The Consumer and the Health Care Process

Lynn Langmeyer, Wright State University
George Misoulis, Wright State University
ABSTRACT - A review of perceived past and current directions in health care delivery research is presented to set the stage for a paper on a suggested future direction in this critical area. Consumer data on attitudes toward health care is presented and discussed in order to reveal a relatively unexplored direction within which constant research can make unique and important contributions: the interpersonal dimension of the health care consumption process. The paper concludes with suggestions for specific research of both a theoretical and practical nature.
[ to cite ]:
Lynn Langmeyer and George Misoulis (1981) ,"The Consumer and the Health Care Process", in NA - Advances in Consumer Research Volume 08, eds. Kent B. Monroe, Ann Abor, MI : Association for Consumer Research, Pages: 612-615.

Advances in Consumer Research Volume 8, 1981      Pages 612-615

THE CONSUMER AND THE HEALTH CARE PROCESS

Lynn Langmeyer, Wright State University

George Misoulis, Wright State University

ABSTRACT -

A review of perceived past and current directions in health care delivery research is presented to set the stage for a paper on a suggested future direction in this critical area. Consumer data on attitudes toward health care is presented and discussed in order to reveal a relatively unexplored direction within which constant research can make unique and important contributions: the interpersonal dimension of the health care consumption process. The paper concludes with suggestions for specific research of both a theoretical and practical nature.

INTRODUCTION

The focus of this paper is consumer behavior issues of health care consumption. It is generally accepted that many consumers are dissatisfied with the quality of health care they receive and, at the same time, feel unable to remedy the situation. In this paper, we suggest that the health care provider - patient interaction, the interpersonal dimension of the system, has often been neglected as an important source of these dissatisfactions. At the same tine, the interpersonal dimension represses an important starting point for dealing rich these dissatisfactions. The objective of the paper in to provoke consideration and exploration of health care consumption behavior and not, at this point, to provide a detailed analysis of constant dissatisfaction with the health care process.

HEALTH CARE DELIVERY -- WHERE'S THE CONSUMER?

Zaltman and Vertinsky (1971) mention, rather briefly, in their article "Health Service Marketing: A Suggested Model," that one of the "perceived harriers to taking proper health action is the psychological distance between patient and physician." This distance, they suggest, "may cause patients to ignore the treatment prescribed by the physician." Health care professionals, particularly nurses, have been aware for many years of the inequality inherent in the physician-patient relationship (See M. Karmer 1972) and the negative effect of this imbalance on the patient. However, the physician component of the profession has changed little in the past ten years with respect to the interpersonal dimension, and little consumer-oriented research has been done in this critical area. Indeed, although the interpersonal dimension has been a relatively unexplored issue of health care research, we can find hints of its importance in health care literature.

For example, Hochbaum (1969) discussing consumer participation in health planning states:

We must recognize and accept the fact that it is the consumers of health services who are the final and proper judges of what kinds of services they went, how they want then delivered, what form they should take and in what setting they should be provided.

It is only on the medical and technical details that the health professions have any exclusive right to make decisions.

To further emphasize, support and underscore this issue, we found the majority of specific dissatisfactions that the Wright State study panel members experience with health care (aside from cost) can be traced to what Zaltman and Vertinsky call "psychological distance," what Kramer calls "power imbalance" and what Hochbaum calls "inequity." As marketers, if we are to assist health care professionals in addressing these dissatisfactions, then We must begin to understand, explain, and eventually model general health care consumer behavior. We believe the first step in this research process is to examine the issues of health care consumption behavior with emphasis on the interpersonal dimension. We will identify and examine these issues by first discussing previous directions in health care literature and research, which suggest or consider but do not thoroughly explore consumption behavior and then, in the balance of the paper, directly address the issue of consumer attitudes and the consumption process.

IDENTIFIED RESEARCH ISSUES (DIRECTIONS?)

The literature and research in the area of the consumer and health care appears to address four major issues and one minor issue. The research issues are:

1) consumer participation in the planning and delivery of health care

2) consumer satisfaction with delivery system

3) health care decision models

4) health promotion

5) health care facility location

Each of theme is summarized below from the perspective of the role of and impact on the consumer.

Planning and Delivery

The passage of Public Laws 88-164, and 93-64 in 1963, 1966, and 1974 respectively, require that representatives of the consumers of health care facilities be participants in the planning and operating councils of such facilities. The conceptual literature and empirical research in this area, with respect to the consumer, focuses on issues such as, "The Whys and Why Nots of Consumer Participation" (Thomson 1973), "Community Health Planning or Who Will Control the Health Care System" (Brown 1972), "Consumer Participation in Health Planning: Toward Conceptual Clarification'' (Hochbaum 1968) and "The Merits of Using Experts or Consumers as Members of Planning Groups: A Field Experiment in Health Planning" (Nutt 1976).

These articles have appeared in public health journals or management journals and emphasize the organizational ramifications and problems concomitant with consumer participation in the planning and delivery of health care. The discussions and research results are useful for educational, skill training and general managerial purposes. They are, however, relatively unuseful for exploring patient health care consumption behavior.

The issue of consumption behavior is not completely ignored. Nutt (1976), in discussing the role of consumers as members of planning groups makes the following observations: "people should have a role in articulating their needs" ..... yet we are "co-opting health consumers by giving then a voice in the decision process and not fundamentally altering the decision process itself (e.g. the criteria selected or criteria weightings used to make decisions)." We would add that additional co-opting occurs when health consumers are given no role or voice in evaluating how well articulated needs are being met which raises the issue of consumer satisfaction with delivery systems.

Consumer Satisfaction Issues

The second major theme, appearing at this tine almost exclusively in public health journals, concerns consumer satisfaction/dissatisfaction with specific types of delivery systems -- HMOs (Pope 1978), prepaid group practice (Weinerman 1954; Bashshur, et al. 1967; Tessler and Mechanic 1975), health plan coverage (Gerst, et al. 1969), etc. The results of these studies are somewhat confusing, perhaps, as Kramer (1972) suggests, due to the lack of differentiation between the "outcome of medical care as contrasted to the activities involved in obtaining or being gives that care." She raises the issue of the interpersonal dynamics in health care consumption and Weinerman (1964) reports "disappointment with the degree of personal interest shows by the doctor" attributing this patient perception to conflict between lay and professional concepts of proper care.

This interpersonal theme is further suggested by others. Pope (1978) states his respondents are "more satisfied with the technical aspect of HMOs than the interpersonal components;" Friedman and Di Matteo (1979) mention "power differential," "the patient as an object," "the impact of health care professionals on patient's reactions," "satisfaction comes from treatment as a person," and "the needs and values of patients determines 'best' procedures," O'Connor (1978) states "accurate and complete information about patients' needs and satisfactions" must be available. Weinerman (1964) summarizes these ideas in his statement, "the most neglected and least appreciated element in medical care planning and evaluation is overall perceptions of patients...the reactions of the consumer to medical care."

Generally, despite these selected comments, the satisfaction/dissatisfaction health care studies are concerned with the implications for health care organizations and not health care consumption itself. For example, Swan and Carroll (1980) conducted an extensive literature review to explore the possible conceptual and research contributions the patient satisfaction literature might provide for research on consumer satisfaction. It is clear from the reviewed research that "physician-patient interactions" are strongly related to patient satisfaction. However, explanations as to why this relationship exists or how it operates in health care consumption are not offered in the literature reviewed.

Decision Models

The contribution of consumer behaviorists to health care marketing, in the form of health care decision models, comprises the third major research theme. These studies have appeared in marketing journals and conference proceedings and have concentrated on modeling action/no actions decisions with respect to illness (Zaltman and Vertinsky 1971) or exploring the demographic and psychographic factors associated with the decision to seek medical care (Wortzel 1976). The emphasis appears to be on social marketing and segmentation issues of health care rather than on identification and exploration of consumption behavior issues. As such these articles contain important implications and suggestions for preventive health care behavior changes. However, we feel it is also important to follow the consumer in this process beyond the initial action/no action state. Indeed, it is possible that action/no action decisions are tied inextricably to prior experiences in health care situations, particularly the interpersonal aspects of those situations, and the existing models do not demonstrate this orientation.

Health Promotion

The fourth area, health promotion, addresses health educators attempts to increase utilization of health services, and to stimulate changes in health behaviors, and changes in health attitudes, knowledge, and values. The focus of Keyes (1972), Rosenstack (1966 and 1974) and most recently Green (1979) has been on those activities designed to increase consumer participation in the health care system and to reinforce consumers' positive health behaviors. Of the five areas being reviewed, health promotion comes closest to identifying and responding to consumption behavior issues. However, health promotion currently fails to consider the consumer's interpersonal .needs as an integral element of the promotion and reinforcement process. Some recent research by Green (1979) and Miaoulis (1979) suggests that health educators are beginning to address this issue and we are suggesting that construct behavior researchers do the same. There is substantial opportunity for marketers to assist in the development process as health educators have not historically recognized the importance of consumer decision processes.

Facility Location

The final theme, rather undeveloped at the present time and therefore somewhat minor, is the use of mathematical models to determine health care facility location. Parker and Srinivasan (1976) report on a modeling approach which incorporates consumer preferences in planning rural primary health care facilities. Their study indicates that the method, although elaborate and time consuming, has "substantial reliability and predictive validity" as well as viability. This aspect of health care delivery, however, is only tangentially related to our field of interest.

CONSUMER ATTITUDES

Consumption Process

The specific theme conspicuously absent (aside from passing mentions here and there) in the previous discussion of health care research (which is by no means meant to be exhaustive) concerns issues surrounding consumer health care behavior subsequent to participating in the location, planning, and operating of a health care delivery system and the decision to use it. In other words -- what factors affect the behavior of a consumer, negatively and positively, as he or she is in the process of consuming general medical care and/or local hospital services?

Imagine that you are a consumer in the examining room of your physician's office. You have just been informed that the results of the series of tests you underwent last week indicate surgery is necessary. Your physician says, "No, it is not really serious, but should be taken care of as soon is possible." This typical exchange between consumer and physician leads to some important consumption issues:

1. Does the consumer participate in the surgery decision making process?

2. Does the consumer question the physician as to the benefits of the surgery and its outcomes? Unfortunately, there is no money back guarantee or trial size.

3. If the consumer seeks a second opinion, how are opinions compared with respect to quality, cost, etc.?

4. If the consumer decides to undergo surgery, does he or she have the authority to determine the who, when where and under what conditions it will be performed?

5. To summarize: Is the consumer a participant in the consumption process?

Now imagine that you have decided to undergo surgery and are seated in the waiting room of "your" hospital, filling out insurance forms since that is the necessary first step in your consumer/patient role. How do you feel? Is there a knowledgeable person available with whom you can share your feelings of anxiety and powerlessness? Are you being treated like "the patient" or "a case"? This scenario certainly suggests you have not been a consumer in the traditional usage of that term -- involved decision maker.

Illustrative Data

To illustrate the consumer's lack of involvement in the health care consumption process, we draw upon a 1978 Wright State University consumer panel study designed to assess the overall quality of medical care and hospital services in the Dayton, Ohio SMSA. [The Wright State University Consumer Pane/ is a randomly selected demographically cross sectional sample of 1,000 households in the Dayton, Ohio SMSA.] While the study was not specifically designed to analyze the health care consumption process, several open-ended questions illustrate the consumer lacks of involvement, and warrant reporting here.

The data from the panel study suggests that consumers are feeling helpless, depersonalized, uninformed and scared. Panelists were asked to respond to the question, "If you could change one thing about the general level of hospital services, what would it be?" The following are selected verbatim comments directed explicitly at the interpersonal component of services:

* Let the patient know more, explain more.

* Take more time to be sympathetic and explain what is happening and why.

* Improve education of personnel, especially to be more compassionate and devoted to patients.

* More caring doctors.

* Quicker more efficient personal attention.

* More communication between physician and patient.

* More individualized care.

* More personal concern.

* Be more aware of the family in regard to the truth of the conditions of the patient.

* More empathy with patients.

* Medical professionals should look past their income levels and more into what they're being paid to do.

* Quality of 'bedside' manner of professionals.

* More personalized service. Patients are scared humans, not just bodies.

* More concern, more interest in people than money.

The following summary to the question, "If you could change one thing about the general level of hospital services, what would it be?", indicates clearly the consumers' need for improving communication between the health care providers and the patients.

Suggested Improvements                        Response

Cost containment                                     25%

Better communications with patients         20

Emergency room services                        15

Better preventive medicine                       15

Better food services                                 15

All other comments                                  10

The results suggest that patients feel they are not active participants in the health care consumption process. They have little or no control and power within the system, and their expressed dissatisfactions (aside from cost) are with interpersonal and other non-technical aspects of the health care system.

Quality of Health Care

It is also evident from panel responses that quality health care is defined in terms of both technical aspects and interpersonal aspects. When asked, "How would you define quality care within a hospital?," panel members gave considerable attention to the non-technical, interpersonal dimension:

Quality of Hospital Care   Response

Technical aspects

   Qualified staff                     24%

   Efficient staff                      16

Non-Technical aspects

   Patient concern                  22

   Patient care                         9

Friendly personnel                  7

All other comments               22

Panel members were asked a similar question regarding their perception of quality care by physicians. Their responses to "How would you define quality care by a physician? also reflect concern for both the technical and interpersonal aspects of health care.

Quality of Physician Care   Response

Technical aspects

   Diagnosis                            25

   Medical knowledge            15

   Proper treatment                11

Non-Technical aspects

   Patient interest                   17

   Personal communication    11

   Physician availability            4

All other comments              17

The interpersonal dimensions of health care are equally as important, and perhaps more important to consumers. To fully participate in the consumption process, and to have the opportunity to assess issues such as quality care, consumers require interpersonal attention and communication. The technical and non-technical aspects of health care cannot continue to be treated as separate elements of the delivery systems. Illness is an inherently anxious condition and hospitals are scary places. If consumers' health care are to be met satisfactorily then we must design human systems to meet them and not simply buildings and support facilities,

IMPLICATIONS

The data strongly suggests that the non-technical, interpersonal dimension of health care consumption, generally ignored or given cursory attention in health care consumer behavior studies, must be considered and studied regardless of the "major themes" being investigated. The issues of lack of active participation, lack of communication, feelings of helplessness, powerlessness and depersonalization not only influence but perhaps determine health care behavior.

If, as consumer behavior researchers, we are to contribute to the understanding and explaining of health care behavior, and provide genuinely useful information to health care professionals, then we must address and systematically investigate the issues of the consumer and the health care consumption process. To this end, we recommend that the following research be undertaken:

* Examination of the formal and informal communications networks in various health care settings.

* Patient oriented research to identify and investigate the role inequities of the interpersonal patient physician relationship.

* Physician oriented research to identify mechanism through which physician (and medical students) can be taught to emphasize the interpersonal dimensions of health care delivery.

* Broader conceptualization and integration of the health care process through more interdisciplinary research.

* In-depth research on consumer motivations and attitudes toward and benefits sought from health care interactions.

The research studies outlined above will contribute to understanding construct attitudes and the health care consumption process.

REFERENCES

Bashshur, R. L., Metzner, C.A., and Worden, C. (1967), "Consumer Satisfaction With Group Practice -- The CHA Case," American Journal of Public Health, 57, 1991-9.

Brown, Douglas R. (1972), "Community Health Planning or Who Will Control the Health Care System?," American Journal of Public Health, 62, No. 10, 1336-39.

DiMatteo, M. Robin (1979), "A Social Psychological Analysis of Physician-Patient Rapport: Toward a Science of the Art of Medicine," Journal of Social Issues, 35, No. 1, 12-33.

Friedman, Howard S. and DiMatteo, M. Robin (1979), "Health Care As An Interpersonal Process," Journal of Social Issues, 35, No. 1, 1-11.

Gerst, A., Rogson, L. and Hetherington, R. (1969), "Patterns of Satisfaction with Health Plan Coverage: A Conceptual Approach," Inquiry, 6, 37-51.

Green, Lawrence W. (1979), "How to Evaluate Health Promotion," Hospitals, 106-108.

Harris, Reuben T. (1978), "Improving Patient Satisfaction Through Action Research," Journal of Applied Behavioral Science, 14, No. 3, 383-402.

Hochbaum, G. M. (1969), "Consumer Participation in Health Planning: Toward Conceptual Clarification," American Journal of Public Health, 59, No. 9, 1698-1705.

Keyes, Lyn Ford L. (1972), "Health Education in Perspective: An Overview," Health Education Monographs, 31.

Kotler, Philip and Zaltman, Gerald (1971), "Social Marketing: An Approach to Planned Social Change," Journal of Marketing, 35, 3-12.

Kramer, Marlene (1972), "The Consumer's Influence on Health Care," Nursing Outlook, 20, No. 9, 547-78.

Miaoulis, George (1979), "Good Samaritan Hospital and Health Care Centers: Conceptual Analysis of Consumer Panel Study," Unpublished Working Paper, Wright State University.

Miaoulis, George (1979), "Marketing and Health Education," Keynote address presented at Ohio Health Education Institute, Kenyon, Ohio.

Nutt, Paul C. (1976), "The Merits of Using Experts or Consumers as Members of Planning Groups: A Field Experiment in Health Planning," Academy of Management Journal, 19, No. 3, 378-96.

O'Connor, John T. (1978), "The Radically New Medical Care Industry," Journal of Applied Behavioral Science, 14, No. 3, 275-305.

Paap, Warren R. (1978), "Consumer-Based Boards of Health Centers: Structural Problems in Achieving Effective Control," American Journal of Public Health, 68, No. 6, 578-82.

Parker, Barnett R. and Srinivasan, V. (1976), "A Consumer Preference Approach to the Planning of Rural Health-Care Facilities," Operations Research, 24, No. 5, 991-1025.

Pope, Clyde R. (1978), "Consumer Satisfaction in a Health Maintenance Organization," Journal of Health and Social Behavior, 19, 291-303.

Rosenstock, Irwin (1966), "Why People Use Health Services," Milbank Memorial Fund Quarterly, 44, 194-227.

Rosenstock, Irwin (1976), "The Health Belief Model and Preventive Health Behavior," Health Education Monographs, 2, 354-386.

Swan, John E. and Carroll, Maxwell G. (1979), "Patient Satisfaction: An Overview of Research -- 1965 to 1978," Paper presented at the Fourth Annual conference on Consumer Satisfaction/Dissatisfaction and Complaining Behavior, Indiana University, Bloomington, Indiana, October 4-5, 1979.

Tessler, R. and Mechanic, D. (1975), "Consumer Satisfaction With Prepaid Group Practice," Journal of Health and Social Behavior, 16, 95-113.

Thomson, Ruth (1973), "The Whys and Why Nots of Consumer Participation," Community Mental Health Journal, 9, No. 2, 143-50.

Weinerman, E. Richard (1964), "Patients' Perceptions of Group Medical Care," American Journal of Public Health, 54, No. 6, 880-89.

Wortzel, Lawrence H. (1976), "The Behavior of the Health Care consumer: A Selective Review," Proceedings, Association for Consumer Research, Sixth Annual Conference, 295-301.

Zaltman, Gerald and Vertinsky, Ilan (1971), "Health Service Marketing: A Suggested Model," Journal of Marketing, 35, 19-27.

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