensions, which are functional quality and technical quality

(Grönroos, 1984). Alternatively, the SERVQUAL model identifies five service

quality dimensions, which are reliability, responsiveness, empathy, assurances, and

tangibles (Parasuraman et al., 1988).

There exists much debate on the merits of both approaches and researchers disagree

on the means of measuring service quality perceptions (Ganesan-Lim, Russell-

Bennett, & Dagger, 2008). However, there appears to be agreement that service

quality is accepted to be a multi-dimensional, higher-order construct (Grönroos,

1984; Parasuraman et al., 1988; Brady & Cronin, 2001). In addition, considerable

research has been conducted on developing more accurate means of measuring

service quality perceptions. However, much of this development has focussed on the

development of generic models (e.g. Brady & Cronin, 2001; Parasuraman et al.,

1985) and relatively fewer have focussed on the development of context-specific

models (e.g. Dagger et al., 2007).

Despite the lack of context-specific models of evaluating service quality, there are a

number of conceptual frameworks that have been developed to evaluate the quality

of care in health services. Many of these frameworks identify dimensions similar to

those of service quality dimensions such as technical and interpersonal processes

(Donabedian, 1966; 1980; 1992) or competences (Wiggers, Donovan, Redman, &

Sanson-Fisher, 1990). However, dimensions that appear most common between the

health care literature and the marketing literature include technical, functional,

environment, and administrative dimensions of the service experience (Dagger et al.,

2007).

However, the current frameworks that assess the quality of health services are

specific to health treatment services, rather than health prevention services. This

represents a gap in the research as there are likely to be significant differences in

consumers‟ motivations to use treatment services, rather than wellness services for

health prevention. Undoubtedly, the service experience is an important factor in

individuals‟ decisions to use wellness services again in the future as their evaluations


of service quality are likely to have an impact on the value they perceive to receive

from their service experiences. Individuals are likely to perceive value as an outcome

of perceptions of high service quality (e.g. Sweeney, 2003). Therefore, consumers

must experience value through their use of wellness services to ensure their

continuation in performing wellness behaviours in the long term. As such, it would

be necessary to review the literature on value, specifically customer perceived value.

2.5 Value

In 2007, the American Marketing Association (AMA) released a revised definition of

marketing which describes it as the activity, set of institutions and processes for

creating, communicating, delivering, and exchanging offerings that have value for

customers, clients, partners, and society (AMA, 2008). This highlighted the

importance and significance of value in the area of marketing.

2.5.1 Perspectives on value

Traditionally, there are two perspectives of value in marketing. The first is customer

perceived value (Kotler & Armstrong, 2008, p.13), or value for the customer, and the

second is customer lifetime value (Kotler & Armstrong, 2008, p.20), or value for the

organisation. Customer lifetime value refers to the value (typically monetary) of the

entire stream of purchases an individual customer can make over a lifetime of

patronage to the organisation (Kotler & Armstrong, 2008). This perspective of value

comes from an organisation‟s perspective, where achieving customer value can be

seen as a means towards achieving organisational goals (e.g. market share, profit,

etc.). As illustrated by Porter (1985), value was first regarded as a means for

achieving competitive advantage. Value is generated through a value-chain, which

depicts the combination of an organisation‟s primary activities with support activities

to generate profit for the organisation (Porter, 1985). The use of this value

perspective still has relevance today, especially in areas of industrial, managerial,

and supply-chain research. However, in seeking to understand the behaviour of

individuals in prevention, it is more appropriate to use the customer perceived value

perspective.


A customer perceived value perspective is more appropriate as it is concerned with

the experiences of consumers when using a service. An investigation of value is

appropriate as it is often referred to in the context of service provision or on the basis

of service quality (Auh, Bell, McLeod, & Shih, 2007; Chang, 2008; Jackson, 2007;

Laukkanen, 2007; Padgett & Mulvey, 2007; Shamdasani, Mukherjee, & Malhotra,

2008). A traditional approach in understanding value has been the adoption of an

economic approach, which considers the utility gained and value is a direct outcome

of a cost-benefit analysis (Payne & Holt, 1999). Value has typically been regarded as

an outcome of an evaluation between “get” components against “give” components

(Zeithaml, 1988). Essentially, this is based on a comparison between what is given

up by the consumers in order to use a product or service, against what is received by

the consumer from using the product or service (Zeithaml, 1988). This

conceptualisation of value is appropriate in understanding buyer behaviour, which

describes much of the early research into customer perceived value.

The concept of value has also traditionally been investigated extensively in

commercial marketing and there is no current investigation on value in a social

marketing, wellness services context. This demonstrates a lack of use of a value

perspective in investigating wellness behaviours through the use of services.

In considering consumers‟ decisions to use services or decisions to perform wellness

behaviours by using social marketing wellness services, an economic approach is

likely to provide limited understanding of the considerations involved in choice.

Important aspects of services such as relationships and interactions are not accounted

for in an economic approach. This describes another gap in the research, which is a

lack of use of experiential perspective in the investigation of value and an over-

emphasis on the use of an economic perspective. Therefore it is necessary to move

beyond an economic approach in this particular investigation.

2.5.2 Experiential value: moving away from an economic approach

The experiential approach to understanding value addresses this gap by offering a

perspective that allows for more meaningful investigation into consumers‟ decisions


to use wellness services. The experiential approach supports the idea that value is

situational and can change before, during, or after a service experience (Woodruff,

1997).

Early work in experiential value or the “experience economy” (Mathwick, Malhotra,

& Rigdon, 2001, p.40) tends to be situated in a commercial marketing context where

the consumption experience is a value-added feature that is used as a point of

differentiation in the selling of goods. Much of experiential value is investigated

from the perspective of hedonistic consumption, as the consumption experience itself

is rich in value (Mathwick et al., 2001) and it is from this process that the individual

derives value. This is not the same as experiential consumption in social marketing

wellness behaviours. The experience of performing a wellness behaviour is not a

value-add and is not meant to be used as a point of differentiation to get the

individual to act. In social marketing, the experience refers to the process that the

individual undergoes in the consumption of a social marketing service.

The economic approach regards the determination of value as an outcome of an

exchange, however in social marketing outcomes alone are insufficient in achieving

sustained wellness behaviour. Individuals seek a positive consumption experience in

addition to positive outcomes, since positive outcomes alone may be insufficient to

sustain long-term behaviour. This can be attributed to the fact that outcomes for

wellness behaviours are often not received immediately. Thus, an experiential

perspective is necessary in the context of social marketing if sustained long-term

wellness behaviour is sought. It is believed that value is contextually bounded and

subjectively experienced (Vargo and Lusch, 2008), which is why it cannot be

assumed that value is created and experienced the same way in a commercial

marketing context (e.g. retail) and a social marketing context (e.g. preventive health

or wellness).

To describe the benefits that value provides, value is said to have both extrinsic and

intrinsic benefits (Batra & Ahtola, 1991; Mano & Oliver, 1993). Extrinsic value

refers to the functional or instrumental benefit of a consumption experience

(Holbrook, 2006) and this is associated with economic value. Intrinsic value refers to


a situation where the consumption experience is appreciated for its own sake

(Holbrook, 2006) and this is associated with experiential value.

To summarise, an economic approach into a value investigation is one that considers

value to be an outcome of an evaluation of costs against benefits (Zeithaml, 1988).

This uses a value-in-exchange approach which is outcomes-oriented and tends to be

goods-based. While there can be both extrinsic and intrinsic benefits in this context,

the benefits tend to lean more heavily towards extrinsic benefits. This perspective is

particularly applicable in commercial marketing, where the outcomes-orientation

tends to be profit for the organisation through delivery of value to the customer. This

approach is suited to the illness paradigm.

Conversely, an experiential approach in investigating value is one that considers

value to be an interactive relativistic preference experience (Holbrook, 2006). This

uses a value-in-use approach which is process-oriented and is more suitable for

services-based offerings. While there are both extrinsic and intrinsic benefits in this

consumption context as well, the benefits tend to lean more heavily towards intrinsic

benefits due to the difference in the nature of this consumption context. As such, this

perspective is more suitable in social marketing, where the outcome orientation is not

financial profit to the organisation, but behaviour change for individuals who use the

service. This approach is suited to the wellness paradigm. Table 2.2 provides a

summary comparison between the two perspectives.

Table 2. 2 Summary comparison table between economic and experiential perspectives

of value

Economic approach Experiential approach

Value definition An outcome of an evaluation of costs against benefits (Zeithaml,

1988)

An interactive relativistic preference experience (Holbrook, 2006)

Value type Value-in-exchange Value-in-use

Orientation Outcomes-oriented Process-oriented

Product context Goods-based Services-based

Benefits Predominantly extrinsic Predominantly intrinsic

Marketing context Commercial marketing Social marketing

Paradigm Illness Wellness


Having established the use of an experiential perspective to drive the investigation to

value in social marketing, the following section turns to a review of the various

dimensions that comprise the value construct.

2.5.3 Dimensions of value

Value has been conceptualised into multiple dimensions, some of which are

proposed to be independent of one another (e.g. Sheth, Newman, & Gross, 1991)

while others have been validated as inter-related dimensions (e.g. Sweeney & Soutar,

2001). While there are differences in the exact terminology of the dimensions by

different authors, there appear to be four common dimensions; functional (sometimes

termed economic) (e.g. Holbrook, 1994), emotional (sometimes termed hedonic)

(e.g. Babin, Darden, & Griffin, 1994), social and altruistic. The dimensions of value

are synthesised in Table 2.3.

Table 2. 3 Comparisons of conceptualisations of value

Sheth, Newman and Gross

(1991)

Holbrook (1994)

Sweeney and Soutar (2001)

This thesis

Research paper Quantitative Qualitative Quantitative Qualitative Quantitative

Dimensions Functional Social

Emotional Epistemic

Conditional

Economic Social

Hedonic Altruistic

Price/Quality Social

Emotional

Functional Social

Emotional Altruistic

Relationship between

dimensions

Independent

Inter-related

Inter-related

Inter-related

The dimensions of value have been developed in a commercial marketing context,

physical goods context, or both. Sweeney and Soutar‟s (2001) value dimensions were

developed in a commercial marketing, goods-based context and example of a value

dimension item includes, “this product has poor workmanship.” Other

conceptualisations of value dimensions have been developed in a services context,

but those that represent commercial services still representing a commercial

marketing context. One example of an item representing a value dimension in a

commercial services setting includes one by Huber, Hermann, and Hennesberg

(2007) which used an automobile mechanic service context for their research, “I was

treated courteously by the mechanic.”


There is a lack of conceptualisation and use of value dimensions in a social

marketing services context. This research seeks to fill this gap by investigating the

value dimensions present in government-provided public health services, specifically

wellness services which are often provided free or at a subsidy (e.g. breast screening

services). The removal of cost in the consumption of these services reduces the

effectiveness of using the economic approach in investigating value as a cost-benefit

assessment of value is no longer adequate in determining the value dimensions

consumers experience. The investigation of value in non-commercial and non-goods

based contexts is slowly on the rise as evidenced by Nelson and Byus‟s research,

which investigates value dimensions in consumers‟ perceptions and support of

government-provided public services (2002). Nelson and Byus (2002) investigate the

value that citizens place on public services using the value dimensions adapted from

Sheth et al. (1991).This represents value research conducted in not only a services-

based context, but also a non-commercial context. The non-commercial context of

Nelson and Byus‟s (2002) research does not precisely reflect a social marketing

context. But, their adaptation of the items by Sheth et al. (1991) that were originally

developed in a goods-based commercial context demonstrates that there is potential

for adaptation of commercial services or commercial goods value dimension items in

social marketing services.

Table 2.4 shows a typology of customer value developed in commercial marketing

by Holbrook (2006) which informed the conceptualisation applied to the social

marketing context in this research. This thesis proposes that functional (economic),

social, emotional (hedonic), and altruistic dimensions of value exist in a social

marketing wellness service.

Table 2. 4 Holbrook’s typology of value

Extrinsic Intrinsic

Self-oriented Economic value Hedonic value

Other-oriented Social value Altruistic value

Functional value (economic value) is extrinsically-motivated (a means to an end),

and for the benefit of the self rather than others (Holbrook, 2006). This value shows a

focus on performance and functionality (Russell-Bennett, Previte, & Zainuddin,

Source: Holbrook (2006, p.715)


2009; Sheth et al., 1991; Sweeney & Soutar, 2001) which can include economic

benefit in a commercial context or the utility provided by the consumption of a

product or service (Tellis & Gaeth, 1990). The functional value dimension is likely to

be applicable to a government social marketing service that delivers a service as part

of the social marketing mix. This relates to the consumption of a social marketing

service as a means to a consumer‟s own objectives (Holbrook, 2006), which in this

context is the maintenance of good health.

Social value is also extrinsically-motivated however it is directed at others

(Holbrook, 2006). This type of value focuses on influencing other people as a means

to achieving a desired goal such as status or influence (Russell-Bennett et al., 2009).

Utility in social value is acquired from a product or service‟s association with social

groups (Sheth et al., 1991) as well as its ability to enhance an individual‟s self-

concept (Sweeney & Soutar, 2001). In social marketing, this value dimension may

also be relevant as women choose to perform socially-desirable behaviours in order

to fulfil social belonging needs or influence others to perform the same behaviours.

Social value is sought when individuals seek to shape the response of others

(Gallarza & Saura, 2006; Holbrook, 2006), which is also relevant in the social

marketing context as consumers seek congruence with the norms of friends and

associates when projecting their health status (Sánchez-Fernández, & Iniesta-Bonillo,

2006).

Emotional value on the other hand, is intrinsically-motivated (an end in itself) and

self-oriented whereby products are consumed for the emotional experience and for

no other end-goal (Holbrook, 2006).This value is related to various affective states,

which can be positive (e.g., confidence and pleasure) or negative (e.g., anger and

fear) (Sánchez-Fernández, & Iniesta-Bonillo, 2006). Utility in emotional value is

derived from the feelings or affective states generated or aroused by the consumption

of a product or service (Sheth et al., 1991; Sweeney & Soutar, 2001). Similarly, in

the context of government social marketing health services, consumers are likely to

experience some form of emotion, particularly when thinking about personal health

and wellbeing. As such, it is believed that this value dimension is relevant as women

may choose to seek tension or anxiety reduction.


Altruistic value is also intrinsically-motivated but directed towards others (Holbrook,

2006) whereby the goal may be self-fulfilment or a sense of well-being. It describes

an individual‟s concern for how their consumption behaviour affects others

(Holbrook, 2006) which is particularly relevant in social marketing. Many consumers

may be motivated to perform socially-desirable behaviours for the good of others and

society than for themselves. Arguably, this value is central to prevention messages,

which aim to identify illness early, so that citizens do not become a cost on society in

the future.

As these dimensions of value have been conceptualised in a commercial marketing

context, it is not known if these dimensions of value are also relevant in social

marketing. This leads to the first sub-research question:

RQ1: What are the dimensions of value experienced by users of wellness

services in social marketing?

2.5.4 Experiential value in wellness services

A key characteristic that differentiates the social marketing context from commercial

marketing is the non-monetary costs such as time and effort (Joyce & Morris, 1990;

Wang, Lo, Chi, & Yang, 2004) involved in most exchanges. This feature minimises

the economic aspect of value that has been central to commercial exchanges and

instead places emphasis on the psychological and emotional dimensions of value.

Alongside economic barriers, the social and emotional forms of value are significant

barriers to the adoption and maintenance of desired wellness behaviours, such as

quitting smoking and moderate drinking.

Additionally, consumers‟ use of government wellness services is voluntary, which is

consistent with the purpose of social marketing in achieving voluntary behaviour in

target audiences (Andreasen, 1995). This voluntary nature suggests that the activity

dimension of experiential value (Holbrook, 1994) is an important consideration in

investigating value in wellness services. Holbrook (1994) distinguishes between

passive value and active value, whereby passive value is experienced by consumers


reactively in response to the consumption of an object or experience, while active

value is participative and requires collaboration between the consumer and the

service. It is important to consider active value in wellness services as consumers‟

use of these services is proactive and voluntary.

This research proposes that in order for governments to achieve sustainable

behavioural change among target consumers, consumers must first see value in

changing their behaviours. In order to provide value to consumers, there must be an

understanding of how value can be created.

2.6 Value creation

Value creation is a paradigm (Sheth & Uslay, 2007) that involves multiple

stakeholders in the marketing process, working together at various points of the

consumption process to create value. Value creation differs from the exchange

paradigm as the value consists of more than utility and the consumption experience is

a critical component. This value creation paradigm is still in infancy and there is a

lack of consensus on the conceptualisation of value. To date, there has been limited

theorisation or empirical evidence to support the value creation process (Smith &

Colgate, 2007).

Value creation is a process in which an organisation and consumers interact at

various stages of the consumption process in order to co-create the product or service

(Prahalad & Ramaswamy, 2004). This notion of value creation is different from an

earlier, traditional conception of value creation which was understood as a process

occurring within the firm without the involvement of the consumer (Prahalad &

Ramaswamy, 2004). This organisation-centric perspective of value creation is

characterised by the “value-chain” concept (Porter, 1985). This perspective

describes the exchange paradigm as only the firm is responsible for creation, while

consumers are only responsible for consumption. It is necessary to move towards

value co-creation as it is important for consumers to be involved in the value

development process so that the best value may be achieved (Lusch & Vargo, 2006;

Sheth& Uslay, 2007).


2.6.1 Value co-creation and service-dominant (S-D) logic

The involvement of consumers in the value development process is a tenant of

service-dominant (S-D) logic. S-D logic is a paradigm that shifts the marketing

orientation from a service-centric approach towards a consumer-centric approach. S-

D logic argues that value can only be determined by the user in the consumption

process (Lusch & Vargo, 2006), which is relevant in wellness services as users of

these services determine the type of value that they seek. As such, value can only be

created by organisations with consumers (Lusch & Vargo, 2006). This describes one

of the foundational premises (FPs) of S-D logic, which identifies that “The customer

is always a co-creator of value” (Vargo & Lusch, 2006, p. 44). As such, open,

collaborative effort shared between consumers and organisations is a key tenant of S-

D logic (Lusch & Vargo, 2006). However, despite the importance of the role of the

consumer, there exists little empirical evidence in the current literature to

demonstrate the significance of the role of the consumer in the value co-creation

process.

Customer co-creation of value with organisations denotes co-production, which is a

central principle of the S-D logic (Vargo & Lusch, 2004). Co-production can lead to

consumer empowerment (Auh et al., 2007), which is highly relevant in the context of

consumers‟ use of wellness services. The need for consumers to be proactive in their

decisions to use wellness services suggests that consumer empowerment may be an

important factor in their decision-making. As consumers are recognised as

endogenous resources involved in co-production activities (Lusch & Vargo, 2006,

p.281) and operant resources in a service setting (Vargo & Lusch, 2004), there is a

need to acknowledge that value co-creation must occur with both the service

organisation and the consumer. This emphasises aspects identified in S-D logic that

are important considerations in value creation, which include interactivity,

connectivity, and ongoing relationships (Vargo & Lusch, 2004) between service

organisations and consumers.

Furthermore, the use of an experiential approach in understanding consumer value

denotes an approach that is process-oriented and predominantly services-based. This

orientation shares great similarities with a service-dominant logic, which focuses on


the shift away from a unit that is exchanged towards the process of exchange (Vargo

& Lusch, 2004). Service-dominant (S-D) logic is a reflection on a shift in marketing

thinking away from tangibles and the production of tangibles, toward intangibles and

the use of intangibles such as skills, information, and knowledge (Vargo & Lusch,

2004) in a service consumption experience. This is important in social marketing, as

the goals of social marketing a focussed predominantly on the adoption of

behaviours and ideas, which are intangible. Therefore, the need for investigating

value co-creation, guided by the use of the experiential approach together with S-D

logic, is important in social marketing as there is a need for a value proposition in

order to incentivise individuals into action (Dann, 2008; Kotler & Lee, 2008).

2.6.2 Value co-creation in social marketing

Value creation is important in social marketing as Kotler, Lee and Rothschild (2006

cited in Kotler & Lee, 2008) describe it as “a process that applies marketing

principles and techniques to create, communicate and deliver value to influence

target audience behaviours that benefit society as well as the target audience.” In

understanding how value is created in a social marketing health service, there is a

need to identify where value comes from and how value is created. Ulaga (2003) and

Huber, Herrmann and Morgan (2001) describe value as a subjective construct that is

comprised of multiple value components. Some of these value components are called

sources of value. Early research identifies sources of value that stem from the value-

chain processes both within and between organisations (e.g. Porter, 1985).

Traditionally in commercial marketing, the purpose for organisations in achieving

customer value is for the achievement of competitive advantage (e.g. Slater &

Narver, 1994; Woodruff, 1997) to gain financial profit. However, in social marketing

and for social marketing organisations, the objective is not the achievement of

financial profit, but for socially desirable ends (Donovan & Henley, 2003). This can

be achieved through consumers‟ use of some services (like health screening services)

because value is relative by virtue of its comparative, personal, and situational nature

(Holbrook, 1994; 1999).


2.6.3 Sources of value

In understanding where experiential value in social marketing comes from and how it

is created, there is a need to identify and understand the sources of value. Based on

the consideration for the importance of active value in experiential consumption,

Mathwick et al. (2001) developed a typology of experiential value on the basis of

active and passive value types against the intrinsic and extrinsic benefits derived

from the consumption which is presented in Table 2.5.

Table 2. 5 Typology of experiential value

Active value Reactive value

Intrinsic value Playfulness Aesthetics

Extrinsic value Customer return on investment Service excellence

They identify aesthetics, service excellence, customer return on investment (CROI),

and playfulness as dimensions of experiential value (Mathwick et al., 2001) but later

describe them as active/reactive sources of intrinsic/extrinsic value. Their typology

reflects sources of value as the elements they identify, aesthetics, service excellence,

customer return on investment (CROI), and playfulness, are all elements that have an

impact on consumers‟ determination of value from the consumption experience.

These four elements describe sources of value that originate from the organisation as

well as consumers. For example, aesthetics and service excellence reflect sources of

value that originate from the organisation and thus, consumers respond passively to

these elements. Aesthetics refers to the visual elements within the consumption

environment, while service excellence refers to the perceived performance of the

service (Mathwick et al., 2001). On the other hand, CROI and playfulness reflect

sources of value that originate from the consumer out of their participation and use of

the service and thus, consumers respond actively to these elements. CROI refers to

the inputs consumers make into a consumption experience, expecting to yield some

return, while playfulness refers to the engagement of the consumer in the activity

(Mathwick et al., 2001). Smith and Colgate (2007) also present a conceptualisation

that offers examples of how different value sources influence a consumer‟s value

construction. They identify five sources of value, which are information, product,

Source: Mathwick, Malhotra and Rigdon, 2001, p. 42


interaction, environment, and ownership/possession transfer (Smith & Colgate,

2007).

Information relates to the marketing materials produced by the organisation that

convey information including promotional material, website, brochures, and

instructions. Information influences economic value by educating and informing

compared to emotional value which is influenced by the creative execution or

sensory experience of the information (Smith & Colgate, 2007). Information can help

consumers identify with peers or social groups thus creating social value (Smith &

Colgate, 2007) and finally it can create altruistic value by showing the benefits to

society that the interaction provides.

The second source of value they identify is product (Smith & Colgate, 2007).

Although goods-oriented, this conceptualisation can be extended to services, and in

line with Vargo and Lusch (2004) adopt the service perspective. Service relates to

the service system (Vargo, Maglio, & Akaka, 2008) and benefits or needs met

through core and supplementary service processes. Services provide value in terms

of the benefits/needs they meet though core and supplementary service delivery.

Functional value is created by the service solving a problem for the consumer i.e. a

water use monitoring service solves the problem of locating where excess water use

is located within a home. The service provides sensory experiences for the consumer

such as the relief of pain by a medical service that provides medication resulting in

feelings of relief, this creates emotional value. Social value is created when the

service allows the consumer to express themselves to other‟s through the experience

of the service and altruistic value is the “sense of doing good” created by receiving

the service.

The third source of value is the interaction with employees within the service system

(Smith & Colgate, 2007) and service-for-service exchange and configuration of

resources (including people and technology). This is the interpersonal aspect of the

service, which also relates to interaction and systems service quality. When the

interactions allow the consumer to achieve the desired outcome, functional value is

created. Additionally the interactions may also influence the emotional state of the

consumer and emotional value may also be experienced. If the interaction allows the


consumer to gain status or protect their ego, social value is created. Finally if the

interaction results in positive outcomes for others (perhaps the employee or other

customers who are present) then the value is altruistic.

The physical environment is another source of value (Smith & Colgate, 2007). The

physical environment includes atmospherics, social servicescape and the physical

aspects of the consumption experience such as the building. In retailing,

atmospherics is important in influencing consumers to visit (Donovan & Rossiter,

1982; Mehrabian & Russell, 1974) which is also applicable in a health service setting

where it is important to have consumers return to the service provider for subsequent

appointments. On the other hand, the social environment includes other consumers of

the service at the time of the service experience. Functional value is influenced if the

physical environment facilitates the consumption of the service such as having

lighting that allows the consumer to read instructions more clearly. Emotional value

is created by the affective state invoked by the environment, for example a non-

crowded reception may put the consumer at ease and relieve anxiety. Social value is

created when the environment increases a consumer‟s status or protects the ego such

as in situations where the service being consumed is prestigious. Finally, altruistic

value is created when the environment allows the consumer to be pro-social, for

example when a consumer chooses a service that performs energy-saving practices,

and this may create altruistic value.

The final source of value they identify is ownership/possession transfer, which

includes activities such as delivery and contracts (for transfer of possessions) (Smith

& Colgate, 2007). This source of value was not included in this research as it relates

to goods-specific products. Ownership/possession transfer is not applicable to

services as the intangible nature of services does not allow a person to “own” a

service, nor does it allow a service provider to “transfer” the service to the consumer

since service provision and consumption occurs simultaneously (Lovelock,

Patterson, & Walker, 2004).

Smith and Colgate‟s (2007) conceptualisation of sources of value only include those

that originate from the organisation. This conceptualisation of value sources has been

developed from an organisational perspective and as such, does not take into


consideration consumers‟ input in the value creation process. On the other hand, the

typology presented by Mathwick, Malhotra and Rigdon (2001) include a

conceptualisation of sources of value that are also contributed by the consumers

themselves based on active value, which is the result of active collaboration on the

part of the consumer.

This is important in social marketing wellness services because consumers are active

in their consumption of wellness services and therefore there is a need to consider

their contribution towards the value they derive from a consumption experience.

Furthermore, in social marketing there are other value creation collaborators apart

from the organisation, which includes the consumers, society, community, or even

government.

To date, there has been no empirical evidence of these conceptualisations of sources

of value, nor is there empirical evidence of additional sources of value. Therefore, an

objective of this research is to discover exploratory evidence for sources of value, as

well as additional sources of value that may be relevant. This leads to the next

question:

RQ2: What are the sources of value that exist in wellness services in social

marketing?

2.6.4 Consumer participation as a source of value

Given the inseparability of services (Zeithaml, Parasuraman & Berry, 1985) it is

anticipated that the consumers themselves are likely to be a source of value in a

consumption experience. Collaboration can be considered a form of joint

participation (Meuter & Bitner, 1998) as this describes a service situation where both

the consumer and the service employees interact, participate and collaborate in

production (Bendapudi & Leone, 2003). The idea of the customer as a collaborator is

a popular focus in contemporary marketing. Recently for example Lusch, Vargo and

O‟Brien (2007) identified the consumer as an endogenous resource that is also


involved in co-production activities (such as advising a radiographer during a

screening process).

However, this idea of collaboration is insufficient in describing individuals‟

involvement in social marketing behaviours because collaboration is limited to the

service encounter as it is part of the interaction with the service provider. In social

marketing, there are other stages in the consumption process in which individuals are

participants, but do not interact (and therefore do not collaborate) specifically with

service providers. These stages include events outside of the actual service

encounter.

Russell-Bennett et al. (2009) identify various consumption stages in a social

marketing service where an individual can experience value. These stages include a

pre-consumption stage, consumption stage (i.e. the service encounter), and a post-

consumption stage (Russell-Bennett et al., 2009). An understanding of the different

consumption stages is especially important in wellness behaviours which are

sustained over the long-term or in situations where there is a long time lapse between

service encounters (e.g. yearly dentist visits as opposed to daily visits to the gym).

The individual is still a participant in this consumption process outside of the service

encounter and therefore, participation is a more appropriate term to use to describe

the involvement of consumers in the creation of value in social marketing.

Participation is currently described as the degree to which the consumer is involved

in producing and delivering the service (Dabholkar, 1990, p.484). However, in a

social marketing context which considers consumption stages outside of the service

interaction to be of equal importance, this research seeks to conceptualise

participation more broadly as an act of taking part in an activity. In wellness

behaviours, the individual is a participant in the entire consumption process which

includes the interaction with the service provider during the service encounter (i.e.

collaboration), as well as interaction with others outside of the service encounter

(during the pre- and post-consumption stages for example). Interaction with others

can include interaction with experts outside of the service organisation, or with peers.

In the context of wellness, experts can include any health professional such as a

general practitioner. There are also stages in the consumption process where


individuals do not interact with others but the individual‟s experience during these

stages are also an important consideration in understanding sustained, long-term

wellness behaviour.

Mathwick et al. (2001) identify that inputs from the consumer can come in the form

of cognitive, behavioural, or financial investment. In the context of a government

social marketing service that is free, financial investment is not as relevant. However,

cognitive and behavioural investments are still important. Specifically, the cognitive

and behavioural investments can be refined as mental, physical and emotional inputs

(Hochschild, 1983; Larsson & Bowen, 1989; Silpakit & Fisk, 1985). These are all

dimensions of consumer participation that are likely to be evident in a social

marketing wellness context. These inputs are all contributed at various staged of the

consumption process and are not limited to only the service encounter. For example,

physical inputs may be important during the consumption stage as the individual may

need to follow the service provider‟s instructions as to how to place themselves

appropriately during the service. On the other hand, mental inputs may be important

during the pre-consumption stage where the individual needs to remember to

organise and appointment or turn up on time. Similarly, emotional inputs may be

important during the post-consumption stage where the individual may need to

assure themselves that the results of their health screen appointment are likely to be

fine. This suggests that individuals have the potential to be highly involved during

the consumption process in social marketing.

It is useful then, to employ relational thinking, which has been identified as being

absent from social marketing theory and practice despite the potential it has for the

high involvement behaviours that social marketing target (Hastings, 2003). The

sources of value incorporate relational thinking with the inclusion of participation,

which is based on building relationships, creating trust, and subsequently

commitment to performing the behaviour long-term. To summarise, the sources of

value proposed for wellness services include information, interaction, service,

environment and participation.

Upon identification of the dimensions as well as sources of value that are present in a

social marketing wellness service, there is then a need to understand how the sources


of value influence the dimensions of value. This leads to the next sub-research

question:

RQ3: What is the relationship between the sources and dimensions of value

in wellness services?

In summary, there is a need to investigate value in a social marketing wellness

service as value is an important proposition in achieving sustained wellness

behaviour over the long-term. This thesis will seek to identify the dimensions of

value present in this context, as well as the sources of value that are likely to have an

influence on them.

2.7 Summary of gaps and propositions

To summarise, there is a lack of investigation in health prevention from a consumer-

centric, marketing perspective. Much of the existing research into wellness

behaviours lies within the areas of public health and medicine. The lack of

investigation from a marketing approach results in a lack of use of consumer value

theories to understanding why individuals perform wellness behaviours, which have

the potential to offer relevant and timely insights. As such, the first research gap is as

follows:

GAP 1: There is a lack of empirical evidence for dimensions of value

in a social marketing wellness service context

Secondly, it is proposed that a value proposition is necessary in incentivising

individuals into performing wellness behaviours, through using wellness services.

However, much of the existing research in value has been conducted in commercial

marketing, often in a goods-oriented context, using an economic perspective. This

presents the next research gap:

GAP 2: There is a lack of empirical evidence for sources of value in

social marketing wellness services.


Finally, it is expected that value dimensions and sources conceptualised in

commercial marketing will be present in social marketing. However, in both

commercial and social marketing it is not known how the dimensions and sources of

value relate as there is no evidence to describe this relationship. As such, the next

research gap is as follows:

GAP 3: There is limited empirical evidence demonstrating the

relationship between value dimensions and sources in a social

marketing wellness service context.

To summarise, value can be created through a value creation process at different

stages of the consumption experience. However it is not known how this process

operates in social marketing wellness services. Study 1 will explore how the sources

of value create dimensions of value for a wellness service and a value creation model

will be developed on the basis of the findings from Study 1. This model will then be

tested in Study 2, to provide the empirical evidence required to support this

hypothesised model of value creation.

2.8 Conclusion

In conclusion, this section has reviewed the streams of literature that form the

theoretical basis of this investigation into value creation in social marketing wellness

services. Specifically, this chapter has discussed preventive health and introduced the

wellness paradigm; social marketing and its role in understanding preventive

behaviours; health services, specifically government wellness services; value and the

dimensions of value; and value creation and the sources of value. The following

chapter describes the methodology for this thesis, which incorporates a multi-study

mixed-method approach in addressing the three sub-research questions.

Chapter 3: Methodology 56

CHAPTER 3 METHODOLOGY

“Wisdom is not wisdom when it is derived from books alone”

Horace

3.1 Introduction

In the previous chapter, the theoretical foundations for this research were established,

the theoretical frameworks underpinning this research were identified, and the

research gaps were highlighted. This current chapter presents the research

methodology for this thesis which seeks to fill the identified research gaps and

answer the overall research question: “How is value created in social marketing

wellness services?” In addressing this overall research enquiry, three sub-research

questions were developed to answer the research gaps. The three sub-research

questions sought to identify the dimensions of value (RQ1) and sources of value

(RQ2) in wellness services, as well as to understand the relationships between these

dimensions and sources of value (RQ3). Addressing these sub-research questions

would aid in the understanding of value co-creation in wellness services using social

marketing.

To answer the three sub-research questions, a two-study multi-method approach was

utilised. Study 1 comprised of a qualitative exploratory study, while Study 2

comprised of a quantitative confirmatory study. The aim of Study 1 was of

exploration and discovery, in which the results were used to develop a theoretical

model of value co-creation in wellness services as well as a set of hypotheses for

testing in Study 2. Subsequently, the aim of Study 2 was to test the model and

hypotheses developed and provide empirical evidence for the constructs and

relationships uncovered in Study 1.

This chapter begins with a discussion of the philosophical underpinnings of this

research (Section 3.2). The next section (Section 3.3) situates this enquiry in the

research context selected, which was government-provided, free breast cancer


screening services. Following this, the overall research program is presented (Section

3.) which includes a discussion of the appropriateness of a multi-method approach.

This is followed by an explanation of the objectives of each of the two studies

undertaken in this thesis.

The detailed research design of Study 1 is presented (Section 3.5), including a

discussion of the qualitative methodological approach used, which informed the

choice of method; individual in-depth interviews. An initial focus group was

conducted to aid in the development of the research instrument, which was an

interview guide (see Appendix A). This was then followed by data collection through

individual in-depth interviews with 25 information-rich respondents. Following this,

coding and thematic analysis of the individual in-depth interview transcripts were

undertaken and facilitated by NVivo 8 software program.

The detailed research design of Study 2 is then presented (Section 3.6), including a

discussion of the quantitative methodological approach used, which informed the

choice of method; large-scale online survey. This section discusses the reliability and

validity of this study, as well as sampling. The survey design and measures are also

presented, followed by an explanation of the quantitative data analysis, which

included Confirmatory Factor Analysis (CFA) and Structural Equation Modelling

(SEM), undertaken using PASW18 and AMOS 18 software programs respectively.

Finally, this chapter concludes with the ethical considerations for the overall research

program, as well for the individual studies undertaken (Section 3.7). The following

chapter (Chapter 4) presents the results of the qualitative inquiry of Study 1. Then,

the theoretical model of value co-creation in wellness services developed based on

the findings of Study 1 is presented and discussed (Chapter 5). In this chapter, the

constructs to be used for empirical testing of the model are identified, as are the

hypotheses for testing in Study 2. Subsequently, the results of the quantitative

inquiry of Study 2 are presented in Chapter 6, followed by a discussion of the

complete findings from both Studies 1 and 2 in the concluding Chapter 7. The

limitations of the research design are also discussed in Chapter 7, where suggestions

for future research to overcome these limitations are posed.


3.2 Philosophical perspectives

Paradigms are sets of propositions, which are used by researchers to explain how the

world is perceived (Sarantakos, 1993). There are four categories of scientific

paradigms; positivism, realism, critical theory, and constructivism (Guba & Lincoln,

1994). In marketing, positivism is the dominant paradigm (Marsden & Littler, 1996).

However, a limitation of the positivist approach is that it does not utilize the

necessary methods to inductively and holistically understand human experience,

which seeks to understand and explain phenomenon (Karami, Rowley, & Analoui,

2006).

In order to overcome the limitation of the positivist paradigm, this study is conducted

within a post-positivist paradigm, which accepts that reality is imperfectly captured

and understood (Guba & Lincoln, 2005). Post-positivism relies on mixed methods as

a way of capturing as much of reality as possible and emphasis is placed on the

discovery and verification of theory (Denzin & Lincoln, 2000). Internal and external

validity are relied upon as evaluation criteria, and qualitative procedures are used to

lend themselves to structured and sometimes statistical analysis (Denzin & Lincoln,

2000).

Consistent with this post-positivist paradigm is the ontology of critical realism (Guba

& Lincoln, 2005). The epistemology of this research is modified dualist or

objectivist, whereby the research findings are likely to be true (Guba & Lincoln,

2005) and never fully understood but only approximated. This epistemology suggests

that appropriate methodologies include modified experimentation or manipulation,

critical multiplism, falsification of hypotheses and some qualitative methods (Guba

& Lincoln, 2005).


3.3 Research context: breast cancer screening services

Theoretically, the context of this research lies within wellness services that use social

marketing. As described in Chapter 2 (Section 2.2) it was explained that it would be

appropriate to investigate consumers‟ wellness behaviour through their use of

wellness services provided by the government as such services are available and

accessible to all members of society. The previous chapter (in Section 2.4) also

describes the appropriateness of situating the investigation in cancer prevention

services and identifies BreastScreen Australia as the only cancer screening program

in Australia that offers a free, government-provided service. Subsequently, the

service context selected for this research investigation is breast cancer screening

services provided by BreastScreen Australia.

Screening services by BreastScreen Australia commenced in 1991 and BreastScreen

Australia operates in over 500 locations nationwide, which includes fixed,

relocatable, as well as mobile screening units (BreastScreen Australia, 2010). The

aim of the screening program is to achieve 70% participation rate among women in

the target age group of 50-69 years but the current participation rate is 56.9%

(BreastScreen Australia, 2010). BreastScreen Australia operates through its state

components for each of the states and territories in Australia. This includes

BreastScreen Queensland, BreastScreen New South Wales, BreastScreen Victoria,

BreastScreen ACT, BreastScreen Tasmania, BreastScreen South Australia,

BreastScreen Western Australia, and BreastScreen Northern Territory. All state

components operate in accordance to national standard guidelines, thus the service

process at each of the states and territories across Australia are consistent. Although

BreastScreen Australia provides free breast cancer screening services to women in

the target age group, these services are also available at other private medical

facilities (such as private hospitals) at a cost.

The challenge and organisational desire to reach targets indicate a need to investigate

the value perceived by women who use the BreastScreen Australia services, and to

identify their motivations for continued use. The use of social marketing allows

BreastScreen Australia to achieve three outcomes. First, it has the potential to


increase participation rates among women in the target age group through the uptake

of screening behaviour among non-users of the service. This refers to women who

have never used breast cancer screening services before despite being in the target

age group. Second, it also has the potential to increase participation rates among

women in the target age group through the uptake of the behaviour again among

lapsed users of the service. This refers to women who have used breast screening

services in the past but have not maintained their use in the long-term and have

stopped using these services. Finally, it has the potential to maintain participation

rates among women who are current users of the service through the maintenance

of their wellness behaviour in the long-term.

This thesis focuses exclusively on current users of breast cancer screening services,

and investigates issues pertaining to long-term use of these services. The focus on

issues of continued use of these services in the long-term is consistent with social

marketing aims of maintaining desired behaviour in the long-term.

As individual in-depth interviews were conducted face-to-face for Study 1,

BreastScreen Queensland (BSQ) was selected as the research site for this stage of the

research. On 26 September 2007, BSQ launched a social marketing campaign, which

aimed to achieve a 30% increase in participation of women aged 50 to 69 years by

addressing the barriers to regular screening and by dispelling myths about breast

cancer (BSQ, 2009d). In Queensland, the participation rate for the target age group in

the period 2006-2007 was 56.4% (BSQ, 2009b), which is below the state and

national target participation rate. Within Queensland, the screening service is

available to the target audience through a number of distribution channels including

11 fixed site screening and assessment services, 16 satellite services (screening only),

5 relocatable services and 4 mobile services, all of which span more than 200

locations in Queensland (BSQ, 2009a). BSQ operates according to the national

standard guidelines (BSQ, 2009a) and uses a fixed operating process shown in Figure

3.1.


Figure 3. 1 Service operating process of BSQ and corresponding stages of consumption

The first stage of this process is the personal invitation stage where women in the

target age group are contacted by Queensland Health using the state Electoral Roll

(BSQ, 2009c). BSQ has permission to use the Electoral Roll on the condition that all

information remains confidential and not used for other purposes in order to protect

client confidentiality. The personalised invitation letter contains information about

how to make an appointment for a free breast screen at the nearest BSQ service. This

stage occurs during the pre-consumption stage of the consumption experience and is

initiated by the service organisation.

The second stage of the process is arranging an appointment with BSQ. Women are

able to organize an appointment over the phone by calling 13 20 50, which will

connect them to the nearest BSQ service for the cost of a local call (BSQ, 2009c).

During the booking process, the caller will be asked by an administration officer for

their essential details such as their name, current residential or mailing address, date

of birth, time and place of previous breast screens (if any) and the presence or

absence of a breast implant (BSQ, 2009c). Provisions are made for those who have

breast prostheses, disabilities or those who require an interpreter. The caller will be

asked by the administration officer for when they would like an appointment and will

proceed to book the caller in. Then, a letter of confirmation for the appointment will

be posted approximately a week prior to the appointment, including a “Consent for

Personal invitation letter

Making the appointment

Arriving at the service

Having a breast screen

After the breast screen

Follow-up (if any)

Pre-consumption

stage

Consumption stage

Post-consumption

stage


Screening” information sheet and a “Consent and Personal Questionnaire Form.”

The information sheet explains the BSQ program and screening process, which

recipients are encouraged to read prior to completing the consent and personal

questionnaire form. This stage also occurs during the pre-consumption stage of the

consumption experience and the process of calling to organise an appointment is

initiated by the consumer.

Arriving at the service is the third stage of the process. Customers are required to

bring any images or results of their most recent breast screens if they were done at a

place other than a BSQ service (BSQ, 2009c). Upon arrival, customers proceed to the

reception desk and are greeted by a female staff member who will check the

customers, have them sign the consent and personal questionnaire forms and then

show then to the screening waiting area. The fourth stage of the process is the actual

breast screen. This is taken by a radiographer who will explain the procedure to the

customer (BSQ, 2009c). The radiographer will then develop and check the images

taken to ensure that the quality is good enough such that as much breast tissue can be

seen. In some instances, the radiographer may need to take another image. The entire

visit takes under 30 minutes. These two stages comprise the consumption stage of the

consumption experience. These stages require both the service organisation and the

consumer to work together (i.e. co-produce) to complete the process.

At the fifth stage, after the breast screen, the results will be posted to the customer

within 10 working days (BSQ, 2009c). If there are no abnormalities, the customer

will be sent another letter for a routine breast screen in two years‟ time. However,

approximately seven out of every 100 women will be asked to return because their

screens showed changes that require further investigation (BSQ, 2009c). These

changes are not necessarily an indication of breast cancer and a nurse counsellor or a

medical officer will telephone customers to explain the reason for their return and

will ask for the customer‟s consent before any tests are carried out. The tests will be

explained to the customer and are provided free of charge by BSQ. These tests could

be carried out by any health care professional including radiologists, nurses and

radiographers and customers are able to consult with these professionals. This

encompasses the post-consumption stage of the consumption experience and is

initiated by the service organisation.


Despite the use of BSQ clients in Study 1, the use of online survey methodology in

Study 2 allowed for the expansion of the scope of the research. As such, women in

other states and territories in Australia were also included in Study 2 as the online

nature of the data collection allowed for nation-wide participation of all eligible

respondents.

3.4 Overall research program

In order to identify the dimensions and sources of value in breast cancer screening

services and understand how they relate, a two-study multi-method research program

was developed. This overall research program sought to answer the three sub-

research questions developed to fill the research gaps inherent in the literature. Study

1 was a qualitative exploratory study that qualitatively addressed the three sub-

research questions, while Study 2 was a quantitative confirmatory study that

quantitatively addressed the three sub-research questions. The objectives and

research methodology of the two studies are discussed further in this section, as are

the analytical techniques used. A summary of the overall research design is

presented in Table 3.1.


Table 3. 1 Overview of research program

Research Questions

Gaps Addressed

Study that addresses

RQs

Objectives of Research

Research Method

Analysis

RQ1: What are the dimensions of value experienced by users of wellness services?

GAP 1: Lack of

empirical evidence for dimensions of value in social marketing wellness services context

Study 1

To identify the dimensions of value experienced by individuals when using wellness services To identify the sources of value experienced by individuals when using wellness services To identify the constructs necessary for value co-creation in wellness services

Qualitative

1. Use of 1 focus group discussion (n=5) for the development and refinement of an individual-depth interview guide 2. Semi-structured individual-depth interviews (n=25)

Thematic analysis using NVivo 8

RQ2: What are the sources of value that exist in wellness services?

GAP 2: Lack of

empirical evidence for sources of value in social marketing wellness services

Study 1

RQ3: What is the relationship between the sources and dimensions of value in wellness services?

GAP 3: Limited

empirical evidence demonstrating the relationship between value dimensions and sources in a social marketing wellness service context

Study 1

and Study 2

To understand the relationships between the individual dimensions and sources of value in wellness services

Quantitative

Survey 1. Initial validation sample (n=397) 2. Final sample (n=400)

Reliability analysis, exploratory factor analysis (EFA) using PASW18 Confirmatory factor analysis (CFA) using PASW 18 Structural equation modelling (SEM) using AMOS 18


3.4.1 Multi-method approach

A multi-method approach was used in this research program and refers to the use of

multiple methods in conducting research, typically using quantitative and qualitative

methods (Creswell, 2003). The advantages of using a multi-method approach include

the ability to use a more comprehensive approach to the research inquiry, the ability

to triangulate results, allowing for a broader set of research questions to be asked,

and enabling discovery (Gil-Garcia & Pardo, 2006). Due the advantages it provides,

the use of a multi-method approach is recommended by a number of scholars in

investigating complex social phenomena (Brewer & Hunter, 1989; Creswell, 2003;

Newman & Benz, 1998).

However, despite these benefits, there are limitations to multi-method approaches

such as the cost of multi-method studies and the perceived incompatibility between

methods (Gil-Garcia & Pardo, 2006). Multi-method studies require considerable

resources for successful execution and completion and in some research studies, the

combination of qualitative and quantitative methods present challenges from the

perceived differences between them (Reichardt & Cook, 1979). However, these

limitations did not pose significant threat to the research inquiry of this thesis and the

combination of both qualitative and quantitative methods were considered

compatible and complementary in this research, which is consistent with the

perspective of other scholars (e.g. Brannen, 2005).

3.4.2 Objectives of qualitative Study 1

The research undertaken in this thesis is based on the experiences of users of

wellness services using social marketing. Specifically, this research seeks to

understand consumers‟ experiential consumption of breast cancer screening services.

Study 1 was a qualitative exploratory study with the purpose of investigating

women‟s experiences with using breast cancer screening services by using an

experiential value approach in the investigation. The first objective of Study 1 was to

qualitatively identify the dimensions of value experienced by users of breast cancer

screening services, which answers the first sub-research question: “What are the

dimensions of value experienced by individuals in a wellness service?” This


addresses the first research gap: There is a lack of empirical evidence for dimensions

of value in a social marketing wellness service context.

The second objective of Study 1 was to qualitatively identify the sources of value

that influence the experiences of users of breast cancer screening services. This

answers the second sub-research question: “What are the sources of value in a social

marketing wellness service context?” This addresses the second research gap: There

is a lack of empirical evidence for sources of value in social marketing wellness

services.

In identifying the dimensions and sources of value in a social marketing wellness

service context, Study 1 also sought to fulfil a third objective, which was to

qualitatively understand how the dimensions and sources of value relate in a wellness

service context. This answers the third sub-research question: “What is the

relationship between the sources and dimensions of value in wellness services?”

This addresses the third research gap: There is limited empirical evidence

demonstrating the relationship between value dimensions and sources in a social

marketing wellness service context.

In achieving these objectives, the results of Study 1 were used to inform the

development of Study 2 in two ways. Firstly, the qualitative findings identified the

relevant constructs necessary for value co-creation in social marketing wellness

services. These constructs were used as the basis for selection of the relevant

measures for quantitative testing in Study 2. Secondly, the qualitative findings

provided an understanding of the relationships between the dimensions and sources

of value, allowing for the development of hypotheses for quantitative empirical

testing in Study 2. In identifying these relevant constructs and their relationships, the

results of Study 1 allowed for the development of a theoretical model that describes

the value co-creation process in a wellness paradigm. This model formed the basis

for hypotheses testing using Structural Equation Modelling (SEM) in Study 2.


3.4.3 Objectives of Quantitative Study 2

Study 2 was a confirmatory study with the purpose of quantitatively addressing the

three sub-research questions of this thesis. The purpose of Study 2 was to empirically

validate the results of Study 1 by testing the theoretical model and hypotheses that

were generated from the results of the Study 1. This second study sought to

quantitatively identify the dimensions and sources of value present in the value

creation process in a wellness service, and describe the relationships between the

dimensions and sources of value in this context.

Study 2 focussed on examining the relationships between the sources of influences

and the end value types experienced by Australian women who were current users of

breast cancer screening services. A quantitative methodology was used in this

confirmatory study, which informed the choice of method: online survey

questionnaire. Following the data collection, exploratory factor analysis (EFA)

followed by confirmatory factor analysis (CFA) was conducted using PASW 18 and

AMOS 18 statistics software respectively. Following this, structural equation

modelling (SEM) was undertaken, facilitated by AMOS 18.

3.5 Research design of Qualitative Study 1

Social marketing remains strongly influenced by positivist methods and objective

evaluation frameworks. In line with other contemporary areas of marketing and

consumer research however, some social marketers (e.g. Hastings, 2007; Kotler et

al., 2002) are moving toward “softer” research approaches that yield consumer

insights that are more closely aligned with the everyday reality of marketing (Tapp &

Hughes, 2008). The inquiry in Study 1 is guided by interpretive consumer research

(ICR) and draws upon qualitative methods to explore and explicate consumers‟

experiences with breast cancer screening services. An exploratory research approach

is appropriate because there is currently little research that has examined consumers‟

perceptions of experiential value, particularly in a social marketing wellness service

context. This information is necessary, as health practitioners, government and social

marketing decision-makers need to be better informed about experience-based value


which is contextually bounded and subjectively experienced during the process of

consumption (Holbrook, 2006; Mathwick et al., 2001). This research is an attempt to

understand the world from the subject‟s point of view, to unfold the meaning of

people‟s experiences, and to uncover the lived world (Kavale, 1996). Applying this

understanding in this study involved talking to women about their consumption

experiences before and after they had used a breast cancer screening service in an

individual in-depth interview setting.

3.5.1 Justification for individual in-depth interviews

Individual in-depth interviews were suitable for this study as qualitative interviews

allowed for the investigation of respondents‟ „perceptions, meanings, definitions of

situations and constructions of reality‟ (Punch, 2005; Strauss & Corbin, 1998).

Furthermore, the purpose of the individual in-depth interviews is to yield explanatory

data (Hesse-Biber & Leavy, 2006). Given that the aim of this research is to

understand the experiences and subjective views of participants, interviewing a

discrete sample of experienced consumers was considered a suitable approach that

provided three major benefits.

Firstly, interviewing enabled the acquisition of multiple perspectives on consumers‟

experiences of the population screening services. King (1994, p.33) argues that

interviews are “ideally suited to examining topics in which different levels of

meaning need to be explored”, such as understanding women‟s experiences of

screening services. Secondly, interviewing a small sample of women was useful

because interviewing is a research tool which occurs in a social context. For

example, 15 women were interviewed at BSQ services during the data collection

period. This was valuable because as Berg (2004, p.75) suggests, the researcher was

able to conduct the interviews as a “conversation with a purpose”, and participants

were more likely to be familiar with the research context and more comfortable, and

thus be more willing to share their experiences with the researcher.

The third reason why interviewing a small, but experienced sample of women was

appropriate was again related to the purpose of the research, which is not


quantification. In contrast, its purpose is to gain a holistic and detailed understanding

of lived experiences by women accessing population screening. This makes the

interview appropriate as Denscombe (1999, p.111) recommends interviewing in

situations where the researcher is seeking in-depth information which can be gained

from a smaller number of informants than a survey would require. The interviews

conducted were semi-structured and lasted between 20 minutes and 50 minutes.

During the interview, a guide was followed however, the list of questions was not

followed with rigidity and it was revised based on the ideas that emerged from a

breadth of women interviewed.

3.5.2 Sample and unit of analysis

Purposeful sampling was used in this research, which involved the selection of

information-rich individuals to interview (Coyle, 1997) and this allows for the use of

a sample which is meaningful and relevant to the research questions (Mason, 2005).

The use of a purposeful sampling technique is not uncommon in marketing research

(e.g. Chiu, Hsieh & Li, 2005; Long & McMellon, 2004) and much of sampling is

purposive and defined prior to the commencement of data collection (Coyle, 1997).

This non-probability sampling method is useful for naturalistic enquiry (Lincoln &

Guba, 1985) and appropriate for the exploratory nature of Study 1. The difficulties of

recruitment due to the sensitive nature of the topic are overcome with the use of this

sampling technique. Furthermore, Study 1 does not seek to achieve sample precision,

rather its aim is to discover patterns and generate hypotheses for testing in Study 2

(Singleton Jr. & Straits, 2005). The respondents were also selected based on their

willingness to give up their time to participate in the research.

The sampling unit for this research are women aged 50 to 69 years who have never

been diagnosed with breast cancer and have used BSQ screening services at least

once. Women in this age group represent the primary target audience for BSQ. It was

essential that the women who participated in this research have no history of breast

cancer as this fulfils both theoretical and managerial criteria. Theoretically, an

objective of this research is to understand consumers‟ social marketing behaviour

that is undertaken proactively and in the context of health, for the maintenance of


good health rather than in response to ill health. Managerially, an objective of BSQ

as a government social marketing wellness service organisation is to ensure the

regular and continued use of their breast screening services amongst “well women”

who represent their primary target audience. Thus, it was imperative that the women

who participated in this research represented “well women” and did not have any

personal history of breast cancer. A description of the recruitment of these

respondents is provided in Section 4.2 Sample of Study 1.

3.5.3 Interview procedure

All interviews were conducted using an interview guide (see Appendix B) which was

developed based on the focus group pre-test. All questions used in the interviews

followed a “zero-order level of communications” style, which is the simplification of

the questions to minimize potential communications problems (Berg, 2009, p.116).

Each interview commenced with general small talk to “warm” the interview and ease

the respondent into the discussion. Questions like: “How are you?” were used to set

the subject at ease. An opening question was then used to begin the discussion. This

allowed for the establishment of rapport between the interviewer and respondent

(Fotana & Frey, 2008). A typical opening question used was: “To begin, I would like

to hear about your thoughts, feelings and opinions about your experiences with

having a breast screen. To start, can you tell me about your experiences?”

Throw-away questions were also used in the early stages of the interview schedule.

Throw-away questions were useful in this study for collecting demographic

information about respondents (Berg, 2009) and an example of a throw-away

question that was used in this study was: “So how long have you been having breast

screens?” This helped to establish the experience level of the respondent with breast

screening and was often followed by probing questions like: “So how old were you

when you started breast screening?” This helped to draw a more complete story

from the respondent (Berg, 2009) about their experience with breast screening and

establish their current age without directly asking them. Some respondents would

offer this information on their own, so this type of question was only asked if they

had not provided this information on their own accord. Subsequent questions in the


interviews were the essential questions, which have the purpose of eliciting specific

desired information about their experiences with breast screening.

These questions were ordered in a sequence that mirrored the BSQ screening process

in Figure 3.1. The discussion typically began with questions and discussion revolving

around the pre-consumption stage of the process without directly asking the

respondent about the reminder letter. An example of a question that would be used

at this stage of the interview is: “When do you start thinking about your next breast

screening appointment?” or: “What usually gets you to start thinking about your

next breast screening appointment?” Probing questions were used to allow the

respondent to elaborate on points they had discussed like: “Why do you find the

reminder letter useful?” A structured series of probes triggered by specific responses

to essential questions were incorporated for the benefit of eliciting more information

(Berg, 2009).

Once the discussion about the respondent‟s experiences at the pre-consumption stage

appeared to diminish, the interviewer would then initiate a discussion about the

experiences revolving around the consumption stage by using statements such as:

“Let‟s now talk about once you are at the service itself on the day of your

appointment.” Probing questions such as: “How did you feel?” and “What do you

think about this whole experience?” were used.

After the discussion about the respondent‟s experiences at the consumption stage, the

discussion then moved on to the respondent‟s experiences revolving around the post-

consumption stage. The interviewer would then introduce this phase of the

discussion with questions like: “Now that your screen is over, what happens next?”

or “After your screen is complete and you are allowed to leave, what happens?”

This strategy helped to ensure that the interview discussion encompassed the entirety

of the respondent‟s experience with breast screening that extended beyond the

service interaction.

Following the discussion about the consumption experience, the interviewer would

then ask the respondent for their general opinions of the process as a whole. An

example of a question would be: “What are the things that make you decide if you


were happy or not happy about your experience?” The purpose of this discussion

was to gain a sense of the respondent‟s attitudes towards the act of breast screening.

This was then followed by a discussion of the respondent‟s opinions about service

providers of breast screening services. Questions asked included: “I would now like

to quickly ask you about your opinions of BreastScreen Queensland. What do you

think of BSQ as a service?” and “Have you ever been to a service other than BSQ?”

At the end of the interview, all respondents were asked the same final question:

“Lastly, what is the most important thing that you hope to get out of having a breast

screen?” to determine their primary motivation for continuing to have breast screens.

The respondents were also given the opportunity to provide any final comments or

thoughts about breast screening. After the discussion is complete, the interviewer

would express appreciation by making statements like: “You were a wealth of

information, I really appreciate that” and “Thank you for taking the time to speak to

me.” All respondents were then presented with a small scented candle as a thank-you

gift as a token of appreciation for their time and thoughts.

3.5.4 Analysis of qualitative data

The analysis of the qualitative data in Study 1 commenced with manual transcription

of the audio recordings of the interviews. The data was transcribed verbatim and

each transcript was assigned with a code to de-identify the transcripts but ensure that

all quotes were attributed to the correct respondent. Thematic analysis was conducted

on the data, which involves the encoding of qualitative information by identifying,

analysing, and reporting patterns of responses (i.e. themes) (Braun & Clarke, 2006).

This analytical technique was suitable for this study as the purpose of Study 1 was to

explore and describe the phenomenon (Ryan & Bernard, 1998).

Despite the study being informed by the theoretical frameworks, the initial analysis

of the qualitative data was conducted inductively as the use of thematic analysis

allows for categories to emerge from the data, rather than using predefined categories

(Ezzy, 2002). This was suitable for the purpose of this study, which was for the

discovery of the dimensions and sources of value that exist in wellness services.


However, since the objective of Study 1 was to inform the development of Study 2,

the inquiry returned to a deductive approach, guided by theory and resulting in the

identification of a set of constructs and proposed theoretical model for quantitative

testing in Study 2.

Thematic analysis was undertaken using NVivo 8 software to identify themes in the

interviews. The use of NVivo software for the analysis of qualitative data was

necessary given the multiple phases of analysis and coding that was conducted. The

use of software such as NVivo is useful in maintaining the effectiveness of the

analysis despite the complexities attributed to the multiple cycles of coding. This

allowed for a greater level of detail to be achieved in the analysis of the data, as

opposed to manual analysis without the aid of software.

The analysis of the qualitative data was undertaken in two phases consisting of open

coding (first phase), followed by axial coding (second phase). The first procedural

step undertaken was the undertaking of open coding as recommended by Strauss and

Corbin (1998). Open coding is a form of unrestricted coding of the data, which

allows for close examination of the data to determine the concepts and categories that

fit (Berg, 2009). Open coding was used in the First Cycle of coding and was

conducted using an inductive process, which typifies qualitative research and begins

with observations of specific instances, then seeking to establish generalisations

about the phenomenon being investigated (Hyde, 2002). The codes that resulted from

this First Cycle of coding included words, short phrases, or complete sentences that

represent an attribute (Saldaña, 2009).

The next phase of analysis involved the undertaking of axial coding, which consists

of intensive coding around categories (Strauss and Corbin, 1990). Coding frames

were used to assist in the organisation of the data and to identify the findings more

clearly (David & Sutton, 2004). This phase of axial coding was conducted using a

deductive process, which is typically a theory-testing process that commences with

an established theory or generalisation, and then seeks to determine if the theory

applies to specific instances (Hyde, 2002). Although deductive processes are not

formally typical of qualitative enquiry, this was an important step in the analysis of

the data as deductive processes are useful in ensuring “conviction” of any qualitative


findings (Hyde, 2002). Furthermore, this was appropriate given that the purpose of

Study 1 was to inform the development of Study 2, which is a quantitative, theory-

testing study.

Axial coding was undertaken in a further four cycles of coding that revolved around

answering the three sub-research questions. The Second and Third Cycles of coding

sought to address RQ1 by determining the dimensions of value that exist in wellness

services. This inquiry was guided by existing research on value dimensions

conceptualised in commercial marketing from an economic value perspective

(Second Cycle) as well as from an experiential value perspective (Third Cycle). The

outcomes of these stages of analyses include the identification of experiential value

in wellness services, which will be discussed in further detail in Chapter 4.

The Fourth Cycle of coding sought to address RQ2 by identifying the sources of

value that exist in wellness services. This inquiry was guided by existing research on

the sources of value conceptualised in the literature. Similarly, an outcome of this

stage of analysis included a comprehensive identification and categorisation of

sources of value, which will be discussed in further detail in Chapter 4.

Finally, the Fifth Cycle of coding sought to address RQ3 by investigating the

relationships between the dimensions of value identified in the Second and Third

Cycles of coding, and the sources of value identified in the Fourth Cycle of coding.

As an outcome of this stage of analysis, an identification of consumer goals in

wellness service experiences was developed which explained the value co-creation

process in wellness services consumption. These findings will also be discussed in

further detail in Chapter 4. The procedure undertaken in the qualitative analysis of

the data is summarised and described in Table 3.2.


Table 3. 2 Summary of research procedure undertaken in Study 1

Phase 1

Coding cycle

Procedure Purpose Outcomes

1 Open coding

Unrestricted coding of data, allowing for themes to emerge

Identification of various in vivo codes

Phase 2

Coding cycle

Procedure RQ

addressed

Literature informing

each phase Purpose

Outcomes

(discussed further in Chapter 4)

2 Axial coding

RQ1 Holbrook (1994; 2006)

Identification of dimensions of value (commercial, economic value) i.e. functional, emotional, social, altruistic value

Synthesis of social marketing experiential value in wellness services, i.e. active & reactive functional value, active & reactive emotional value, active social value, active altruistic value

3 Axial coding

RQ1 Holbrook (1994), Mathwick et al. (2001)

Identification of activity aspects of value (commercial, experiential value) i.e. active, reactive value

4 Axial coding

RQ2 Smith and Colgate (2007), Dabholkar (1990)

Identification of sources of value conceptualised in existing literature Identification of consumer participation sources of value

Development of a further classification of sources of value in wellness services value creation, extending beyond existing classification identified in existing literature

5 Axial coding

RQ3 Vargo and Lusch (2004), Prahalad and Ramaswamy (2004)

Identification of how value dimensions and sources relate

Identification of consumer goals & value creation through the achievement of consumer goals

The analysis of the qualitative data revealed evidence for functional, emotional,

social, and altruistic dimensions of value present in the breast cancer screening

service experience. In addition, evidence was found for organisational, consumer,

and third party sources of value. These findings formed the basis for the selection of

constructs to be used in Study 2, which included functional value, emotional value,

administrative quality, technical quality, interpersonal quality, motivational direction,

co-production, and stress tolerance. A complete and detailed discussion of the

findings for the qualitative analysis as well as the coding frames used is presented in

Chapter 4, while a complete and detailed discussion of the constructs selected for use

in Study 2 are presented in Chapter 5.


3.6 Research design of Quantitative Study 2

Quantitative methods allow for the representativeness and generalisability of findings

due to the great amount of data it generates (Sarantakos, 1993). The use of structured

techniques in terms of the data collection allows for quantification and the

development of hypotheses and measurements (Sarantakos, 1993). Quantitative

measures are appropriate for Study 2 as the aim of this study is to generalise the

relationship between the dimensions of value and sources of value identified in the

qualitative exploratory phase of Study 1. The primary quantitative data collection

method used in this study is online survey questionnaire, involving a self-report

approach.

3.6.1 Reliability and validity

Data collected in this study was tested for reliability and validity of its constructs

before proper analysis. Reliability refers to the extent to which a scale is able to

produce consistent results, should repeated measurements be made (Babbie, 2007;

Malhotra, Hall, Shaw, & Oppenheim, 2006). Reliability is assessed by examining the

correlation between items and assessing the Cronbach‟s alpha for the score, whereby

the minimum acceptable level for Cronbach‟s alpha is .60 (Nunnally & Bernstein,

1994). An item-to-total correlation of less than .30 should usually be removed as it is

deemed to be less reliable (Nunnally & Bernstein, 1994). When these items are

removed, an increase in the Cronbach‟s alpha is achieved.

Validity refers to the extent to which observed scale scores of a scale reflect the true

differences among objects on the characteristics being measured (Malhotra et al.,

2006). There are three types of validity; content validity, criterion validity, and

construct validity (Carmines & Zeller, 1979). Content validity is also known as face

validity (Malhotra et al., 2006) and is the extent to which a set of items has the ability

to reflect a content domain (DeVellis, 1991). Criterion validity is the reflection of

how well a scale performs as it is expected in relation to other variables selected as

meaningful criteria (Malhotra et al., 2006). Construct validity addresses how well the

items measure the concept it is designed to measure (Cook & Campbell, 1979).


Confirmatory factor analysis helps to address the issue of content and construct

validity by removing items with a factor loading of less than .03 and items that cross-

load across multiple dimensions.

Non-response bias and self-selection

A common problem associated with quantitative studies that can limit the reliability

and validity of the results is non-response bias. Non-response occurs when

respondents refuse to participate in the survey or choose to ignore the questionnaire

(Malhotra et al., 2006). Non-response error causes the net sample to be different in

size or composition from the original sample (Malhotra et al., 2006). Incentives have

the potential to introduce bias as this gives rise to the selectivity of respondents

(Zikmund, 2003b). However, surveys based on appeal without the offer of any

incentives are weak stimulators of response rates (Linsky, 1975). By comparing early

and late respondents on key demographics, this allows for the testing of non-response

bias (Armstrong & Overton, 1977).

Self-selection bias is a second limitation of this study (Hair, Bush, & Ortinau, 2003).

Self-selection bias occurs when survey respondents are given the option to

participate. This biases the results as individuals who are interested in the subject of

the study are more inclined to respond than those who are less interested in the same

subject (Zikmund & Babin, 2007). Hence, women who feel more strongly about

wellness, or about breast cancer will be more likely to participate than women who

do not (Zikmund & Babin, 2007). The generalizability of the results to the population

is reduced as a result of the refusal to participate by other members of the population

(Hair et al., 2003).

In order to increase response rates, several strategies were employed. First, the use of

a web-link allows ease of access to the survey, a cover letter using the university

logo on the front page of the survey was also presented. This provided background

information to the study and importance of the study, as well as articulating the

benefits of completing the survey for the respondent (Zikmund & Babin, 2007).

Common method bias


Common method bias, also known as common method variance, is one of the main

sources of measurement error. This treated the validity of the conclusions made

about the relationships between the measures (Podsakoff, MacKenzie, Lee, &

Podsakoff, 2003). Common method bias can occur randomly or systematically

(Bagozzi & Yi, 1988; Nunnally, 1978; Spector, 1987) and result in potentially

misleading conclusions (Campbell & Fiske, 1959). Harman‟s single-factor test was

used to test for common method bias. This involves loading all the variables into an

exploratory factor analysis and examining the unrotated factor solution to determine

the number of factors that are necessary to account for the variance in the variables

(Andersson & Bateman, 1997; Aulakh & Genturk, 2000; Greene & Oegan, 1973;

Schriesheim, 1979).

Justification for online survey questionnaire

A survey-based method was used in the collection of data for Study 2 as it is an

appropriate method to study naturally occurring phenomenon and inter-relationships

among many variables (Czaja & Blair, 2005; Zikmund, 2003a). Advantages of

survey-based methods include low cost of administration, flexibility in research

topics, and efficiency in collecting large amount of data for statistical analysis

(Singleton Jr. & Straits, 2005). On the other hand, disadvantages of surveys include

weak explanatory power compared to conducting experiments, susceptibility for

social desirability in responses, and neglect of contextual information that should be

interpreted over time (Singleton Jr. & Straits, 2005). Despite these disadvantages, the

use of a qualitative exploratory study in Study 1 helps in overcoming these

shortcomings.

An online survey questionnaire was used to collect data for this study as this method

of survey administration provided several benefits; more speedy responses, lower

costs, increased quality of answers, and easy access to unique populations. The ease

of access to unique populations is of particular importance to this research, in which

respondents must fulfil very specific sample criteria. The limitations of online

surveys include coverage and sampling errors, and difficulty in verifying

respondents‟ identity. Despite this, online research was most suitable for this study

given the unique sample required, and also the potential sensitivity of this topic is


overcome as online surveys are relatively anonymous in nature and thus, encourage

more truthful responses (Miller, 2006).

3.6.2 Sampling

For internet-based research, there are two sampling methods; random and non-

random sampling (Fricker, 2008; Sue & Ritter, 2007). In random sampling, each

member of the target population has a known probability of being sampled (Sue &

Ritter, 2007). However, in non-random sampling the probability of selection is

unknown and involves some form of subjectivity or judgement (Sue & Ritter, 2007).

Inadequate coverage and self-selection bias also render non-random samples less

generalizable. Inadequate coverage is a situation whereby members of the population

are insufficiently represented in the online sample (Sue & Ritter, 2007; Wright,

2005) such as when internet penetration is less than the population of interest to the

research enquiry (Schillewaert & Meulemeester, 2005).

A consumer list of women who fulfilled the age criteria was acquired from First

Direct Solutions, a division of Australia Post. The consumer database provided

comprised of respondents who had completed the Australian Lifestyle Survey (First

Direct Solutions, 2010) and who had provided their consent to be contacted again to

participate in future research. An email invitation was sent to members of the

database requesting for their participation in the survey (see Appendix C).

Unit of analysis

During the sampling process, the elements of the population must be selected

(Zikmund, 2003a, p.295). The unit of analysis is a single element or group of

elements selected for a sample. The unit of analysis for this research were individual

women.

Target population

In order to identify the correct sources from which to collect the data, it was

important to carefully define the target population (Zikmund, 2003a, p.292). The

target population for this research was Australian women aged 50 to 69 years old

(inclusive) who have used breast screening services at least once. For the purpose of


this research enquiry, the women must have been “well-women” at the time of their

participation with the research, meaning that they must not have been diagnosed with

breast cancer before. Women who were current users of government or free breast

cancer screening services were targeted, as opposed to women who were current

users of private or paid breast cancer screening services.

Sampling method

Non-probability sampling technique was used in this research as a consumer list of

members who opted-in via a lifestyle survey was procured. Despite the limitations,

this allows for the identification of respondents that fulfil the age criteria (women

aged 50 to 69 years). In order to minimise sampling bias, precautions were taken to

ensure the consumer list consistent of a large number of members and efforts were

taken to that the members were representative of the Australian population (Evans &

Mathur, 2005). The consumer list consisted of members from all the states and

territories in Australia. However, the number of women in the list from each state

was proportionate to the percentage population of Australian women in the target age

bracket for each of the states and territories.

Sample size

The appropriate sample size was determined by the data analysis technique selected

for this study. Section 3.6.4 identifies structural equation modelling (SEM) as the

data analysis technique used and also discusses appropriate sample sizes in further

detail for this method of analysis. Further discussion of the final sample size is

provided in Chapter 6, Section 6.2 under the discussion of response rate for Study 2.

3.6.3 Survey design and measures

An online survey was designed for the purpose of collecting data for Study 2. The

first page of the survey identified the name of the study, the names and contact

details of the investigators, and a description of the study as well as details of

participation as prescribed by the ethical requirements of Queensland University of

Technology, Australia (see Appendix D). Subsequently, the next section of the

online survey comprised of the screening questions used to ensure all respondents


met the eligibility criteria. Following this, the subsequent section of the survey asked

respondents questions relating to the goals they sought to achieve from using breast

cancer screening services, which related to their experience of the dimensions of

value in wellness services that were found in Study 1. The following section then

asked respondents questions relating to aspects of their consumption experience,

reflecting the sources of value. Then, the respondents were asked questions related to

their satisfaction with their experiences, followed by their behavioural intentions.

As identified previously (in Section 3.5.4), constructs used in Study 2 included

functional value, emotional value, administrative quality, technical quality,

interpersonal quality, motivational direction, co-production, and stress tolerance.

Two outcome variables were also used in Study 2, which were satisfaction and

behavioural intentions. Multiple item scales for each latent construct were drawn

from existing literature, which were well-established scales that have been

empirically-validated in previous studies. A multi-dimensional scale was used in the

survey with 8 items for the dimensions of value (4 items for functional value, 4 items

for emotional value), and 26 items for the sources of value (9 items for organisational

sources, 17 items for consumer participation sources). For satisfaction, 5 items were

used, while 8 items were used for behavioural intentions. It was important to orient

any questions towards a specific act (Azjen & Fishbein, 1980), hence some of the

items were modified to reflect the context of consumers‟ use of breast cancer

screening services as they were contextually inappropriate in their existing form.

Lead-in questions were also used to explain the purpose for each of the different sets

of questions. Each of the constructs were measured using a 5-point Likert-scale with

1=strongly disagree and 5 = strongly agree.

Screening questions

In Section 1 of the survey, screening questions were used to ensure that the eligibility

criteria were met by respondents. Although the use of a consumer panel allowed for

the specification of age, it did not allow for the specification of the other selection

criteria; experience with breast cancer screening services, and a “well-woman”

background. As such, two screening questions were required. Respondents were first

asked if they had used breast cancer screening services at least once, as previous


experience with this wellness service was necessary in order to complete the survey

(see Appendix E).

Q1: Have you ever used breast screening services, or have had a

mammogram before?

Yes, I have had a breast screen/mammogram before.

No, I have never had a breast screen/mammogram.

Women who have never had breast screens before were directed to a page thanking

them for their interest, but informing them that they were ineligible to complete the

survey (see Appendix F). The page displayed the following message:

“Thank you for your interest in participating in this survey. However, this

research seeks to understand your experiences with breast screening services.

As you have indicated that you have never had a breast screen before, we

regret to inform you that you are unable to progress any further in this survey.

We thank you again for your time and appreciate your interest in this

research.”

The respondents who had indicated that they had used breast cancer screening

services before were then prompted to complete a second screening question (see

Appendix G). This second screening question asked respondents if they had ever

been diagnosed with breast cancer.

Q2: Have you ever been diagnosed with breast cancer?

Yes, I have been diagnosed with breast cancer previously.

No, I have never been diagnosed with breast cancer.

Respondents who had been diagnosed with breast cancer before were screened out of

the survey as the focus of the investigation was on healthy “well-women.” The

respondents who indicated that they had been diagnosed with breast cancer

previously were then directed to a page thanking them for their interest, but


informing them that they were ineligible to complete the survey (see Appendix H).

The page displayed the following message:

“Thank you for your interest in participating in this survey. However, this

research seeks to understand the experiences of women who have never been

diagnosed with breast cancer. As you have indicated that you have been

diagnosed with breast cancer previously, we regret to inform you that you are

unable to progress any further in this survey. We thank you again for your

time and appreciate your interest in this research.”

Section 1: Breast cancer screening service providers

Next, in Section 1, the respondents were asked to identify the breast cancer screening

provider that they usually use (see Appendix I). As the study sought to sample

women who had used government-provided breast cancer screening services, the

names of the BreastScreen Australia service providers for the different states and

territories in Australia were provided as options. The respondents were also provided

with an option if they could not remember the name of the service provider. In

addition, in order to accommodate respondents who were users of private services

(i.e. not provided by the government), an “other” option was provided that allowed

them to indicate the name of the service provider if it was not a BreastScreen

Australia service. Furthermore, in order to ascertain if these service providers were

free or paid services, a question was included asking the respondents to indicate if

they pay for their breast screens or if they were free.

Section 2: Dimensions of value in breast cancer screening

The next section of the survey sought to measure the functional and emotional

dimensions of experiential value experienced by users of wellness services (see

Appendix J). Items from Sweeney and Soutar (2001) and Nelson and Byus (2002),

were used. Items from Sweeney and Soutar (2001) best reflect the functional reasons

as to why consumers use a physical product and are similar to the purpose of this

research, which is to understand the functional and emotional reasons as to why

consumers use a wellness service. Items from Nelson and Byus (2002) best reflected


emotional value as they included terms that best described affective states that could

be achieved through the experience of emotional value.

However, the items developed by Sweeney and Soutar (2001) were very product-

oriented, thus providing some limitations even after the items had been modified to

become breast screening-oriented. However, as the purpose was to capture the utility

and functionality of breast screens (the act), these items were deemed suitable. A

lead-in statement was used at the start of this section.

Lead-in statement:

In this section, we would like to know about the reasons why you have chosen

to have breast screens/mammograms. Please indicate whether you strongly

disagree (1) or strongly agree (5) with each statement.

Items for functional value

In order to measure functional value in wellness services, items from Sweeney and

Soutar (2001) were used as these original items were based on functionality of a

product and consumers‟ use of a physical product for functional reasons. The items

were modified to reflect the context of breast screening services as the original items

reflected the acquisition of physical products (see Table 3.3). Two items were

removed as they were particularly goods-oriented creating an inability to modify

them to suit a services context. In the context of wellness services, a breast screen is

the core “product” provided to women who use the service. The items were

aggregated to form a single summated score with 1 = low functional value and 5 =

high functional value.


Table 3. 3 Items for functional value

Original items Modified items

This product has consistent quality Breast screens have consistent quality

This product is well made Breast screens are well delivered

This product has an acceptable standard of quality

Breast screens have an acceptable standard of quality

This product has poor workmanship (*) Item removed

This product would not last a long time (*) Item removed

This product would perform consistently Breast screens perform consistently

Items for emotional value

In order to measure emotional value in wellness services, items from Nelson and

Byus (2002) were used and modified to reflect the context of breast screening (see

Table 3.4). Similarly, the “product” that is referred to in the original items refers to a

breast screen in the context of this study. The items were aggregated to form a single

summated score with 1 = low emotional value and 5 = high emotional value.

Table 3. 4 Items for emotional value


Protected Having breast screens makes me feel protected

Comfortable Having breast screens makes me feel comfortable

Safe Having breast screens makes me feel safe

Happy Having breast screens makes me feel happy

Calm Having breast screens makes me feel calm

Relieved Having breast screens makes me feel relieved

Proud Having breast screens makes me feel proud

Section 3: Organisational sources of value; administrative quality, technical

quality, and interpersonal quality

The subsequent section of the survey sought to measure the organisational sources

that influence the dimensions of experiential value experienced by users of wellness

services (see Appendix K). Items from McDougall and Levesque (1994), Brady and

Cronin (2001), and Rust and Oliver (1994) were used. A lead-in statement was used

at the start of this section.


Lead-in statement:

Think about the breast screening service that you usually use. In this section,

we would like to know about your experiences with this service. Please

indicate whether you strongly disagree (1) or strongly agree (5) with each

statement.

Administrative quality items for interaction with systems and processes

In order to measure consumers‟ interaction with the systems and processes of

wellness services, administrative quality items from McDougall and Levesque

(1994) are used. Administrative quality is a primary dimension of service quality and

comprises of administrative service elements to facilitate the production of a core

service for consumers and adds value to the consumer‟s service consumption

experience (Grönroos, 1990; McDougall and Levesque, 1994). These include aspects

such as timeliness and operation, which were found in the qualitative data and

supported by the literature (e.g. Dagger, Sweeney and Johnson, 2007; Thomas,

Glynne-Jones and Chaiti, 1997; Meterko, Nelson and Rubin, 1990).

These items from McDougall and Levesque (1994) have been modified and used in

the context of health treatment services by Dagger et al. (2007). As such, these scale

items appeared to be most appropriate for use in the context of this study, which was

health prevention or wellness services. These items were then modified again to

reflect the context of wellness (breast screening) services as the original items

reflected health treatment (cancer treatment) services (see Table 3.5). The items were

aggregated to form a single summated score with 1 = low administrative quality and

5 = high administrative quality.

Table 3. 5 Items for administrative quality


The administration system at the clinic is excellent

The administration system at the place I usually go to is excellent

The administration at the clinic is of a high standard

The administration at the place I usually go to is of a high standard

I have confidence in the clinic's administration system

I have confidence in the administration system at the place I usually go to


Technical and interpersonal quality items for interaction with staff

In order to measure consumers‟ interaction with staff of wellness services, two sets

of items from Brady and Cronin (2001) and Rust and Oliver (1994) are used. The

first set of items relates to technical quality of the staff, which refers to the technical

competence of the service provider (Ware, Davies-Avery and Stewart, 1978), thus

influencing the outcomes achieved (Grönroos, 1984; McDougall and Levesque,

1994). This includes aspects such as the competence, knowledge, qualifications, or

skill of the staff (Aharony & Strasser, 1993), or the high standard of service provided

by staff (Zifko-Baliga & Krampf, 1997). These aspects were found in the qualitative

phase of this research and as such, these scales were most appropriate for use in this

study.

These items from Brady and Cronin (2001) and Rust and Oliver (1994) have been

modified and used in the context of health treatment services by Dagger et al. (2007).

These items were then modified again to reflect the context of wellness (breast

screening) services as the original items reflected health treatment (cancer treatment)

services (see Table 3.6). The items were aggregated to form a single summated score

with 1 = low technical quality and 5 = high technical quality.

Table 3. 6 Items for technical quality


The quality of the care I receive at the clinic is excellent

The quality of the service I receive at the place I usually go to is excellent

The care provided by the clinic is of a high standard

The service provided by the place I usually go to is of a high standard

I am impressed by the care provided at the clinic

I am impressed by the service provided at the place I usually go to

The second set of items relates to interpersonal quality of the staff, which refers to

the interpersonal relationship and exchange between the consumer and service

provider (Brady and Cronin, 2001; Grönroos, 1984). This includes aspects such as

manner and communication of the staff, which were found in the qualitative data.

Manner of the staff describes their attitudes and behaviour during the service setting

(Bitner, Booms, & Tetreault, 1990; Brady & Cronin, 2001), while communication

describes the interactive element of service process (Wiggers, Donovan, Redman, &

Sanson-Fisher, 1990; Zifko-Baliga & Krampf, 1997) and includes the transfer of


information (Dagger et al., 2007), which includes instructions and information, as

identified in the results of the qualitative study. As these concepts were also

identified in the qualitative phase of this research, these scales were also appropriate

for use in this study.

Similarly, these items from Brady and Cronin (2001) and Rust and Oliver (1994)

have been modified and used in the context of health treatment services by Dagger et

al. (2007). These items were then modified again to reflect the context of wellness

(breast screening) services as the original items reflected health treatment (cancer

treatment) services (see Table 3.7). The items were aggregated to form a single

summated score with 1 = low interpersonal quality and 5 = high interpersonal

quality.

Table 3. 7 Items for interpersonal quality


The interaction I have with the staff at the clinic is of a high standard

The interaction I have with the staff at the place I usually go to is of a high standard

The interaction I have with the staff at the clinic is excellent

The interaction I have with the staff at the place I usually go to is excellent

I feel good about the interaction I have with the staff at the clinic

I feel good about the interaction I have with the staff at the place I usually go to

Section 4: Consumer participation sources of value; motivational direction, and

co-production

The fourth section of the survey sought to measure the consumer participation

sources that influence the dimensions of experiential value experienced by users of

wellness services, specifically motivational direction and co-production (see

Appendix L). Items from Kelley, Skinner and Donnelley (1992) and Auh et al.

(2007) were used. A lead-in statement was used at the start of this section.


Lead-in statement:

Think about the part that you have played in your use of breast screening

services (e.g. organising your appointment, following instructions from staff,

etc.). In this section, we would like to know about your role in using the

breast screening service you usually go to. Please indicate whether you

strongly disagree (1) or strongly agree (5) with each statement.

Motivational direction items for cognitive inputs

In order to measure consumers‟ cognitive inputs in their use of wellness services,

motivational direction items from Kelley et al. (1992) are used. Motivational

direction refers to the activities to which an individual directs and maintains effort

(Katerberg and Blau, 1983). Motivation drives consumers to fulfil their goals

(Maslow, 1943). In the context of breast screening, the qualitative data provided

evidence to show the cognitive effort input by consumers included aspects such as

understanding their role in the consumption process, leading them to make the effort

to organise their own appointments and remembering to turn up to their

appointments on time.

Items from Kelley et al.‟s (1992) motivational direction were used. These scale items

were selected as they most accurately depicted the cognitive effort required from

consumers in a service exchange. These items were modified to reflect the context of

breast screening services as the original items were developed in the context of

financial services (see Table 3.8). Examples were provided to increase the clarity of

the statements for respondents. The items were aggregated to form a single

summated score with 1 = low motivational direction and 5 = high motivational

direction.


Table 3. 8 Items for motivational direction


It is important for me as a customer to know how to use this service

It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one

I try to think out beforehand how I am going to get the service I want

I try to think out beforehand how I am going to get the service I want, e.g. deciding what time of day would suit best for my appointment before calling to organise the appointment

It is important for me as a customer to understand my role associated with the service

It is important for me as a customer to understand my role associated with the service, e.g. filling in all my paperwork correctly

Having a plan is important to me as a bank customer

Having a plan is important to me as a breast screen customer, e.g. planning for waiting

Co-production items for behavioural inputs

In order to measure consumers‟ behavioural inputs in their use of wellness services,

co-production items from Auh et al. (2007) are used. Co-production refers to the

participation of the consumer in the service process to produce the core service

offering with the service provider (Bendapudi & Leone, 2003). In the context of

breast screening, the physical or behavioural contributions of the consumer are

essential to produce the core service offering, which is a breast screen. The

qualitative data offers evidence of physical or behavioural inputs from users of breast

screening services such as positioning their bodies in a more optimal way to produce

a better screen.

Items from Auh et al. (2007) were used as they most accurately depicted the co-

production inputs provided by consumers in a service exchange. The items were

modified to reflect the context of breast screening services. The original items were

developed in the context of physician-patient relationships, which was not accurate

for the breast screening context (see Table 3.9). Examples were provided to increase

the clarity of the statements for respondents. The items were aggregated to form a

single summated score with 1 = low co-production and 5 = high co-production.


Table 3. 9 Items for co-production


I try to work co-operatively with my doctor I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised

I do things to make my doctor's job easier I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily

I prepare my queries before going to an appointment with my doctor

I prepare my queries before going to a breast screen appointment

I openly discuss my needs with my doctor to help him/her deliver the best possible treatment

I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury

Section 5: Consumer participation sources of value; stress tolerance

The fifth section of the survey also sought to measure the consumer participation

sources that influence the dimensions of experiential value experienced by users of

wellness services, specifically stress tolerance (see Appendix M). Items from Bar-On

(1997) were used. A lead-in statement was used at the start of this section.

Lead-in statement:

Many women describe breast screening as something that can be

uncomfortable, unpleasant, or even stressful. In this section, we would like to

know about how you manage the stressful aspects of breast screening that

many women face. Please indicate whether you strongly disagree (1) or

strongly agree (5) with each statement.

Stress tolerance items for affective inputs

In order to measure consumers‟ affective inputs in their use of wellness services,

stress tolerance items from Bar-On (1997) are used. Stress tolerance is one of the

composite factors of the Emotional Quotient Inventory (EQ-i) which assesses

emotional intelligence (Bar-On, 1997). Stress tolerance is most relevant of the five

composite factors as it involves the management of emotions for the attainment of a

specific goal (Mayer & Salovey, 1997). In the context of breast screening services,

the qualitative data found evidence for the management of them women‟s emotions

in their use of breast screening services in order to achieve the goal, peace of mind.


Items from Bar-On (1997) were used and examples were provided to increase the

clarity of the statements for respondents (see Table 3.10). The items were aggregated

to form a single summated score with 1 = low stress tolerance and 5 = high stress

tolerance.

Table 3. 10 Items for stress tolerance


I know how to deal with upsetting problems I know how to deal with upsetting problem, e.g. if my results indicated that there were any problems

I believe that I can stay on top of tough situations

I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen

I can handle stress without getting too nervous I can handle stress without getting too nervous e.g. waiting for the results of my breast screen

I don't hold up well under stress* I don't hold up well under stress, e.g. wondering what my results might say to the point I get stressed*

I feel that it's hard for me to control my anxiety* I feel that it's hard for me to control my anxiety, e.g. when I wait for the result of my breast screen*

I know how to keep calm in difficult situations I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful

It's hard for me to face unpleasant things*

It's hard for me to face unpleasant things such as breast screens*

I believe in my ability to handle most upsetting problems

Item removed

I get anxious* I get anxious when it comes to having breast screens*

Section 6: Satisfaction with breast cancer screening and behavioural intentions

Section 6 of the survey sought to measure respondents‟ satisfaction with the act of

breast screening and their intentions to have a breast screen again in the future (see

Appendix N). The respondents were asked about satisfaction with screening, rather

than satisfaction with the service provider as the social marketing objective in this

context is for individuals to perform the wellness behaviour in the long-term. This

behaviour is facilitated through the consumer‟s use of a service (i.e. a breast cancer

screening service). As such, the focus of the individual‟s satisfaction was on the

behaviour, as opposed to the service provider consumers used to facilitate that

behaviour. Similarly, the objective of measuring behavioural intentions revolved

around assessing consumers‟ intentions to perform this wellness behaviour again in

the future. As such, items that were worded in a service-oriented fashion were


removed as these items did not allow for modification towards a behaviour-oriented

fashion.

In order to measure satisfaction and behavioural intentions, items from Greenfield

and Attkisson (1989), Hubbert (1995), Oliver (1997), Headley and Miller (1993),

Taylor and Baker (1994) and Zeithaml, Berry and Parasuraman (1996) were used. To

measure satisfaction, items from Greenfield and Attkisson (1989), and Hubbert

(1995) and Oliver (1997) were used, which were modified by Dagger et al. (2007) in

measuring consumers‟ satisfaction with a health treatment service. The items used by

Dagger et al. (2007) were modified again in this study to reflect the context of a

health prevention service, rather than a health treatment service. A lead-in

statement was used.

Lead-in statement:

Thinking again about the service where you usually go to have a breast

screen/mammogram, please answer the following questions. Please indicate

whether you strongly disagree (1) or strongly agree (5) with each statement.

Table 3. 11 Items for satisfaction


My feelings towards the clinic are very positive

My feelings towards breast screening are very positive

I feel good about coming to this clinic for my treatment

I feel good about having breast screens

Overall, I am satisfied with the clinic and the service it provides

Overall, I am satisfied with breast screening and the benefits it provides

I feel satisfied that the results of my treatment are the best that can be achieved

I feel satisfied that the results of my breast screen are the best that can be achieved

The extent to which my treatment has produced the best possible outcome is satisfying

The extent to which my breast screen has produced the best possible outcome is satisfying

In order to measure behavioural intentions, items from Headley and Miller (1993),

Taylor and Baker (1994), and Zeithaml, Berry and Parasuraman (1996) were used.

These items were also used and modified by Dagger et al. (2007) in measuring

consumers‟ behavioural intentions to continue using a health treatment service.


These items used by Dagger et al. (2007) were subsequently modified to reflect the

context of a health prevention service, rather than a health treatment service. The

behavioural intentions this research seeks to measure is consumers‟ intentions with

breast screening, and not with the specific service provider that they use.

Table 3. 12 Items for behavioural intentions


If I had to start treatment again I would want to come to this clinic

Item removed

I would highly recommend the clinic to other patients

I would highly recommend breast screening to other women

I have said positive things about the clinic to my family and friends

I have said positive things about breast screening to my family and friends

I intend to continue having treatment, or any follow-up care I need, at this clinic

I intend to continue having breast screens

I have no desire to change clinics I have no desire to stop breast screening

I intend to follow the medical advice given to me at the clinic

I intend to follow any medical advice given to me about breast screening

I am glad I have my treatment at this clinic rather than somewhere else

Item removed

In addition, a question about the respondents‟ intentions towards having breast

screens in the future was also asked.

Q60: How likely are you to have a breast screen again in the future?

Not very likely Not likely Neutral Likely Very likely

1 2 3 4 5

Section 7: Demographic questions

In the last section of the survey, respondents were then asked to answer a series of

questions about themselves and further general questions about their experiences

with breast screening (see Appendix O). The phrasing of these questions was

informed by the qualitative insight provided by Study 1. The purpose of this section

was to gather demographic questions about the respondents and their breast

screening behaviour and the following lead-in statement was used:


Lead-in statement:

We would now like to know a little bit about you. In this section, please

answer the following questions about yourself and your preferences with

breast screening.

Q61: How old are you now?

Q62: How old were you when you first started having breast

screens/mammograms?

Q63: Why did you decide to start having breast screens? Please select all

that apply.

I received a letter recommending that I start having breast screens

I saw some advertising and decided to start having breast screens

My doctor recommended me to have breast screens

I experienced menopause

Other. Please elaborate

__________________________________________________

Q64: How long ago was your last breast screen/mammogram appointment

in terms of months?

_______________________________ months

Q65: Do you know other people (e.g. colleagues, friends, or family

members) who have or had breast cancer? Please select one option.

Yes, a female relative/colleague/friend of mine has had breast

cancer.

No, I do not know anyone who has or had breast cancer

Q66: Is there any history of health problems in your family (including both

male and female family members)? Please select one option.

Yes. My [specific relative] has/had [specific health problem]

No, there is no history of any health problems in my family

Q67: Have you ever been to other places for a breast screen/mammogram

other than the one you usually go to? Please select one option.

No, I only go to the same place for a breast screen/mammogram.

Yes, I have been to other places for a breast screen/mammogram.

I have been to

____________________________________________________


Q68: How often do you typically go for breast screens? Please select one

option.

Less than every 2 years. Please specify

____________________________

Every 2 years

More than every 2 years. Please specify

___________________________

Q69. What is your current employment status? Please select one option.

Employed

Self-employed

Not currently in employment

Retired

Q70: Which state do you live in? Please select one option.

Queensland

New South Wales

Victoria

Tasmania

South Australia

Western Australia

Northern Territory

ACT

At the end of the survey, the respondents were thanked for their time taken to

complete the survey and that their response was much appreciated (see Appendix P).

A request was also made for the respondents to forward the survey link on to other

women they know in the appropriate age category and a survey link was provided for

them to copy if they so desired. The following message was displayed upon

completion of the survey:

“Thank you for taking the time to complete this survey. Your response is

much appreciated and will contribute greatly to our understanding of

women‟s experiences and preferences with using breast screening services. If

you know of other women who are between 50 and 69 years old and go for

breast screening as well, we would love if you could forward the survey link

to them so we may be able to gather as much data as possible for this study!

Thank you.”


3.6.4 Analysis of quantitative data

Preparing the data

When preparing the data for analysis, the data needs to be coded and edited. Once

this is done, data analysis using the appropriate analysis technique can be used.

Coding is the process of translating the responses into numbers as this will facilitate

data entry, the use of the data, and to minimise any errors (Sarantakos, 1993). Each

response category or item is allocated a numerical code and all the codes are

mutually exclusive.

Missing data analysis

Missing data occurs for three different reasons; missing-completely-at-random

(MCAR), missing at random (MAR), and biased (Arbuckle, 1996). MCAR is a

random event where the missing data has nothing to do with the data (Arbuckle,

1996). Listwise and pairwise deletion methods treat missing data as being MCAR,

but if the data is MAR or biased, then the estimate may be biased (Arbuckle, 1996).

There is risk in treating data as MCAR if there is no evidence for true randomness in

the data. Thus, Little‟s MCAR test was performed to assess the level of missing data.

Structural equation modelling

In order to test the model presented in Chapter 5, structural equation modelling

(SEM) was undertaken using AMOS 18.0. SEM is a multivariate analysis technique

that can be used to examine relationships between latent factors represented by

multiple variables (Hair Jr., Black, Babin, Anderson, & Tatham, 2006) and has

advantages over regression modelling. SEM has more flexible assumptions, such as

with multicollinearity; use of confirmatory factor analysis (CFA) to reduce

measurement error by having multiple indicators per latent variable; better model

visualisation through its graphical interface; and the desirability of testing overall

models rather than individual coefficients (Bagozzi & Yi, 1998; Marcoulides &

Schumacker, 2001). Additionally, SEM has the ability to test models with multiple

dependents, model mediating variables rather than be restricted to an additive model

such as in regression, and the ability to model error terms (Byrne, 2001; Kaplan,

2009, Raykov & Marcoulides, 2000).


SEM is a quantitative analytical technique that specifies, estimates, and tests

theoretical relationships between observed endogenous variable and latent,

unobserved exogenous variables (Byrne, 2001). It covers a multitude of statistical

techniques such as multiple regression, factor analysis and uni- and multi-variate

analysis of variance. The method begins with model specification that links variables

understood to affect other variables and directionalities of those effects (Kaplan,

2009). Specification is a type of visual representation to the hypotheses and a

measurement scheme involving theory, information, and a developed model (Raykov

& Marcoulides, 2000). SEM produces regression wrights, variances, covariances and

correlations in its iterative procedures converged on a set of parameter estimates in

its estimation process (Raykov &Marcoulides, 2000).

It is the most appropriate statistical technique to test the hypothesised structure of the

model presented in the previous chapter, as SEM is a method for testing a specified

theory about relations between constructs (Raykov & Marcoulides, 2000). A

hypothesised model can be statistically tested with the entire system of variables in

order to determine the extent to which it is consistent with the data. SEM is typically

viewed as a confirmatory procedure, rather than exploratory and thus is suited to the

confirmatory nature of Study 2. One of three approaches is used: strictly

confirmatory; alternative methods approach, and model development approach

(Byrne, 2001; Raykov & Marcoulides, 2000).

Two-step approach

A two-step approach recommended by Anderson and Gerbing (1988) to conduct

SEM was used. First, the measurement model was tested. The measurement model

for the latent variables is estimates and assumes these to be freely correlated and

individual factor scores for these latent variables. Next, the structural model is tested

by directly observing the latent variables (Anderson & Gerbing, 1988).

Fit indices

Fit statistics are used to determine if the proposed model fits the data, or if model re-

specification is required to improve fit. There are three types of model fit statistics;

absolute fit indices, incremental or comparative fit indices, and indices of model


parsimony. There are different rules of thumb for the required level of score/value

for good fit for each of these types (Byrne, 2001).

Assumptions of SEM

There are several assumptions of SEM such as sample sizes, missing data, and

multicollinearity.

Sample sizes for SEM should be relatively large as there is a reliance on tests that

are sensitive to sample size and to the magnitude of differences in covariance

matrices. Sample sizes of approximately 200-400 are typical for models with 10-15

indicators in SEM (Kaplan, 2009; Raykov & Marcoulides, 2000).

Data level in SEM is assumed that data is interval.

Multivariate normality. In general, data may be assumed as normal if skew and

kurtosis is within the range of +/- 1.0 (Schumacker & Lomax, 2004). In the model,

each dependent latent variable should be normally distributed for each value of each

other latent variable (Schumacker & Lomax, 2004).

Linearity. SEM assumes linear relationships between indicator and latent variables.

Multiple indicators should be used to measure each latent variable in the model

(three or more indicators) (McDonald & Ho, 2007). If there are fewer indicators

(two), they should be correlated so that the correlation can be used as a third

indicator, preventing under-identification of the model.

Missing data. A complete or near-complete dataset is required for low measurement

error, otherwise the appropriate data imputation methods for missing cases must be

used (Hair Jr. et al., 2006).

Multicollinearity. Complete multicollinearity prevents an SEM solution and is

assumed to be absent. However, correlation among the independents may be

modelled explicitly in SEM. Complete multicollinearity will result in singular


covariance matrices, which are ones on which one cannot perform certain

calculations (e.g. matrix inversion) because division by zero will occur.

Estimation: Maximum likelihood is recommended.

Structure: Before the factor analysis is performed, a strong conceptual foundation

must support the assumption that a structure exists. The data matrix should have

sufficient correlations to justify the use of factor analysis. If there are no substantial

number of correlations above .30, factor analysis is likely to be inappropriate (Hair

Jr. et al., 2006). For both the overall test and each individual variable, the measure of

sampling adequacy (MSA) values must exceed .50. Those variables below this are

omitted from the factor analysis. This is done starting with the smallest, and only one

variable is omitted at a time (Hair Jr. et al., 2006).

3.7 Ethical considerations

This research is being conducted to create new knowledge and a better understanding

of consumer behaviour. Thus, the research will be undertaken in accordance to the

National Statement on Ethical Conduct in Research Involving Humans

(http://www.nhmrc.gov.au/publications/humans/contents.htm) developed by the

National Health and Medical Research Council (NHMRC) and the Queensland

University of Technology ethics guidelines. The research involves interviewing and

surveying humans aged 18-65 years and as such, a Level 1 (Low Risk) Ethical

Clearance application was prepared for ethical review.

Ethical clearance for Study 1 was approved by the Queensland University of

Technology Faculty Ethics Research Advisor (Approval number: 0800000648) and

confirmed as meeting the requirements of the National Statement on Ethical Conduct

in Human Research. In addition, ethical clearance was also sought from Queensland

Health due to their participation in the first research study. An ethics application was

submitted to the Monitoring, Evaluation and Research Subcommittee (MERS)

Queensland Health, which was approved.


Ethical clearance for Study 2 was approved by the Queensland University of

Technology Faculty Ethics Research Advisor (Approval number: 1000000871) and

also confirmed as meeting the requirements of the National Statement on Ethical

Conduct in Human Research. As Queensland Health did not participate directly in

the second research study, ethical clearance was not sought from MERS Queensland

Health.

In order to make certain that this research was free of coercion, discrimination and

exploitation (Aguinis & Henle, 2001), participation in both studies of this research

was completely voluntary and participants were able to withdraw at any time without

penalty. In Study 1, informed consent was obtained from all participants. Each

participant was provided with a participant information sheet as well as a consent

form (Appendix Q) prior to the commencement of each interview. Confidentiality

was maintained by removing identifying features from the interview, such as the

participant‟s name. All participants were briefed and made aware of the intentions

and uses of the information gathered from the study (Aguinis & Henle, 2001).

In Study 2, the completion of the online survey by each participant indicated

informed consent, which was communicated to potential respondents through the

introduction page of the online survey. The introduction page also emphasised that

confidentiality would be maintained as identifying features of each completed survey

was removed. The online survey also provided background information to the study

in order to make potential respondents aware of the intentions and uses of the

information gathered (Aguinis & Henle, 2001).

3.8 Conclusion

In conclusion, this chapter has provided an outline and description of the research

methodology undertaken in this thesis. First, the chapter discussed the philosophical

underpinnings of this research, followed by a discussion of the overall research

program, citing the multi-method approach undertaken in this research. Next, the

research context of this thesis, which was situated in breast cancer screening

services, was presented. This was followed by an explanation of the purposes of each

of the two research studies. Following this, the research design for Qualitative Study


1 was discussed, which provided justifications for qualitative exploratory research, as

well as the appropriateness of individual in-depth interviewing techniques. The

interviewing procedures undertaken and sampling considerations were also

discussed.

Subsequently, the research design for Quantitative Study 2 was then presented,

which provided justifications for quantitative confirmatory research, as well as the

appropriateness of the use of online survey methodology. The reliability and validity

issues of this research were also discussed, and an explanation of the sampling

strategy for the study was provided. The survey design and measures were presented,

describing in detail the constructs and items used in this second study. Following

this, a description of the analysis technique was provided. Finally, ethical

considerations for this research were discussed.

Following this chapter, Chapter 4 will present the results of the analysis undertaken

in Qualitative Study 1. This will be followed by Chapter 5, which provides a

discussion of the theoretical model developed as a result of the qualitative findings

and the subsequent hypotheses that were generated. Chapter 6 then presents the

results of the analysis undertaken in Quantitative Study 2, which describes the

outcomes of the model-testing.

Chapter 4: Results of Study 1 103

CHAPTER 4 RESULTS OF QUALITATIVE STUDY 1

“Healthy citizens are the greatest asset any country can have”

Winston Churchill

4.1 Introduction

The previous chapter outlined the methodology for this thesis and described the

process undertaken in the analysis of the data collected in both Study 1 and Study 2.

This chapter provides a report of the qualitative findings for Study 1, which was an

exploratory study with the objective of qualitatively answering all three sub-research

questions. This chapter begins by presenting a description of the sample

characteristics (Section 4.2), followed by a report on the dimensions of value

uncovered, addressing RQ1 (Section 4.3). Then, a report on the sources of value

present in wellness services is provided, addressing RQ2 (Section 4.4). Following

this, a discussion of the relationships between the dimensions and sources of value is

presented, addressing RQ3 (Section 4.5).

The following Chapter 5 then presents a model of these relationships between the

dimensions and sources of value in wellness services, identifying the corresponding

hypotheses for empirical validation. This model forms the basis of model testing in

Study 2, which served to empirically test the hypothesised relationships, thus

quantitatively addressing the three sub-research questions.

4.2 Sample of Study 1

In Study 1, the respondents were required to have experience with BSQ screening

services at least once to be able to discuss their experiences with this service

provider. This is based on the assumption that their experiences with the service and

specific service provider can increase external validity of the research (Burnett &

Dunne, 1986). As discussed in the methodology (see Section 3.5.3), purposeful


sampling was conducted in order to obtain a sample of information-rich respondents

to interview.

Participants were recruited through using personal networks and a snowball sampling

technique, as well as from BSQ itself. A total of 25 women were interviewed, of

which the first 10 respondents were recruited through personal networks and

snowball sampling technique, and the subsequent 15 respondents were recruited

through BSQ. A personal email was sent to the personal networks of the investigator,

describing the study and requesting for participants who fulfilled the selection

criteria. The 10 respondents recruited through personal networks and snowball

sampling were asked by a person they knew if they were interested in participating in

the study. Those who were willing to participate consented to their contact details to

be passed to the investigator for the purposes of organising the interview. The 15

respondents recruited through BSQ were clients who had existing appointments for a

breast screen. They were contacted by BSQ staff who gave the women a courtesy

reminder telephone call and it was during this reminder that they were asked if they

were willing to participate in the study. None of their details were passed to the

investigator as BSQ staff were able to organise the interviews at the service

locations.

The small number of participants interviewed was deemed sufficient as a wealth of

detailed data can be achieved from a small number of individuals through the use of

qualitative methods (Patton, 1991). Based on the interview responses generated,

there were little differences in the responses of the women recruited through personal

networks and snowball sampling technique and those recruited through BSQ. The

respondents were selected on the basis of their fulfilment of the selection criteria,

which determined their ability to discuss the phenomenon being investigated.

The individual-depth interviews were conducted from October 2008 to February

2009 and lasted between approximately 20 minutes and 50 minutes. All participants

were provided with a participant information sheet and an interview consent form to

complete (see Appendix Q). Each interview was audio-recorded with the permission

of the respondent and later transcribed verbatim. All respondents were offered the

option of receiving a copy of the transcript for verification. Incentives were not


offered to respondents to participate in order to avoid bias. However, every

participant was presented with a small scented candle as a thank-you gift to show

appreciation for their participation, time, and thoughts.

4.2.1 Sampling criteria

The sampling criteria for Study 1 were women aged 50 and 69 years old (inclusive)

who have used BSQ screening services at least once previously and have never been

diagnosed with breast cancer. In this study, 25 women who reflected the BSQ client

profile were interviewed. This was a sufficient sample size, given the exploratory

purposes of this study. The documented experiences of these women provided

“adequate data” (Morse, 1995) to give insight to their breast screening experiences,

which were then explored to identify appropriate value themes. As such, “theoretical

saturation” on this group of women was reached after the researcher was able to

document similar experiences reported in later interviews, and did not discover new

insights about service interactions and value perceptions during later interviews.

4.2.2 Sample characteristics

All the women interviewed in for Study 1 were current users of BSQ‟s services.

Most of the women had only used screening services provided by BSQ, but 8 of the

women interviewed had experiences with other service providers. These service

providers included government-provided breast screening services in other states

(e.g. BreastScreen New South Wales), private services (e.g. The Wesley Hospital),

and services in other countries for some of the women who had lived overseas.

The women interviewed ranged in experience with breast screening in terms of the

number of years they have been health screening consumers; one woman was a first

time user of breast screening services, seven women had been using the service for

less than 10 years, and 17 were experienced users, i.e. they have been using breast

screening services for 10 years or more.


The average age of the women interviewed was 57 years, with their ages ranging

from 50 to 66 years old (inclusive). The women were predominantly of Anglo-

Australian ethnicity, with 20 of them being Anglo-Australian. Of the remaining

women, four were Eastern European and one was Asian. Table 4.1 provides a

summary of the sample characteristics and demographic information.

Table 4. 1 Summary of sample description

Number of women

Total sample size 25

Ethnicity

Anglo 20

Eastern European 4

Asian 1

Employment status

Employed 15

Retired 6

Not currently in employment 4

Screening Experience

First time 1

< 10 years 7

10 to < 20 years 15

20 years or more 2

Service providers used

Used BSQ services only 18

Used other services in addition to BSQ services

7

In Table 4.2, further descriptive of the interview sample are presented to provide

further insight into the characteristics of the women interviewed and their breast

screening behaviour. In the interview sample, 18 of the women commenced breast

screening when they were younger than 50 years old. Despite the recommendation to

start using breast screening services from age 50, only seven of the women

interviewed started breast screening when they were 50 years old or older. Although

women who are younger than 50 are welcome to use breast screening services, BSQ

actively targets women exclusively in the 50-69 year old age group as their research

identified this demographic group as the group that receives the most benefit from

breast screening (BSQ, 2009a).


Of the 18 women interviewed who started breast screening before the age of 50, only

half of them were considered to be “well-women” meaning that they did not have

any outstanding health issues, breast-related or otherwise. Of these nine “well-

women” four of them were recommended by their General Practitioners (GPs) to

start breast screening, while four of them approach BSQ on their own accord.

The other nine women who were below 50 years old when they started breast

screening reported that they experienced some outstanding health issues that led to

their early commencement of breast screening. Six of these women reported that they

experienced breast-related health issues; most common was the discovery of non-

cancerous breast lumps. The remaining three women experienced other health issues

(menopause, heart operation, and hysterectomy) as were recommended by their GPs

to start breast screening. Table 4.2 provides a summary of the sample descriptive at

the commencement of their breast cancer screening behaviour.

Table 4. 2 Sample descriptive at commencement of breast screening behaviour

Age at commencement Well-women

Atypical women

Total Breast-specific issues

Other health issues

50 years or older (BSQ’s target age group)

6 NIL 1 7

Younger than 50 years old 9 6 3 18

Total 15 10 25

The subsequent sections will describe the results of the qualitative analysis of the

interviews conducted with these 25 women. The results qualitatively addresses the

three sub-research questions proposed in this thesis.


4.3 Dimensions of value

The data was coded and analysed to determine the dimensions of value that exist in

wellness services. This qualitatively addressed RQ1: What are the dimensions of

value experienced by consumers when using wellness services? Overall, it was

determined that customers‟ perceived value in their use of wellness services is

subjective and varies among different individuals. There were two main findings

from this stage of analysis;

First, evidence was found for the functional, emotional, social, and altruistic

dimensions of value. However, the functional and emotional dimensions of value

appeared to be the dimensions of value that were more prominently experienced by

the women interviewed. This was unsurprising, given the personal nature of health

and how the context of this research represents what Kotler and Zaltman (1971)

describe as a personal health social marketing cause.

Second, evidence was also found for both active and reactive value, which

represents the activity aspects of experiential value. However, it was found that

reactive value appeared to be more prevalent amongst the women interviewed than

active value. This was a surprising finding, given the preventative, rather than

treatment purpose of breast cancer screening behaviour. This behaviour is often

thought of as proactive behaviour and thus, assumed to be “active” rather than

“reactive.”

As a consequence of these findings, a new conceptualisation of value was developed

in wellness services using social marketing, giving rise to a new typology of

experiential value in wellness. The following sub-sections will discuss these findings

in further detail.


4.3.1 Dimensions of customer perceived value

In analysing the qualitative data for evidence of dimensions of value in social

marketing that had been conceptualised in commercial marketing, a codebook was

developed and used (see Appendix R), which functioned as a useful frame

constructed to systematically map the information within the text (MacQueen,

McLellan, Kay, & Milstein, 1998). The coded data was examined closely to

determine which of the four dimensions of value were most closely reflected in the

codes. Evidence was found for functional, emotional, social, and altruistic value.

Functional value

Functional value emphasises the performance and functionality aspects of a service

(Russell-Bennett et al., 2009) and can also include the utility provided by the

consumption of a product or service (Tellis & Gaeth, 1990). The performance,

functionality and utility of the breast screening service are characterised by aspects

such as service efficiency, the professionalism of the staff and a satisfying service

experience overall. This is described by one of the respondents, showing the

experience of functional value through the professionalism and efficiency of the

service:

“It was efficient, it was professional, I‟m going to get information that I need.

I‟ve got something checked off... I had a satisfying professional experience

and I had a health care need that I‟ve taken care of...” – Respondent 23;

aged 50, first-time user, employed.

This other respondent describes functional value in terms of the accuracy of the

breast screen as an accurate means of early detection of breast cancer, demonstrating

the utility of the service:

“I‟m, you know, confident that the majority of the time…what they‟re doing is

perfectly fine and accurate…” – Respondent 3; aged 54, 10 years‟

experience, employed.


Emotional value

Emotional value, on the other hand relates to various affective states that include

both positive and negative affect (Sánchez-Fernández & Iniesta-Bonillo, 2006).

Emotional value in this study was characterised by the promotion of positive feelings

or the reduction of negative feelings in the consumers. One woman interviewed

describes the negative emotion that the issue of breast cancer creates in individuals,

and then goes on to say that having regular breast screens helps to alleviate the

negative emotions:

“Well because breast cancer‟s such a terrible thing and it‟s so; seems to be

so prevalent and um, when I was listening to the ladies talking at the...Pink

Ribbon Breakfast? You know, it‟s just... if they can get it early, you know, you

stand a chance. But if you just pretend that it‟s... you know, „ah, I‟ll be

alright, mate‟ so to me it‟s, as I said, part of a set of ongoing tests anyway,

but even if it wasn‟t I would go because once I turn fifty, they send you a

letter to say „right, you know you‟re on our register now, you‟re supposed to

have it every... two years‟ and to me it‟s like an hour out of my day every two

years that reassures me that I‟m okay” – Respondent 6; aged 56, 4 years‟


Another woman describes the positive emotion she experiences when she receives

the results letter informing her that her breast screen showed no sign of breast cancer:

“Basically it‟s a very pleasant letter from them saying „thank you very much,

but everything is fine, we don‟t need to see you in another two years‟ and

yeah, I‟m very happy because I know that… anything can pop out at any time.

So yes, I am very happy” – Respondent 8; aged 53, 20 years‟ experience,

employed.


Social value

Social value is focussed on influencing other people (Russell-Bennett et al., 2009)

and the data provided evidence to show that some of the respondents sought to

influence the behaviour of others. These respondents sought to shape the responses

of others (Gallarza & Saura, 2006; Holbrook, 2006) by using their own behaviour to

encourage others to use breast screening services as well. This woman identifies

herself as an advocate for breast screening and describes how she tries to ensure that

her colleague has breast screens as well:

“I‟m a bit of an advocate for the breast screening and I would be thinking

about it because there‟s one young lady at work whose sister passed away

with breast cancer and I‟m on her back. But she‟s actually got an

appointment next week so that makes me feel good” – Respondent 16; aged

62, 11 years‟ experience, employed.

This other woman believes that despite the importance of having breast screens, it

was an activity that was not often discussed by women. She described how she

would use her social influence over other women to encourage them to have breast

screens:

“I would encourage anyone to go… When you‟re fifty, I think it‟s important

that everyone should go… I just tell them that it‟s important to go and you

never really talk about this” – Respondent 10; aged 58, 10 years‟ experience,

employed.


Altruistic value

Altruistic value describes an individual‟s concern for how their consumption

behaviour affects others (Holbrook, 2006). In a wellness paradigm, some consumers

may be motivated to use preventive health or wellness services so that illnesses may

be identified early and subsequently, can be treated early and thus the individual does

not become a cost to society or a burden on their families. The data provided

evidence of this, as one woman describes that she uses breast screening to ease the

worry for her family:

“You don‟t... like really want to go but you still go, then that‟s a sense that

you know, you‟ve gone out of your way to do the right thing by yourself and

your family because I think that was a good point that you said before about

why you‟re doing it and I think it‟s for your family as well” – Respondent 9;

aged 56, 8 years‟ experience, employed.

This other woman discusses how she believed that the consequence of not having

regular breast screens also affects her family and not just herself. As such, she

believes that it was important to have regular breast screens for her family as well,

demonstrating altruistic value:

“It‟s for my family… I want to be with them longer and I want to live a

healthy life… from people that I know (who have cancer), it just devastates

the family. The whole family is shattered. It‟s not only me and my life, it‟s

everybody around me” – Respondent 12; aged 50, 10 years‟ experience,

employed.

Apart from the altruistic value that some of the women derive from having breast

screens for the benefit of their families, some of the women also consider the benefits

to society such as this woman:

“There are community costs involved in any kind of illness so if I don‟t do the

screening and have my breast cancer diagnosed at a later stage, then there

are costs, higher costs in terms of hospitalisation costs and medical costs” –

Respondent 5; aged 56, 8 years‟ experience, employed.


4.3.2 Activity aspects of experiential value

Upon the completion of the analysis of the data for dimensions of value, it was

determined that further analysis was necessary as the data had been analysed from

the economic perspective of value dimensions conceptualised in commercial

marketing. It was necessary to analyse the data from the experiential perspective of

value, thus the existing data was coded according to the activity aspect of

experiential value conceptualised by Holbrook (1994) and Mathwick et al. (2001). A

second codebook (see Appendix S) was developed in analysing the data for evidence

of experiential value in wellness services across two activity dimensions; active and

reactive. Evidence for both active and reactive value was found in the data, however

it was discovered that reactive value featured more prominently among the women

interviewed in this study.

Reactive value

Reactive value describes consumers‟ comprehension of, or response to, the

consumption of an object or experience and is describe by Mathwick et al. (2001) as

passive value. This implies that consumers are more passive in their consumption

experience and their experiential value perceptions are based on “distanced

appreciation” of aspects of the service (Mathwick et al., 2001, p.41). In contrast,

active value implies a heightened collaboration between the consumer and the

service organisation and is also known as participative value (Mathwick et al. 2001).

This involves consumers participating more actively in their consumption experience

and their experiential value perceptions are based on direct usage of the service as

they have deliberately sought a service exchange (Mathwick et al., 2001).

All 25 respondents cited instances of reactive value, which is characterised by their

“distanced appreciation” for aspects of BSQ‟s service. A typical response by women

that characterises reactive value is behaviour in response to the receipt of a reminder

letter from BSQ informing them that they were due for a breast screen and

encouraging them to organise an appointment. The woman‟s response below reveals

why some women allow, or even need, BSQ to be the active participant in initiating

screening behaviour. This statement reveals the woman‟s satisfaction and value


exchange from being a reactive participant in BSQ‟s “staging of a health

experience.”

“Oh they send me a letter. They always send me a letter to say you know,

you‟re due right about this time, it‟s normally in March. And so I get a letter

from them to say you know, „it‟s time you need to book yourself in‟ so I just

respond to that” – Respondent 6; aged 55, 4 years‟ experience, employed.

This other woman describes how she was not particularly active in organising a date

for her breast screen appointment and just accepted the appointment date and time

provided to her by the staff at BSQ. This also demonstrated her reactive participation

in the consumption process:

“They said, „Oh, well you can come on the 16th

February.‟ I didn‟t query

whether it was the earliest…just whatever they told me” – Respondent 16;


Active value

Many of the women (n=22) also cited instances of active value, characterised by

their heightened collaboration during the consumption experience. Active value is

characterised by the additional effort expanded in order to have the breast screen.

This quote from another woman illustrates this aspect as she describes the effort

made to set aside time for an appointment despite her busy schedule:

“I make time to do it. If it‟s important enough, you make time to do it... I

don‟t think you‟re ever too busy to do anything, it just depends on how

important it is to you and what sort of priority you give it” – Respondent 5;


This other woman describes how she would usually telephone her GP to check that

the results of her breast screen are fine. This is in contrast to many of the other

women interviewed who would assume that their screens were fine if they did not

hear from either BSQ or their doctors. This woman demonstrates the activity that she


contributes towards her consumption experience in achieving emotional value from

knowing that her results are fine:

“I‟d always ring just to make sure, but he‟s efficient enough that he seems to

pretty much get onto it, but… I would ring because I like to know and I like to

hear that confirmation that everything is clear…” – Respondent 16; aged 62,

11 years‟ experience, employed.

In the current sample, the overall incidence of active participation was less than the

incidence of reactive participation. This could be attributed to the length of time in

between service encounters (2 years) which could account for a decline in women‟s

ability to sustain engagement with the screening behaviour. This suggests an

imperative for health service organisations such as BSQ to be conscious of

maintaining their relationships with their target consumers since women do not

appear to be actively thinking about re-screening unless prompted by the service. As

such, the use of social marketing in focussing on aspects of re-screening that support

women‟s active participation is likely to be beneficial.

4.3.3 New conceptualisation of value in wellness services using social marketing

As an outcome of analysing the qualitative data for dimensions of value, as well as

for activity dimensions, a new conceptualisation of value that synthesises these

findings was developed (see Table 4.5)

Table 4. 3 Conceptualisation of value in wellness services using social marketing

Value Dimensions

Functional Emotional Social Altruistic

Activity

Dimensions

Active Yes Yes Yes Yes

Reactive Yes Yes No No

As shown in Table 4.5, the data suggested that functional and emotional value can be

either active or reactive, while social and altruistic value are only active. These

differences could be attributed to the orientation of the dimensions; functional and


emotional dimensions of value are self-oriented, while social and altruistic

dimensions of value are other-oriented (Holbrook, 2006). The details of each type of

value will be discussed in the remainder of this section.

Functional value is derived by consumers both actively and reactively. An example

of when functional value is derived actively is exemplified by this quote from this

woman who identifies a utilitarian outcome that is achieved by having a breast

screen, which also describes heightened collaboration that is evidenced by her

proactive attitude towards getting screened:

“I‟m an early detection girl. That‟s huge for me. So yes, in addition to

breast exams and everything else like that I‟m all about early detection. I

think you know if something happens I need treatment, I need chemo, I need

whatever…the only thing that I know…I‟m of a certain age where I know

women who have gotten breast cancer and the ones who wait, they‟re ones

who just bloody die. And so…that‟s just the God awful truth and those who

were proactive, their survival statistics just so much better. And that‟s sort of

the way I see it I guess” – Respondent 23; aged 50, first-time user, employed.

An example of functional value that is derived reactively is exemplified by this

quote from this woman who identifies the utilitarian outcome in terms of service

efficiency, which is characterised by her “distanced appreciation” of the service

process:

“Um, but the process was fairly smooth, um, fairly quick to get an

appointment, um, during the actual process of having a mammogram, it‟s

just, I guess it‟s like any doctor‟s appointment where there‟s a bit of, um, just

being put out by having to change, disrobe, go through the process and the

process itself can be fairly uncomfortable. But I have to say that the people

who have handled it, I think in every case have been really good and very

friendly and warm enough and um, and then, in that instance there would

have been, they usually give you some kind of feedback on the day, or

certainly that one and the early ones do. Um, so that‟s good so you‟re given


some feedback so the actual anticipation, waiting period was not very long”

– Respondent 2; aged 56, 10 years‟ experience, employed.

Emotional value is also experienced by consumers of wellness services actively and

reactively. An example of emotional value that is experienced actively is described

in this quote by this woman who describes suppressing negative emotions and worry

in order to achieve peace of mind:

“I think that, you can‟t constantly think about these things, you know. You‟d

be driving yourself nuts (laughs), all the things that could happen. Yeah, I

just feel that okay, while I was reassured that there‟s nothing is wrong, let‟s

just get on with my other stuff” – Respondent 2; aged 56, 10 years‟


An example of emotional value that is experienced reactively is described by this

woman who finds the service environment pleasant. This has an impact on

consumers‟ moods and feelings:

“The one in the city that I go to? It‟s just a normal waiting room, it‟s

pleasant enough um, clean, and then they have the x-ray in a separate room.

It‟s good, quite okay. Nothing wrong with that” – Respondent 10; aged 56,


The data provided evidence to suggest that social value is experienced by consumers

of wellness services actively only and there was no evidence of social value being

experienced reactively in this current sample. An example of social value

experienced actively is exemplified by this woman who describes how she

proactively encourages other women to have breast screens:

“Anybody who doesn‟t [go for breast screens], I just don‟t understand. So if I

hear of anybody especially in my age group and a little bit younger if they

haven‟t had one for like 5 years or something I‟m really an advocate for them


going. I just say, „Look just go and make an appointment you know and get it

done‟” – Respondent 16; aged 62, 11 years‟ experience, employed.

Similarly, the data suggests that altruistic value is also experienced actively by

consumers of wellness services and there was no evidence of altruistic value being

experienced reactively. One example of altruistic value that is experienced actively

is this quote by a woman who identifies her family as a big reason why she continues

to have breast screens:

“Well, I don‟t‟ think my family would be very happy if I said „Oh, I‟m not

having that done‟ you know? Like my mother, I mean my mother‟s some

indescribable age because she won‟t tell anyone but I think she‟s in her

eighties. And she absolutely won‟t go. She went for one and I went down with

her because she doesn‟t know where she is half the time! I mean not that

she‟s gaga but, um, but she‟s never been back even though she‟s supposed to

go for two-yearly exams, she won‟t go. Her attitude is, you know, „I don‟t

want to go through that.‟ So I think, for me, it would be selfish of me to say,

no because then... if I got breast cancer then my family, my husband would be

upset, my kids would be upset, my grandson, you know. There‟s lots of family

issues” – Respondent 6; aged 55, 4 years‟ experience, employed.

There are several reasons why the functional and emotional dimensions of value are

experienced both actively and reactively, while the social and altruistic dimensions

of value are experienced only actively. Firstly, Holbrook (2006) describes functional

and emotional value as self-oriented. In the context of health and wellness,

individuals are likely to engage in wellness behaviours because they derive the most

benefits for themselves. This is supported by the notion that individuals often act out

of self-interest (Rothschild, 1999). This is also supported by the data in this study,

which suggests that functional and emotional goals are those that are prioritised by

the women interviewed in this study as this leads to the achievement of functional

and emotional value. More women in this sample placed importance on the

achievement of functional and emotional value than they did on social and altruistic

value.


Secondly, the data revealed that more women were satisfied in being passive

(reactive) participants in their service experiences and would be satisfied with their

experiences as long as their functional and emotional goals were fulfilled, resulting

in the experience of functional and emotional value. One reason why more women

were satisfied with being passive participants could be that it reduces the amount of

effort required for them to engage in the wellness behaviour. This is an important

consideration in social marketing if sustained behaviour over the long-term is

desired.

Finally, Holbrook (2006) describes social and altruistic value as other-oriented. In

the context of wellness, despite the benefit to others that arises from individuals‟

engagement in wellness behaviours, this is not the primary driver for many

individuals to use wellness services. In addition, the data revealed that other-oriented

benefits were not a priority for many of the women interviewed. Few of the women

interview reported social and altruistic value being sought from their experiences,

however these benefits were not sought alone and were always accompanied by the

seeking of functional and emotional value. As such, social and altruistic value can be

thought of as non-priority benefits. The fulfilment of these dimensions of value is

likely to have little impact on women‟s likelihood to continue having breast screens,

as long as the functional and emotional dimensions of value are achieved. For the

few women who identified social and altruistic value as being important to them,

they would need to be more active participants in order to achieve these dimensions

of value.

These insights can be used to explain how value is created in breast screening

services. The next section describes the findings of the analysis of the data for

sources of value, which addresses the second sub-research question of this thesis.


4.4 Sources of value

The data was also coded and analysed to determine the sources of value that exist in

wellness services. This qualitatively addressed RQ2: What are the sources of value that

exist in wellness services? A codebook was developed (see Appendix T) with four

literature-derived sources of value in mind that formed the initial basis for the analysis of

the data. There were two main findings from this stage of analysis:

First, evidence was found for four sources of value conceptualised in the literature;

information, interaction, environment, and consumer participation.

Second, the data revealed three broader categories of sources, which incorporate

aspects of the initial four literature-derived sources. These three categories are

organisational sources of value, consumer participation sources of value, and third

party sources of value. These three categories each include a set of specific sources

of value in wellness:

o Organisational sources of value include interaction, information, and

environment;

o Consumer participation sources of value include cognitive inputs, behavioural

inputs, and affective inputs;

o Third party sources of value include information, and interaction.

As a consequence of these findings, a new categorisation for the sources of value in

wellness services using social marketing was developed. Figure 4.1 illustrates this

new categorisation for the sources of value in wellness services using social

marketing.


Figure 4. 1 Categorisation of sources of value in wellness services using social marketing

A third finding of this stage of analysis was the occurrence of various sources of value at

each of the three identified consumption stages; pre-consumption, consumption, and

post-consumption (Russell-Bennett et al., 2009). It was found that:

Organisational sources of value appear to occur most prominently at the

consumption stage;

Consumer participation sources of value appear to occur consistently across all

consumption stages;

Third party sources of value appear to occur more prominently at the pre-

consumption and post-consumption stages.

The following sub-sections will discuss these findings in further detail.

Organisational

Sources of Value

Consumer

Sources of Value

Third Party

Sources of Value

Information

Environment

Interaction

Cognitive

inputs

Behavioural

inputs

Affective

inputs

Information

Interaction

Sources of Value


4.4.1 Organisational sources of value

The data revealed that organisational sources of value in wellness services appeared

to manifest in information, interaction, and environment sources of value. Examples

of organisational information include formal communication such as the reminder

letter sent to women when they are due for another breast screen, and the results

letter sent to them after their breast screen. On the other hand, interaction sources of

value include interaction with the staff of the organisation, as well as interaction with

the systems and processes used by the organisation. Finally, organisational

environment sources of value refer to the physical environment such as the waiting

areas, or screening rooms. This section describes organisational sources of value in

further detail.

Organisational information sources of value

BSQ sends a reminder letter to its clients in the mail when they are due for another

breast screening appointment. This reminder letter was useful in maintaining

women‟s screening behaviour as the women interviewed identified the reminder

letter as being an important information source that acts as a stimulus to remind them

to continue using the service. Many women relied on this letter to remind them when

they were due to have another breast screen because the long time lapse in between

breast screens causes many women to lose track of time. The reminder letter is an

information source that occurs during the pre-consumption stage of the consumption

process. In one interview, this woman noted:

“I don‟t [contact BSQ]. They contact me. I usually get a letter to say that I‟ve

got one [appointment] coming up... they always do it for me, which is good”


In addition to the reminder letter, the women interviewed also identified the results

letter as an important information source of value in their consumption experiences.

The results letter is sent in the mail from BSQ to women who had recently completed

their breast screen. In the sample of women interviewed, none had received negative

results, which further illustrated that they were “well-women.” The positive results

indicated in the letter provide confirmation to the women of their good health. The


results letter is an information source that occurs after the service encounter, which

influences consumers at the post-consumption service stage.

“I wait for the [results] letter. I wait for the letter to come to say

„everything‟s clear, we‟ll see you in two years‟ that‟s what I wait for” –


Some of the women interviewed also mentioned having seen advertising for BSQ.

Various advertising mediums including television advertising and print advertising

such as posters at bus shelters and pamphlets were identified by the women

interviewed as information sources that were useful in keeping breast screening top

of mind. BSQ advertising serves as “information reminders” and is useful in ensuring

that breast screening behaviour is salient for target audiences due to the long time

lapse between breast screens. This information source occurs outside of the service

encounter, thus influences consumers at the pre-consumption and post-consumption

stages of the consumption process.

“With all the advertising everywhere, I am aware that I have to go [for breast

screening]” – Respondent 8; aged 53, 20 years‟ experience, employed.

Instructions and explanations provided to the women during their service encounters

were also mentioned by some of the women interviewed as having some impact on

their service experience. Specifically, instructions provided by the radiographer to

the consumer during the actual mammogram were identified by many women

interviewed as being an important information source. They liked being provided

with instructions from the radiographer on how to stand or position themselves

because it provided them with a sense of contributing towards achieving a better

mammogram. They also appreciated when the radiographer provided them with

explanations on the process and what was being done because it kept them informed

at every stage of the mammogram. Instructions and explanations are information

sources that occur at the consumption stage of the consumption process.


“Lindsay [the radiographer] asked me to remove my T-shirt and bra and

then gave me some instructions about where to stand and how to place my

arm and so on. Which way to face, where to turn my head so that she could

do the examination for me” – Respondent 25; aged 56, 8 years‟ experience,

employed.

Two women interviewed mentioned the BSQ webpage as being a source of

information for them. This woman talks about visiting the BSQ website to find a

screening clinic that was located closer to her workplace, which would make going

for breast screens more convenient for her. This information source was used by this

woman outside of the consumption stage, thus occurring at the pre-consumption and

post-consumption stages of the consumption process.

“I went onto the web to find out…when I realised…when I made the decision

that I didn‟t want to go into the city because it was too far away from where I

was working. I went onto the web page to have a look to see where there

were clinics more…well closer to where I was working so I got on the web

page” – Respondent 11; aged 54, 6 years‟ experience, employed.

The instructions and explanations provided to women during their service encounters

appeared to be the most important information sources of value. This could be

attributed to the fact that instructions and explanations provided at the time of the

breast screen are most important in producing an effective and efficient service for

the women. In contrast, the other information sources appeared to function as

secondary, or even tertiary information sources of value.

Organisational interaction sources of value

In addition to organisational information sources of value, the data identified

organisational interaction sources of value as having an impact on consumers‟

consumption experiences with breast screening. Interaction sources of value are used

to indicate interactions between consumers and the organisation‟s systems and

processes, as well as interactions between consumers and the organisation‟s

employees (Smith & Colgate, 2007). These two types of interactions have an


influence over consumer behaviour in a consumption experience. Evidence was

found in the data for both these types of interaction.

Interaction with the organisation’s systems and processes

Aspects of the organisation‟s systems and processes that were identified in the data

include the organisation of appointments, the actual mammogram, and general

timeliness of the appointments. The women interviewed described their experiences

with organising an appointment as a process that was accommodating of their

schedules as they were able to organise appointments that suited them fairly easily.

Some of the women noted that when organising their appointment over the phone, it

was not uncommon to find that the next available appointment was several weeks

away. However, these women were not concerned with having to wait for their

appointments as they had no reason to be concerned about their health.

“You can‟t just ring and say „I want an appointment tomorrow‟ because

there are other people who have already booked appointments. And maybe

they could fit you in sooner but that probably, that time wouldn‟t probably

suit me. So if I want the time and the date that‟s convenient to me, I have to

wait and within four to six weeks? That‟s okay” – Respondent 10; aged 58,


The women interviewed also discussed their experiences with the actual

mammogram and described this as a quick process despite the discomfort.

“It was only, five minutes at the most or so. Straightforward and she‟d

checked it there and then and said everything was okay” – Respondent 19;

aged 65, 12 years‟ experience, retired.

Most women who use BSQ‟s screening service do not require a follow-up. The

purpose of a follow-up is for BSQ to see women whose results have returned with

some signs of change in their breasts, which could mean that a cancer has been

detected. This follow-up stage is likely to be an important interaction source of value

for any women who may have to return for a follow-up to check for suspected breast

cancer.


During the interviews, the women commented on the general timeliness of the

service encounter. They described the process from arriving at the service, to leaving

the service as being very quick. Many women commented on the efficiency of the

process as a result of BSQ being able to predict how much time is required to screen

each woman. As a result of this, BSQ has been able to schedule women‟s

appointments effectively such that each woman does not have to wait long before

they are seen.

“My expectation is to be not waiting in the queue. Just that, when I expect

they go right on time, which generally it is always with the Queensland

Government... here it is always efficient, quick... Basically, everything is very

well-organised, I don‟t have to go far away, everything is within my time and

everything is quick” – Respondent 8; aged 53, 20 years‟ experience,

employed.

Interaction with the organisation’s employees

Interaction with BSQ staff members was identified as a very important source of

value. The women interviewed identified three different types of BSQ staff that they

encounter when using the service. The first type of BSQ staff is the telephone

operator who helps organise the appointments for the women; the second type of

BSQ staff is the administrative staff who the women encounter when they first arrive

at the service; and the third type of BSQ staff is the radiographer who conducts the

actual mammogram for the women.

The women interviewed indicated that helpfulness and general friendliness of the

staff are qualities that are important in achieving a pleasant service encounter. At the

same time, the manner of the staff was also influential in determining if the women

had a pleasant or unpleasant experience.

“I expect to be treated like everybody else, which is you know, right, and they

treat me well and the girl at reception is really nice and pleasant and

helpful... I walked in here, I handed my forms to the girls at the counter. They

were helpful. They checked my details and everything, and they showed


where I can make a cup of coffee, make yourself comfortable and before I had

a sip of coffee, I was called in, which was great you know” – Respondent 12;


Interaction with the radiographer was also a very important for the women,

especially since radiographers are the BSQ staff members who are responsible for

conducting the mammograms. Radiographers who were friendly, pleasant, and kept

the women informed of the processes were appreciated by many of the respondents

and had a positive impact on their service experience.

“She told me what she was doing and you know when it was going to squeeze

and I don‟t know, you know. I mean they just put you in the position and

everything and they‟re just sort of talking and telling you what they‟re doing

and tell you when they‟ll squeeze. I think that‟s important that you know that

you know and to hold your breath. Not hold your breath to be quiet and don‟t

speak while you‟re getting it squeezed and taking the picture. Yeah I find it,

yeah they‟re fine. They‟re very friendly lovely ladies” – Respondent 18; aged

53, 10 years‟ experience, not currently in employment.

It was an expectation and assumption of the women interviewed that BSQ staff

members would be technically competent and adequately qualified. However, it was

the interpersonal skills of the staff that appeared to enhance the women‟s service

experiences. While the women did not expect the staff members to be overtly

friendly, they reported that having friendly and personable staff made their service

experience more pleasant.

Organisational environment sources of value

Environment sources of value relate to facilities and interior design (Smith &

Colgate, 2007). This includes the atmospherics and physical aspects of the service

organisation. Evidence for environment sources of value that impact consumers‟

experiences with breast screening was found in the data. The women interviewed

commented on the atmosphere of BSQ services, describing the service centres as

comfortable. They describe the atmosphere at the service centres as being in contrast


with that of a hospital atmosphere and they liked that it was unlike a hospital

environment. The seven women who had used other service before commented that

they preferred the environment at BSQ as the environment at these other services

were very similar to a hospital environment. They disliked this hospital-like

environment as it brought about negative connotations of ill-health and sickness for

many of them.

“[The BSQ service centre] doesn‟t feel like hospital, it doesn‟t feel like

clinical, it feels like you know…just an area to come and sit down and have a

coffee. Even if you have to make your own” – Respondent 12; aged 50, 10

years‟ experience, employed.

The physical aspects identified by the women interviewed predominantly revolved

around the physical elements within the waiting area. Some women identified the

chairs in the waiting rooms as being very comfortable, while other women mentioned

gossip magazines were available for them to read while waiting. The women enjoyed

these physical aspects because it made their time at the service more comfortable.

“I think it‟s comfortable. I just walk from the mammograms and look at those

chairs... my God those chairs are really made for people to sit down and, in

comfort. You know, it‟s not like plastic old chairs or some benches. They

just... it‟s not like a waiting area. It‟s just like, you know a little coffee shop

or something. You can sit down and have a coffee and even if you bring a

friend or someone. Like a lounge” – Respondent 12; aged 50, 10 years‟


The facilities provided by BSQ were also identified by the women interviewed as

being important and influential elements in their service experience. This included

aspects such as location of the services, parking facilities, and tea or coffee making

and snack facilities. For many women, the location of the BSQ service was an

important factor that influenced their decision to use the service. Many women

selected services that were conveniently located to home or work, or service

locations that they were familiar with. Parking facilities was an important

consideration for other women, which influenced their decision to use the service.


The women explained how adequate parking facilities influence their service

experience more positively as it creates greater convenience for them to use the

service. The women also discussed how available snacks, and tea and coffee making

facilities in waiting areas were valued. These free food and drink facilities are

provided to the women and many of the respondents liked that this was made

available to them.

“They have tea and coffee and cold water…none of which I wanted but it‟s

there for you if you want it. It‟s very comfortable” – Respondent 15; aged

66, 10 years‟ experience, retired.

Many of the women interviewed reported that the waiting area at BSQ service

centres were not usually crowded whenever they were there. Women reported that

there would only be one or two other women in the waiting area with them whenever

they were there for an appointment. As there were only a small number of co-

consumers around them, there was little crowding, which the women liked.

“Because there‟s another waiting room for women when you first come in

they were there and there was just the lady on the desk and she was…I don‟t

know what she was doing and I just sort of walked up and she spoke to me

straight away so no as I say it was so quiet. Nobody around, and I walked

into the big waiting room and there was one other lady in there when I

walked in and as I walked in I hadn‟t even got a cup out yet alone anything

else and she went and then I thought…I said there‟s probably only one

radiographer and they‟ll be awhile and the next thing the other lady came

and got me so. It was almost like they were waiting for customers” –

Respondent 20; aged 56, 6 years‟ experience, retired.

In summary, the atmospherics of BSQ screening services appeared to have a great

impact on the women‟s experiences with the service. They appreciated the non-

medical nature of the service environment as some of the women interviewed

explicitly noted that they were “not sick” and were healthy women. The atmosphere

of the service reflected the healthy nature of the target audience, which they liked.

These important environment sources of value occur at the consumption stage, as do


the interaction sources of value. In contrast, some of the information sources of value

occur at the pre-consumption and post-consumption stages of the consumption

process, such as the reminder letter, results letter, and advertising.

4.4.2 Consumer participation sources of value

Consumer participation is defined as the extent to which the consumer is involved in

producing and delivering the service (Dabholkar, 1990). The data was initially

analysed for evidence of consumer participation in wellness services. Further

examination of the coded data revealed three different types of consumer

participation that exist in the consumption experiences of the women interviewed.

These were cognitive inputs, behavioural inputs, and affective (or emotional) inputs.

These three different types of consumer participation provided more meaningful

explanations of the women‟s experiences with breast screening, and thus the

literature was consulted further. In the following section, this interpretation of

consumer participation at the different stages of the consumption process is discussed

by differentiating according to cognitive inputs, behavioural inputs (Mathwick et al.,

2001), and emotional (or affective) inputs (Hochschild, 1983).

Cognitive inputs

Evidence was found for cognitive inputs from the women interviewed, which refers

to cognitive mental effort exerted as a result of a consumer‟s participation in breast

screening. Cognitive inputs were predominantly made at the pre-consumption stage

of the consumption process. Evidence of cognitive input included mental effort

exerted by the women interviewed to remember to organise their appointment once

they had received the reminder letter. Some women described strategies that they

used to help them remember to telephone BSQ, which ranged from completing the

task straight away, or leaving the reminder letter in a prominent place in their homes.

“They send you the reminder; it‟s pretty much straight away that you ring.

What‟s the point of holding back, you know? You‟ll probably forget then...” –



This other woman illustrates another cognitive strategy that some of the women

interviewed use to remember their breast screening appointment. She organises her

health screens around the same period as her birthday, which allows her to keep track

of her health screening:

“…birthday is in September, so when my birthday comes around, I think,

„Okay, there be a breast screen probably in October.‟ It‟s also a gift to

yourself to make sure that you‟re okay… I always start thinking about it near

my birthday” – Respondent 17; aged 62, 12 years‟ experience, not currently

in employment.

Behavioural inputs

Behavioural inputs refer to behavioural or physical efforts exerted by consumers as a

result of their participation in breast screening. Evidence was found for behavioural

inputs in the breast screening context, which occurs predominantly at the

consumption stage of the consumption process. Evidence of behavioural input

included following radiographers‟ instructions during the mammogram to stand,

move, or position themselves in a specific way in order to aid with capturing the

most optimal mammogram.

“You know I think she said to me, „Put your right breast here‟ and I‟m going,

which one‟s my right one? But that‟s only confusion for a second. But no,

they‟re very friendly and very helpful and really I guess from their

perspective if they didn‟t help you move around they wouldn‟t get the breast

in the right position and wouldn‟t get the right pictures so they know what

they‟re doing. Just be guided by them” – Respondent 15; aged 66, 10 years‟

experience, retired.


Another example of a behavioural input is in the woman‟s selection of attire to wear

to her breast screen appointment to achieve greater efficiency in her breast screen.

This woman describes how she chooses her attire such that it becomes easy for her to

participate in the screening process:

“I always wear a shirt that I can just pull down so I don‟t have to sort of do a

major dress, so… it was really quick” – Respondent 18; aged 53, 10 years‟

experience, not currently in employment.

Affective inputs

Affective inputs or emotional inputs refer to emotional effort exerted by consumers

as a result of their participation in breast screening. Evidence was found for

emotional inputs in the breast screening context, which occurs predominantly at the

post-consumption stage of the consumption process. Evidence of emotional input

was identified in the data where some of the women interviewed reported not

allowing themselves to think or worry about what their breast screening results might

say after their screening appointment. The women explained that they believed it was

not useful to worry that they might receive a bad result and thus, try not to think of it

before the results are sent to them.

“Why worry about something until you find out [if there is something to

worry about]” – Respondent 13; aged 60, 10 years‟ experience, employed.

In summary, the data revealed that consumers‟ participation as a source of value can

be described in the form of cognitive, behavioural, and affective inputs. These were

all present for many of the women interviewed and further explained their value

constructions from a preventive health service. Specifically, cognitive inputs appear

to occur predominantly at the pre-consumption stage of the consumption process. On

the other hand, behavioural inputs appear to occur predominantly at the consumption

stage of the consumption process. Finally, emotional inputs appear to occur

predominantly at the post-consumption stage of the consumption process.


4.4.3 Third party sources of value

Upon completion of the initial analysis of the data, it became apparent that value

sources with origins from neither the organisation nor the consumer were also

present in a wellness service consumption context. The data suggested that a third

origin of value sources were also present; third parties. In particular, the data

suggested that information from third parties and interaction with third parties were

additional value sources that were present in the women‟s experiences with breast

screening.

Third party information sources of value

Many of the women interviewed identified general practitioners (GPs), family

doctors, or medical specialists who advised these women to commence breast

screening, as having some impact on their experiences. These information sources

were also influential in initiating women‟s screening behaviour. Medical

professionals, particularly GPs were perceived by many of the women as a trusted

and reliable source of information. Hence, their recommendation to commence breast

screening with BSQ was influential in the women‟s decisions to start breast

screening. This information source also influences consumers at the pre-consumption

stage of the consumption process. One woman describes her GP recommending her

to start breast screening with BSQ:

“I was recommended by my GP. She just suggested I should get into a

programme like this, it was free and reliable and it was a good idea and

something I should consider doing” – Respondent 11; aged 54, 6 years‟



Media coverage on breast screening, breast cancer, or BSQ that did not originate

from BSQ itself was also mentioned by some women. Media coverage originating

from external sources were also influential in keeping the issue of breast screening

current in the minds of the women interviewed. Exposure to this media coverage also

occurs outside of the service encounter, thus influencing consumers at the pre-

consumption and post-consumption stages of the consumption process as well.

“There‟s a lot of media about breast cancer so it‟s in my brain as an area

that you have to do this... so just do it. So I just sort of got up and did it, type

of thing” – Respondent 11; aged 54, 6 years‟ experience, employed.

Three women discussed breast cancer-related events, specifically Pink Ribbon Day,

as having an influence over their experiences. One respondent discusses how

attending the Pink Ribbon Breakfast made her aware that early detection can

improve a woman‟s likelihood of successfully treating breast cancer. This in turn,

encourages her to continue with breast screening.

“Well because breast cancer‟s such a terrible thing and it‟s so, seems to be

so prevalent and um, when I was listening to the ladies talking at the, you

know the breakfast? The Pink Ribbon Breakfast? You know, it‟s just... if they

can get it early, you know, you stand a chance” – Respondent 6; aged 55, 4


Third party interaction sources of value

While their interactions with BSQ employees appeared to influence their perceptions

of their service experiences, the experiences of the women interviewed did not

appear to be affected by interactions with other people such as family members,

colleagues, or friends. Instead, the interactions that the women interviewed

experienced with other people served to either keep the issue of breast cancer or

breast screening top of mind, or served as reinforcement for the women to have

regular breast screens.


For example, it was reported that breast screening was not a typical topic of

conversation with their friends or colleagues, unless someone they knew personally

had been affected by breast cancer. Other women reported talking about breast

screening on very general terms with their female friends and colleagues who were

also in the target age group. This interaction with other women kept the issue of

breast cancer and breast screening top of mind for the women.

Similarly, it was also reported that the women interviewed sometimes spoke about

breast screening with some family members, usually their husbands or their

daughters. The women who spoke to their husbands about breast screening reported

that they used breast screening services because their husbands would be upset if

they did not use the services. This served as reinforcement for the women to have

regular breast screens.

“Ralph (the respondent‟s husband) is always pleased when the letter comes

to say everything‟s okay” – Respondent 5; aged 56, 8 years‟ experience,

employed.

4.4.4 New categorisation of sources of value and stages of consumption

As an outcome of this stage of analysis of the qualitative data, a new categorisation

of sources of value in wellness services using social marketing was developed (see

Figure 4.1). In addition the results offer an identification of the stages of the

consumption process at which these sources of value occur. Table 4.8 provides a

summary of the different sources of value and the stages of the consumption process

in breast screening. The table identifies the consumption stage at which the sources

of value appear to exist and examples of each source of value at each stage of the

consumption process are provided.


Table 4. 4 Summary of sources of value categorisation with stages of consumption

Main Categories

Sub-categories

Stages of the consumption process

Pre-consumption

Consumption Post-consumption

Organisational sources

Information BSQ reminder letter BSQ advertising

Instructions and explanations

BSQ results letter BSQ advertising

Interaction Interaction with telephone operator in organising an appointment Ease of organising an appointment that suits

Interaction with administrative staff on arrival Interaction with radiographer during the mammogram General timeliness of the service

Follow-up (if any)

Environment NA Atmospherics Physical aspects Facilities Crowd density

NA

Consumer Participation

Cognitive inputs Remembering to organise an appointment

NA NA

Behavioural inputs

NA Following instructions during the mammogram

NA

Affective inputs NA NA Not thinking or worrying about what the results may say

Third parties Information Doctor’s recommendation Media coverage

NA Results from doctor Media coverage

Interaction Family members, friends, or colleagues

Other co-consumers in the waiting area

Family members, friends, or colleagues


4.5 Consumer goals & relationships between value dimensions and

sources

After analysing the data for evidence of dimensions and sources of value in wellness

services, “inter-relationships” became more evident between the dimensions and

sources of value. As such, the data was analysed and examined further to explore

these “inter-relationships” and in doing so, this qualitatively addressed RQ3: What is

the relationship between sources and dimensions of value in wellness services? The

main findings from this stage of analysis revealed the discovery of six consumer

goals which explain the relationships between the dimensions and sources of value in

breast screening. The following sub-sections discuss these consumer goals in detail,

followed by a discussion of the inter-relationships between the dimensions and

sources of value, explained by the consumer goals achieved.

4.5.1 Consumer goals

Six consumer goals in breast screening health prevention were identified in the data.

They are utility, convenience, control, peace of mind, self as influencer, and benefit

to others. The achievement of these consumer goals relate to the fulfilment of

consumer needs, which relate to motivation (Maslow, 1970). This motivation to

achieve these consumer goals in breast screening explains how the sources of value

influence the value dimensions identified by the qualitative findings. This section

explains each of the six consumer goals in further detail.

Consumer goal one: Utility

Many women interviewed reported utility to be an important factor in their decision

to use breast screening services regularly. Utility is defined as the functional

outcomes derived from using the service. In the context of BSQ, the utility of breast

screening services is the detection of breast cancer (if any) or the confirmation of no

breast cancer. When one woman was asked what she sought to achieve from using

breast screening services, her response was as follows:


“Free of cancer. I know you can still get it by having [breast screens] but I

just hope that well, if I do get it, it will be picked up before it gets to be a

death sentence I suppose” – Respondent 18; aged 53, 10 years‟ experience,

not currently in employment.

Many of the women who cited utility as an important factor also acknowledged that

breast screens are never completely accurate. However, in the interviews, the women

acknowledged that the service could never be completely accurate, but trusted that

the technology and equipment performs to the expected standard of performance.

“You have to sign a waiver to say that you know they can‟t give you a 100%

guarantee that they‟ll detect something. Technology is, you know, there‟s still

room for improvement and I don‟t... I mean, if I went home and 6 months

later I found a lump and it became cancerous and you know, went down that

path, I don‟t hold 100% store in the fact that it will detect. But it‟s better than

not doing anything I guess” – Respondent 11; aged 54, 6 years‟ experience,

employed.

Utility reflects the functional dimension of value as functional value is extrinsically-

motivated (a means to an end) and for the benefit for the self (Holbrook, 2006). This

suggests that the use of breast screening services fulfils a desired end or outcome,

which is detection of breast cancer (if any) or confirmation of no breast cancer. This

provides a direct benefit to the individual who uses breast screening services. This

demonstrates the utility provided by the consumption of the service (Tellis & Gaeth,

1990), which in this context is a breast screening service. The use of breast screening

services is a demonstration of the consumption of s social marketing service as a

means to a consumer‟s own objectives (Holbrook, 2006), which in this context is the

maintenance of good health.

Utility is achieved through a woman‟s consumption of breast screening services.

Thus, aspects such as elements of the service and consumer participation are key to

the achievement of utility for the consumer. Thus, utility can be achieved either

actively or reactively. Utility is achieved reactively when the individual merely co-

produces the service with the service provider and responds to the service process by


fulfilling their core role in the delivery and consumption of the service. On the other

hand, utility is achieved actively when the individual takes on a more proactive and

more highly involved role in the service delivery by providing additional inputs that

go above what is necessary for the production of the core service.

Consumer goal two: convenience

The second consumer goal identified in the data was convenience. Many women

reported convenience to be a very important factor in their decision to use BSQ‟s

screening services. Convenience is defined as the facilitation of the desired

behaviour through the implementation of relevant processes and structures. This can

include distribution of the service, such as ensuring widespread availability of

service centres throughout the state, convenient location of service centres to the

homes or workplaces of the target audience, useful facilities in and around the

service centres such as parking, and other support services such as a courtesy phone

call reminder. These enable target audiences to perform the desired behaviour easily.

In this context, it allows women in the target age group to use breast screening

services easily.

Convenience is a form of ability-enhancement (Moorman & Matulich, 1993) in order

to ensure continuation of the behaviour. Providing convenience to target audiences to

encourage uptake and maintenance of social marketing behaviour through the

necessary processes and structures makes performing the desired behaviour more

attractive. This is a result of the reduction of barriers in consumers‟ uptake of the

behaviour and encourages easy maintenance of the behaviour. Continuation in the

long term is likely when there is facilitation of an easy performance of behaviour.

This is illustrated by one of the women interviewed:

“I think that BSQ has done everything that they can, short of going to your

house and picking you up and delivering you to the service, um, they have

made it as accessible as they possibly can. And I think that‟s very important”



Convenience reflects the functional dimension of value as it relates to practical

aspects of the service experience such as having adequate parking spaces or

receiving a courtesy phone call to remind the individual of their upcoming

appointment. As such, many of the women interviewed reported that BSQ had

“made it as easy as possible” for them to have a breast screen and as such, there was

no reason for them to avoid doing so.

Convenience is achieved through aspects provided by the service organisation (e.g.

car parking facilities) and these aspects are experienced by consumers from a

distance. Thus, convenience is achieved reactively as there is no need for high levels

of involvement for the consumer to use the various elements that provide

convenience to them.

Consumer goal three: Peace of mind

The third consumer goal that was identified in the data was peace of mind. When the

women were asked for the main reason why they chose to have regular breast

screens, many of them cited peace of mind. Peace of mind is defined as the reduction

of negative emotions and the enhancement of positive emotions. The achievement of

peace of mind is a form of motivation-enhancement (Moorman & Matulich, 1993)

through an individual‟s emotions in order to continue performing the behaviour. This

is described by one of the women interviewed:

“I tend to think „I‟ve had it now, I don‟t have to think for two years.‟ I feel

very peaceful about that, I‟ve got peace of mind” – Respondent 9; aged 56, 8


Many respondents admitted that they believed it was their own personal

responsibility for protecting their health and maintaining their wellbeing. Some of

the women explained that they experience feeling of relief after having their breast

screen, as well as at times, experiencing a sense of pride that they had fulfilled their

perceived obligation to themselves. This is explained by one woman:


“Once it‟s done, I feel immensely proud of myself that I‟ve just accomplished

that thing yet again, that part of my health check (laughs) at least I‟m doing

one part of my health check properly. And then I get all righteous about it

and then it leaves my mind” – Respondent 5; aged 56, 8 years‟ experience,

employed.

Peace of mind is an experience theme that reflects the emotional dimension of value.

Appraisal theory posits that emotions such as relief are derived from situations where

there is certainty that engaging in the situation will avoid or minimise pain

(Roseman, 1991) and relief is the emotion that accompanies peace of mind. Peace of

mind provides positive emotional reinforcement and reassurance to the users of

breast screening services. This ensures their performance of the desired social

marketing behaviour is maintained through their continued use of BSQ‟s service.

Peace of mind, like utility, is also achieved through a woman‟s consumption of

breast screening services. Thus, aspects such as elements of the service and

consumer participation are also keys to the achievement of peace of mind for the

consumer. Thus, peace of mind can also be achieved either actively or reactively.

Peace of mind is achieved reactively when the individual responds to the aspects of

the service that influences their emotions. One example is the interaction with a staff

member. A staff member who is pleasant towards a client will have a positive impact

on the way the client is feeling and this impact can be appreciated by the client at a

distance. On the other hand, peace of mind is achieved actively when the individual

takes on a more proactive role in suppressing their own negative feelings and

promoting positive feelings. One example is if a woman assures herself that the

results will be fine, eliminating her likelihood to worry.

Consumer goal four: Control

The fourth consumer goal identified in the data was control. Many of the women

interviewed reported that their decision to use breast screening services was a

decision that allowed them to experience a sense of control over their lives. Control

is defined as a sense of management and organisation that allows an individual to

feel that they have made decisions that they determine are right for them. In the

context of breast screening, it was important for the women interviewed to achieve


control and achieving a sense of having done all they could to avoid any negative

consequences (i.e. letting possible breast cancer go undetected). The achievement of

control is a form of motivation-enhancement (Moorman & Matulich, 1993) through

cognition in order to continue performing the behaviour. According to one woman:

“Yes, things can crop up in the two years but... knowing you‟re in the process

and... scheduled for appointments … it‟s a good positive” – Respondent 3;


The decision to use breast screening services is within the control of the individual

woman. When a woman in the target age group makes the decision to use breast

screening services, this is a demonstration of proactive social marketing wellness

behaviour, which falls within a wellness paradigm. The women interviewed

expressed their belief that developing breast cancer was something that was

unavoidable and outside of their control. However, these women believed breast

cancer could be managed more effectively if it were detected early. Hence, ensuring

that they went for regular breast screens was seen as a behaviour that they could

control as this was a proactive means of managing the occurrence of breast cancer.

The women expressed their belief that early detection of breast cancer presented

them with more options to treat the cancer and the idea of having more options or

choices gave women a sense of control. One woman expresses this clearly:

“It makes me feel that at least I‟m doing something to maintain my health

(laughs) you know. Let‟s me off the hook a little bit because I‟m actually

doing something about it” – Respondent 5; aged 56, 8 years‟ experience,

employed.

Respondents expressed the belief that early detection led to more effective treatment

and an improved chance of survival. This is consistent with the findings of the DHA

(2008) that treating individuals with early disease detected through screening leads to

better outcomes for both the individual and society than detecting and treating

disease at a later stage. As another woman put it:


“I guess if I‟m going to face this event in my life, at least I will be diagnosed

early in my life to save my life. The best thing about it is you get to find out

early and get treatment early” – Respondent 2; aged 56, 10 years‟


Control is reflective of both the functional and emotional dimensions of value.

Control provides the use of functional means to achieve a desired emotional state

(Bandura, 1993). In this context, the women are able to feel better about themselves

(desired emotional state) through their behaviour, which is using breast screening

services when they can (a functional means) in order to avoid negative consequences.

Control is achieved through the inputs provided by the consumer either cognitively,

behaviourally, or affectively. The woman would need to be fairly proactive in

supplying these inputs, thus a heightened collaboration is required. As such, control

is achieved actively.

Consumer goal five: Self as influencer

The fifth consumer goal identified in the data was self as influencer. Some of the

women interviewed identified themselves as women who tried to influence other

women in the target age group to have breast screens as well. Self as influencer is

defined as performing the desired behaviour for the purpose of exerting social

influence over others into performing the same behaviour. In their interviews, these

women reported trying to encourage as many women as possible to have breast

screens because they felt that it was an important social marketing wellness

behaviour. One woman noted during her interview:

“I believe that you should be talking to people about it, especially those who

haven‟t done it yet or haven‟t thought of having these screen tests” –


Many of the women interviewed reported that breast screening was not a typical

topic of discussion with others, however their belief that breast screening was

important for and beneficial to women in the target age group allowed them to

discuss breast screening with others. As these women believed that breast screening


was important for women in the target age group, they believed that women who

were non-screeners and avoided breast screens were doing a disservice to

themselves.

“You don‟t have to pay for it which is another reason why I can‟t understand

why people wouldn‟t want to do it for the short time that you‟ve been here,

it‟s free and you‟ve got a worry off your shoulders and everybody is nice to

you so why would you not want to come and do it?” – Respondent 17; aged

62, 12 years‟ experience, not currently in employment.

Some of the women interviewed take it upon themselves to encourage their friends or

colleagues in the same age group to either take up breast screening if they were non-

screeners, or continue screening if they were current users of breast screening by

reminding them to book their appointments.

“The woman I work with, my teacher aid, her breast screen is due around the

same time as mine and I‟m always saying to her „have you made your

appointment yet?‟ so I tend to, I guess the fact that I get the letter reminding

me that it‟s time to have another appointment, that triggers me to remind

Jan… she tends to put it off and put it off and put it off. So I guess in that way,

it‟s in my mind just to be um, reminding someone else” – Respondent 5; aged

56, 8 years‟ experience, employed.

Many of the women interviewed were regular users of breast screening services and

have been consistently performing this wellness behaviour long-term. As such, they

saw themselves as a legitimate source of influence over others into performing the

same behaviour. This behaviour then forms part of the normative influence that

women have on other women. This is an example of subjective norms, which

influences the individual‟s behaviour (Azjen, 1991). This exemplifies the concept of

opinion leadership, whereby the women‟s experiences with breast screening is taken

as knowledge power (Menzel, 1981), which the women then use on other women.

The self as influencer theme reflects the social dimension of value as the objective of

these women is to influence other women into performing and maintaining the same


behaviour. This is similar to the concept of market mavens, where individuals

actively transmit information to others (Walsh, Gwinner & Swanson, 2004).

In these situations, some of the women interviewed indicated that they take it upon

themselves to convince non-screeners who they knew to take up regular screening.

This theme situates well in the social dimension of value as the objective of these

women is to influence other women into performing and maintaining the same

behaviours. Self as influencer is achieved when women proactively encourage or

remind other women to have breast screens and act as advocates for the behaviour.

This demonstrates an active behaviour, thus self as influencer is achieved actively.

Consumer goal six: Benefit to others

The final experience theme identified in the data was benefit to others. Benefit to

others is defined as the performance of the desired behaviour for the benefit of

others. Respondents identified themselves as those who would primarily benefit from

their use of breast screening services, however secondary and tertiary beneficiaries

were also identified. Families and friends were identified as secondary beneficiaries

of their use of wellness services, while the wider community was identified as a

tertiary beneficiary.

For the women who identified families and friends as secondary beneficiaries, they

indicated in their interviews that they used breast screening services because they

wanted to not only “do the right thing” by themselves, but also by their families.

One woman expresses this point clearly:

“Half of the motivation for wanting to stay well is that you are still around

for the rest of your family and your friends” – Respondent 2; aged 56, 10


This denotes a sense of altruism that the women seek, as they expressed concern for

the impact on their families and friends, should they stop having breast screens and

then suffer negative consequences. This reflects the altruistic dimension of value as

the women‟s motivations for using breast screening services are driven by their


desire to protect their health and wellbeing for the benefit of their family members

and friends who have a vested interest for them to do so.

At the same time, some of the women interviewed also indicated that part of their

motivation to use breast screening services was to please their family members. The

women noted that since breast screening services were easily available and offered

for free by BSQ, it was an expectation of their loved ones that they would use the

services as they had no reason not to. In particular, some women noted in their

interviews that they continue breast screening to avoid disapproval from their family

members, particularly their husbands. This desire to seek approval from the

important people in these women‟s lives reflects the social dimension of value. This

woman articulates this point clearly:

“I don‟t think my family would be very happy if I said, „Oh, I‟m not having

that done,‟ you know? ...My husband would be furious if anything happened”


A small number of women interviewed also identified the community at large as a

tertiary beneficiary of their behaviour. Their belief informs the view that since their

behaviour contributes towards early detection and early treatment of breast cancer, it

benefited the community through a reduction in health costs. These women believed

that the cost of treatment is greater when treating advanced cancer than treating

early-stage cancer. According to one of these women:

“There are community costs involved in any kind of illness; so if I don‟t do

the screening and have my breast cancer diagnosed at a later stage, then

there are costs, higher costs in terms of hospitalisation costs and medical

cost. I believe that if the cancer is caught at an early stage then the impact is

much lower … yes, very definite benefits for me and my family and in terms of

health cost to the overall community” – Respondent 3; aged 54, 10 years‟


This is reflective of the altruistic dimension of value, as the behaviour denotes a

sense of altruism. Performing desired behaviour for the benefit of others creates


additional marketing value beyond the value received by the individual performing

the behaviour. From a societal perspective, the benefit is that the public health

system is not over-burdened and that the cost to society to treat individuals with

cancer is reduced due to prevention efforts.

In both instances of benefit to others (for social and altruistic gains), this goal is

sought actively by users of breast screening services as it requires their conscious

consideration for others and how others will be affected by their decision to use

breast screening services.

4.5.2 Relationships between dimensions and sources explained by consumer goals

These six consumer goals explain the apparent inter-relationships between the

dimensions and sources of value, which addressed RQ3. This section explains these

inter-relationships in further detail.

Table 4. 5 Relationships between organisational sources of value and dimensions of value

explained by consumer goals

Category of sources

Sources of value Dimensions of value

Functional Emotional

Organisational Interaction with systems

Utility (reactive)

Convenience (reactive)

Nil

Interaction with staff Utility (reactive)

Peace of mind (reactive)

Environment Utility (reactive)

Convenience (reactive)

Peace of mind (reactive)

Table 4.5 shows the inter-relationships between the organisational sources of value

and the dimensions of value. Specifically, the organisational sources of value appear

to be inter-related with the functional and emotional dimensions of value. The

qualitative data suggests that interactions with the organisation‟s systems and

processes create functional value for users of breast screening services. This

functional value is experienced reactively by women through the achievement of

utility and convenience.


On the other hand, interactions with the organisation‟s staff members create both

functional and emotional value. Both functional and emotional value dimensions are

experienced reactively by women who use breast screening services. These value

dimensions are experienced through the achievement of utility and peace of mind for

the users respectively.

Finally, the organisation‟s environment sources of value also create both functional

and emotional value. These value dimensions are also experienced reactively by

women. The functional dimension of value is experienced through the achievement

of utility and convenience goals, while the emotional dimension of value is

experienced through the achievement of peace of mind goals.

Table 4. 6 Relationships between consumer participation sources of value and dimensions

of value explained by consumer goals

Category of sources

Sources of value

Dimensions of value

Functional Emotional

Consumer participation

Cognitive inputs Utility (active) Control (active)

NIL

Behavioural inputs Utility (active & reactive)

Control (active)

NIL

Affective inputs Control (active) Peace of mind (active)

Table 4.6 shows the inter-relationships between the consumer participation sources

of value and the dimensions of value. Specifically, the consumer participation

sources of value also appear to be inter-related with the functional and emotional

dimensions of value. The qualitative data suggests that cognitive inputs create

functional value for users of breast screening services. This functional value is

experienced actively by women through the achievement of utility and control.

On the other hand, behavioural inputs also create functional value, which is

experienced both actively and reactively by women who use breast screening

services. The achievement of utility causes functional value to be experienced both

actively and reactively, while the achievement of control causes functional value to

be experienced actively only.


Finally, affective inputs create both functional and emotional value for women who

use breast screening services. These value dimensions are also actively by women

through the achievement of control and peace of mind goals respectively.

Table 4. 7 Relationships between third party sources of value and dimensions of value

explained by consumer goals

Category of sources

Sources of value

Dimensions of value

Functional Social Altruistic

Third parties Information Utility (active)

NIL NIL

Interaction NIL Self as influencer (active)

Benefit to others (active)

Benefit to others (active)

Table 4.7 shows the inter-relationships between the third party sources of value and

the dimensions of value. Specifically, the third party sources of value appear to be

inter-related with the functional, social, and altruistic dimensions of value. The

qualitative data suggests that information from third parties create functional value

for users of breast screening services. This functional value is experienced actively

by women through the achievement of utility.

However, interactions with third parties create social and altruistic value for users of

breast screening services and these value dimensions are experienced actively. Social

value is experienced actively through the achievement of self as influencer and

benefit to others consumer goals, while altruistic value is experienced actively

through the achievement of benefit to others.

In summary, the qualitative data yielded three broad findings that relate to the

relationships between sources and dimensions of value in wellness services. Firstly,

the data showed that different sources influence different dimensions of value in

wellness services. Secondly, the data also showed that some sources can influence

multiple dimensions of value and that some dimensions of value are influenced by

multiple sources. Finally, the data also showed that some dimensions of value can be

created both actively and reactively (i.e. functional and emotional value), while other

dimensions are only created actively (i.e. social and altruistic value).


4.6 Conclusion

This chapter provided the qualitative findings for Study 1. The results addressed the

three sub-research questions by identifying the value dimensions experienced by

consumers in wellness, identifying the sources of value that exist in breast screening

consumption experiences, and explaining the inter-relationships between the

dimensions and sources of value in this context. These findings led to the

development of a conceptual model of value creation in wellness shown in Figure

4.2. This model identifies the different sources of value and the dimensions of value

they influence. It illustrates the relationships between these constructs and also

identifies satisfaction and behavioural intentions as outcomes of value creation in

breast screening.


Behavioural

intentions

Satisfaction

Functional

value

Emotional

value

Tangibles

Timeliness

Operation

Expertise

Atmosphere

Interaction

Cognitive inputs

Behavioural

inputs

Affective inputs

Consumer

participation

Environment

Interaction with

systems &

processes

Interaction

with staff

Information

from third

parties

Interaction with

third parties

Social value

Third

parties

Altruistic

value

Organisational

sources

Figure 4. 2 Conceptual model for qualitative findings of Study 1


The following chapter will explain this theoretical model in further detail and

identify aspects of the model that are likely to have a strong impact on experiential

value creation in wellness services. A series of propositions and hypotheses that have

been developed based on the findings in this chapter will be presented in the

following chapter. The proposed conceptual model, hypotheses and propositions then

form the basis for quantitative empirical testing in Study 2.

Chapter 5: Theoretical Model and Hypotheses 153

CHAPTER 5 THEORETICAL MODEL AND

HYPOTHESES

“I never see what has been done; I only see what remains to be done”

Budda

5.1 Introduction

The previous chapter presented the qualitative findings of Study 1, which addressed

all three sub-research questions. Firstly, the results addressed the first sub-research

question.

RQ 1: What are the dimensions of value experienced by users of wellness

services?

The data identified that the functional, emotional, social, and altruistic dimensions of

value were present in wellness services. In addition, the data revealed that active and

reactive value were experienced by users of wellness services and that reactive value

featured more prominently than active value for the women interviewed in Study 1.

In synthesising the understanding of value in wellness services, a conceptualisation

of value dimensions for wellness services using social marketing were presented;

functional and emotional value can be experienced actively and reactively, while

social and altruistic value are only experienced actively.

The results also addressed the second sub-research question.

RQ 2: What are the sources of value that exist in wellness services?

The data identified three categories of sources that influenced women‟s experiences

with breast screening services; organisational sources, consumer participation

sources, and third party sources. Within organisational sources, it was found that


information from the organisation, interaction with the organisation‟s systems,

processes, and staff, as well as the environment all had an influence on the value

experienced by the women interviewed. Within consumer participation sources,

cognitive inputs, behavioural inputs, and affective inputs from the consumers had an

influence over their value interpretations. Finally, information received from third

parties and interactions with third parties also had an influence on the dimensions of

value that the women experienced.

Finally, Study 1 also qualitatively addressed the third sub-research question.

RQ 3: What is the relationship between sources and dimensions of value in

wellness services?

The results suggest that some sources can influence multiple dimensions of value,

and that some dimensions of value can be influenced by multiple sources. In

addressing the research questions, a full conceptual model was presented in the

previous chapter with accompanying propositions, illustrating the potential

relationships between the specific sources of value within each of the three

categories of sources and the dimensions of value. The outcomes of value were also

identified in Study 1 as being satisfaction and behavioural intentions, thus the

relationship between value and these key outcome variables will also be included in

this chapter. Those relationships form the basis for the hypotheses to be tested in

Study 2.

While there are a number of potential relationships in the conceptual model in

Chapter 4, the aspects of the model to be tested in Study 2 are those that represent

greater importance in value creation in wellness services as identified in Study 1 and

in the extent literature. The purpose of this chapter is to therefore outline these

important aspects and justify the selection of specific variables and relationships that

will be empirically tested in Study 2. From the qualitative findings of Study 1, it

appears that organisational sources and consumer participation sources have a greater

impact on the value creation process in wellness services.


Two of the three aspects of organisational sources appear to have a greater impact on

value creation; these are “interaction with systems and processes,” and “interaction

with staff.” Thus, this chapter does not contain the third type of organisational

source, which is environment. Interaction with systems and processes is represented

by one service quality variable; administrative quality, while interaction with staff is

represented by two service quality variables; technical quality and interpersonal

quality. The consumer participation sources of value are represented by motivational

direction (cognitive input), stress tolerance (affective input), and co-production

(behavioural input).

The data in Study 2 indicates that two of the four value types are of more significant

importance in wellness services; functional and emotional value. These value

dimensions represent the core value dimensions that women seek from breast

screening services, as evidenced by the results of Study 1. While the achievement of

the other value dimensions (social and altruistic value) are also sought by some of

the women interviewed, they are sought together with functional and emotional value

and not on their own. Furthermore, the functional and emotional dimensions of value

typify experiential value well as they can be experienced both actively and reactively

by consumers. This is important in understanding the full nature of value co-creation

in wellness services.

This chapter also addresses two key outcomes of consumer value; satisfaction and

behavioural intentions. The receipt of value demonstrates the fulfilment and

achievement of consumer goals such as utility, convenience, and peace of mind, as

evidenced by the qualitative results of Study 1. Thus, the fulfilment of these goals is

likely to result in satisfaction for the consumer with their consumption experience. It

has also been well-documented in commercial marketing that satisfaction has an

influence of behavioural intentions, as such it is anticipated that this will apply in

social marketing as well.

This chapter will also present the hypotheses developed as a result of the knowledge

gained from the findings of Study 1. A summary of the propositions, hypotheses, and

research questions addressed in Study 2 is shown in Table 5.1. The table identifies


the propositions that developed as a result of the analysis of the qualitative data in

Study 1 as well as the subsequent hypotheses developed from those propositions.

Table 5. 1 Summary of propositions, hypotheses and research questions

Research questions Propositions Hypotheses

Overall RQ: How is value created in wellness services? RQ 1: What are the dimensions of value experienced by users of wellness services? RQ 2: What are the sources of value that exist in wellness services? RQ 3: What is the

relationship between sources and dimensions of value in wellness services?

Organisational sources will influence functional and emotional value for users of wellness services

H1 a: Administrative quality is significantly and positively associated with functional value for consumers of wellness services. H1 b: Technical quality is significantly and positively associated with functional value for consumers of wellness services. H1 c: Interpersonal quality is significantly and positively associated with emotional value for consumers of wellness services.

Consumer participation will influence functional and emotional value for users of wellness services

H2 a: Motivational direction is significantly and positively associated with functional value for consumers of wellness services. H2 b: Co-production is significantly and positively associated with functional value for consumers of wellness services. H2 c: Stress tolerance is significantly and positively associated with emotional value for consumers of wellness services.

The experience of value will lead to satisfaction of consumers using wellness services

H3 a: Satisfaction is significantly and positively associated with functional value in wellness services. H3 b: Satisfaction is significantly and positively associated with emotional

value in wellness services. Satisfaction of consumers who use wellness services will influence their behavioural intentions

H4: Behavioural intentions are positively associated with satisfaction in wellness services.


5.2 Proposed model and hypotheses

Based on the qualitative findings of Study 1, a proposed model (Figure 5.1) was

developed that will test the relationships between specific sources and dimensions of

value in wellness services.

Figure 5.1 shows the hypothesised relationships between the sources and the

dimensions of value. These relationships form the propositions of this research. The

model also illustrates that when consumers experience value within their service

experiences, it creates satisfaction with their experience, which influences their

intentions to use wellness services again in the future. The following section explains

in further detail the specific relationships between the sources of value and

dimensions of value in wellness services and will introduce four sets of hypotheses

based on the propositions.

Functional

value

Emotional

value

Satisfaction Behavioural

intentions

Administrative

quality

Technical

quality

Motivational

direction

Co-production

Stress

tolerance

H1a

H1b

H1c

H2a

H2b

H2c

H3a

H3b

H4

Interpersonal quality

SERVICE

INTERACTION

CONSUMER

PARTICIPATION

Figure 5. 1 Proposed model of value creation for testing in Study 2


5.3 Value in wellness services

The experiential approach defines value as an interactive, relativistic, preference

experience (Holbrook, 2006). The value experienced by consumers refers to value-

in-use and is process-oriented and services-based. Value is a multi-dimensional

construct, however only functional and emotional dimensions of value are

investigated in Study 2.

5.3.1 Functional value in wellness services

Functional value is focussed on the value that is derived from performance and

functionality (Russell-Bennett et al., 2009). This can include the utility provided by

the consumption of a good or service (Tellis & Gaeth, 1990), which in a wellness

paradigm can refer to the utility derived from using wellness services. In the context

of breast screening, this refers to the utility that women derived from having breast

screens, which is early detection of any cancerous breast lumps. From the results of

Study 1, having detected no cancerous lumps also provides utility to the women who

use breast screens because it gives them the all-clear on their health status in that

area. According to the qualitative results, utility was the most important goal for the

women interviewed. Their primary objective for having breast screens was to find

out if they were in good health or if they had developed any cancer since their last

check. The achievement of utility represents the experience of functional value and

given that this was the most important goal for the women, functional value will be

investigated further in Study 2.

5.3.2 Emotional value in wellness services

Emotional value is related to various affective states which can be positive or

negative (Sánchez-Fernández & Iniesta-Bonillo, 2006). Goals achieved that relate to

emotional value are those that are derived from the feelings or affective states that

are achieved through the consumption of a product or service (Sheth et al., 1991;

Sweeney & Soutar, 2001). In the context of breast screening, this refers to the peace

of mind achieved by the women from having breast screens. According to the


qualitative results of Study 1, peace of mind is achieved through the minimisation of

negative states such as anxiety, stress, or worry and the promotion of positive states

such as relief and calm. The qualitative results suggest that peace of mind is another

important goal for women who use breast screening. For some of the women, it is as

important at achieving utility, while for others, it is the next most important goal. The

achievement of peace of mind represents the experience of emotional value. Given

the importance of this goal for the women in Study 1, emotional value will also be

investigated further in Study 2.

5.4 Interaction in wellness services

Interpersonal interactions in a service often have the greatest effect on consumers‟

service quality perceptions (Bitner, Booms, & Mohr, 1994; Bowen & Schneider,

1985; Grönroos, 1982; Hartline & Ferrell, 1996; Suprenant & Solomon, 1987).

Interaction denotes joint production, which represents a situation where the consumer

and the employees of an organisation interact and participate in the production

(Meuter & Bitner, 1998) of the core service. Interaction is important in value creation

in wellness services because of the inseparable nature of services whereby both the

consumer and the service provider must be present in order to simultaneously deliver

and consume the service (Zeithaml, Parasuraman & Berry, 1985).

In Chapter 2, interaction was identified as one of the sources of value that were

anticipated to have an impact on consumers‟ experiences with wellness services. The

literature supports this notion as there is strong support for the significance of the

interaction dimension in perceived service quality (Brady & Cronin, 2001). Evidence

was found in the qualitative results for interaction with the organisation‟s systems

and processes, and staff as being influential elements to consumers‟ experiences with

breast screening services. In health care, technical and interpersonal processes are

important elements in managing health care quality (Donabedian, 1966; 1980; 1992)

and these as aspects of the service that consumers come into contact and interact

with. Specifically, in operationalisating the interaction construct for Study 2, the

service quality dimensions of administrative quality (McDougall & Levesque, 1994),

technical quality (Brady & Cronin, 2001; Rust & Oliver, 1994), and interpersonal


quality (Brady & Cronin, 2001; Rust & Oliver, 1994) are used. These dimensions

represent service quality dimensions arising from the interpersonal interactions

between the staff and consumers, or the employee-customer interface (Hartline &

Ferrell, 1996). Furthermore, these service quality dimensions have been applied in a

context-specific model of health service quality developed by Dagger, Sweeney and

Johnson (2007) in a health treatment service context.

5.4.1 Administrative quality

Technical processes in health services can refer to the systems and processes of the

organisation, which denotes the administrative competencies of the service. For

example, the qualitative results identified that the quality administration of BSQ

services were important in creating convenience and utility for the women who used

the service. Many of the women mentioned in their interviews that the process of

organising a breast screen and having a breast screen at BSQ was very easy and this

had a positive impact on their overall consumption experience. Furthermore, the

women found the overall process at the service itself to be smooth. They also found

the after-service (post-consumption) processes to meet their satisfaction, for example

their results would usually reach them in a reasonable amount of time. This denotes

administrative quality of BSQ‟s systems and processes. As the qualitative evidence

suggest that this is an important influence in consumers‟ experiences with wellness

services, interaction with systems and processes will be investigated further in Study

2 through the operationalisation of the administrative quality construct.

5.4.2 Technical quality

Technical processes can also refer to the technical expertise of the staff. This is refers

to technical quality, another service quality construct. In Study 1, many of the

women interviewed noted the professionalism and perceived expertise of the staff at

BSQ. One woman mentioned in her interviewed that she believed the staff at BSQ

were as well-trained as staff at other breast screening services and that their technical

capabilities were comparable. This observation was derived from their interactions

with the staff members during the consumption experience. This aspect of interaction


was also important in consumers‟ experience of value in breast screening, because

the perceived expertise and technical competence of the staff were important in

providing assurance to the women that their health was being looked after by capable

professionals, achieving both peace of mind and utility for the women. As the

qualitative evidence suggests that is an important influence in consumers‟

experiences with wellness services, the technical quality of staff will be investigated

further in Study 2.

5.4.3 Interpersonal quality

The interpersonal aspect of the interaction between the women and staff was another

important aspect of the consumption experience that was identified in the qualitative

results. In Study 1, many of the women interviewed expressed that having a staff

member who was personable had a great impact on their consumption experience

with breast screening and this denotes the interpersonal quality of the staff. Feelings

of anxiety and discomfort during a breast screen were not uncommon among the

women interviewed and many of them noted that having a friendly staff member

significantly helped to alleviate any negativity experienced. Additionally, being

treated nicely by staff helped the women feel good about themselves as well as their

choice to have a breast screen, thus reinforcing the likelihood of repeating this

behaviour in the future. Given the qualitative results suggest the great importance

and influence this has on women‟s experiences with breast screening, interpersonal

quality of staff will also be investigated further in Study 2.

5.5 Consumer participation in wellness services

The qualitative results of Study 1 identified the consumers themselves as being co-

contributors of value in their consumption experiences. This is evidenced by their

participation in the consumption experience and the role that the consumers play at

all stages of the consumption process. Consumer participation is “the degree to

which the customer is involved in producing and delivering the service” (Dabholkar,

1990, p.484). Consumer participation is important for value creation in wellness as

there has been a shift towards the notion that consumers create value with the


organisation, as opposed to the organisation creating value for the consumer

(Lengnick-Hall, 1996; Prahalad & Ramaswamy, 2004; Vargo & Lusch, 2004). This

follows the concept of co-creation of value, whereby the consumer not only jointly

creates value with the organisation, but co-constructs the experience to suit her

context (Prahalad & Ramaswamy, 2004). This is evidenced by the qualitative

findings of Study 1, which suggest that different women can have different goals

they seek from having breast screens, thus demonstrating different contexts. From an

organisational perspective, this is also reflected by the rise of the service-dominant

logic (S-D logic) (Vargo & Lusch, 2004) whereby the consumer is seen as a “co-

creator of value” (Vargo & Lusch, 2008, p.7). This demonstrates the relevance,

significance and importance in examining the role of consumer participation in the

creation of value for consumers of wellness services.

The results of Study 1 provides evidence to suggest that consumer participation lends

a sense of control to the users of breast screening services, therefore enhancing their

overall consumption experience and identifies cognitive inputs, behavioural inputs,

and affective inputs present in consumer participation in wellness services. Cognitive

inputs are reflected by the motivational direction variable, while behavioural inputs

are reflected by the co-production variable, and affective inputs are reflected by the

stress tolerance variable. There are three aspects to consumer participation that are

required for the achievement of successful outcomes from a wellness service

experience. Consumer must have clarity of the task, ability or competence, and

motivation (Bettencourt, 1997; Lengnick-Hall, 1996; Lovelock & Young, 1979;

Meuter, Bitner, Ostrom, & Brown, 2005). According to Proposition 2, consumer

participation will influence functional and emotional value in wellness services. This

section explains the specific variables of consumer participation.

5.5.1 Motivational direction

Motivational direction considers the appropriateness of the activities to which an

individual directs and maintains effort (Katerberg & Blau, 1983). It has been

suggested that the motivation of the service consumer improves the productivity of

the service organisation and the quality of the service provided (Mills, Hall,


Leidecker, & Margulies, 1983). Motivation is an important aspect in wellness as

motivation is a process that leads people to behave in a specific way (Maslow, 1943).

Thus, an understanding of motivational direction can aid in the understanding of why

consumers use wellness services.

The motivational direction of the consumer is necessary for the achievement of the

desired outcomes, such as the goals identified in Chapter 4. In order to achieve these

goals, the consumer must have an understanding of their role in the consumption

process and the inputs required from them in order to successfully achieve the

desired goals.

For example, many of the women interviewed in Study 1 mention that BSQ has

“done a lot of the work for them” meaning that BSQ sends them reminder letters

when they are due for a breast screen and advises them of the service location closest

to their home of workplace. This removes a lot of the effort that is normally

expended by the consumer in trying to remember when they are due for an

appointment again and locating a service on their own. Thus, these women

acknowledge that it was their responsibility to telephone BSQ once they receive the

letter to organise the appointment, otherwise it will be forgotten. This is an example

of the women understanding that while BSQ has taken on much of the responsibility

in ensuring that these women have their regular breast screens, they are also

responsible for ensuring that this happens by organising their appointments

themselves. Thus, it is hypothesised that motivational direction will influence

functional value, because utility from breast screening cannot be achieved if women

do not have breast screens. Subsequently, motivational direction will be used to

investigate consumer participation further in Study 2.

5.5.2 Co-production

Co-production is constructive customer participation in the service creation and

delivery (Auh et al., 2007). This occurs when consumers are engaged as “active

participants in the organisation‟s work” (Lengnick-Hall, Claycomb, & Inks, 2000,

p.359). Co-production is a central principle of the S-D logic (Vargo & Lusch, 2004)


whereby the consumers create value with the organisation, rather than the

organisation creating value for the consumer alone. Co-production can lead to the

empowerment of the consumer (Auh et al., 2007) which demonstrates the

achievement of control, one of the goals identified in the results of Study 1.

In the context of wellness services, in particular, breast screening, the core service is

the mammogram or breast screen undertaken by the consumer, which is facilitated by

the radiographer. In having a mammogram or a breast screen, the positioning of the

woman‟s body is very important in ensuring that an effective image of the breast can

be taken. It is important for the woman to be positioned correctly, and to hold her

breath while the image is being taken. It is important that the woman is competent

enough or able to adhere to these guidelines to ensure that an accurate screen is

taken. Thus, the woman must know how to co-produce a breast screen with the

radiographer in order to achieve an effective screen. This in turn, creates utility for

the woman from her use of breast screening services, which is reflective of the

functional dimension of value. Thus, it is hypothesised that co-production influences

functional value. This aspect of the co-production is behavioural, as the physical

behaviour of the woman directly affects the outcomes sought. It is necessary for

women to provide these inputs during the consumption experiences in order to

achieve their goals. Thus, co-production is only hypothesised to influence functional

value and not emotional value.

5.5.3 Stress tolerance

Stress tolerance refers to an individual‟s ability to manage stress. It represents one of

the two sub-dimensions of stress management, the other sub-dimension being

impulse control. Stress management is one of the five composite factors of the

Emotional Quotient Inventory (EQ-i) which assesses emotional intelligence (Bar-On,

1997). The management of one‟s emotions to achieve a specific goal represents an

emotional intelligence skill and emotional intelligence is the ability to process

emotions and emotion-relevant stimuli in order to guide thinking and behaviour

(Mayer, Salovey, & Caruso, 2008).


In wellness services, stress tolerance is an appropriate variable that reflects the

emotional effort exerted by consumers (Hochschild, 1983) during their consumption

experiences. Stress tolerance is a form of managing one‟s emotions in order to

achieve specific goals (Mayer & Salovey, 1997). In the context of wellness services,

the qualitative data provided evidence to show that women exerted emotional effort

in order to achieve peace of mind, one of the goals sought by women who use breast

screening services. The qualitative results suggested that a number of the women

interviewed considered breast screening to be a stressful experience, as there is the

negative anticipation of the pain and discomfort of a mammogram as well as the

worry that their results might indicate a problem. However, many of the women

reported that they would not allow themselves to have negative thoughts and made

the effort to either remove these negative thoughts from their minds, or to think

positively instead.

This provided them with a sense of control and allowed for the achievement of peace

of mind, which is reflective of the emotional dimension of value. Thus, it is

hypothesised that stress tolerance will influence emotional value. As this allows the

women to feel better and does not have a direct impact on the core service outcome

(i.e. an accurate breast screen), therefore stress tolerance is hypothesised to only

influence emotional value and not functional value.

5.6 Relationship between interaction and value

The results of Study 1 identified interaction with systems and process and with staff

as important sources in the creation of value for consumers of wellness services.

Interaction with systems and processes is reflected by the service quality variable;

administrative quality. Administrative service elements facilitate the production of a

core service while providing value to the consumer using the service (Grönroos,

1990; McDougall & Levesque, 1994). The extent to which this is done well reflects

administrative quality. Although the results of Study 1 also identify information from

the organisation as a source of value, this is encompassed within interaction with

systems and processes. For example, information from the reminder letters that are


routinely sent to women who are due for an appointment forms part of the service

process at BSQ.

Interaction with staff is reflected by two service quality variables; technical quality

and interpersonal quality. Technical quality of staff refers to the technical

competence of staff (Ware, Davies-Avery, & Stewart, 1978), while interpersonal

quality of staff refers to the dyadic relationship between the consumer and the service

provider (Brady & Cronin, 2001; Grönroos, 1984). Information is also encompassed

with interaction with staff. For example, information is provided by the staff to

women in the form of instructions to hold their breath while an image is taken,

followed by an explanation as to why this helps achieve a better screen. According to

Proposition 1, the variables within organisational sources of value will influence

functional and emotional value for consumers using wellness services. This section

explains the relationship between the specific variables of organisational sources

with the dimensions of value.

5.6.1 Administrative quality and functional value

It is anticipated that a woman‟s interaction with the service organisation‟s systems

and process will have an influence over her determination of functional value. The

systems and processes of the organisation can be considered as administrative service

elements, which facilitate the production of a core service and at the same time, adds

value to the customer‟s use of the service (Grönroos, 1990; McDougall & Levesque,

1994). Aspects such as timeliness of the service and service operation (Dagger et al.,

2007) contribute towards the administrative quality (McDougall & Levesque, 1994)

of the service. Evidence was found in the qualitative findings for aspects such as

timeliness of the service and service operation, which contribute towards the overall

administrative quality of the service.

These aspects reflect the systems and processes of the organisation that the

consumers interact with and create utility for the women using the service, thus will

having an impact on the functional value that is experienced by the women. These

aspects of the service experience also create convenience for women if the processes


are easy to use and understand. As such, this gives rise to the first hypothesis to be

tested:

H1 a: Administrative quality is significantly and positively associated with

functional value for consumers of wellness services.

The creation of functional value occurs reactively through the consumers‟ interaction

with the organisation‟s systems and processes. The value creation is reactive because

the systems and processes are determined by the organisation and the user is only

required to respond towards the systems and processes put in place. The user is not

required to participate in heightened collaboration with the organisation.

5.6.2 Technical quality and functional value

It is anticipated that a woman‟s interaction with the service organisation‟s staff will

also have an influence over her determination of functional value. This interaction is

likely to lead to an assessment of technical quality possessed by the staff, as well as

interpersonal quality possessed by the staff. The technical quality of staff has an

impact on the outcomes achieved (Grönroos, 1984; McDougall and Levesque, 1994)

from an individual‟s use of a service. Aspects such as the expertise of the staff and

the outcomes the women expect as a result of the service received (Dagger et al.,

2007) are sub-dimensions of technical quality (Brady & Cronin, 2001; Rust &

Oliver, 1994). Evidence was found in the qualitative findings for aspects such as

outcome and expertise, which contribute towards the overall technical quality of the

service staff.

These aspects of the service experience also create utility for the woman using the

service, thus having an impact on the functional value that is experienced by the

women using breast screening services. As such, this gives rise to the second

hypothesis to be tested:

H1 b: Technical quality is significantly and positively associated with



The creation of functional value occurs reactively through the consumers‟ interaction

with the organisation‟s staff. The value creation is reactive because the users are able

to assess the quality of their interactions at a distance without the need for heightened

engagement with the service provider.

5.6.3 Interpersonal quality and emotional value

The data also suggests that the nature of the interaction between the women and staff

members at breast screening services will also have an impact on the women‟s

determination of emotional value. This is due to the quality of the interpersonal

interactions, where friendliness and warmth of the staff were identified by the

women interviewed as having an influence over their experiences with the service.

Aspects such as the nature of the interaction and relationship (Dagger et al., 2007)

contribute towards interpersonal quality (Brady & Cronin, 2001; Rust & Oliver,

1994) of the service. Relationship refers to the relationship between a consumer and

service provider on the basis of closeness and strength of the relationship (Beatty,

Mayer, Coleman, Ellis, & Lee, 1996). In breast screening, it is unlikely that

relationship with have an impact on consumers‟ service experiences due to the long

time lag between service encounters. As such, there is little opportunity for the

service to develop ongoing, close relationships with their clients, which are attributes

that typify service relationships (Koerner, 2000).

Despite this, aspects of interaction such as manner, attitude, and communication of

the staff towards the consumers is important in breast screening. In the interviews,

many of the women highlighted that the manner and attitude of staff were influential

in their experiences with the service and that having pleasant staff made the service

interaction more pleasant. These aspects create peace of mind for the woman using

the service, thus will have an impact on the emotional value that is experienced.

Evidence was found in the qualitative findings for interaction, which is a sub-

dimension of the interpersonal quality construct. This contributes towards the overall

interpersonal quality of the service staff. As such, this gives rise to the third

hypothesis to be tested:


H1 c: Interpersonal quality is significantly and positively associated with

emotional value for consumers of wellness services.

The creation of emotional value occurs reactively through the consumers‟ interaction

with the organisation‟s staff. The value creation is reactive because the users are able

to assess the quality of their interactions at a distance without the need for heightened

engagement with the service provider.

5.7 Relationship between motivational direction and functional

value

It is hypothesised that motivational direction will influence functional value, because

consumers must be motivated to use breast screening services and utility from breast

screening cannot be achieved if women do not have breast screens. In the context of

breast screening, it is important that the women understand the contributions that

they have to make in order to achieve the outcomes they desire. Examples from the

qualitative data include knowing that it was the woman‟s responsibility to call BSQ

herself to organise her own appointment, or following the radiographer‟s instructions

during the mammogram despite any physical discomfort experienced. Motivation

drives consumers to achieve specific goals (Maslow, 1943) and for many of the

women interviewed, the qualitative data identified control and utility as two goals

they seek to achieve from their use of breast screening services. Control is achieved

when the women feel that they have contributed towards the core service production

by being an active participant in the service exchange. This creates utility out of the

service experience, thus influencing the functional value experience.

The creation of functional value occurs both actively and reactively. In active

creation of functional value, the women who provided cognitive inputs into their

service experiences were the ones who were more engaged and involved in the

consumption process, as evidenced by the qualitative results of Study 1. These

women tended to be more conscientious, and therefore more active in thinking about

how they could contribute towards achieving a better outcome from their service

experience. However, a basic understanding of the women‟s role in the consumption


process was also necessary in order to successfully achieve functional value from the

use of the service. This exemplifies the creation of functional value that occurs

reactively. The women are required to have a basic understanding of their roles as

consumers, such as the responsibility to organise an appointment rests with them and

not with BSQ.

Since consumers‟ motivational direction propels them to use wellness services,

which in turn creates utility from the use of the service, this gives rise to the

following hypothesis to be tested in Study 2:

H2 a: Motivational direction is significantly and positively associated with


5.8 Relationship between co-production and functional value

Co-production is hypothesised to influence functional value as women must know

how to co-produce a breast screen with the radiographer in order to achieve an

effective screen. For example, they must position or move their bodies according to

the instructions of the radiographer, or even wearing a two-piece outfit for easy

removal of the top to have a breast screen. These represent the physical aspects of

the contributions provided by the women that affect the efficiency and effectiveness

of breast screens. By acting as a co-producer of the service experience, this creates

control for the consumer as it allows the woman to be proactive in contributing

towards achieving a good outcome from the service with the service provider.

Subsequently, this leads to utility being created out of the service experience, thus

having an impact on the functional value experienced.

The creation of functional value can occur either reactively or actively when

behavioural inputs are supplied. This appears to be contingent on the extent of the

involvement the user is willing to have with the service experience. Some of the

women interviewed were satisfied in merely responding to the service provider‟s

request for behavioural inputs (e.g. holding their breath when asked to) and this

demonstrates the creation of functional value that is reactive and this achieves utility


for the consumer from the breast screen. This is supported by the literature, which

describes some customers as being reluctant to exert a high level of involvement in

the service process (Solomon, Suprenant, Czepiel, & Grutman, 1985).

On the other hand, other women interviewed were more active in supplying

behavioural inputs towards the service because they wanted to contribute towards

achieving the best outcome possible with the service provider. This achieves control

for the user and demonstrates the creation of functional value that is active. This

higher level of co-production is appealing to other customers because it allows them

to experience perceived control over the service delivery process (Bateson, 1985).

Co-production can be seen as the extent to which customers are engaged in the

service process as active participants (Lengnick-Hall et al., 2000) at the

customer/service provider level (Auh et al., 2007) demonstrating the active creation

of functional value. Since co-production of breast screening services is necessary for

the creation and delivery of the core service, this gives rise to the next hypothesis:

H2 b: Co-production is significantly and positively associated with functional

value for consumers of wellness services.

5.9 Relationship between stress tolerance and emotional value

Stress tolerance is hypothesised to influence emotional value, because the ability to

control their stress experienced from breast screening provides women with a sense

of control and allowed for the achievement of peace of mind, which is reflective of

the emotional dimension of value. Examples of contributions made by the women

that demonstrate stress tolerance include practicing positive thinking when

wondering what their results might say, or telling themselves that the discomfort or

embarrassment of breast screening is only momentary and does not outweigh the

benefits it provides. This creates emotional value for these women.

The creation of emotional value from affective inputs occurs actively. The qualitative

data revealed that the women who contributed to their consumption experiences by

practicing stress tolerance were also the ones who were more engaged and involved


in the consumption process. Since these women were more engaged and involved, it

was beneficial for them to provide affective inputs, particularly at the end of the

service encounter, so that they would not overthink about their results. Furthermore,

the women had to be active in their management of any stress or negative emotions

they might experience from wondering what their results might say. This is a form of

control for these women, which in turn results in peace of mind. Since peace of

mind is reflective of the emotional dimension of value, this leads to the next

hypothesis:

H2 c: Stress tolerance is significantly and positively associated with

emotional value for consumers of wellness services.

5.10 Marketing outcomes of value creation in wellness services

It is anticipated that the marketing outcomes of value creation in wellness services

are satisfaction and behavioural intentions. This proposition is guided by service

quality research which shows that consumers‟ perceptions of service quality lead to

their satisfaction with the service, which subsequently influences their behavioural

intentions (e.g. Dagger et al., 2007). This can be applied to wellness services and it

can be posited that consumers‟ experience of value can lead to their satisfaction with

the wellness behaviour, which subsequently influences with behavioural intentions to

perform the behaviour again in the future. This proposition is supported by research

in the Business-to-Business (B2B) area, which has found that consumer value leads

to satisfaction, which subsequently leads to behavioural intentions (Eggert & Ulaga,

2002). Thus, it is anticipated that the same will apply in the social marketing area.

Satisfaction is an evaluation of a consumption experience and is determined by the

consumer‟s overall feelings or attitudes they have about a product or service after it

has been purchased (Oliver, 1997). Satisfaction is applicable in the context of social

marketing and wellness because it can be an evaluation of a consumption experience

and in this context, a woman‟s evaluation of her experiences with breast screening.

In commercial marketing, satisfaction is an important predictor for future

behavioural variables such as repurchase intentions, word-of-mouth, and loyalty


(Liljander & Strandvik, 1995; Ravald & Grönroos, 1996). In social marketing and

especially in the use of wellness services, the long-term continuation of the desired

behaviour is key in successfully achieving social marketing goals. Thus, it is

important to explore the behavioural intentions of consumers in wellness services in

order to determine the likelihood of sustained behaviour over the long-term.

5.11 Relationship between value and marketing outcomes:

satisfaction and behavioural intentions

This thesis proposes that individuals‟ propensity to use wellness services would be

influenced by the value they experience from their use of these services. It is posited

that when consumers who use wellness services experience value from their

consumption experiences, this will influence their satisfaction with the experience.

This section will elaborate further the hypothesised relationships between value,

satisfaction, and behavioural intentions.

5.11.1 Relationship between value and satisfaction

The qualitative results provide evidence that the experience of value reflects the

achievement of goals for women who use breast screening services. Women can be

satisfied with their consumption experience if they have experienced functional

value, as this would indicate that utilitarian goals such as utility and convenience are

achieved. Likewise, satisfaction can arise from having experienced emotional value

through the achievement of peace of mind, another goal identified in the qualitative

results.

As consumers act out of self-interest (Rothschild, 1999), it is logical to expect that

they will be satisfied once they have experienced value and fulfilled the goals that

they sought from their use of wellness services. Although there is some research that

argues consumer value has a direct impact on behavioural outcomes and disregards

the role of satisfaction (e.g. Zeithaml, 1988, p.4) other research in the B2B area

suggests that while there is a direct relationship between consumer value and


behavioural intentions, consumer value does lead to satisfaction, which then leads to

behavioural intentions and that satisfaction is still a robust predictor of behavioural

intentions (Eggert & Ulaga, 2002). Therefore, it is worth investigating the

relationship between value and satisfaction in the context of wellness services. Thus,

it is anticipated that the experience of value will lead to satisfaction with overall

experience. Given that Study 2 will test the relationships between the identified

sources of value with functional and emotional value, the following two hypotheses

are developed:

H3 a: Satisfaction is significantly and positively associated with functional


H3 b: Satisfaction is significantly and positively associated with emotional


5.11.2 Relationship between satisfaction and behavioural intentions

The women‟s satisfaction with their consumption experiences will then have an

influence over their intentions to have breast screens again in the future as

satisfaction is a widely accepted predictor of behavioural intentions. The qualitative

results suggest that all of the women interviewed have the intention to have breast

screens again in the future and all of these women have had satisfying experiences at

BSQ. Some of the women interviewed expressed dissatisfaction with their

experiences at other service providers that they have used in the past but were current

users of BSQ‟s services at the time of their interviews. Many of the women

interviewed expressed their satisfaction with the preventive health behaviour of

breast screening, as it was an effective health check that provided them with utility

and gave them peace of mind that their health remains well.

Satisfaction is widely accepted as a strong predictor for behavioural variables such as

repurchase intentions, word-of-mouth, or loyalty (Liljander & Strandvik, 1995;

Ravald & Grönroos, 1996). In the context of wellness services, this can be likened to

consumers‟ intentions to use breast screening services again in the future, which is


similar to repurchase intentions. In addition, other intentions include spreading

positive word-of-mouth about breast screening to other women, which exemplifies

self-as-influencer, one of the goals identified from the qualitative results in Chapter

4. Another example of intentions is a commitment towards the act of breast screening

which reflects loyalty, specifically attitudinal loyalty (Parkinson, 2009). Thus, it is

anticipated that satisfaction with breast screening will influence women‟s

behavioural intentions around breast screening, which gives rise to the final

hypothesis:

H4: Behavioural intentions are significantly and positively associated with

satisfaction in wellness services.

5.12 Summary of propositions, hypotheses and model to be tested

Based on the theoretical model developed from the findings of Study 1, eight

hypotheses were developed to answer the three sub-research questions. In this

chapter, it was identified that only functional and emotional value will be tested in

Study 2. This will still address the first sub-research question as Study 2 will

quantitatively test for evidence of functional and emotional value in wellness

services:

RQ 1: What are the dimensions of value experienced by users of wellness

services?

This chapter also identified that only organisational and consumer participation

sources of value will be tested in Study 2. This addresses the second sub-research

question as Study 2 will quantitatively test for evidence of administrative quality,

technical quality, interpersonal quality, motivational direction, co-production, and

stress tolerance in wellness services:

RQ 2: What are the sources of value that exist in wellness services?


In identifying the dimensions and sources of value, Study 2 will also test the

relationships between them in order to answer the third sub-research question:

RQ 3: What is the relationship between sources and dimensions of value in

wellness services?

It is hypothesised that administrative quality, technical quality, motivational

direction, and co-production will be positively associated with functional value,

while interpersonal quality and stress tolerance will be positively associated with

emotional value. Table 5.2 summarises the propositions explained in Chapter 4 and

identifies the subsequent hypothesised relationships, as well as the goals that explain

these relationships.

Table 5. 2 Summary of propositions & hypotheses to be tested in Study 2 and relevant

goals

Propositions Goal(s) identified in Study 1

Hypotheses

Proposition 1:

Organisational sources will influence functional and emotional value for consumers of wellness services

Utility Convenience

H1 a: Administrative quality is significantly and positively associated with functional value for consumers of wellness services.

Utility

H1 b: Technical quality is significantly and

positively associated with functional value for consumers of wellness services.

Peace of mind H1 c: Interpersonal quality is significantly and positively associated with emotional value for consumers of wellness services.

Proposition 2:

Consumer participation will influence functional and emotional value for consumers of wellness services.

Control Utility

H2 a: Motivational direction is significantly and positively associated with functional value for consumers of wellness services.

Control Utility

H2 b: Co-production is significantly and positively associated with functional value for consumers of wellness services.

Control Peace of mind

H2 c: Stress tolerance is significantly and positively associated with emotional value for consumers of wellness services.

Proposition 3: The experience of value will lead to satisfaction of consumers of wellness services

NA H3 a: Satisfaction is significantly and positively associated with functional value in wellness services.

NA H3 b: Satisfaction is significantly and positively associated with emotional value in wellness services.

Proposition 4: Satisfaction of consumers who use wellness services will influence their behavioural intentions

NA

H4: Behavioural intentions are significantly and positively associated with satisfaction in wellness services.


Three additional hypotheses were developed to demonstrate that when consumers

experience value from their use of wellness services, they derive satisfaction, which

in turn influences their behavioural intentions to use wellness services again. This

fulfils the social marketing objective of achieving wellness behaviour that is

maintained in the long-term.

In addition, to the hypotheses presented, a measurement model was developed

(Figure 5.1). This model illustrates the hypothesised relationships discussed in this

chapter and shows the relationships between the constructs that will be tested in

Study 2. The model also illustrates the hypothesised relationship between functional

and emotional value with satisfaction with breast screening, and between satisfaction

with breast screening and behavioural intentions. The method for testing this model

is outlined in the next chapter.

5.13 Conclusion

In conclusion, this chapter provided detailed explanation of the hypothesised

relationships between the sources and dimensions of value in preventive, wellness

services and explains these relationships using the goals identified in Study 1. In

Study 2, these relationships will be tested and will quantitatively address all three

sub-research questions. These hypotheses were derived from the findings from Study

1, which qualitatively addresses all three sub-research questions. The following

Chapter 6 will present the results of the quantitative analysis of Study 1, and a

discussion of the overall findings from both studies will be presented in the

subsequent Chapter 7.

Chapter 6: Results of Quantitative Study 2 178

CHAPTER 6 RESULTS OF QUANTITATIVE STUDY 2

“By three methods we may learn wisdom: First, by reflection, which is noblest;

Second, by imitation, which is easiest; and third by experience,

which is the bitterest”

Confucius

6.1 Introduction

In the previous chapter, the research methodology for Study 2 was discussed in

detailed for the testing of the hypotheses presented in Chapter 5. In this chapter, the

results of Study 2 are presented, including the sample characteristics, data screening,

measurement model assessment and structural model fit. Initial analysis of the data

was undertaken using PASW 18 statistics software, followed by a structural equation

analysis using AMOS 18 software that was undertaken to test the relationships

between the constructs identified in the theoretical model. The analysis of the data is

presented in this chapter.

6.2 Sample and response rate

The data for this study was collected over a 12-day period between 23 September

2010 and 3 October 2010. Email invitations to 5,459 members of a consumer list

were sent to women 50 and 69 years old (inclusive) to seek their participation in the

survey. The members were recruited from First Direct Solutions, which acquired a

database of members through consumers‟ completion of the Australian Lifestyle

Survey. Of this group, 98.8% (n=5394) of the emails were successfully sent and

32.6% (n=1757) of these emails were opened by the recipients. However, 69.4%

(n=1219) of these recipients clicked on the survey link provided while the remainder

did not. Of the recipients who clicked on the survey link, 90.6% (n=1105) went on to

complete the survey. A summary is presented in Figure 6.1.


Figure 6. 1 Summary of online responses to email invitation to participate in Study 2

The number of survey completions based on the initial sample size of 5,459

represents a response rate of 20.2%. In order to ensure that the sample was reflective

of the primary target segment for breast cancer screening, the respondents were

screened to fulfil the three eligibility criteria. First, in order to fulfil the age criteria,

the email invitation to participate in the study was sent to women born between 1941

and 1960 in order to ensure that respondents were aged 50 to 69 years old

(inclusive). Next, in order to ensure that the respondents had used breast cancer

screening services at least once, a screening question was used However, the

respondents were screened further to ensure that the remaining eligibility criteria

were fulfilled.

The first screening question asked the respondents if they had used breast screening

services before. Of the 976 respondents, 88.8% (n=981) of them had used breast

screening services before while the remainder had not. The respondents who had

indicated that they have used breast screening service before were asked to answer

the second screening question, which was if they had ever been diagnosed with

breast cancer. Of this group, 6.4% (n=63) of the women indicated that they had been

TOTAL EMAILS SENT, n=5459

Successfully sent, n=5394

(98.8%)

Unsuccessfully sent, n=65

(1.2%)

Total opened, n=1757

(32.6%)

Total did not open, n=3637

(67.4%)

Clicked on link, n=1219

(69.4%)

Did not click on link, n=538

(30.6%)

Completed survey, n=1105

(90.6%)

Did not complete survey, n=114

(9.4%)


diagnosed with breast cancer before and were removed from the sample. The

remaining respondents were screened again according to the service provider that

they use. Women who indicated that they use BreastScreen Australia services in the

different states and territories were retained (n=804). The remainder of the

respondents either indicated that they use other breast screening services, or could

not remember the service provider that they use. Women who indicated that they

used mobile screening services and did not pay for them (n=6) were retained.

Similarly, women who could not remember the service provider they used but

indicated that they did not pay for them (n=21) were also retained as this indicated

that they were users of free government service providers. Finally, the remaining

respondents were then screened further to remove any women outside of the target

age group as the data indicated that some of the respondents fell outside of the 50-69

year age bracket. This produced a final sample size of n=797. A sample of this size is

deemed appropriate for theory testing, as the purpose of this study is to explore the

relationships between the sources and dimensions of value, as well as satisfaction

and behavioural intentions, rather than to provide parameters applicable to the

population (Ferber, 1977). A summary of the screening process is presented in

Figure 6.2.


Figure 6. 2 Sample screening process

TOTAL COMPLETIONS,

n=1105

Have had breast screens before, n =981

(88.8%)

Have never had breast screens, n = 124

(11.2%)

Never been diagnosed with breast cancer, n=919

(93.6%)

Have been diagnosed with breast cancer, n=63

(6.4%)

Cannot remember,

n=31

Use BreastScreen, n=804

Use other services,

n=83

Paid services,

n=5

Free services,

n=21

No response,

n=5

Private services,

n=77

Mobile and free

services, n=6

Below 50 years,

n=27 TARGET AGE GROUP,

n=797

70 years and above,

n=7

Sub-total,

n=831


6.3 Tests for non-response bias, missing data and common-

method bias

Using time-trend analysis (Armstrong & Overton, 1977), non-response biased was

assessed and no significant differences were found between early and late

respondents. In the treatment of missing data, the all-available approach (i.e. pairwise

deletion) was used as this provides fewer problems with convergence and factor

loading estimates are relatively free of bias (Hair Jr. et al., 2006). Data entry was

accurate as the data was entered directly into MS Excel, which was then copied into

PASW18. Harman‟s one-factor test was performed to assess common method bias

(Podsakoff et al., 2003) and no bias was present.

6.4 Sample characteristics

The respondents were asked a series of demographic questions such as their age,

employment status, state of residence, and ethnicity (see Table 6.1). The mean age of

the women who participated in the survey was 58.8 years and within this sample,

38.8% of women were in employment and 38.9% were retired. Data was collected

from women residing in all states and territories in Australia with the highest

proportion of the respondents residing in New South Wales (30.1%), followed by

Queensland (28.6%). The majority of the women who participated in the survey were

of Caucasian ethnicity (97.0%), although a small number of women of other

ethnicities also participated in the survey. These included women who were Asians,

Aboriginal or Torres Strait Islanders, Maoris, and Middle Eastern.


Table 6. 1 Sample characteristics – demographic information

Percent

Employment status Employed 38.8 Self-employed 7.7 Not currently in employment 14.6 Retired 38.9

State Queensland 28.6 New South Wales 30.1 Victoria 17.4 Tasmania 3.4 South Australia 7.9 Western Australia 10.1 Northern Territory 1.1 ACT 1.5

Ethnicity Caucasian 97.0 Asian 0.8 Aboriginal or Torres Strait Islander 0.4 Other 1.9

As the qualitative data of Study 1 suggested that the influence of family was an

important factor in women‟s determination of value from their breast screening

experiences, the respondents were also asked questions about their family

background. Most of the women in the study were married (53.2%) and most had

children (87.3%). The qualitative data of Study 1 also suggested that family history

of health problems (cancer or non-cancer) also had an impact on the women

interviewed. Thus the respondents of Study 2 were asked about any family history of

health problems. While most of the respondents indicated family history of health

problems (59.1%), a large proportion of the respondents indicated no family history

(40.9%). The respondents were also asked specifically if they knew of others with

breast cancer, including both family members and non-family members. A very large

proportion of the respondents (87.3%) indicated that they knew at least one woman

with breast cancer. A summary of these findings are presented in Table 6.2.

Table 6. 2 Sample characteristics – family background

Percent

Marital status Married 53.2 Never married 6.5 Divorced/separated 30.1 Widowed 10.2

Children Daughters only 17.2 Sons only 19.6 Both male and female children 50.6 No children 12.7

Know of others with breast cancer Yes 87.3 No 12.7

Family history of health problems No family history of health problems 40.9 Family history of health problems 59.1


Finally, the respondents were also asked a series of questions about their history of

use of breast screening services. In Study 1, it was found that more women

commenced breast screening before the age of 50. In Study 2, the respondents were

asked for their age when they commenced breast screening and it was found that the

largest proportion of women started breast screening in their forties (45.5%). This

was followed closely by women who started breast screening in their fifties (40.5%)

as recommended. The reason for commencement was also asked and it was found

that the majority of women commenced breast screening because they received an

introduction letter to screening (31.1%). This was in contrast to the qualitative

findings of Study 1 which indicated more of the women interviewed commenced

breast screening on the recommendation of their doctor. Doctor‟s recommendation

was the next highest cited reason for commencement (26.2%). Many women also

cited other reasons for the commencement of breast screening (23.5%); the discovery

of non-cancerous breast lumps was the most commonly cited reason. Most of the

respondents have their breast screens every 2 years as recommended (81.0%), while

the number of women who screen more frequently was comparable with the number

of women who screen less frequently (9.7% and 9.3% respectively). Approximately

two-thirds of the respondents have only used the same breast screening service

provider (66.3%).

Table 6. 3 Sample characteristics – breast screening history

Percent

Age when first started breast screening 60s or older 1.0 50s 40.3 40s 45.2 30s 8.7 20s or younger 1.8 Unsure 3.1

Reason for starting breast screening Introduction letter 30.9 Advertising 17.7 Doctor’s recommendation 28.4 Menopause 9.9 Other 22.8

Frequency of breast screening Less than every 2 years 9.5

Every 2 years 80.4

More than every 2 years 10.0

Service providers used Only use the same service provider 65.2 Have been to other service providers 34.8


6.5 Construct Reliability

Construct reliability (CR) is a measure of the reliability and internal consistency of

the indicators within a latent construct (Hair Jr. et al., 2006). The scales used in this

study were adapted from the literature as the existing scales were not specific to the

setting of this research. It was necessary to test the appropriateness of using these

scales in a different research context (Nunnally & Bernstein, 1994) thus reliability

tests were performed on all the items of the latent constructs. Cronbach‟s Alpha and

item-to-total correlations were used to assess internal reliability of the instrument

(Nunnally & Bernstein, 1994). The Cronbach‟s Alpha and item-to-total statistics for

the latent variables in this study are presented from Table 6.4 to Table 6.13.

Table 6. 4 Cronbach’s Alpha and Item-to-total statistics for functional value

Items Item-to-total correlation

Breast screens have consistent quality .70 Breast screens are well delivered .70 Breast screens have an acceptable standard of quality .72 Breast screens perform consistently .73 Breast screening helps women live healthy lives .71 Breast screening helps women prevent breast cancer .52 Breast screening helps women lead healthy lives .66

Cronbach’s alpha .88

Table 6. 5 Cronbach’s Alpha and Item-to-total statistics for emotional value


Breast screening is something that I enjoy .62 I want to have breast screens .61 I feel relaxed about having breast screens .67 Having breast screens makes me feel good .75 Having breast screens gives me pleasure .61 Having breast screens makes me feel protected .63 Having breast screens makes me feel comfortable .72 Having breast screens makes me feel safe .67 Having breast screens makes me feel happy .78 Having breast screens makes me feel calm .79 Having breast screens makes me feel relieved .64 Having breast screens makes me feel proud .65


Table 6. 6 Cronbach’s Alpha and Item-to-total statistics for administrative quality


The administration system at the place I usually go to is excellent .91 The administration at the place I usually go to is of a high standard .93 I have confidence in the administration system at the place I usually go to .89



Table 6. 7 Cronbach’s Alpha and Item-to-total statistics for technical quality


The quality of the service I receive at the place I usually go to is excellent .89 The service provided by the place I usually go to is of a high standard .90 I am impressed by the service provided at the place I usually go to .87


Table 6. 8 Cronbach’s Alpha and Item-to-total statistics for interpersonal quality


The interaction I have with the staff at the place I usually go to is of a high standard

.91

The interaction I have with the staff at the place I usually go to is excellent .92 I feel good about the interaction I have with the staff at the place I usually go to .87


Table 6. 9 Cronbach’s Alpha and Item-to-total statistics for motivational direction



.59


.69

It is important for me as a customer to understand my role associated with the service, e.g. filling in all my paperwork correctly

.57


.60


Table 6. 10 Cronbach’s Alpha and Item-to-total statistics for co-production


I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised

.66

I do things to make the radiographer’s job easier e.g. wearing a two-piece outfit so my top can be removed easily

.68

I prepare my queries before going to a breast screen appointment .65 I openly discuss my needs with the staff to help them deliver the best possible service, e.g. letting them know if I have an injury

.68



Table 6. 11 Cronbach’s Alpha and Item-to-total statistics for stress tolerance


I know how to deal with upsetting problems, e.g. if my results indicated that there were any problems

.39


.60

I can handle stress without getting too nervous e.g. waiting for the results of my breast screen

.64

I don't hold up well under stress, e.g. wondering what my results might say to the point I get stressed*

.59

I feel that it's hard for me to control my anxiety, e.g. when I wait for the result of my breast screen*

.64

I know how to keep calm in difficult situations, e.g. when I find the breast screen to be painful

.46

It's hard for me to face unpleasant things such as breast screens* .58 I get anxious when it comes to having breast screens* .58


Table 6. 12 Cronbach’s Alpha and Item-to-total statistics for satisfaction


My feelings towards breast screening are very positive .76 I feel good about having breast screens .71 Overall, I am satisfied with breast screening and the benefits it provides .80 I feel satisfied that the results of my breast screen are the best that can be achieved

.76


.79


Table 6. 13 Cronbach’s Alpha and Item-to-total statistics for behavioural intentions


I would highly recommend breast screening to other women .80 I have said positive things about breast screening to my family and friends .71 I intend to continue having breast screens .81 I have no desire to stop breast screening .81 I intend to follow any medical advice given to me about breast screening .81


6.6 Construct validation – Exploratory Factor Analysis

Construct validity is the extent to which a set of measured variables represent the

theoretical latent construct that the variables were designed to measure (Hair Jr. et

al., 2006) and convergent validity refers to the extent to which these variables

converge or share variance (Hair Jr. et al., 2006). Construct validity was conducted

on the indicators of the latent constructs using Exploratory Factor Analysis (EFA) in

PASW 18. Principal axis factoring using direct oblimin rotation was conducted in the

items after reliability analysis (Tabachnick & Fidell, 1996). Items with low loadings


below .60 as recommended by Nunnally and Bernstein (1994) and items that cross-

loaded onto multiple dimensions were removed on the basis of low loadings or split.

Exploratory factor analysis (EFA) was conducted on all the constructs after the initial

reliability analysis, resulting in seven factors. First, the items for functional value

(FV) loaded onto a single factor, as well as the items for emotional value (EV)

loading onto a single factor. In comparison, the items for administrative quality

(AQ), technical quality (TQ), and interpersonal quality (PQ) all loaded onto the same

factor. This could be attributed to these constructs belonging to an overall service

quality (SQ) construct. The items for motivational direction (MD), co-production

(CP), and stress tolerance (ST) loaded onto three separate factors. Finally, the items

for satisfaction (SAT) and behavioural intentions (BI) loaded onto a single factor.

This could be attributed to these constructs being outcome variables in the

hypothesised model.

The EFA also revealed two items cross-loading onto two separate factors. The first

item that cross-loaded was “I feel good about breast screens” which belonged to the

satisfaction construct, however it cross-loaded on to the emotional value construct.

Thus, this item was removed on the basis of cross-loading. The second item that

cross-loaded was “It is important for me as a customer to understand my role

associated with the service, e.g. filling in all my paperwork correctly” which

belonged to the motivational direction construct, however it cross-loaded on to the

co-production construct. This item was also subsequently removed on the basis of

cross-loading.

Finally, the EFA revealed one item that loaded onto the factor of a different

construct. The item “Having breast screens makes me feel protected” belonged to the

emotional value construct, however it loaded on to the functional value construct

with a low loading of .362 and thus, was removed. As such, three items were

removed in total after the initial EFA conducted.


A second EFA was then conducted on the individual constructs. For functional value,

the items continued to load onto the same factor with no cross-loadings and no low-

loadings. This resulted in four final items.

Table 6. 14 Summary of initial items for functional value

Item Factor loading

Breast screens have consistent quality .82 Breast screens are well delivered .80 Breast screens have an acceptable standard of quality .86 Breast screens perform consistently .85

Variance explained 69.3%

The second EFA conducted on emotional value also showed that the items continued

to load onto the same factor with no cross-loadings and no low-loadings. This

resulted in six final items.

Table 6. 15 Summary of initial items for emotional value

Item Factor loading

Having breast screens makes me feel comfortable .75 Having breast screens makes me feel safe .68 Having breast screens makes me feel happy .85 Having breast screens makes me feel calm .84 Having breast screens makes me feel relieved .68 Having breast screens makes me feel proud .67


As the initial EFA revealed the three service quality constructs loading onto the same

factor, the items from these constructs were subjected to a second EFA as a

combined service quality construct. This revealed no cross-loadings and no low-

loadings. However, a third EFA was conducted with an attempt to force a three-

factor construct but this resulted in cross-loadings and low-loadings of two of the

items. Thus, a uni-dimensional construct of service quality was retained. This

resulted in nine final items.

Table 6. 16 Summary of initial items for service quality

Item Factor loading

The administration system at the place I usually go to is excellent .86 The administration at the place I usually go to is of a high standard .86 I have confidence in the administration system at the place I usually go to .87 The quality of the service I receive at the place I usually go to is excellent .91 The service provided by the place I usually go to is of a high standard .88 I am impressed by the service provided at the place I usually go to .91 The interaction I have with the staff at the place I usually go to is of a high standard

.86




The second EFA conducted on motivational direction showed that the items loaded

on to the same factor and there were no cross-loadings or low-loadings. This resulted

in three final items.

Table 6. 17 Summary of initial items for motivational direction

Item Factor loading


.64


.85


.73


The second EFA conducted on co-production showed that the items also loaded on to

the same factor and there were no cross-loadings or low-loadings. This resulted in

four final items.

Table 6. 18 Summary of initial items for co-production

Item Factor loading

I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised

.75


.81


.64


The second EFA conducted on stress tolerance showed that the items loaded on the

same factor and there were no cross-loadings. However, low-loadings occurred for

two of the items. The item with the lowest loading (.55) was removed, however the

second item with low-loading (.58) was not removed as a minimum of three items, as

is the recommended approach in the literature (e.g. Hau & Marsh, 2004) was

required to conduct confirmatory factor analysis (CFA) on the remaining items and

the loading was just below the minimum .60 required. This resulted in three final

items.


Table 6. 19 Summary of initial items for stress tolerance

Item Factor loading

I know how to deal with upsetting problem, e.g. if my results indicated that there were any problems

.55


.84


.89


.58


As the initial EFA revealed that the items for satisfaction and behavioural intentions

loaded on to the same factor, a second EFA was conducted on these constructs

together. This revealed a two-factor structure, however two of the items cross-loaded

on to the two factors. These two items were word-of-mouth (WOM) items “I have

said positive things about breast screening to my family and friends” and “I would

highly recommend breast screening to other women.” These two items were

removed and a third EFA was conducted on the remaining items, which revealed a

uni-dimensional construct with no cross-loadings or low-loadings. However, as

satisfaction and behavioural intentions are two conceptually distinct constructs, a

fourth EFA was conducted on these constructs separately.

The EFA conducted on the satisfaction construct only revealed a uni-dimensional

construct with no cross-loadings or low-loadings. This resulted in four final items.

Table 6. 20 Summary of initial items for satisfaction

Item Factor loading

My feelings towards breast screening are very positive .72 Overall, I am satisfied with breast screening and the benefits it provides .88 I feel satisfied that the results of my breast screen are the best that can be achieved

.89


.85



The EFA conducted on the behavioural intentions construct also included the word-

of-mouth items, and revealed a uni-dimensional construct with no cross-loadings or

low-loadings. This resulted in five final items.

Table 6. 21 Summary of initial items for behavioural intentions

Item Factor loading

I intend to continue having breast screens .96 I have no desire to stop breast screening .90 I intend to follow any medical advice given to me about breast screening .81 I would highly recommend breast screening to other women .84 I have said positive things about breast screening to my family and friends .72


6.7 Construct validation – Confirmatory Factor Analysis

Confirmatory factor analysis (CFA) was conducted on all construct indicators using

AMOS 18. Modification and standardised loadings (i.e. standardised regression

weights) verify the dimensionality of the measurement model and verify the model

fit. Modification indices (MI) comprise of variances, covariances and regression

weights and are assessed to evaluate model fit. None of the indicators were removed

as the factor loadings met the minimum threshold of .60 with the exception of one

indicator. This indicator “Having a plan is important to me as a breast screen

customer, e.g. planning for waiting” had a factor loading of .56 but was not removed

as the factor loading was deemed close to the minimum factor loading and a

minimum of three indicators were required for the latent construct (motivational

direction) for analysis in SEM (see Table 6.22).


Table 6. 22 Factor loadings for all indicators

Construct Indicators Final factor loading

FV Breast screens have consistent quality .87 Breast screens are well delivered .89 Breast screens have an acceptable standard of quality .84 Breast screens perform consistently .88

EV Having breast screens makes me feel comfortable .71 Having breast screens makes me feel safe .79 Having breast screens makes me feel happy .78 Having breast screens makes me feel calm .78 Having breast screens makes me feel relieved .75 Having breast screens makes me feel proud .69

AQ The administration system at the place I usually go to is excellent .96 The administration at the place I usually go to is of a high standard .97 I have confidence in the administration system at the place I usually go to .91

TQ The quality of the service I receive at the place I usually go to is excellent .93 The service provided by the place I usually go to is of a high standard .95 I am impressed by the service provided at the place I usually go to .90

PQ The interaction I have with the staff at the place I usually go to is of a high standard

.94


MD It is important for me as a customer to know how to use this service, e.g. I have to call the service to organise my appointment when I am due for one

.76


.86


.56

CP I try to work co-operatively with the staff e.g. not wearing any perfume or deodorant if advised

.91


.86


.65

ST I believe that I can stay on top of tough situation, e.g. feeling uncomfortable or embarrassed when I’m having a breast screen

.91


.73


.64

SAT My feelings towards breast screening are very positive .81 Overall, I am satisfied with breast screening and the benefits it provides .86 I feel satisfied that the results of my breast screen are the best that can be achieved

.78


.82

BI I would highly recommend breast screening to other women .83 I have said positive things about breast screening to my family and friends .74 I intend to continue having breast screens .85 I have no desire to stop breast screening .85 I intend to follow any medical advice given to me about breast screening .86

Achieved Fit Indices

CMIN/DF 2.121

RMSEA .053


The output produced a Chi-square = 1306.50, with df = 616 with probability level =

.000. For the dimensions of value, functional value was measured by 4 items and

emotional value was measured by 6 items. For the sources of value, administrative

quality, technical quality and interpersonal quality were all measured by 3 items

each, while motivational direction and stress tolerance were measured by 3 items

each, and co-production was measured by 4 items. Finally, satisfaction was measured

by 4 items and behavioural intentions was measured by 5 items. These items were

subject to CFA to determine dimensionality and assess whether the model was an

adequate fit to the data. The fit indices suggest that the model was a good fit to the

data.

The Average Variance Extracted (AVE) was also calculated for each of the

constructs. AVE is a measure of the shared or common variance in a latent variable

(Fornell & Larker, 1981) and is the amount of variance captured by the latent

variable in relation to the amount of variance due to its measurement error (Dillon

and Goldstein, 1984). The AVEs for all the constructs were calculated and compared

with the squares of the parameter estimates between factors (Ø2). All the calculated

AVEs were greater than the squares of the parameter estimates between factors (see

Table 6.23).


Table 6. 23 Squares of Parameter Estimate between Factors (Ø2) and Average Variance Extracted for Pairs of Factors

AVE Construct FV EV AQ TQ PQ MD CP ST SAT BI

.78 FV

.56 EV Ø = 0.61

(Ø2 = 0.37)

.90 AQ Ø = 0.60

(Ø2 = 0.36)

Ø = 0.53

(Ø2 = 0.28)

.86 TQ Ø = 0.62

(Ø2 = 0.38

Ø = 0.57

(Ø2 = 0.32)

Ø = 0.88

(Ø2 = 0.77)

.88 PQ Ø = 0.57

(Ø2 = 0.32)

Ø = 0.63

(Ø2 = 0.40)

Ø = 0.79

(Ø2 = 0.62)

Ø = 0.85

(Ø2 = 0.72)

.54 MD Ø = 0.29

(Ø2 = 0.08)

Ø = 0.29

(Ø2 = 0.08)

Ø = 0.19

(Ø2 = 0.04)

Ø = 0.18

(Ø2 = 0.03)

Ø = 0.23

(Ø2 = 0.05)

.59 CP Ø = 0.43

(Ø2 = 0.18)

Ø = 0.41

(Ø2 = 0.17)

Ø = 0.53

(Ø2 = 0.28)

Ø = 0.56

(Ø2 = 0.31)

Ø = 0.53

(Ø2 = 0.28)

Ø = 0.34

(Ø2 = 0.12)

.61 ST Ø = 0.43

(Ø2 = 0.18)

Ø = 0.46

(Ø2 = 0.21)

Ø = 0.39

(Ø2 = 0.15)

Ø = 0.45

(Ø2 = 0.20)

Ø = 0.45

(Ø2 = 0.20)

Ø = 0.26

(Ø2 = 0.07)

Ø = 0.43

(Ø2 = 0.18)

.68 SAT Ø = 0.73

(Ø2 = 0.53)

Ø = 0.73

(Ø2 = 0.53)

Ø = 0.64

(Ø2 = 0.41)

Ø = 0.70

(Ø2 = 0.49)

Ø = 0.66

(Ø2 = 0.44)

Ø = 0.27

(Ø2 = 0.07)

Ø = 0.57

(Ø2 = 0.32)

Ø = 0.48

(Ø2 = 0.23)

.68 BI Ø = 0.51

(Ø2 = 0.26)

Ø = 0.61

(Ø2 = 0.37)

Ø = 0.46

(Ø2 = 0.21)

Ø = 0.57

(Ø2 = 0.32)

Ø = 0.54

(Ø2 = 0.29)

Ø = 0.17

(Ø2 = 0.03)

Ø = 0.51

(Ø2 = 0.26)

Ø = 0.35

(Ø2 = 0.12)

Ø = 0.78

(Ø2 = 0.61)


6.8 Descriptive analysis of constructs

Descriptive analysis for all the indicators of all the constructs was undertaken to

determine the means and standard deviations. The descriptive for the final items are

shown in Table 6.24 and the bivariate correlations in Table 6.25.

Table 6. 24 Latent variable indicators and descriptives

Latent variable

Indicators N Min Max Mean Std. Dev

FV Breast screens have consistent quality 783 1.00 5.00 3.78 .73

Breast screens are well delivered 776 1.00 5.00 3.97 .70


783 1.00 5.00 3.99 .64

Breast screens perform consistently 780 1.00 5 3.86 .74

EV Having breast screens makes me feel comfortable

782 1.00 5.00 3.00 1.06

Having breast screens makes me feel safe 779 1.00 5.00 3.65 .93

Having breast screens makes me feel happy

776 1.00 5.00 2.82 .96

Having breast screens makes me feel calm

781 1.00 5.00 2.89 1.01

Having breast screens makes me feel relieved

779 1.00 5.00 3.66 .94

Having breast screens makes me feel proud

781 1.00 5.00 2.91 .94

AQ The administration system at the place I usually go to is excellent

788 1.00 5.00 4.04 .73


784 1.00 5.00 4.05 .74


783 1.00 5.00 4.10 .69

TQ The quality of the service I receive at the place I usually go to is excellent

785 1.00 5.00 4.14 .75


783 1.00 5.00 4.15 .72


783 1.00 5.00 4.03 .77


780 1.00 5.00 4.04 .78


779 1.00 5.00 3.99 .83


781 1.00 5.00 4.00 .80


786 1.00 5.00 3.74 .91


783 1.00 5.00 3.75 .84


783 1.00 5.00 3.72 .81

*table continued on following page


*table continued from previous page Latent

variable Indicators N Min Max Mean Std.

Dev


788 2.00 5.00 4.36 .56


788 2.00 5.00 4.34 .59


784 1.00 5.00 3.88 .75


782 1.00 5.00 4.04 .69


790 1.00 5.00 4.00 .68


787 1.00 5.00 3.87 .78


784 1.00 5.00 3.83 .81

SAT My feelings towards breast screening are very positive

790 1.00 5.00 4.00 .80


789 1.00 5.00 4.16 .65


782 1.00 5.00 4.01 .73


784 1.00 5.00 4.01 .67

BI I would highly recommend breast screening to other women

789 1.00 5.00 4.39 .73


786 1.00 5.00 4.00 .91

I intend to continue having breast screens 784 1.00 5.00 4.39 .73

I have no desire to stop breast screening 789 1.00 5.00 4.28 .82


785 1.00 5.00 4.43 .63

Note: Range for latent constructs was 1-5


Table 6. 25 Bivariate correlations matrix

Functional

value

Emotional

value

Administrative

quality

Technical

quality

Interpersonal

quality

Motivational

direction

Co-

production

Stress

tolerance

Satisfaction

Emotional value .539**

.000

1

Administrative

quality

.579**

.000

.489**

.000

1

Technical

quality

.581**

.000

.515**

.000

.850**

.000

1

Interpersonal

quality

.537**

.000

.573**

.000

.773**

.000

.824**

.000

1

Motivational

direction

.295**

.000

.290**

.000

.212**

.000

.207**

.000

.245**

.000

1

Co-production .431**

.000

.421**

.000

.507**

.000

.520**

.000

.539**

.000

.402**

.000

1

Stress tolerance .377**

.000

.388**

.000

.350**

.000

.397**

.000

.406**

.000

.224**

.000

.363**

.000

1

Satisfaction .669**

.000

.634**

.000

.603**

.000

.647**

.000

.612**

.000

.286**

.000

.527**

.000

.411**

.000

1

Behavioural

intentions

.490**

.000

.558**

.000

.458**

.000

.541**

.000

.525**

.000

.199**

.000

.462**

.000

.344**

.000

.709**

.000

** Correlation is significant at the 0.01 level (2-tailed)


6.9 Theory assumptions

This section addresses the assumptions applicable to this research in its undertaking

of SEM.

Sample size: The sample size of 400 did not violate this assumption in SEM. Sample

sizes of 200 is commonly accepted as sufficient and sample sizes of 200-400 are

commonly run for models with 10-15 indicators (Kaplan, 2009; Raykov &

Marcoulides, 2000).

Data level: The data was interval data

Multivariate normality: Normal data is the conventional assumption in the

estimation process (Bai & Ng, 2005). Non-normality is indicated by data distribution

with a highly skewed nature or high kurtosis, which has random effects on

specification or estimation (Hall & Wang, 2005). Values >1.96 mean there is

significant kurtosis, indicating significant non-normality (Byrne, 2001). Table 6.26

indicates skewness from -.97 to 1.76 and kurtosis values from -.51 to 5.24.


Table 6. 26 Sample skewness and kurtosis

Latent variabl

e

Indicators Skewness Kurtosis Statistic Std.

Error Statistic Std.

Error

FV Breast screens have consistent quality -.24 .09 .11 .18

Breast screens are well delivered -.53 .09 .82 .18


-.62 .09 1.82 .18

Breast screens perform consistently -.39 .09 .29 .18

EV Having breast screens makes me feel comfortable

-.17 .09 -.51 .18

Having breast screens makes me feel safe -.75 .09 .65 .18

Having breast screens makes me feel happy .07 .09 -.03 .18

Having breast screens makes me feel calm -.12 .09 -.32 .18

Having breast screens makes me feel relieved

-.87 .09 .85 .18

Having breast screens makes me feel proud .04 .09 .14 .18

AQ The administration system at the place I usually go to is excellent

-.34 .09 -.22 .17


-.51 .09 .40 .17


-.48 .09 .43 .18

TQ The quality of the service I receive at the place I usually go to is excellent

-.71 .09 .75 .17


-.71 .09 .94 .18


-.50 .09 .08 .18


-.54 .09 .09 .18


-.51 .09 -.02 .18


-.55 .09 .39 .18


-.86 .09 .56 .17


-.82 .09 .70 .18


-.57 .09 .61 .18


-.22 .09 -.24 .17


-.51 .09 .59 .17


-.38 .09 .26 .17


-.38 .09 .23 .18

*table continued on following page


*table continued from previous page

Latent variable

Indicators Skewness Kurtosis Statistic Std.

Error Statistic Std.

Error


-.97 .09 2.42 .17


-1.03 .09 1.61 .17


-1.19 .09 2.16 .17

SAT My feelings towards breast screening are very positive

-1.05 .09 2.07 .17


-1.35 .09 5.40 .17


-1.03 .09 2.55 .18


-.79 .09 2.37 .17

BI I would highly recommend breast screening to other women

-1.57 .09 4.01 .17


-.80 .09 .58 .17

I intend to continue having breast screens -1.76 .09 5.24 .17

I have no desire to stop breast screening -1.65 .09 3.88 .17


-1.28 .09 4.15 .17

Valid N (listwise) = 602

Missing values: Pairwise deletion was used in the treatment of missing data.

Multiple indicators: Multiple indicators was used for each variable

Estimation: Maximum likelihood was used, which makes estimates based on

maximising probability (likelihood) that the observed covariance are drawn from a

population assumed to be the same as those reflected in the coefficient estimates

(Byrne, 2001). This meets the SEM estimation assumption.


6.10 Hypothesis testing outputs

In order to address the research questions presented in Chapter 1, a theoretical model

and a set of hypotheses were developed and presented in Chapter 5. This model and

the subsequent hypotheses were developed as a result of the findings of Study 1,

which were presented and discussed in Chapter 4. The model and hypotheses were

tested in Study 2 by using the outputs of SEM. The hypothesised path results of the

theoretical model are reported in the following section to test the hypotheses.

The path terms used in this table are:

FV = Functional value

EV = Emotional value

AQ = Administrative quality

TQ = Technical quality

PQ = Interpersonal quality

MD = Motivational direction

CP = Co-production

ST = Stress tolerance

SAT = Satisfaction

BI = Behavioural intentions


The reported findings of the SEM output in Table 6.27 are assessed based on the

estimated path coefficient β value with critical ratio (C.R. equivalent to t-value) and

p-value. The standard decision rules (t-value ≥ 1.96, and p-value is ≤ .05) apply here

to decide the significance of the path coefficient between DV and IV (Byrne, 2001).

When the Critical Ratio (CR) is >1.96 for a regression weight, that path is significant

at the .05 level, indicating that its estimated path parameter is significant (Blunch,

2008).

Table 6. 27 SEM output for hypothesised path relationships in the proposed model

Hypotheses Paths SEM Output Results* β S.E C.R (t) P

H1a AQ→FV .18 .10 1.90 .057 Non-significant

H1b TQ→FV .40 .09 3.92 p≤.001 Significant

H1c PQ→EV .50 .06 9.47 p≤.001 Significant

H2a MD→FV .16 .07 3.19 .001 Significant

H2b CP→FV .09 .07 1.55 .122 Non-significant

H2c ST→EV .22 .09 3.95 p≤.001 Significant

H3a FV→SAT .54 .05 11.13 p≤.001 Significant

H3b EV→SAT .42 .03 9.23 p≤.001 Significant

H4 SAT→BI .74 .05 13.55 p≤.001 Significant

*Results supported at Significance Level: p≤.001, p≤.01, and p≤.05

The output revealed that two of the hypothesised relationships were non-significant.

The hypothesised relationship H1a AQ→FV was non-significant due to its p-value of

.057, which was above the minimum p-value of .05. Similarly, the hypothesised

relationship H2b CP→FV was also non-significant due to its p-value of .122. All

other hypothesised relationships were found to be significant as they fell within the

significance levels of p≤.001, and p≤.01.


6.11 Post Hoc tests

Post hoc tests were conducted on the data as the modification indices suggested eight

additional paths within the model. These additional paths were included in the

model, and the model was tested again. As a result, one of these non-hypothesised

paths was revealed to be non-significant, while the remaining seven were found to be

significant. This section discusses each of these non-hypothesised path relationships

and provides the estimated path coefficient β value with critical ratio and p-value for

each of these path relationships.

6.11.1 Non-hypothesised relationships between sources and dimensions of value

Non-hypothesised relationships between the sources of value and the dimensions of

value were tested and two relationships were found to be significant. It was found

that motivational direction had a positive influence on emotional value with an

estimated path coefficient β value of .24, with critical ratio (C.R.) 2.44 and p-value of

.015. This was the first significant non-hypothesised relationship identified in the

model. It was also found that stress tolerance had a positive influence on functional

value with an estimated path coefficient β value of .13, with critical ratio (C.R.) 1.90

and p-value of .057.

6.11.2 Non-hypothesised relationships between the dimensions of value

Next, non-hypothesised relationships between the two dimensions of value were

tested. While the path relationship FV → EV was non-significant, the path

relationship EV → FV was significant with an estimated path coefficient β value of

.20 with critical ratio 5.17 and p-value ≤.001 demonstrating that emotional value

positively influences functional value.


6.11.3 Non-hypothesised relationships between sources of value and satisfaction

Non-hypothesised relationships between the sources of value and satisfaction were

also tested and two relationships were found to be significant. Technical quality and

co-production were both found to positively influence satisfaction. For TQ → SAT

the estimated path coefficient β value was .23 with critical ratio 4.90 and p-value

≤.001demonstrating that technical quality positively influences satisfaction. For CP

→ SAT the estimated path coefficient β value was .17 with critical ratio 3.32 and p-

value ≤.001 demonstrating that co-production also positively influences satisfaction.

6.11.4 Non-hypothesised relationships between sources of value and behavioural

intentions

Further path relationships between sources of value and behavioural intentions were

also tested and one relationship was found to be significant. Co-production was

found to positively influence behavioural intentions with an estimated path

coefficient β value of .14 with critical ratio 2.72 and p-value .007. A second path

relationship between administrative quality and behavioural intentions was also

tested, but was found to be non-significant. For AQ → BI the estimated path

coefficient β value was -.06 with critical ratio -1.37 and p-value .172 demonstrating a

non-significant path relationship.

6.11.5 Non-hypothesised relationships between dimensions of value and

behavioural intentions

Finally, path relationships between the value dimensions and behavioural intentions

were explored and only one relationship was found to be significant. Emotional value

was found to positively influence behavioural intentions with an estimated path

coefficient β value .09 with critical ratio 2.54 and p-value .01.


6.11.6 Mediated relationships in the model

The post hoc tests also suggested that there were a number of mediated relationships

between constructs in the model. Mediation for two relationships was tested. To

establish mediation, steps suggested by Baron and Kenny (1986) and Judd and

Kenny (1981) were undertaken. The following section describes the findings of the

post hoc tests conducted on the possible mediated relationships.

The above model illustrates a basic mediational model whereby X represents the

independent variable, Y represents the dependent variable, and M represents the

mediating variable. In addition, a, b, and c‟ represent the paths between these

variables.

The data suggested that the effect of technical quality (TQ) on satisfaction (SAT) is

mediated by functional value (FV) (see Figure 6.2). The first step suggested by

Baron and Kenny (1986) and Judd and Kenny (1981) was to show that TQ is

correlated with SAT to establish that there is an effect that may be mediated. Using a

stepwise linear regression, it was found that TQ predicts 42% of SAT and is

significant (p<.05).

TQ SAT

FV a b

c’

X Y

M a b

c’

Figure 6. 3 Basic mediational model

Figure 6. 4 Mediational model for technical quality, satisfaction, and functional value


The second step was to show that TQ is correlated with FV, treating FV as if it were

an outcome variable (Baron & Kenny, 1986; Judd & Kenny, 1981). Using a stepwise

linear regression, it was found that TQ predicts 45% of FV and is significant (p<.05).

The next step was to show that FV affects the outcome variable, SAT (Baron &

Kenny, 1986; Judd & Kenny, 1981). A hierarchical regression was conducted using

TQ and FV as predictors. The results indicated that TQ contributes 42% of variance

in SAT and is a significant predictor (p<.05). At the second step, the R Square

Change statistic and the Sig. F Change value indicates that FV makes a significant

unique contribution of 13% to the variance of SAT and is significant (p<.05).

Although TQ is a salient predictor of SAT, F(1.398) = 286.577, p<.05, the results

suggest that functional value (FV) acts as a partial mediator on the relationship

between technical quality (TQ) and satisfaction (SAT).

The data also suggested that the effect of co-production (CP) on behavioural

intentions (BI) is mediated by satisfaction (SAT). The same procedure suggested by

Baron and Kenny (1986) and Judd and Kenny (1981) was used. A stepwise linear

regression showed that CP predicts 21% of BI and is significant (p<.05). Next, it was

found that CP predicts 20% of SAT and is also significant (p<.05). Finally, a

hierarchical regression was conducted using CP and SAT as predictors. The results

indicated that CP contributes 21% of variance in BI and is a significant predictor

(p<.05). At the second step, the R Square Change statistic and the Sig. F Change

value indicates that SAT makes a significant unique contribution of 30% to the

variance of BI and is significant (p<.05). Although CP is a salient predictor of BI,

F(1,398) = 107.801, p<.05, the results suggest that satisfaction (SAT) acts as a partial

mediator on the relationship between co-production (CP) and behavioural intentions

(BI).

CP BI

SAT a b

c’

Figure 6. 5 Mediational model for co-production, behavioural intentions, and satisfaction


6.11.7 Summary of SEM output for hypothesised and non-hypothesised

relationships

All the non-hypothesised path relationships were included in the proposed model

with the existing hypothesised relationships and the model was re-run in AMOS. The

SEM output indicated that all path relationships were significant, with the exception

of CP→FV which remained non-significant. Also, the non-hypothesised path

relationship ST→FV was significant at .058, which was deemed to be close to the

.05 threshold and thus this path relationship was retained. The SEM output for all

hypothesised and non-hypothesised relationships in the proposed model is presented

in Figure 6.6.

Table 6. 28 SEM output for hypothesised and non-hypothesised relationships in the

proposed model

Relationships Paths SEM Output Results

β S.E C.R (t) P

Hypothesised AQ→FV .20 .09 2.15 .032 Supported

TQ→FV .20 .09 2.18 .029 Supported

PQ→EV .57 .07 8.87 p≤.001 Supported

MD→FV .15 .07 2.21 .027 Supported

CP→FV .02 .07 .34 .735 Not

supported

ST→EV .31 .10 3.32 p≤.001 Supported

FV→SAT .34 .05 6.66 p≤.001 Supported

EV→SAT .20 .03 5.87 p≤.001 Supported

SAT→BI .54 .07 8.54 p≤.001 Supported

Non-hypothesised

MD→EV .24 .10 2.44 .015 Significant

ST→FV .13 .07 1.90 .057 Significant

EV→FV .20 .04 5.17 p≤.001 Significant

TQ→SAT .23 .05 4.90 p≤.001 Significant

CP→SAT .17 .05 3.32 p≤.001 Significant

AQ→BI -.06 .05 -1.37 .172 Non-

significant

CP→BI .14 .05 2.72 .007 Significant

EV→BI .09 .03 2.54 .011 Significant

*Results supported at Significance Level: p≤.001, p≤.01, and p≤.05


Figure 6.6 shows the path diagram indicating the significant hypothesised

relationships, non-significant hypothesised relationships, and the significant non-

hypothesised relationships.

Figure 6. 6 Full path model with all relationships

The model produced a CMIN/DF of 2.54, with RMSEA of .06 and CFI of .93 which

suggested good fit. The model was found to be a good fit to the data as indicated by

its χ2 to degrees of freedom ratio (CMIN/DF = 2.54). Although this value does not

strictly meet the threshold ≤ 2 it was deemed to be of moderate fit. Similarly, its root

mean square error of approximation (RMSEA = .068) value closely met the threshold

of ≤.06 and was deemed to be of moderate fit as RMSEA values of ≤.05 indicate

models with good fit, while RMSEA values of ≥.10 suggest poor fit (Bollen & Long,

1993). Finally, its comparative fit index (CFI = .914), met the threshold of ≥.9

suggesting good model fit to the data.

AQ

TQ

PQ

MD

CP

ST

EV

FV

SAT BI

indicates significant non-hypothesised path relationships

.24

.13 .20

.23

.17

.14

-.06

.09

.20 .20

.57

.15

.02

.31

.34

.20

.54

indicates non-significant hypothesised path relationships

indicates non-significant non-hypothesised path

relationships

indicates significant hypothesised path relationships


6.12 Summary

In summary, this chapter presented the results of Study 2, which was a large-scale

quantitative confirmatory study. The data collected through online-survey method

yielded a usable sample size of n=797 and the data was analysed using PASW18 and

AMOS18 statistics software. The results of the structural equation modelling

conducted on the data showed support for all the hypothesised relationships with the

exception of one (H2b). The data also indicated additional non-hypothesised path

relationships between the variables in the proposed model. Post hoc testing revealed

eight additional significant non-hypothesised path relationships in the proposed

model. The following chapter (Chapter 8) provides a discussion of the overall

findings from both Study 1 and Study 2, offering theoretical and managerial

implications of the findings, as well as a discussion of the limitations of the research

and suggestions for future research.

Chapter 7: Discussion and Conclusion 211

CHAPTER 7 DISCUSSION AND CONCLUSION

“We shall not cease from exploration and the end of all our exploring will be to

arrive where we started and know the place for the first time”

T.S. Eliot

7.1 Introduction

This final chapter provides a detailed discussion of the results of the overall research

inquiry that comprised of an exploratory qualitative stage, followed by a

confirmatory quantitative stage. The qualitative results of Study 1 and quantitative

results of Study 2, presented in Chapters 4 and 6 respectively, served to answer the

overall research question posed in the introduction of this thesis:

Overall RQ: How is value created in social marketing wellness services?

In addressing this overall research question, three specific sub-research questions

were developed. The first sub-research question sought to identify the dimensions of

value experienced by users of wellness services, while the second sub-research

question sought to identify the sources that influence these value dimensions. The

third and final sub-research question examined the relationship between these

sources and dimensions of value in wellness services, specifically breast cancer

screening, which was the specific wellness service context selected for this research.

These research questions were addressed qualitatively in Study 1 and quantitatively

in Study 2, filling the three research gaps identified in Chapter 1.

The first sub-research question sought to identify the dimensions of value in wellness

services with RQ1: What are the dimensions of value experienced by users of

wellness services? The second sub-research question sought to identify the sources of

value in wellness services with RQ2: What are the sources of value that exist in

wellness services? Finally, the third sub-research question sought to explore the

relationship between the sources and dimensions of value in wellness services with


RQ3: What is the relationship between the sources and dimensions of value in

wellness services?

A detailed discussion of how the findings from both studies have addressed each of

the three research questions, filling in the gaps in presented in this chapter. The

theoretical and managerial contributions of this overall research are then presented,

followed by a consideration of its limitations. Finally, directions for future research

are also proposed in order to address these limitations.

7.2 Value dimensions in wellness services

The first sub-research question, “What are the dimensions of value experienced by

users of wellness services?” sought to identify the dimensions of value present in

wellness services in secondary health prevention. In addressing this first sub-research

question, this research inquiry adopted the perspective of experiential value, rather

than the traditional perspective of economic value. Situating this investigation in an

experiential value framework supports the idea that value is situational and can

change before, during, and after a service experience (Woodruff, 1997). This shows

consideration for the entire consumption process, that includes pre-consumption,

consumption, and post-consumption (Russell-Bennett et al., 2009). This approach

considers the consumption experience in its entirety, acknowledging the dynamism

of value and how it changes for individuals through the course of the consumption

process.

7.2.1 Value dimensions in wellness: the prominence of functional and emotional

value and the diminished role of social and altruistic value

The qualitative findings of Study 1 identified four dimensions of value present in

consumers‟ use of wellness services. These dimensions are functional, emotional,

social, and altruistic value, and are commonly found in commercial marketing (see

Holbrook, 1994; Sheth et al., 1991; Sweeney & Soutar, 2001). These new findings

lend empirical evidence to support the existence of these value dimensions in social

marketing and in wellness.


Functional and emotional value were found to be the most prevalent of the four

dimensions of value and appeared to be the more important to the participants of

Study 1 over social and altruistic value. From the interviews conducted, it was

evident that the first primary objective for having breast screens for the participants

interviewed was the early detection of breast cancer. This fulfils the fundamental aim

of secondary health prevention, which is early detection (Fielding, 1978) and

demonstrates the fulfilment of a utilitarian goal. The second primary objective for

having breast screens for the participants interviewed was the reassurance of good

health. This reassurance provided emotional relief through the alleviation of worry or

anxiety, reflecting peace of mind. Utility and peace of mind were two of the

consumer goals identified in the results of the analysis of Study 1.

The prevalence of functional and emotional value led to the selection of these

dimensions value over social and altruistic value for further investigation in Study 2.

The analysis of the data collected from the large-scale quantitative survey in Study 2

provided quantitative, empirical evidence for these two dimensions within a social

marketing context. The EFA and CFA conducted on the indicators for these value

constructs showed that functional and emotional value were separate and distinct

constructs. This is consistent with literature that suggests that while value is a multi-

dimensional construct (Holbrook, 2006), its dimensions are separate and distinct.

Social and altruistic value were reported less frequently by the participants in Study 1

in their interviews compared to functional and emotional value. In addition, the

participants who reported social and altruistic value only experienced these

dimensions of value together with functional and emotional value. It appeared that if

the functional and emotional dimensions of value were not experienced by the

women, then social and emotional value could not be experienced either.

The prominence of functional and emotional value over social and altruistic value

could be attributed to the context-specific nature of this inquiry. This inquiry used a

service, designed for secondary prevention purposes (Fielding, 1978) within the

social marketing category of personal health causes (Kotler & Zaltman, 1971). This

describes wellness services aimed at providing the most direct benefits to the


individuals using the service, rather than to others or to society. The other social

marketing categories of social betterment (e.g. recycling) and altruistic causes (e.g.

blood donation) are more likely to show social and altruistic value as higher

motivators for individual action. Activities in these categories and contexts are those

that result in direct benefits to others and society (as described in Table 2.1 of

Chapter 2) and as such, social and altruistic value may feature as the primary value

dimensions sought in these instances while functional and emotional value could be

relegated to secondary value dimensions being sought. This lends further credibility

to the notion that value is dynamic and that context matters.

7.2.2 Experiential value in wellness: incorporating new understanding of

consumer goals

Based on new understanding of the six consumer goals identified in Section 4.5 of

Chapter 4, utility and peace of mind related to primary goals that the interviewed

participants sought from their experiences with wellness services. These goals relate

to functional and emotional value. Convenience and control also relate to functional

and emotional value, and were two consumer goals that were found to represent

secondary goals that the interviewed participants sought from their experiences. Self

as influencer and benefit to others, which were the two remaining consumer goals,

relate to social and altruistic value and were found to reflect tertiary goals that the

interviewed participants sought from their experiences. The differences in the

different levels of goals also helps explain the differences in the way value

dimensions are determined, created, and experienced by users of wellness services.

These differences lend further support to the dynamism of value and the importance

of context.

7.2.3 Experiential value in wellness: the prominence of reactive over active value

As this research investigation was conducted using the experiential value approach,

the results of the analysis of Study 1 suggested that reactive value featured more

prominently over active value for the participants interviewed. As highlighted in

Table 4.3 of Chapter 4, only functional and emotional value were experienced both


actively and reactively by the participants of Study 1, while social and altruistic

value were only experienced actively.

This could be attributed to the differences in whether the value dimensions

experienced by consumers related to primary, secondary, or tertiary goals sought.

Utility and peace of mind related to functional and emotional value and were the

primary goals sought and experienced by all the participants of Study 1 who were

users of wellness services. This included those participants who were actively

engaged in their consumption experiences as well as those who were reactively

engaged in their consumption experiences. As it was critical that these goals were

fulfilled, and subsequently functional and emotional value being derived from the

consumption experience, these value dimensions needed to be created both actively

and reactively in order to fulfil the goals of all the users, regardless of their level of

engagement and participation. However, since self as influencer and benefit to others

reflected social and altruistic value and represented tertiary goals, these were sought

by only some participants. As such, these participants were required to actively seek,

co-create, and experience these value dimensions instead.

7.2.4 Experiential value in wellness services: the development of a new typology

of value

The results of the qualitative study provided evidence for the four dimensions of

functional, emotional, social, and altruistic value in social marketing, while the

results of the quantitative study provided further evidence for functional and

emotional value. In addition, qualitative evidence for active and reactive value was

also provided. By integrating this new knowledge and understanding, a new typology

of value in social marketing was created. This new typology of value in social

marketing was developed with the following features:

It incorporates the traditional value dimensions typically found in commercial

marketing. Studies 1 and 2 provide empirical evidence for the existence of

these dimensions in social marketing.


It incorporates the experiential value approach through the inclusion of the

activity dimensions; active and reactive value.

It explains the differences in the type of value dimensions sought on the basis

of social marketing understanding, i.e. the direct benefit of behaviours can be

experienced by either the self or by others.

It also explains the differences in the type of value dimensions sought on the

basis of new understanding of consumer goals in wellness, and whether these

goals represented primary, secondary, or tertiary goals for consumers.

Table 7.2 shows a summary of the dimensions of value, aims and corresponding

goals with the inclusion of the activity dimension of experiential value.

Table 7. 1 Summary of dimensions of value and aims with corresponding goals and

activity dimensions

Dimensions of value

Functional

Emotional Social Altruistic

Activity dimension

Both active & reactive

Active only

Direct benefit

experienced by

Self Others

Goals

Primary

Utility Peace of mind NIL NIL

Secondary

Convenience Control

Control NIL NIL

Tertiary

NIL NIL

Self as influencer

Benefit to others

7.2.5 Summary of findings for RQ1

In summary, this research provides qualitative evidence for four dimensions of value

in wellness services, demonstrating that these value dimensions constructed in

commercial marketing also exist in social marketing. Furthermore, quantitative


evidence was found for two of these value dimensions (i.e. functional and emotional

value) showing that these two dimensions are separate and distinct constructs.

This research also demonstrates the existence of experiential value in social

marketing and provides a typology of experiential value that synthesises the

understanding of the value dimensions, with the activity aspects of experiential

value. Qualitative evidence suggests that some of the dimensions of value (i.e.

functional and emotional) can be experienced both actively and reactively, while

other dimensions of value (i.e. social and altruistic) can only be experienced actively.

The differences are likely to be attributed to the different consumer goals that

consumers seek from their use of wellness services and whether these goals

represented primary, secondary, or tertiary goals.

7.3 Value sources in wellness services

The second sub-research question, “What are the sources of value that exist in

wellness services?” sought to identify the sources of value that have an impact on the

value dimensions experienced by consumers of wellness services. Early research in

the commercial marketing literature on value identifies sources of value that stem

from the value-chain processes both within and between organisations (e.g. Porter

1985). This is consistent with the traditional perspective of value, which considers

value from the organisation‟s perspective and regards value as a means for achieving

competitive advantage through value-chain processes (Porter, 1985). However, due

to the adoption of the customer perceived value perspective for this research (Kotler

& Armstrong, 2008, p.13), this research considers sources of value that influence

consumers‟ value construction and not sources of value that influence the

achievement of competitive advantage for the organisation.

7.3.1 Providing empirical evidence for sources of value in wellness services

The qualitative findings of Study 1 identified four main sources of value in wellness

services; information, interaction, environment and consumer participation. These

sources were found to originate not only from the service organisation or the


consumer (as discussed in Sections 2.6.3 and 2.6.4 in Chapter 2), but also from

sources external to the exchange. These were identified as third parties. In addition,

within consumer participation sources of value, three further sub-dimensions of

consumer participation were identified. They were motivational direction, co-

production, and stress tolerance.

Study 2 provided further empirical evidence for the existence of sources of value in

social marketing wellness services. As interpersonal interactions were discussed (in

Section 5.4, Chapter 5) as having the greatest effect on consumers‟ service quality

perceptions (Bitner et al., 1994; Bowen & Schneider, 1985; Grönroos, 1982; Hartline

& Ferrell, 1996; Suprenant & Solomon, 1987), interaction was investigated further in

Study 2 using the service quality constructs of administrative quality, technical

quality, and interpersonal quality. The three sub-dimensions of consumer

participation were also tested further in Study 2 as S-D logic suggests that the role of

the consumer is a vital component in value co-creation. The results of the analysis of

the data collected in Study 2 provided quantitative empirical evidence for the

existence of all the sources of value, which were also all shown to be separate and

distinct.

7.3.2 A new development of categorisation of sources of value in wellness

services

The qualitative findings of Study 1 suggested evidence for three categories of

sources of value; organisational sources, consumer participation sources, and third

party sources of value. The organisational sources of value category included

information, interaction and environment sources. In the consumer participation

sources category, motivational direction, co-production, and stress tolerance were

identified. Information and interaction sources were also found in the third party

sources of value category. In light of this apparent clustering of the various sources

of value, a new categorisation of sources of value in wellness services was developed

(see Figure 4.1). This classification provides empirical evidence to demonstrate the

role of some service quality dimensions as sources of value in co-creation. This

classification also provides empirical evidence for the S-D logic foundational


premise “the customer is always a co-creator of value” (Vargo & Lusch, 2006, p.

44), which to date has only been theoretically conceptualised. This section discusses

each of the three categories of sources of value in detail.

Figure 4. 3 Categorisation of sources of value in wellness services using social

marketing

Organisational sources of value

The organisational sources of value category refers to sources of value that originate

from and that are directly controlled by the organisation. Within this category,

evidence was found for information, interaction, and environment sources of value

conceptualised by Smith and Colgate (2007). Due to the nature of services, the core

service offering was encompassed within aspects of “information” and “interaction.”

In order for the successful delivery and consumption of a breast screen, the provision

of information between consumers and service through their interaction was

necessary. However, this was not limited to face-to-face interaction at the

consumption stage, but also included non-face-to-face interactions at the pre- and

post-consumption stages. This refers to interactions with the systems and processes,

such as the process of receiving a reminder letter at the pre-consumption stage or the

results letter at the post-consumption stage. However, this also includes other

interaction elements such as exposure to advertising by the service organisation.

Organisational

Sources of Value

Consumer

Sources of Value

Third Party

Sources of Value

Information

Environment

Interaction

Cognitive

inputs

Behavioural

inputs

Affective

inputs

Information

Interaction

Sources of Value


Environment was also found to be an important organisational source of value,

however it appeared to relate more closely to the augmented service. Unsurprisingly,

the results of the analysis of Study 1 revealed that aspects of the environment did not

relate closely to the core service offering. As such, only information and interaction

were investigated further in Study 2.

Consumer participation sources of value

The results of the analysis of the date from Study 1 also provided evidence for

consumer participation. These results suggested that consumer participation extends

beyond the consumption stage and includes participation at the pre-consumption and

post-consumption stages as well. The traditional perspective on consumer

participation typically considers participation at the consumption stage only, where

consumers meet face-to-face with service providers to produce and deliver the

service (Dabholkar, 1990). The results suggest that value is not just created at the

consumption stage, but at all three stages of the consumption process.

The results also suggested that consumer participation could be further delineated

into three sub-dimensions; cognitive, behavioural, and affective. The different types

of consumer participation required differ at the various stages of the consumption

process. For example, at the pre-consumption stage, cognitive inputs are required

more so than behavioural or affective inputs because consumers are required to

remember to organise their appointments and inform the staff of a day and time that

is suitable for them. This demonstrates motivational direction of the consumer where

the consumer understands their role in the consumption experience. In the context of

breast screening, a woman must understand that it is her responsibility to organise

her own appointment with BSQ unlike some other medical services which inform the

consumer of the appointment date and time. On the other hand, at the consumption

stage, behavioural inputs are required more so than cognitive or affective inputs

because breast screening involves careful positioning of a woman‟s body in order to

perform the breast screen as an example. These behavioural inputs serve to facilitate

the work of the service provider, demonstrating co-production. Finally, at the post-

consumption stage, affective inputs are required more so than cognitive or

behavioural inputs. For example, some women may worry about what their results


might say, whereas others choose not to think about it and put it out of their minds or

imagine positive outcomes. This exemplifies stress tolerance, which helps the

women to manage the emotions they may experience after their breast screen.

These results demonstrate that consumers are jointly responsible for influencing their

consumption experiences and that the burden of value creation does not lie with the

organisation alone. By using the experiential value approach in this research inquiry,

it was determined that consumers have the ability and opportunity to not only

determine the specific value dimensions that they seek, but also the extent to which

these dimensions are achieved. In order to do so, consumers must be jointly

responsible for the creation of the value that they seek through their participation at

all stages of the consumption process.

Third party sources of value

The results of the analysis of the data from Study 1 also provided evidence to show

that information and interaction sources of value occur outside of the service

organisation. They originated from third party sources. Third party sources of value

have received little consideration in value creation literature; however the impact of

peers, social groups, and referent groups has been investigated in other areas of

marketing such as consumer decision making. The original conceptualisation for

information and interaction sources by Smith and Colgate (2007) referred to those

originating from within the organisation. However, the data lends support to the idea

that these specific sources of value can also originate from third parties outside of the

organisation.

It is important to note that information from third parties and interaction with third

parties have an impact on consumers‟ consumption experiences because third parties

can provide opportunities or pose threats to encouraging consumers to use wellness

services. The results suggest that third party sources are influential in behaviour

uptake and behaviour maintenance for the women interviewed. Referent groups such

as doctors were influential in women‟s uptake of breast screening, while social

groups such as family members were influential in women‟s continuation with breast

screening.


In testing the sources of value further in Study 2, organisational and consumer

participation sources of value were selected as these were central to the theoretical

concept of value co-creation using SD-logic. In operationalising the organisational

sources, service quality aspects of administrative quality, technical quality, and

interpersonal quality were selected to represent the information and interaction

aspects of the sources of value conceptualised by Smith and Colgate (2007). These

aspects of the organisation were determined to be most central to the consumption

experience in wellness services. The EFA conducted on the construct indicators

showed that all the service quality indicators belonged to the same factor, however in

conducting the CFAs they were treated as separate and distinct on the basis of

theoretical conceptualisation. The proposed model tested in SEM showed that the

three service quality dimensions were separate and distinct.

In operationalising the consumer participation sources of value, motivational

direction, co-production, and stress tolerance constructs were used. Both the EFAs

and CFAs provided evidence that these were separate and distinct constructs that

exist in the value creation process in wellness services.

7.3.3 Summary of findings for RQ2

In summary, this research has addressed RQ2 by providing empirical evidence for

the sources of value conceptualised in the commercial marketing literature.

Furthermore, this research demonstrates that these sources of value exist in a social

marketing context. A new categorisation of sources of value was developed,

providing further insight into the current understanding of the sources of value.

These results demonstrate the importance of each of the different categories of

sources of value and provide evidence to show that there is a need to consider

sources of value extending beyond the service organisation. The role of the consumer

is of significant importance in value co-creation and the impact of third parties on the

value created should also be considered.


7.4 Inter-relationships of value sources and dimensions in wellness

The third sub-research question, “What is the relationship between the sources and

dimensions of value in wellness services?” sought to shed light on how value

dimensions are created from value sources in wellness services. Hypothesised

relationships between the sources and dimensions of value were developed based on

the findings of Study 1. These hypothesised relationships were presented in Chapter

5 and were subsequently tested in Study 2. The results of Study 2 show that all the

hypothesised relationships were supported (significant positive) except one. This

section discusses in detail the significant hypothesised relationships that were

supported in the data, while the subsequent section (Section 7.5) will discuss in detail

the non-significant hypothesised relationship as well as seven further significant non-

hypothesised relationships that were found in the data.

7.4.1 Organisational sources of value and the value dimensions

The relationships between the organisational sources of value and the dimensions of

value were hypothesised accurately. As anticipated, administrative quality has a

positive, significant relationship with functional value because it creates utility and

convenience for the consumer in wellness services. Similarly, technical quality also

has a positive significant relationship with functional value as it also creates utility

for the consumer. Finally, interpersonal quality has a positive and significant

relationship with emotional value as hypothesised because it creates peace of mind

for the consumer.

7.4.2 Consumer participation sources and the value dimensions

As discussed previously in Section 7.3, consumer participation sources of value were

found to be more complex than originally conceptualised. Two of the relationships

between consumer participation sources of value and dimensions of value were

hypothesised accurately while the third hypothesised relationship was found to be

non-significant. Motivational direction has a positive, significant relationship with

functional value because the consumer‟s understanding of the role that they play in


the service exchange is important for the achievement of utility. Stress tolerance has

a positive, significant relationship with emotional value because the consumer‟s

ability to withstand stressful situations and control her emotions provides peace of

mind. However, it was found that co-production did not have a significant

relationship with functional value as hypothesised. This is discussed further in

Section 7.5 under the additional findings.

There were two additional non-hypothesised significant relationships between

consumer participation sources and the dimensions of value that were found in the

model and these relationships are also discussed further in Section 7.5. These overall

findings on consumer participation suggest that consumer participation in value co-

creation in wellness is complex and further research is warranted to explore the role

of the consumer in value co-creation further.

7.4.3 Summary of findings

In summary, as hypothesised, all the sources of value relate to the dimensions of

value with the exception of one. These results indicate that the service quality

dimensions relate to value as hypothesised and this is consistent with existing

knowledge in the service quality research area of its impact on consumers‟ service

consumption experiences. These results also show that consumer participation as a

source of value is more complex than originally conceptualised, and is also of

significant importance in the value co-creation process.

7.5 Additional findings

Several additional findings were uncovered at the conclusion of the analysis, which

is discussed in this section. These additional findings provide greater depth in

understanding the answers discovered in addressing the research questions. Some of

these findings present thought-provoking ideas that are worthy of further

investigation in future academic research that will undoubtedly provide a more

rounded understanding of value co-creation.


7.5.1 The influence of emotional value over functional value in wellness

The SEM output of the quantitative study revealed that emotional value exerts a

significant and positive influence over functional value in wellness services. The

same is not true in the opposite direction as functional value does not have a

significant influence over emotional value. This finding offers two insights. Firstly, it

provides further empirical evidence to support the notion that value dimensions are

inter-related, as suggested by other such as Holbrook (1994) and Sweeney and Soutar

(2001). Secondly, the influence of emotional value over functional value could be

attributed to the preventive health context of this research. The issue of cancer

prevention is a particularly emotive issue for many and the data collected in Study 2

shows that the majority of respondents know of someone who has been diagnosed

with breast cancer, whether the person is a family member, friend, colleague or

acquaintance. Given the prominence of the occurrence of breast cancer in society, it

is unsurprising that emotional value is widely sought after by users of cancer

prevention services. The understanding that early detection leads to better treatment

options and thus, more effective treatment, provided emotional value to the women

interviewed in the form of peace of mind. The quantitative results also lend further

support to this idea by suggesting that as long as consumers experience emotional

value in their use of breast screening services, this would suffice in their derivation

of satisfaction.

7.5.2 The influence of emotional value on behavioural intentions

Emotional value was also found to have a significant and positive influence on

behavioural intentions. Emotional value indicators reflect emotional outcomes of

having breast screens, for example “having breast screens makes me feel happy” and

“having breast screens makes me feel relieved.” Similarly, the behavioural

intentions indictors also reflect outcomes and thus it is not surprising that emotional

value and behavioural intentions would be related. Furthermore, it has been

discussed extensively that emotional value is the more “important” value dimension

that consumers in breast screening services seek, as evidenced by the higher beta

values of the relationships between the sources of value and emotional value, as


opposed to the lower beta values between the sources of value and functional value.

Thus, given the significance and importance of emotional value to consumers, it is

not surprising that the experience of emotional value is enough to illicit the desired

behavioural intentions within the target audience.

7.5.3 The curious case of co-production

The results of the analysis of the data from Study 2 showed that co-production did

not have a significant relationship with functional value as hypothesised. This

could be attributed to the fact that co-production refers to the inputs provided by the

consumer in the service exchange and that there may be the perception among

consumers that the greater the inputs they provide, the less the input the organisation

is require to provide. Co-creation is a paradigm that has dominated the marketing and

management literature in recent years with the assumption that consumers desire to

be co-creators of value. However, in co-producing an outcome with an organisation,

consumers can sometimes be seen as performing tasks normally handled by the

organisation (Humphreys & Grayson, 2008). Co-creation can in some instances be

seen as a reconfiguration or redistribution of labour (Terranova, 2004) and can

subsequently be seen as an exploitation of consumer labour (Zwick, Bonsu &

Darmody, 2008). As such, this may explain the lack of relationship between co-

production and functional value.

Despite the lack of relationship between co-production and functional value, the

results of the analysis of the data from Study 2 revealed that co-production has a

positive significant relationship with satisfaction. This could be attributed to the

similarities between the indicators used to operationalise these constructs. Co-

production indicators reflect the things that consumers can do during the service

exchange, such as openly discussing their needs and wearing clothing that better

facilitates the health service. It could be that these inputs provided by the consumer

are enough to provide them with feelings of satisfaction from the service exchange.

Indicators used for satisfaction include “the extent to which my breast screen has

produced the best possible outcome is satisfying” and perhaps, the co-production of


the consumer provides them with a sense of control, which is enough to result in

satisfaction.

It was also found that co-production has a positive, significant influence on

behavioural intentions. As discussed previously, the co-production indicators

reflect the activities that the consumers can perform during their service exchange,

giving them a sense of control over the situation. There are similarities with some of

the behavioural intentions indicators, such as “I have no desire to stop breast

screening” and “I intend to continue having breast screens” which are choices made

by the consumer to continue performing the behaviour and using the service again in

the future. These choices also provide the consumer with a sense of control as it is

the consumer‟s choice to have breast screens and use breast screening services. As

the aspects of co-production also relate to control (i.e. they control the extent to

which they choose to co-produce the service), perhaps it is not surprising that co-

production would have a significant and positive influence over behavioural

intentions. However, the mediation tests suggest that the influence of co-production

on behavioural intentions is partially mediated by satisfaction. The mediating

effect of satisfaction is unsurprising, given that it is widely accepted that customer

satisfaction does have a strong influence over behavioural intentions (e.g. Dagger et

al., 2007).

7.5.4 Consumers co-create value through motivational direction and stress

tolerance

The results of the analysis of the data from Study 2 showed that motivational

direction had a significant and positive influence over emotional value, which

was a non-hypothesised relationship. The motivational direction indicators refer to

the consumers‟ understanding of their role associated in the service exchange and

thus it was hypothesised that this would influence the utility of the service, relating to

functional value. The additional influence on the emotional outcomes generated from

using the service could be attributed to the fact that by understanding their role

associated with the service exchange and by acknowledging the importance of the

role that they play in the exchange, this creates control for the consumer.


Subsequently, this creates a sense of relief and peace of mind. The sense of control

allows consumers to feel that they have played an active part in creating a

meaningful consumption experience for themselves, rather than being participants

that are powerless and without control. This creates emotional value through the

provision of a sense of relief or achievement, thus explaining why motivational

direction has a significant and positive relationship with emotional value.

Finally, the results of the analysis of the data from Study 2 also showed that stress

tolerance had a significant and positive influence over functional value. The

stress tolerance indicators used refer to the individual‟s ability to handle difficult

situations or control their emotions. The quantitative results show that this has a

significant and positive relationship with functional value, which refer to the utility

provided by having breast screens. This non-hypothesised relationship could be

attributed to the fact that some degree of stress tolerance is necessary for consumers

to be able to effectively co-produce the service with the service provider. For

example, if the consumer is unduly stressed or distressed by the breast screen, it is

less likely that they would effectively co-produce the service with the service

provider, thus diminishing the utility that is created. However, if the consumer is able

to remain calm and understand that any unpleasantness is necessary in order to

produce the desired functional outcomes, then their high stress tolerance is likely to

create higher functional value from their use of breast screening services. In the

qualitative interviews, some of the participants acknowledged that while there were

unpleasant aspects to breast screening, these were merely part of the experience and

necessary to endure in order to achieve the utility that they desire. As such, this

might explain why stress tolerance has a significant and positive influence over

functional value.

7.5.5 The direct influence of technical quality on satisfaction

Study 2 also showed that technical quality had a positive, significant influence

over satisfaction. Technical quality indicators refer to the quality of the service

provided. This would imply that if high service quality is perceived by consumers,

this would be sufficient to arouse feelings of satisfaction for the individual. This is


consistent with the service quality literature which suggests that perceptions of

service quality will result in satisfaction with the service (e.g. Dagger et al., 2007).

However, the mediation tests suggest that the influence of technical quality on

satisfaction is partially mediated by functional value. This means that the

experience of value, particularly functional value in this context, is still relevant and

important to achieving satisfaction from an individual‟s experience with a wellness

service.

7.5.6 Summary of findings

In summary, the role of the consumer in value co-creation was found to be more

complex than originally conceptualised. Different aspects of consumer participation

not only influence both functional and emotional value, but they also influence

satisfaction and behavioural intentions directly. This warrants the need for further

research in co-creation, which will be discussed in Section 7.8.3 for directions of

future research.

The significant and positive influence of emotional value on functional value

demonstrates the prominence of emotional value in value co-creation in wellness

services. This finding has implications on how wellness services should operate,

communicate, and work together with their target markets as it indicates the

importance of emotional benefits to users of wellness services. These implications

will be discussed further in Section 7.7 under the practical contributions of this

research.

Satisfaction was found to be achieved from aspects of the organisation (i.e. technical

quality) which is consistent with the existing literature on the impact of service

quality on customer satisfaction. However, it was also found that satisfaction can

also be achieved from aspects of consumer participation, namely co-production

which demonstrates that consumers can easily derive satisfaction from a

consumption experience on the basis of the inputs that they have provided to the

exchange. This again provides implications for practice, which will be discussed in

Section 7.7.


Finally, while behavioural intentions are influenced by feelings of satisfaction with

the consumption experience, the desired behavioural intentions can also be achieved

directly through some aspects of the organisation (i.e. administrative quality) and

some aspects of consumer participation (i.e. co-production). This finding also

provides implications for practice, which will be discussed in Section 7.7.

7.6 Theoretical contributions

The major theoretical contribution of this research is that this inquiry has

demonstrated the dynamism and complexity of value co-creation in social marketing

wellness services. The findings of this research add to the existing knowledge on

consumer value, service quality, and S-D logic. A significant gap in the literature

was addressed by integrating and situating these three marketing theoretical

frameworks in a social marketing inquiry. The overall results provide a major

contribution to theory by demonstrating the dynamism of consumer value as it

changes throughout the consumption process. This value is determined, created, and

experienced differently by different individuals. Due to its complexity, the nature of

value is likely to change in different consumption situations, demonstrating the

importance of context and showing how context is an important factor for

consideration in value co-creation research.

7.6.1 Contributions to service quality

Two theoretical contributions were made to the area of service quality. First, the

service quality dimensions that are keys to value co-creation in wellness services

using social marketing were identified. Empirical evidence was provided for

interaction quality, technical quality, administrative quality, and environment quality

through both the qualitative and quantitative studies of this thesis.

Second, the development of a model of value co-creation in wellness services

specifies the specific dimensions of value that each of the service quality constructs

create. Quantitatively, empirical evidence was provided to show that administrative

and technical qualities can lead to the creation of functional value, while


interpersonal quality can lead to the creation of emotional value. Qualitatively, it was

demonstrated that environment quality can lead to the creation of functional and

emotional value.

7.6.2 Contributions to consumer value

Five theoretical contributions were made to the area of consumer value. First, the use

of an experiential approach over an economic approach in the investigation of

consumer value in social marketing reflects the current academic shift away from the

traditional and often-used economic approach. Its use demonstrates the relevance and

necessity of using an experiential perspective in academic inquiry into value co-

creation, as well as acknowledges the growing significance and importance of this

approach.

Second, empirical evidence for experiential value dimensions was provided through

the development and provision of a new typology of experiential value in wellness

services using social marketing. The various types of value present in the value co-

creation process are presented in this typology, which combines traditional thinking

of value dimensions developed in commercial marketing with the activity aspect that

characterises experiential value. The resulting synthesis has clarified the concept of

consumer value in social marketing, and wellness services.

Third, empirical evidence for sources of value, which have to date only been

theoretically conceptualised was provided. As a result, a categorisation of sources of

value was developed, which identifies the sources of value that are present in

wellness services and social marketing.

Fourth, an understanding of how the value dimensions and sources relate was also

provided by this research. Both the qualitative and quantitative studies identify the

specific relationships between the experiential value dimensions with the identified

sources of value and explain the nature of these relationships from the consumer

goals identified from the qualitative study.


Finally, empirical evidence was provided to show the inter-relationship between the

value dimensions in wellness services using social marketing. It was demonstrated

through the quantitative study that emotional value has a positive and significant

influence over functional value, adding to the literature that considers consumer

value dimensions to be inter-related, rather than separate and distinct.

7.6.3 Contributions to S-D logic

Four theoretical contributions were made to the area of S-D logic. First, empirical

evidence for S-D logic was provided through the identification of consumer

participation as one of the categories of sources of value in social marketing and

wellness services. It was shown that consumers are indeed co-creators of value and

provides empirical proof to one of the S-D logic foundational premises that identify

consumers as co-creators of value.

Second, consumer participation was explored further and delineated into three types

of participation, which are motivational direction, co-production, and stress

tolerance. This demonstrates that consumers are able to co-create value in a

multitude of different ways and that they are not just empowered in their

determination of the type of value that they seek, but how they choose to create it

with the service.

Third, the model of value co-creation that was developed identifies how the various

types of consumer participation specifically create the different dimensions of

experiential value. It was identified that consumer participation can create both

functional and emotional value, specifically from both motivational direction and

stress tolerance. In addition, while it was found that one aspect of consumer

participation (i.e. co-production) did not directly lead to the creation of experiential

value, it was still demonstrated to lead to the outcome variables of satisfaction and

behavioural intentions which are important outcomes in social marketing.

Finally, the complexity of the role of the consumer was demonstrated through

showing that consumer participation impacts the value co-creation process in a


multitude of ways. This provides further empirical justification for the importance

and significance for the adoption of S-D logic in consumer research.

7.7 Practical contributions

This research also provided a number of practical contributions that are beneficial to

wellness services, social marketers, governments and other policy makers in the area

of preventive health. This research provides wellness services with insight that would

lead to a greater likelihood of achieving organisational strategies and objectives, as

well as consumer satisfaction through more effective delivery of the service and

provision of value to consumers. Specifically, this research clearly identifies

consumers‟ expectations of value from a wellness service, in particular, a free

service. This knowledge is useful for wellness services in their planning and allows

for the setting of realistic targets towards achieving consumer satisfaction through

the provision of value.

Secondly, this research provides a diagnostic tool for improving organisational

competences through the value co-creation model developed. This tool allows for the

identification of the different factors that have an impact on consumers‟

determination of value when using wellness services. Different aspects of the value

co-creation process that can be fully-controlled, partially-controlled, or not controlled

at all are now easily identifiable. This allows wellness services to better manage the

various factors that influence consumers‟ determination of value in order to

maximise positive outcomes and minimise negative outcomes. Insights into

consumers‟ consumption experiences that allow for the identification of areas of

strengths, weaknesses, as well as opportunities, leading to a greater likelihood of

achieving organisational strategies and objectives. The diagnostic tool also allows for

the achievement of more effective delivery of the service and provision of value to

consumers, resulting in greater consumer satisfaction and repeat usage.

This research also provides strong evidence to encourage wellness service

organisations to regard consumers as operant resources as this research has

demonstrated the significant role that consumers play in the value co-creation


process in their consumption experiences. Effort should be invested in not only

educating consumers about their role in the consumption process, but also in building

customer loyalty and retaining existing consumers as they are more educated about

their role in the consumption experience.

In addition, as technical competencies are found to directly influence consumer

satisfaction, staff development and training need to be areas of priority for the

organisation. Staff must be adequately trained to be proficient in the technical aspects

of their work, and the technical competences of staff must be acknowledged and

understood by consumers. Staff training in the non-technical aspects of their work is

also an important are of consideration for service organisations as the research

demonstrates that interpersonal quality of staff significantly influences emotional

value, which subsequently influences satisfaction and behavioural intentions.

Furthermore, emotional value also significantly influences functional value, thus if

consumers perceive that they have been treated well by the organisation‟s staff, this

is likely to influence their perceptions of the utility derived from using the service.

Finally, organisations must acknowledge the significance and importance of

emotional value to consumers and realise that emotional value is often more

important than functional value in the wellness services context. Consumers trust that

the organisation is competent in fulfilling utilitarian needs; however the provision of

emotional fulfilment can offer service organisations a point of differentiation over its

competitors.


7.8 Limitations and future research

There are several limitations that are inherent in this research which can be addressed

in future studies. Thus, a discussion of the limitations of the current research is

presented and suggestions for future research are also discussed.

7.8.1 The context of secondary prevention

In understanding wellness, despite the many different types of wellness activities that

individuals can undertake, this research focussed on wellness services related to

secondary prevention efforts. In wellness and preventive health, distinctions are

drawn between primary prevention efforts, which relate to preventing the occurrence

of a condition, secondary prevention, which relate to detection and early treatment of

conditions, and tertiary prevention, which relate to alleviating the effects of a

condition after its occurrence (Fielding, 1978). Given the importance of context from

a theoretical point of view, the results of these findings are limited to the context of

secondary prevention and cannot be extended to primary or tertiary prevention

efforts. Further research should seek to explore any differences in value

conceptualisation, co-creation, and experience in primary and tertiary prevention

contexts.

7.8.2 The nature of women

Given the selection of breast cancer screening services as the secondary prevention

service selected to situate this research inquiry, the data for both studies was

collected from female-only samples. In many studies on gender differences, it is the

consensus that women are more likely than men to utilise preventive health services

(Haefner et al., 1967; Lairson & Swint, 1978), particularly asymptomatic check-ups

(Nathanson, 1977) like breast cancer screening. Further research is required in

investigating preventive health services aimed at men only (such as prostate checks)

as well as those aimed at both men and women to determine the differences in the

value co-creation in these different groups of people.


7.8.3 The nature of Baby Boomer women

This inquiry was conducted on older women aged 50 to 69 years within the Baby

Boomer generational cohort. It is widely acknowledged by the literature on

generational cohorts that there are differences in the characteristics of different

generational groups. These differences are very likely to have implications on how

these different groups of consumers behave and interact with wellness service

providers and how the formulate attitudes and opinions on wellness behaviour. Given

the cross-sectional nature of this current inquiry, it is not known how these younger

women co-create value in breast cancer screening services or if there are any

differences compared to the Baby Boomers. Further research could consider the

adoption of a longitudinal approach in investigating co-creation in breast cancer

screening services to compare any differences in different generational cohorts.

Alternatively, further research could consider other secondary preventive health

services such as PAP tests that are predominantly utilised by younger women in the

Generation X and Y age cohorts.

7.8.4 The context of an Australian study

This research was conducted on an Australian sample and it is not known if there

may be differences among consumers in other countries on the basis of cultural

differences. Culture theory would suggest that there may be differences. As such,

further research could consider the adoption of a cross-cultural study to investigate

any differences in the value co-creation process for different groups of consumers on

the basis of culture and nationality. There is a strong emphasis on cancer-prevention

efforts in Australia, which may not be the same in other countries, and thus

consumers‟ attitudes and the roles that they play in wellness may differ.

7.8.5 The selection of current users of the service

This research inquiry focussed on investigating women‟s experiences with breast

cancer screening services. One of the eligibility criteria was that they had used these

services at least once. All of the participants of both studies were current users of


breast cancer screening services. Women who were non-users (i.e. those who have

never used breast cancer screening services before) and women who were lapsed

users (i.e. those who have used breast cancer screening services before but do not

maintain regular usage every 2 years) were not included in the inquiry. Future

research undertaken among these two groups of women would be worthwhile in

understanding any differences in value co-creation for different target market

segments of a wellness service. This has the potential to lead to a better theoretical

understanding in the differences of consumer experiences among different target

market segments, and also has the potential to provide better practical understanding

of how to more effectively target different target market segments beyond the current

knowledge. This can provide good contributions to practical knowledge, as well as

theoretical knowledge in the area of value co-creation and S-D logic.

7.8.6 The focus on functional and emotional value

In Study 2, only functional and emotional value dimensions were explored further as

the qualitative findings suggested that these two dimensions were more important to

the women in the study. These dimensions reflected the primary goals that women

sought from breast screening, which were utility and peace of mind, as well as the

secondary goals, which were convenience and control. Social and altruistic value

represented the tertiary goals, which were benefit to others and self as influencer.

These value dimensions were excluded from the empirical study. Further research

should consider the investigation of social and altruistic value, given their particular

relevance in social marketing.

7.8.7 The exclusion of environment and third parties

Study 2 also limited its focus of the sources of value to those that encompassed the

interaction element in a service consumption experience. As a consequence,

environment and third party sources of value that were identified in Study 1 were

excluded from Study 2. There is much existing research on the impact of the

servicescape in services. In the context of health services marketing research, much

of the existing research is conducted in health treatment services as opposed to health


prevention services (e.g. Dagger & O‟Brien, 2010; Dagger et al., 2007). Further

research could consider examining the servicescape further in the context of wellness

services.

The investigation of third parties was also excluded in Study 2. There is much

research in the current body of knowledge conducted on the impact of social groups

on individual decision-making. Future research could consider examining further the

influence that third parties have on value co-creation in social marketing. This may

be particularly relevant, given the highly social and altruistic nature of some social

marketing activities (e.g. volunteering).

7.8.8 A consideration of other social marketing activities

The typology of social marketing activities described by Kotler and Zaltman (1971)

identify three different causes; personal health causes, social betterment causes, and

altruistic causes. The current inquiry focuses on investigating value co-creation in

wellness services, which exemplifies a personal health cause in social marketing.

Future research should consider investigating value co-creation in the other social

marketing causes of social betterment and altruistic causes. Social betterment causes

can include social marketing activities such as recycling, while altruistic causes can

include social marketing activities such as blood donation. This has the potential to

reveal differences in the value co-creation process that are likely to be attributed to

the differences in the type of social marketing activity that is being undertaken. This

can provide good contributions to theoretical knowledge in the areas of value co-

creation and social marketing.


7.9 Conclusion

In conclusion, this research inquiry has investigated consumers‟ experiences with

wellness services by seeking to understand the experiential value experienced during

their consumption process. This research has identified how value is created in

wellness services by identifying the value that consumers seek, the sources that

influence these value determinations, and testing for causal relationships between the

dimensions and sources of value as well as linking those to satisfaction and

behavioural intentions. The results indicate that the experience of value influences

consumers‟ satisfaction with the wellness behaviour, which subsequently influences

their likelihood of performing the behaviour again in the future. The results also

show the prominence of the role of the consumer in value co-creation, demonstrating

an area worth further academic investigation.

References 240

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Appendices 259

APPENDIX A: Exploratory Focus Group Guide & Process

Study 1: Identifying types of value and sources of value for consumers

of breast screening services

24th

August 2008, Sunday

Facilitated by Nadia Zainuddin

Study 1 Objectives:

1. To determine if consumers follow the consumption process

2. To identify the types of value present in the value creation process model

3. To identify the sources of value present in the value creation process model

4. To identify the stages within the value creation process model where the different

types and sources of value are present

PROCESS

A. THANK THE PARTICIPANTS FOR THEIR TIME

Moderator to start with introductions

Thank you all for agreeing to participate in this focus group discussion. My name is

Nadia and some of you may already know me. We are here today to discuss your

experiences with the breast screening services, also known as mammogram services.

This focus group is part of my PhD research and I appreciate your participation in

this discussion.

There are no right or wrong answers to the questions that we will discuss. I am

simply interested in your opinions and experience. This is a completely confidential

conversation and information that is recorded and your full name or demographic

information will not be kept by the Queensland University of Technology or

Queensland Health.

B. EXPLAIN THE PROCESS OF THE FOCUS GROUP INTERVIEW

Today‟s process involves a small group to discuss your opinions and feelings about

your service experience with breast screening services, also known as mammogram

services. I expect that the complete process will take approximately one and a half to

two hours. I would also like to voice record today‟s session, because this discussion

will be transcribed for analysis purposes. When we have completed the analysis, I

will write and provide all participants with a copy of the summary report for

feedback and to ensure that your views have been appropriately represented.

As part of the University‟s ethical clearance policies, I also require you to complete

the two forms in front of you:

1. An ethical clearance form; it is a requirement of the university‟s research

policy to complete this form. The document outlines that the research team

will represent your confidentiality and that any information discussed here

Appendices 260

today will not be used to personally identify participants here today in any

publications or conference discussions.

2. Informant details sheet; general demographic information about you. Only

members of the research team will be privy to this information.

To start, I would like to go around the group and have everybody say their first

name.

C. DISCUSSION OF CONSUMPTION PROCESS EXPERIENCED BY

RESPONDENTS

Objective: to determine if consumers follow the process outlined in the proposed

value creation process model

25 min

Today we will be discussing your experiences with having a breast screen. I will

refer to this process as a service experience. This can include your thoughts, feelings

and opinions outside of the actual service encounter. So please feel free to talk about

issues that occur outside of the actual screen itself.

I would like to know about the process that you go through when you have a breast

screen. Take me through the process that you go through personally from when you

start thinking about having a screen. Then just tell me what you do from there and

what your feelings throughout this whole process from start to finish are like?

Moderator to probe for:

▪ Do consumers go through a consumption process: pre-consumption,

consumption, post-consumption, satisfaction, intentions, and outcome?

▪ Pre-consumption – do you think about breast screening before you go and have

one? What do you do when you start thinking about this?

▪ Post-consumption – do you think about your screen after you have had your

appointment? Do you think about it before you receive your results? Do you still

think about your service experience after you have received your results?

▪ Satisfaction – how do you feel after the service experience is over and you have

received your results? Tell me about your feelings towards the service

encounter, not necessarily about your results. Do you consciously decide how

you feel about the overall encounter?

▪ Behavioural intentions – do you actively decide to come back again or not?

When do you decide?

▪ Outcomes – how often do you follow through on your decision to go back for

your next screen? Do you make an appointment for the next screen straight

away? Do you wait before you make an appointment? Or do you make an

appointment with the intention to go, but then decide not to? Do you forget or

have you simply changed your mind?

Appendices 261

D. DISCUSSION OF TYPES OF VALUE INFLUENCING RESPONDENTS

Objective: to identify the types of value present in the process model

25 mins

Let‟s now talk specifically about the things you would expect from a breast screen.

What do you hope to gain from consuming this service?

Moderator to probe for value at pre-consumption stage:

▪ Functional value – it was a quality service, my nervousness was reduced, I was

made to feel calm, they helped me relax

▪ Emotional value – I felt satisfied, I felt confident, I felt safe, I felt positive, I like

▪ Social value – reduce my insecurities, approved by others, favourable

perception among others

▪ Altruistic value – concerned about others, how it affects others

Now tell me if this changes once you are at the service itself. How is this different to

what you have anticipated?


▪ Value at consumption stage & how this might differ from previous stage

So what happens after you leave the service? Do you then reflect upon your

experience and decide if it matched your expectations of how it would be like?

Then do you come to a decision on how you feel about the entire experience overall?


▪ Value at post-consumption stage

E. DISCUSSION OF SOURCES OF VALUE EXPERIENCED BY

RESPONDENTS

Objective: to identify the sources of value present in the process model

25 mins

Now some of you have mentioned that at the start of the process, there were a few

things you had hoped to gain from consuming this service.

Let‟s talk about how you came about deciding that these were the things you were

hoping to get from this service. What made you decide on these things?


▪ Influences that make them start thinking about breast screening

▪ Influences to their decision to have an appointment

During your service encounter, while you were at the clinic, what were the things

around you that in your opinion, affected your experience in some way?


▪ Factors that influence them during the consumption stage

Appendices 262

Now, you have told me about how you felt after you left the clinic. Can you

remember if there were other things that affected the way you felt about your service

experience after you had your screen?


▪ Factors that influence them during the post-consumption stage

So what are the things that make you decide if you were happy or not happy about

your service experience?


▪ How respondents derive satisfaction

As a result of this, what are the things that make you decide that you are going to go

back again? Or not go back again?


▪ How respondents derive behavioural intentions

So once you‟ve decided to go back, did any of you change your mind? Or did you

just not go?

Did any of you go back for another screen if you decided you would?

Was there anyone who initially thought they would not return for another screen but

ended up having one anyway?


▪ Outcomes

F. DISCUSSION OF CONSUMER PERCEPTIONS OF BSQ

Objective: to understand consumer opinions regarding government services,

particularly BSQ

15 mins

I would now like to quickly ask you about your opinions of BreastScreen

Queensland.

What do you think of BSQ as a service?


▪ Service quality

Do you think the fact that it is a free service has any implications on the quality of

service you expect to receive?

Why did you pick BSQ to get your screening? Where did you go for information

about breast screening?


Appendices 263

▪ Sources of value influencing decision

Have you ever been to a private clinic?

If you have, how does the private clinic compare to BSQ?

For those who have never been to a private clinic, would you consider trying that or

are you satisfied with staying with BSQ?

G. WOULD YOU LIKE TO ADD ANYTHING ELSE, OR RAISE ANY

OTHER POINTS?

H. THANK PARTICIPANTS FOR THEIR TIME

Appendices 264

APPENDIX B: Individual-depth Interview Guide & Process

Study 1: Identifying types of value and sources of value for consumers

of breast screening services

Facilitated by Nadia Zainuddin

Study 1 Objectives:

5. To determine if consumers follow the consumption process

6. To identify the types of value present in the value creation process model

7. To identify the sources of value present in the value creation process model

8. To identify the stages within the value creation process model where the different

types and sources of value are present

PROCESS

A. THANK THE PARTICIPANT FOR THEIR TIME

Interviewer to start with introductions

Thank you for agreeing to participate in this interview today to discuss your

experiences with the breast screening services.

There are no right or wrong answers to the questions that we will discuss. I am

simply interested in your opinions and experience. This is a completely confidential

conversation and information that is recorded and your full name or demographic

information will not be kept by the Queensland University of Technology or

Queensland Health.

B. EXPLAIN THE PROCESS OF THE INDIVIDUAL-DEPTH INTERVIEW

Today‟s process involves an individual-depth interview to discuss your opinions and

feelings about your service experience. I expect that the complete process will take

approximately thirty minutes. I would like to voice record the interview, because this

discussion will be transcribed for analysis purposes. The interview is completely

anonymous and non-identifiable to protect your privacy. You may choose to receive

a copy of the transcript of our discussion for verification, should you wish to ensure

that I have represented your views accurately and appropriately.

As part of the University‟s ethical clearance policies, I also require you to complete:

An ethical clearance form; it is a requirement of the university‟s research

policy to complete this form. The document outlines that the research team

will represent your confidentiality and that any information discussed here

today will not be used to personally identify you in any publications or

conference discussions.

I can send you a copy of the transcript if you would like. You can choose to have me

send this to you so that you can read through it to verify that I‟ve represented you

accurately before I continue with the analysis phase of the research. Otherwise, you

Appendices 265

choose not to have me send you a copy and I will go ahead and use the transcript for

the analysis.

C. DISCUSSION OF CONSUMPTION PROCESS EXPERIENCED BY

RESPONDENTS – PRE-CONSUMPTION


value creation process model and identify types and sources of value at the pre-

consumption stage

15 min

To begin, I would like to hear about your thoughts, feelings and opinions about your

experiences with having a breast screen. I am interested in your comments from

when you start thinking about having a screen, right up till after you receive your

results.

To start, could you please tell me how long have you been having breast screens?

Interviewer to find out age of respondent

So how old were you when you started having breast screens?

Interviewer to find out age of respondent

When or how do you usually start thinking about your next breast screening

appointment?

Apart from the reminder letter, are there other things that get you thinking about this?

Interviewer to probe for alternative triggers (e.g. doctor, media, friends,

family) apart from reminder letter

What do you do once you remember that your next breast screen is coming up?

How long do you wait before you call BreastScreen (to make your appointment)?

Do you have any trouble remembering to call them?

What are the things that you might do to remind yourself to call them?

Do you continue to think about your upcoming breast screen until the day of your

appointment (or do you stop thinking about it once the appointment has been made)?

Interviewer to probe for pre-consumption stage of the consumption process

Why do you not think about your upcoming appointment?

Do you find it unhelpful or unnecessary? Why?

Is this a way of avoiding negative feelings?

What sort of negative feelings do you think you might experience if you do

think about your upcoming appointment?

Could this be a way of reducing anxiety?

How long do you usually have to wait to get an appointment?

Do respondents have a preferred appointment?

Appendices 266

Do they get their preferred appointment relatively easily?

Are they willing to wait longer if they are able to get a preferred

appointment?

Was it easy to get the appointment that you wanted?

What was the person who helped you on the phone like?

Were they helpful?

Were they nice or polite or courteous?

What was the conversation like?

What did you think about this phone call?

Let‟s now talk specifically about the things you would expect from a breast screen.

What do you hope to gain from consuming this service?

Interviewer to probe for value at pre-consumption stage

How did you come about deciding that these were the things you were hoping to get

from this service? What made you decide on these things?

Interviewer to probe for:

▪ Influences that make them start thinking about breast screening

▪ Influences to their decision to have an appointment

Would you consider yourself as someone who is busy or time-poor?

Do you find that if BSQ makes it as easy as possible for you to fit in a screen

into your busy schedule, that you like that?

Do you consider a screen just another thing on your list of things to do or is it

more important than that?

D. DISCUSSION OF CONSUMPTION PROCESS EXPERIENCED BY

RESPONDENTS – CONSUMPTION


value creation process model and identify the types of value present at the

consumption stage

15 mins

Let‟s now talk about once you are at the service itself like today. Is this different to

what you have anticipated prior to actually going for your screen?

Interviewer to probe for any changes in value when respondent moves from

pre-consumption to consumption stage

Could you describe to me what you did once you arrived here?

What did you do while you are waiting? Why do you think that you do this?

Were there many other people around waiting to have screens done too? How did

this make you feel?

Can you describe what the inside of the clinic is like? What do you think about it?

How does it make you feel?

Appendices 267

Did you have to wait long before you were called into the screening room to have

your screen?

Does the actual screen take very long?

Can you describe what the experience was like for you when you were in the

screening room?

How did you feel?

What was the radiographer like?

What do you think about this whole experience?

Do you think there is anything else that could be done to make this experience better

for you?

After your screen, do they ask you to wait while they check the scans? Do you have

to wait long for this before they tell you that you can go?

Was there anything else that you can remember that may have impacted on your

experience in any way?

Interviewer to probe for sources of value at the consumption stage

How are you feeling now that your screen is done?

Interviewer to probe if the respondent feels relief. What is the respondent

feeling now that the screen is over?

E. DISCUSSION OF CONSUMPTION PROCESS EXPERIENCED BY

RESPONDENTS – POST-CONSUMPTION


value creation process model and identify the sources of value present at the post-

consumption stage

15 mins

Now that your screen is over, what happens next?

Do you think you will be thinking about your screen today for a while? / Do you

think you will be reflecting on your screen today after you leave?

Interviewer to probe for any changes in value when respondent moves from

consumption to post-consumption stage

Why do you stop thinking it about it?

Do you think it is unnecessary? Why?

What do you think are the things that might enter your mind if you do think about it?

Do you think about your results (before you receive them)?

Do you wait for your official letter about your results?

Appendices 268

When do you expect to receive your official letter?

Why do you not think about what the results might say in this time?

Do you assume that everything is fine?

Do you just forget because life goes on?

Does it matter how long it takes for your results to reach you?

What do you think you might do after you receive your results?

Why do you stop thinking about it?

F. DISCUSSION OF REMAINDER OF CONSUMPTION PROCESS –

SATISFACTION, BEHAVIOURAL INTENTIONS, AND OUTCOMES


value creation process model and identify the sources of value present at the

remaining stages of the process model

10 mins

What are the things that make you decide if you were happy or not happy about your

service experience?

Interviewer to probe for how respondents derive satisfaction

As a result of this, what are the things that make you decide that you are going to go

back again? Or not go back again?

Interviewer to probe for how respondents derive behavioural intentions

Do you think anyone else, apart from yourself, benefits from you going for a breast

screen?

Interviewer to probe for altruistic value

Do you consider having a breast screen to be a fairly routine activity? Why?

G. DISCUSSION OF CONSUMER PERCEPTIONS OF BSQ

Objective: to understand consumer opinions regarding government services,

particularly BSQ

15 mins

I would now like to quickly ask you about your opinions of BreastScreen

Queensland.

What do you think of BSQ as a service?

Interviewer to probe for service quality

Have you ever been to more than one BSQ clinic? If you have, has the service been

consistent at all the clinics? If it is not consistent, what are some of the differences

that you can remember?

Do you think the fact that it is a free service has any implications on the quality of

service you expect to receive?

Appendices 269

Why did you pick BSQ to get your screening?

Where do you get your information about breast screening from?

Are there any other places or sources from which you get information about breast

screening besides from your GP?

Interviewer to probe for sources of value influencing decision

Have you ever been to a private clinic?

If you have, how does the private clinic compare to BSQ?

If not, would you consider trying that or are you satisfied with staying with BSQ?

Lastly, what would you say for yourself, is the most important thing that you hope to

get out of having a breast screen?

H. WOULD YOU LIKE TO ADD ANYTHING ELSE, OR RAISE ANY

OTHER POINTS?

I. THANK PARTICIPANT FOR THEIR TIME

Appendices 270

APPENDIX C: Email invitation to participate in survey EMAIL to be sent by Nadia Zainuddin, PhD Candidate, Queensland University of Technology

1. Text that is to appear in the e-mail subject line

Invitation to Participate in Health Services Research

2. Text that is to appear in the body of the e-mail

Dear <Name of Respondent>,

I am a PhD candidate at Queensland University of Technology in Brisbane, Australia and would like

to invite you to participate in my research by completing an online survey. This survey forms part of

my final study about understanding women‟s experiences with preventative health services, in the

hope of providing health organisations with an understanding of how they can provide better service,

better value, and better experiences for women. In particular, this research is about understanding

women‟s experiences with using breast screening (i.e. mammogram) services, one of the many health

services that people use.

As you can imagine, finding people to participate in research is not an easy task, so this email has

been sent to you as a result of completing the Australian Lifestyle Survey.

About this survey

Survey length: Approximately 15 minutes to complete

Benefits: A small donation will be made towards breast cancer research for every

woman who fills in this survey, so please help a worthy cause.

Survey close date: 3rd

October 2010

All you have to do is click on this web link http://survey.qut.edu.au/survey/170391/e845/ and

complete an online survey about your experiences with breast screening services. Your input is very

important and your responses are completely anonymous and confidential. Only I will have access to

the data collected. Your participation is completely voluntary and you may withdraw your

participation at any time.

Thank you very much for sharing your experiences.

3. Any graphics that will appear in the e-mail

4. Who the e-mail will appear to be from in the recipient's inbox

The email will appear to come from Nadia Zainuddin

5. Text that clearly identifies the data user: company name, ABN, registered address, contact,

telephone number and web address/URL

The standard signature for a QUT staff member contains this information:

Nadia Zainuddin | PhD Candidate

School of Advertising, Marketing & Public Relations | Faculty of Business | Queensland University of

Technology | www.bus.qut.com

phone: 07 3138 8393| fax: 07 3138 1811| email: [email protected] | CRICOS No. 00213J

http://survey.qut.edu.au/survey/170391/e845/

https://outlook.qut.edu.au/OWA/redir.aspx?C=12409c8caf2b4992a9d426cc801aef96&URL=http%3a%2f%2fwww.bus.qut.com

Appendices 271

APPENDIX D: Online survey – Front page

Appendices 272

APPENDIX E: Online survey – Screening question 1

Appendices 273

APPENDIX F: Online survey – Negative response to

screening question 1

Appendices 274

APPENDIX G: Online survey – Screening question 2

Appendices 275

APPENDIX H: Online survey – Positive response to

screening question 2

Appendices 276

APPENDIX I: Online survey – Section 1: BreastScreen

Providers

Appendices 277

APPENDIX J: Online survey – Section 2: Functional and

emotional value

Appendices 278

APPENDIX K: Online survey – Section 3: Organisational

sources of value

Appendices 279

APPENDIX L: Online survey – Section 4: Consumer

participation (co-production & motivational direction)

Appendices 280

APPENDIX M: Online survey – Section 5: Consumer

participation (stress tolerance)

Appendices 281

APPENDIX N: Online survey – Section 6: Satisfaction and

behavioural intentions

Appendices 282

APPENDIX O: Online survey – Section 7: Demographic

questions

Appendices 283

Appendices 284

Appendices 285

APPENDIX P: Online survey – Concluding page

Appendices 286

APPENDIX Q: Participant information sheet & interview

consent

PARTICIPANT INFORMATION for QUT RESEARCH PROJECT

“Identifying types of value and sources of value for consumers of breast screening

services”

Research Team Contacts

Nadia Zainuddin, PhD Candidate

Rebekah Russell-Bennett, Associate

Professor (07) 3138 8393 (07) 3138 2894

[email protected] [email protected]

Description This project is being undertaken as part of a PhD project for Ms Nadia Zainuddin, who is a

PhD candidate with the School of Advertising, Marketing and Public Relations in the

Faculty of Business, Queensland University of Technology. Ms Zainuddin is working

under the supervision of Associate Professor Rebekah Russell-Bennett from Queensland

University of Technology, and Dr Josephine Previte from the University of Queensland.

This research is undertaken with the support of BreastScreen Queensland (BSQ), a breast

cancer screening service provided by the Queensland Government under Queensland

Health.

The purpose is to understand consumer experiences with breast cancer screening services,

specifically those offered by BreastScreen Queensland (BSQ). The objective is to identify

the benefits that consumers perceive to have experienced from such a service, as well as the

benefits that consumers perceive to not have received, but were expecting to receive.

Examples of questions that participants might be asked include “Describe your experience

with BSQ‟s screening service.” Secondly, this project also seeks to determine the various

factors that might influence consumers‟ expectations of benefits. Examples of questions

that participants might be asked include “How did you come about to expecting these

benefits?”

The importance of this research is twofold. First, it will allow for the improvement of

service delivery in order to better meet the needs of consumers. Secondly, it will allow for

the development of more effective social marketing campaigns that would involve better

informing consumers of the benefits that they will experience and receive from consuming

the service.

In order to identify the different benefits that are experienced by consumers and the things

that can or may affect this, our research has identified three stages of the service process

where consumers can experience benefits from the overall service process: the pre-

consumption stage (before you have your screen), the consumption stage (the day that you

have your screen), and the post-consumption stage (after you have your screen).

The research team requests your assistance because the aim of this research is to identify

from the consumer‟s perspective, the different types of benefits that can exist in such a

Appendices 287

service. Also, as this research aims to identify the different influences on consumers‟

determination of these benefits, this can only be achieved through the participation of

consumers through sharing their experiences with the research team, and using their own

words to describe the service experience and any accompanying benefits experienced from

consuming the service.

Participation Your participation in this project is voluntary. If you do agree to participate, you can withdraw

from participation at any time during the project without comment or penalty. Your decision to

participate will in no way impact upon your current or future relationship with QUT or with

BreastScreen Queensland.

Your participation will involve an individual-depth interview.

The interview is anticipated to last for approximately 45 minutes.

Expected benefits It is expected that this project will benefit you. Your participation will aid in the improvement

of breast screening services offered by BSQ, of which you are likely to be a customer.

Risks The research team anticipates that there are minimal risks beyond normal day-to-day living

associated with your participating in this project as questions of a clinical or medical nature will

not be asked as this research is focussed solely on the service delivery aspect of breast screening.

Where the research may cause distress, independent counselling services may be offered: QUT

provides for limited free counseling for research participants of QUT projects, who may

experience some distress as a result of their participation in the research. Should you wish to

access this service please contact the Clinic Receptionist of the QUT Psychology Clinic on

3138 4578. Please indicate to the receptionist that you are a research participant.

Confidentiality All comments and responses are anonymous and will be treated confidentially. The names of

individual persons are not required in any of the responses.

Discussions are likely to be audio recorded for transcription purposes. Transcripts of all

discussions will only be used for the research described in this form and not for any other

purpose. Only the principle researcher will have access to the audio recordings and transcripts.

After a research report is prepared, participants may be asked to verify if their views have been

represented accurately and if all identifiable traits of their identity have been adequately removed.

Consent to Participate We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to

participate.

Questions / further information about the project Please contact the researcher team members named above to have any questions answered or if

you require further information about the project.

Concerns / complaints regarding the conduct of the project QUT is committed to researcher integrity and the ethical conduct of research projects. However,

if you do have any concerns or complaints about the ethical conduct of the project you may

contact the QUT Research Ethics Officer on 3138 2340 or [email protected]. The

Research Ethics Officer is not connected with the research project and can facilitate a resolution

to your concern in an impartial manner.

mailto:[email protected]

Appendices 288

CONSENT FORM for QUT RESEARCH

PROJECT

“Identifying consumer value and influencers of value in breast screening

services”

Statement of consent By signing below, you are indicating that you:

have read and understood the information document regarding this project

have had any questions answered to your satisfaction

understand that if you have any additional questions you can contact the research team

understand that you are free to withdraw at any time, without comment or penalty

understand that you can contact the Research Ethics Officer on 3138 2340 or [email protected] if you have concerns about the ethical conduct of the project

agree to participate in the project

understand that the project will include audio recording

understand that your contact information is required only for the purpose of a follow-up interview if required or to send you the results if you have indicated that you would like to receive this

Name

Contact no Email address

Date / / Signature

Would you like to receive a copy of the results from this study?

Please circle either “yes” or “no” to indicate your preference

Yes.

Please send me a copy of the results

No.

Thank you

mailto:[email protected]

Appendices 289

APPENDIX R: Codebook for customer perceived value

constructs

Dimensions Source Definitions Key words/thing

to look for

Functional Sheth, Newman

and Gross, 1991

“the perceived utility acquired from an

alternative‟s capacity for functional,

utilitarian, or physical performance”

“accurate”,

“convenient”,

“easy”, “reliable”

Nelson and

Byus, 2002

“the perceived benefit of a health

department‟s programs and services”

Sweeney and

Soutar, 2001

the utility derived from the perceived

quality and expected performance of the

product”

Holbrook, 2006 product or consumption experience serves

as a means to a consumer‟s own

objectives”

Emotional Sheth, Newman

and Gross, 1991


alternative‟s capacity to arouse feelings or

affective states. An alternative acquires

emotional value when associated with

specific feelings or when precipitating or

perpetuating those feelings. Emotional

value is measured on a profile of feelings

associated with the alternative”

“peace of mind”,

“reassurance”,

“worry”, “relief”,

“happy”

Nelson and

Byus, 2002

“feelings about the health department”

Sweeney and

Soutar, 2001

“the utility derived from the feelings or

affective states that a product generates”

Holbrook, 2006 “arises from one‟s own pleasure in

consumption experiences appreciated for

their own sake ascends in themselves”

Social Sheth, Newman

and Gross, 1991


alternative‟s association with one or more

specific social groups. An alternative

acquires social value through association

with positively or negatively stereotyped

demographic, socioeconomic, and

cultural-ethnic groups. Social value is

measured on a profile of choice imagery”

“remind my

colleagues”, “role

model”, “show

others”, “tell

others”,

“influence”

Nelson and

Byus, 2002

“reference groups of people that „are most

and least likely to benefit directly from the

programs and services‟ provided from the

health department”

Sweeney and

Soutar, 2001

“the utility derived from the product‟s

ability to enhance social self-concept”

Holbrook, 2006 occurs when one‟s own consumption

behaviour serves as a means to shaping

the responses of others”

Altruistic Holbrook, 2006 “entails a concern for how one‟s own

consumption behaviour affects others

where this experience is viewed as a self-

justifying end-in-itself”

“my family”, “my

friends”,

“community”,

“community

costs”, “society”

Appendices 290

APPENDIX S: Codebook for experiential value dimensions

Constructs Dimensions Source Definitions Key words/thing

to look for

Experiential

value

Active

Mathwick,

Malhotra and

Rigdon (2001)

Derived from

“heightened

collaboration

between the

consumer and the

marketing entity”

“I made an

appointment”, “I

called”, “find the

time”, “don‟t

worry”, “don‟t

think about it”

Reactive Mathwick,

Malhotra and

Rigdon (2001)

Derived from “the

consumer‟s

comprehension of,

appreciation for, or

response to a

consumption object

or

experience”

“staff”, “friendly”,

“warm”, “good

service”,

“atmosphere”,

“pleasant

environment”,

“lighting”, “chairs”,

“waiting room”

Appendices 291

APPENDIX T: Codebook for sources of value

Constructs Source Definitions Key words/thing to look

for

Information Smith and

Colgate

(2007)

“marketing materials produced by the

organisation that convey information

including promotional material,

website, brochures, and instructions”

“reminder letter”,

“brochures”,

“pamphlets”,

“recommendation”

Interaction Smith and

Colgate

(2007)

“interaction with employees within the

service system and service-for-service

exchange and configuration of

resources (including people and

technology)”

“warm”, “friendly”,

“professional”,

“efficient”, “quick”,

“easy”

Environment Smith and

Colgate

(2007)

“atmospherics, social servicescape and

the physical aspects of the consumption

experience such as the building”

“atmosphere”,

“comfortable”, “warm”,

“chairs”, “coffee and

tea”

Participation Dabholkar

(1990)

“the degree to which the consumer is

involved in producing and delivering

the service”

“remember to call”,

“follow instructions”,

“try to help”

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