The Determinants of Satisfactionfor a High Involvment Product: Three Rival Hypotheses and Their Implications in the Health Care Context

ABSTRACT - In contrast to our understanding of satisfaction with low involvement products, there is still very little understanding of the factors that influence satisfaction with high involvement products. This paper draws upon two distinct bodies of research, satisfaction theory and decision making theory, to develop three rival hypotheses on satisfaction with high involvement products. These three hypotheses have important, yet different implications, for satisfaction with a unique high involvement product health care. According to these hypotheses, satisfaction is determined by (1) by the discrepancy between patient expectations and physician performance, or (2) primarily by physician performance, or (3) by providing the consumer with more information about health care alternatives.

Citation:

Mary Beth Barber and Meera Venkatraman (1986) ,"The Determinants of Satisfactionfor a High Involvment Product: Three Rival Hypotheses and Their Implications in the Health Care Context", in NA - Advances in Consumer Research Volume 13, eds. Richard J. Lutz, Provo, UT : Association for Consumer Research, Pages: 316-320.

Advances in Consumer Research Volume 13, 1986      Pages 316-320

THE DETERMINANTS OF SATISFACTIONFOR A HIGH INVOLVMENT PRODUCT: THREE RIVAL HYPOTHESES AND THEIR IMPLICATIONS IN THE HEALTH CARE CONTEXT

Mary Beth Barber, University of Pittsburgh

Meera Venkatraman, Boston University

ABSTRACT -

In contrast to our understanding of satisfaction with low involvement products, there is still very little understanding of the factors that influence satisfaction with high involvement products. This paper draws upon two distinct bodies of research, satisfaction theory and decision making theory, to develop three rival hypotheses on satisfaction with high involvement products. These three hypotheses have important, yet different implications, for satisfaction with a unique high involvement product health care. According to these hypotheses, satisfaction is determined by (1) by the discrepancy between patient expectations and physician performance, or (2) primarily by physician performance, or (3) by providing the consumer with more information about health care alternatives.

INTRODUCTION

While researchers have focused on the determinants of satisfaction for a low involvement, frequently purchased, convenience product (Olshavsky & Miller 1972; Prakash & Lounsbury 1983; Swan & Combs 1976), less attention has been devoted to the factors that influence the satisfaction with a high involvement product (Day 1977; Oliver & Bearden 1983; Churchill & Surprenant 1982). The Disconfirmation Theory, which is the dominant paradigm in the satisfaction literature, has been successful in explaining satisfaction/dissatisfaction with a variety of low involvement products, but it is less successful in explaining the same phenomenon for high involvement products (Oliver & Bearden 1983; Churchill & Suprenant 1982). Other explanations of satisfaction with these types of products are suggested by the empirical research on consumer satisfaction but have not been systemically explored (Oliver & Bearden 1983: Churchill & Suprenant 1982).

It is important to understand the processes by which the satisfaction with a high involvement product is determined, since involvement affects the extent and nature of post-purchase processing, which in turn influences satisfaction. As defined by Petty and Capicippo (1981) and others, involvement refers to the activation of problem solving behavior when the act of purchase or consumption is seen by the decision maker as having high personal importance or relevance. The greater the involvement with a product the greater the likelihood of post-purchase evaluation, and the more extreme the post-purchase evaluations (Gronhaug 1977; Richins 1982). The strength of post-purchase evaluations influences satisfaction, which determines the post-purchase behaviors such as repeat purchase and word-of-mouth. While the importance of repeat purchase is self-explanatory, word-of-mouth communication is important because it influences the purchase of others for high involvement products (Assael 1981; Engel & Blackwell 1982). Thus, satisfaction becomes an even more important issue for a high involvement product.

In this context, this paper examines the determinants of satisfaction for a high involvement product. Its contribution is that it studies the factors which influence satisfaction not only from the perspective of current research in consumer satisfaction theory but also from the consumer decision making theory perspective.

Consumer Satisfaction Theory: The Disconfirmation Paradigm

The disconfirmation theory is the dominant framework in the consumer satisfaction literature (Cardozo 1965; Olshavsky & Miller 1972; Swan & Combs 1976). According to this theory, satisfaction is related to the size and direction of the discrepancy between prior expectations and actual performance. Specifically, when performance is equal to the prior expectations, confirmation results, which leads to satisfaction. Disconfirmation results when performance does not equal prior expectations. Positive disconfirmation is the result of performance exceeding prior expectation, which also leads to satisfaction. Negative disconfirmation, in contrast, is the result of performance being less than prior expectations, which leads to dissatisfaction. Thus, satisfaction results when prior expectations are confirmed or positively disconfirmed. Based on the disconfirmation theory of consumer satisfaction it is hypothesized that:

H1: Satisfaction with a high involvement product is determined by the discrepancy between expectations and performance.

Thus, according to the Disconfirmation Theory, EXPECTATIONS and PERFORMANCE determine satisfaction with a high involvement product. The theory and its building blocks, expectations and performance, have to be tailored to the study of satisfaction with high involvement products, since the dimensions of these building blocks that are relevant for high involvement products are different from those that are relevant for low involvement products. These dimensions will be briefly discussed next. EXPECTATIONS differ by tope (Miller 1977), nature(Day 1977), and source (LaTour & Peat 1980). Four types of expectations have been identified: ideal, expected, minimum tolerable, and desirable (Miller 1977). "Ideal" expectations seem to be most relevant for high involvement products since highly involved consumers tend to have "higher" expectations (Oliver 1980). In contrast, "minimum tolerable" expectations seem to be a more relevant standard to compare performance with a low involvement product. The "minimum tolerable" standard implies a conjunctive decision making rule (Bettman 1979) that low involvement consumers are likely to use to reduce the cognitive and physical effort of searching and evaluating.

The nature of the expectations refers to the dimensions of the product about which the consumer has expectations (Day 1977). In the purchase of a high involvement product, the social, psychological and functional risks involved are high and consequently, consumers hold expectations about a greater number of attributes than they do for low involvement products. For example, in the purchase of an automobile, consumers have expectations regarding the appearance and style of the vehicle, quality of materials, the quality of the workmanship, warranty coverage, etc. (Day & Ash 1978). In contrast, for a low involvement product, the risks involved are fewer and lower and therefore, consumers have expectations about fewer attributes.

The source of the expectation refers to the information sources from which the consumer derives his/her expectations. Traditionally, research has concentrated on the expectations derived from test reports, manufacturers, and unspecified sources (La Tour & Peat 1980). However, this extant research ignores other important sources of expectations, such as personal past experience and others' past experience (La Tour & Peat 1980). These sources play a key role in the determination of expectations for a high involvement product. Since high involvement product decisions are risky and important, consumers tend to rely heavily on their own past experience and the past experience of others in the determination of expectations. The utilization of information from others rends to alleviate some of the uncertainty surrounding complex product evaluations (Cohen & Golden 1972) such as in the case of a with involvement product.

Two dimensions of PERFORMANCE become important in determining the satisfaction with high involvement products. The first is the functional or instrumental performance of the product. However, this dimension of performance is also important for low involvement products. The second dimension, expressive or psychological performance, becomes particularly relevant for high involvement products due to their high degree of social, financial, physical, and/or psychological risk (Swan & Combs 1976).

In summary, according to the disconfirmation theory, satisfaction for a high involvement product results from the discrepancy between expectations and performance. For a high involvement product,-the standards used to compare performance are "ideal" expectations, which the consumer derives from a number of sources; the most important of which is personal sources. Further, the performance dimension that becomes particularly relevant in determining satisfaction with a high involvement product is the expressive/psychological performance dimension.

Rival Hypothesis to the Disconfirmation Theory

While much of consumer satisfaction research is based on the disconfirmation paradigm, alternatives to this classical model are suggested by both the conceptual and the empirical research on consumer satisfaction. Oliver and Bearden (1983) found that the importance of expectations as a determinant of satisfaction decreases for high involvement products and the importance of performance increases. Thus, according to Oliver and Bearden (1983, p. 253), "high involvement decreases his/her sensitivity to pre-usage phenomena and increases his/her sensitivity to outcome phenomena." This means that, performance becomes an independent determinant of satisfaction.

Churchill and Suprenant (1982) report this independent role of performance in the determination of satisfaction for a video disk player. In an empirical research study of 126 respondents, they found that satisfaction with a video disc player is primarily determined by the performance of the product. "Neither the disconfirmation experience nor subjects' initial expectations affected subjects' satisfaction with the product" (Churchill & Suprenant 1982, p. 502). rhus, the authors report the existence of a direct performance-satisfaction link for some products.

Even though these empirical findings could be the result of an artifact of gross differences in the performance manipulation, nonetheless further attention is warranted before a decision can be made to support or disregard the findings. As a result of this conceptual and empirical research an alternative to Hypothesis One is proposed

H2: Satisfaction with a high involvement product is determined primarily by the performance of the product.

CONSUMER CHOICE LITERATURE

The consumer choice literature should help us understand the processes through which satisfaction or dissatisfaction is achieved. However, the research that links consumer decision making processes with satisfaction is very limited (Bettman 1979; Day & Hunt 1979). In applying consumer decision making theory to satisfaction, this paper adopts the interactionist model proposed by Punj & Stewart (1983). This framework is relevant for high involvement products since involvement is the result of the interaction between person and situation (Mitchell 1979; Kassarjian 1981).

The research on consumer decision making indicates that involvement has a tremendous impact on consumer choice processes. This research is summarized into five categories: (1) Pre-purchase Expectations; (2) Search; (3) Processing; (4) Post-purchase Evaluation; and (5) Consequences.

Pre-purchase Expectations: Little research has been conducted which relates pre-purchase expectations to choice processes (Bettman 1979). Search: The risk and uncertainty of high involvement decisions stimulates a high degree of search (Jacoby, Chestnut & Fisher 1978; Swan 1972; Wright 1975) and encourages consumers to rely on referent groups and other alternative sources of information (Assael 1981; Engel & Blackwell 1982: Leibenstein 1976, 1978).

High involvement decisions are associated with high search costs and high experience costs. The high experience costs of high involvement products are a result of the psychological, social, financial, and physical risk associated with purchasing an unsatisfactory product (Price 1981). The high search costs result from a possible delay in the purchase decision (Engle, Blackwell, & Kollat 1978), from the frustrations incurred in search (Downs 1961), and from the amount and appropriateness of existing information (Engel & Blackwell 1982). Processing: The literature indicates that consumers conduct extensive information processing and attempt to maximize their expected satisfaction with the purchase of a high involvement product (Assael 1981; Engel & Blackwell 1982). Likewise, high involvement decisions tent to produce faster evaluation and more alternative (brand) evaluations (Gartner, Mitchell, & Russo 1972; Wright 1972). Post-purchase Evaluations: The level of product involvement will affect the strength of the post-purchase evaluation (Oliver & Bearden 1983) and whether or not post-purchase evaluations are triggered (Day 1977). The higher the level of involvement, the more active and more extreme the post-purchase evaluations. Consequences of Satisfaction/Dissatisfaction: Consumer satisfaction is generally a significant determinant of repeat sales, positive word-of-mouth, and consumer loyalty (Bearden & Teel 1983; LaBarbara & Mazursky 1983). Day and Landon (1977) suggest that dissatisfaction encourages three different consumer behavior patterns: (1) No Action; (2) Private Action, e.g., warning friends, family, etc. and personal decision to stop buying the product and/or boycott the store; and (3) Public Action, e.g., seek redress from the firm or manufacturer; complain to business, private or government agency; take legal action.

To summarize this discussion, the greater the involvement with the product the greater the search for information about the product, the larger the number of information sources used, and the more extensive the information processing undertaken by the consumer. More importantly, the consumer undertakes extensive post-purchase evaluation and attempts to maximize their satisfaction with the product. The implication of this paradigm is that by providing the consumer with more information about a product with which the consumer is highly involved, the satisfaction with the product can be increased, since the consumer will process this information and develop well defined and realistic expectations.

The empirical research on consumer choice behavior for a high involvement product suggests an alternative to Hypothesis One and Two.

H3: The greater the amount of information available the greater the satisfaction of the consumer. [This hypothesis assumes that the product's performance would be adequate and/or satisfactory and therefore, the consumer would deserve to be satisfied.]

This hypothesis suggests that given more information, consumers will conduct extensive choice processing, develop well defined expectations, and consequently make better decisions and be more satisfied. However, this premise has generated some dialogue and controversy in the area of consumer decision making. Those in support of the proposition favored the development of consumer information programs to bring about significant changes in the cognitive processes, behaviors, and satisfaction levels of consumers (Bloom 1976; Richardson 1975). They contended that the possession of more information is a sufficient condition for improved decision making (Stern 1967).

Those in opposition argued that more information is not necessarily better, and in fact, may lead to substantially worse decisions (Jacoby 1974). These less optimal decisions may be due to information overload (Jacoby, Speller, & Kohn 1974). Moreover, not only is the amount of information related to decision making, but the content of the information is also relevant. Consumers are often unable to use the information because they do not understand its significance (Capon & Lutz 1979).

In the case of high involvement products, however, it is hypothesized that more information will lead to better decisions. This is due to the fact that since the consumer is highly involved, he/she is motivated to search for this information, evaluate and integrate it, and base decisions on this information. Thus, the critical difference between research that found that more information does not improve decision making and this research, is the nature of the product.

A UNIQUE HIGH INVOLVEMENT SITUATION: THE CHOICE OF A PHYSICIAN

Based on a review of the research on satisfaction and consumer decision making, three alternative hypotheses on the determinants of satisfaction for a high involvement product are proposed. The three explanations are:

H1: Satisfaction with a high involvement product is determined by the discrepancy between expectations and performance.

H2: Satisfaction with a high involvement product is determined solely by performance of the good.

H3: The greater the amount of information available about a high involvement product the greater the satisfaction of the consumer.

The requirements of a decision making context in which to test these hypotheses are (1) It should be a high involvement decision making situation (2) There should be a paucity of relevant information based on which the consumer can make the decision, and (3) Satisfaction or dissatisfaction should have important implications.

The health care context is an appropriate setting in which to test these hypotheses because: (1) the choice of a physician is a high involvement decision with a great deal of risk and uncertainty (Berkanovic & Reeder 1974), (2) there is a lack of objective information on which to base this decision (Feldman 1966), and (3) satisfaction and dissatisfaction have significant implications for consumers (patients), practitioners, and society at large.

High Involvement Situation: According to the definition of involvement previously stated - 'the activation of extended problem solving behavior when the act of purchase or consumption is seen by the decision maker as having high personal importance or relevance' - the choice of a physician and the subsequent utilization of medical services may be considered a high involvement situation. While the level of involvement may vary across different types of health care services, the purchase and utilization of health care services has traditionally tended to have a high degree of personal importance or relevance to the patient. Therefore, in choosing a doctor, patients often experience high levels of perceived risk and uncertainty (Swan & Caroll 1979). Of course the level of risk and uncertainty may vary according to the type of care sought (immunization shot versus pre-natal care), seriousness of the illness (common cold versus lung cancer), costs involved in care ($25 office fee versus $1000 surgical fee), and the personality of the person seeking care (healthy woman in her 20's versus a sickly elderly man in his 70's). Moreover, the research indicates that in general, patients, as consumers in the health care market, tend to be highly involved in the purchase of medical services, often fearing blame, punishment, and victimization in medical encounters (Berkanovic & Reeder 1974).

Type of Available Information: In the choice of a physician, an "individual decision maker must rely upon a variety of informal. highly subjective, sometimes inconsequential, and perhaps conflicting sources of information" (emphasis added) (Feldman 1966, p. 580). One important source of information is the recommendations of friends, family, neighbors, etc. (Wolinsky & Steiber 1982). Although individuals usually consider the information acquired from interpersonal sources the "next best" thing to personal experience (Feldman 1966), this information is sometimes irrelevant, informal, and conflicting which results in confusion. In summary, in the health care context, there is a lack of objective, verifiable, and relevant information on which to base decisions.

Implications of Satisfaction/Dissatisfaction: Patient satisfaction and dissatisfaction has significant implications in the health care context. The former has been shown to enhance patients' psychological trust, physical well-being, compliance, and utilization of medical care. Dissatisfaction has been found to encourage doctor shopping and the incidence of malpractice (Betz & O'Connell 1983; Hulka, Kupper, Cassel, and Babineau 1975; Jasnoski 1985).

IMPLICATIONS OF ALTERNATIVE HYPOTHESES IN THE HEALTH CARE CONTEXT

These three alternative hypotheses have important, yet different implications, for actions that need to be taken to increase satisfaction with health care.

Implications of Hypothesis One

Hypothesis One proposes that satisfaction with high involvement products is determined by the disconfirmation paradigm or the relationship between expectations and performance. This implies that practitioners should attempt to influence both EXPECTATIONS and PERFORMANCE. The former can be impacted through consumer education programs, advertising campaigns, community workshops, brochures about office procedures, cost of services, medications prescribed, etc. The goal of such endeavors is to adequately inform patients about what to expect in the medical encounter. In terms of PERFORMANCE, practitioners should concentrate on the "caring" aspects of performance. Performance will be addressed in more detail in the next section.

Implications of Hypothesis Two

Hypothesis two states that satisfaction with a high involvement product is determined primarily by the performance of the product. Support for this hypothesis would suggest that practitioners should focus their attention on the PERFORMANCE aspect of medical care. Two types of behaviors are important in a patient's evaluation of a physician's performance: tl) Caring behavior, and (2) Curing behavior. The latter refers to the technical competency of the physician and the former refers to his/her affective behaviors or interpersonal skills. Lacking the ability to judge or evaluate the technical competency of a physician, patients confine their judgements to the mode of interaction, the caring behaviors of a physician (Ben-Sira 1976). Thus, to enhance patients' evaluation of performance, efforts should concentrate on the affective or caring behaviors of physicians. Some suggestions would include (1) developing course-work on interpersonal skill training and requiring it in the medical school curriculum, (2) offering continuing education seminars for physicians which allow them to sharpen existing skills and acquire new skills in verbal and non-verbal communication, and (3) strengthening the physician-patient rapport.

Implications of Hypothesis Three

Hypothesis Three proposes that if consumers are given more information, they will conduct extensive choice processing, develop well defined expectations, and consequently achieve high levels of satisfaction. Support for this hypothesis would indicate that consumers should be provided with more information to assist them in their choice of a health care delivery system such as solo practice, group practice, emergency care centers, health maintenance organizations, preferred provider organizations, etc.

In today's rapidly changing environment, the consumer is faced with a confusing multitude of alternatives that have only recently emerged. The Hypothesis Three suggests that to increase satisfaction with health care services, the consumer needs to be educated about how to choose a health care delivery system. As opposed to Hypothesis One, which implies that consumers must be educated about what to expect from their encounter with the physician, Hypothesis Three suggests the need to educate the consumer about health care alternatives. The focus of such an education program must be two-fold. One objective is to make the consumer aware of the alternatives, and the second is to educate the consumer about the advantages and the disadvantages of the alternatives and the criteria that can be used to evaluate them.

In summary, Hypothesis One implies that to increase satisfaction with health care, consumer education programs need to focus on influencing the consumer expectations about the encounter with the doctor. The performance of the doctor is also important according to this theory, since the discrepancy between the doctor's performance and expectations influences satisfaction. According to Hypothesis Two in contrast, the performance is the sole influencing factor of satisfaction. This suggests that the performance of the doctor needs to be improved especially in terms of the "caring" aspects of the encounter. The third Hypothesis implies that consumer education programs need to be instituted to make consumers aware of the health care delivery alternatives which are available and provide them with criteria to evaluate these alternatives.

SUMMARY

This paper examines the determinants of satisfaction for a high involvement product from the perspective of consumer satisfaction theory and consumer choice theory. This investigation of the determinants of satisfaction leads to the development of three alternative hypotheses on the factors that influence satisfaction for high involvement products. The first hypothesis, based on the dominant paradigm in consumer satisfaction literature, the disconfirmation theory, suggests that the discrepancy between expectations and performance influences satisfaction with a product. The second hypothesis which is derived from recent research on consumer satisfaction proposes that satisfaction is influenced primarily by performance. The third hypothesis, based on consumer decision making theory, is that "reliable" and "valid" information can help increase consumer satisfaction with high involvement products.

The health care context is proposed as a relevant context in which to test these hypotheses because: (1) the choice of a physician is a high involvement decision; (2) there is a lack of objective information; and (3) satisfaction and dissatisfaction have significant implications for consumers (patients), practitioners, and society at large.

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