Keywords

Advertising, Brand Image, Hospital, Online Media, Word-Of-Mouth.

Introduction

Hospitals, nursing homes, hospices, physician practices, managed care organizations, rehabilitation centres and other healthcare organizations didn’t think about marketing until the early 1970’s. In the early years, healthcare professionals did not like the amalgamation of the words’ healthcare and marketing. Many misconstrued marketing for advertising, and advertising for healthcare services was considered inappropriate. Therefore, healthcare service providers had long resisted the incorporation of formal marketing activities into their operations. The importance of marketing has now grown in hospitals. In present day context, a hospital is a multidisciplinary super specialty medical centre with international standards. Now, however as the consumer ecosystem is changing, it is expected that the healthcare industry will encounter unprecedented change and growth as baby boomers mature and governmental healthcare reforms results in

millions of newly insured patients. Further, as more healthcare options become available to patients (e.g. minute clinics in drug stores, after-hour urgent care clinics), more competition will exist within the industry. It is predicted that the first decade of twenty first century will be the decade of the consumer in healthcare and ample evidence supports this assertion. “Patient driven healthcare” is one of the latest buzzwords in the field and a “consumer choice” environment is emerging in healthcare organizations. They are required to cater to the needs and wants of a more demanding set of customers.

In response to these growing challenges, many corporate hospitals have increased efforts to reinforce their brands. A brand is a promise to consumers that the hospital will deliver on the kind of care needed. It can drive business and growth for the organization, especially when high levels of satisfaction and emotional commitment are present. Healthcare branding requires a solid, organized commitment for delivering unique standards of consistency through the institution’s products and services. A successful branding strategy must address on how to preserve equity and leverage equities to build trust as well as how to manage consumer perceptions and emotions regarding the healthcare organizations (Speak, 1996).

A service brand is a promise of future satisfaction, and service companies build strong brand through distinctiveness, performance, message consistency and by appealing to consumers emotionally (Berry, 2000; Berry & Seltman, 2008). Berry (2010) stated that branding services is different from branding goods because of the characteristics that make services distinct from goods. One distinguishing attribute of services is that there are often fewer cues for consumers to evaluate, which elevates purchasing risks suggested that branding is critical in service because the intangibility of services makes quality difficult to evaluate. Branding a service can help consumers by assuring them of a uniform level of service quality (Berry, 2007) consequently, the development of effective branding strategies is important for healthcare organizations as well. Every hospital stands for a certain image or brand value either low-cost care or specialized services. It is of essential importance that everyone on staff from CEO to the volunteer at the reception desk should communicate the organization’s mission effectively. The result is a brand guided organization.

In the competitive healthcare environment, hospitals should focus their marketing efforts on effective strategic brand management. This is especially significant; given the changes the healthcare industry is facing. First, as deductibles and co-pays increase, patients are becoming more selective about their healthcare and the availability of diverse options makes this possible. Secondly, a growing and new market for healthcare services will exist. Almost 60 million Baby Boomers have moved into the mature market segment and will need healthcare services. In the above-said background, branding is pivotal even in the healthcare and the strategies used for brand management in healthcare are Integrated Marketing Communication, CSR and loyalty programs (Kumar, et al. 2014).

Floor and Van Raaij (2011) defined IMC as "a process where all messages and methods are geared to each other in such a way that they complement and reinforce each other, and that added value is the result ". The foremost dominance of IMC is that; it makes use of the innate strengths of each individual communication channel in order to attain significant results concurrently. IMC encompasses the traditional promotion mix elements - advertisement, public relations, sales promotion, publicity & personal selling as well as the extended communication mix elements - online media, e-mail marketing, events, direct selling, interactive marketing, website marketing etc. For the current paper, both the traditional and the extended IMC elements were taken into consideration which includes a) advertising b) word-of-mouth c) online media. The current research is done in the evolving market context and focusses specifically on the Indian hospital segment.

IMC: This paper operationalized IMC as a "multi-functional method for creating & strengthening valuable relationships with patients and other stakeholders by strategically controlling and/or influencing all messages sent to the stakeholders which builds brand efficacy in the mode of brand equity”.

Advertising: This paper operationalized advertising as the “non-personal dissemination of details generally charged for and generally compelling by its very essence concerning the goods, services or plans by recognized promoters via different media”.

Online media: In this study, online media refers to the “health information shared by the healthcare providers on different online media platforms”.

Word-of-mouth: In this study, word-of-mouth refers to “an unpaid kind of promotion in which a satisfied patient talks to other individuals regarding how much he/she likes a business or service and recommends it to others”.

Brand Image: This study operationalized Brand Image as "the intentions patients have for selecting a hospital and what is perceived by a patient against the hospital based on the information obtained, the activities undertaken by the hospital, previous experience, performance and prospects for the home pain in the future”.

Literature Review and Hypotheses Development

Studies on consumer attitudes towards hospital advertisement predominantly evolved the emergence of hospital’s marketing communication as the subject of research (Miller & Waller, 1979). A review of literature on hospital advertisement indicated that patients’ hold a positive attitude towards hospital advertisement (Johns & Moser, 1988; Marks & Totten, 1990; Lim & Zallocco, 1997). The more hospital advertisement provides a sort of beneficial advice during the decision-making process by the patients’, the more it is perceived positively (Andaleeb, 1994). Hoeffler and Keller (2002) in their study concluded that, brand image captures the customer’s judgment of a brand meaning which the firm conveys to the customer via IMC channels such as advertising and sponsorship processes Subsequently, several studies have examined the effect of advertising on brand image and the results indicated that perceived advertisement spending affects perceived quality, brand awareness, and brand image. Furthermore, Ahmad (2016) developed a 19-item scale to investigate the impact of IMC elements on the hospitals’ Brand Image and it was found that, there is a significant positive relationship between advertising and hospitals’ brand image. Cham et al. (2020) empirically investigated the impact of marketing aspect (hospital advertisement) on the hospitals’ brand image on a sample of 720 medical tourists who availed the medical services from six hospitals in Malaysia and the results inferred that hospital advertisement would significantly influence their perceptions of the hospital’s brand image. For the purpose of the current paper, the above findings were considered which reveals that advertisement has a significant influence on the hospital’s brand image and thus the following hypothesis was developed.

H1: Advertisement has a significant and positive effect on Brand Image.

Studies on the different aspects of the hospital online marketing communications were mostly fuelled by the steep development of the hospital websites (Sanchez, 2000; Revere and Robinson, 2010). Websites offer great, but yet unexploited, marketing communication potential for hospitals (Zingmond, et al. 2001). If used appropriately, online media provide numerous benefits, meaning that the communication between the hospital and patient becomes more dynamic and interactive, information exchanges take place faster and the relationships with patients become closer. Online presences of more specialized hospitals (e.g., cancer facilities) perform better in overall quality assessments, as they address potential patients over larger distances and rely on online media as a core communication channel (Ford et al., 2012). Cham et al. (2016) in their research study examined the influence of online media on the hospital’s brand image on a sample of 400 medical tourists who visited four major hospitals in the northern state of Malaysia and the outcomes of the study were that: hospital-handled social media had a significant positive influence on the hospitals’ brand image. Subsequently, Cham et al. (2020) in their research study employed a 39- item scale to empirically investigated the impact of hospital-generated social media and user- generated social media on the hospitals’ brand image from 720 medical tourists who availed the medical services from six hospitals in Malaysia and from the results it was found that, both the hospital-generated social media and user-generated social media significantly influenced the perception of medical tourists on the hospitals’ brand image. Hence based on the above findings, the following hypothesis has been framed:

H2 - Online media has a significant and positive effect on Brand Image.

Social influence via word-of-mouth is been considered as one of the most important factors that influences brand image. It is one of the most influential and reliable approaches for transmitting information among customers in the marketplace and in the consumers’ decision-making process. Word-of- mouth is able to instil the brand message in the mind of consumers, and it leads to a better understanding and impression of the brand as a whole. It has been found to have a strong positive influence on customers’ perception of brand image and consequently on their purchase intention. In addition, word-of-mouth has also been reported to have a positive impact on brand awareness, brand trust (Ha, 2004), brand purchase intention and consumer-based brand equity. A review of past empirical studies showed that there is a significant positive relationship between the word of mouth and the hospitals’ brand image (Ahmad, 2016; Cham et al., 2016, 2020). Hence based on the above findings, the following hypothesis has been framed:

H3- Word-of-mouth has a significant and positive effect on Brand Image.

On the basis of the discussions held above, the present study developed the below given research model (Figure 1).

Figure 1 The Research Model

This study is assumed to be unique in terms of drawing the relationships amongst the IMC mix and Brand Image in the Indian healthcare sector especially in the hospital settings (patients’ availing hospital services). Most of the research studies linking IMC mix and Brand Image are confined to the geographic context of the Asian settings, and there is a negligible empirical work available specifically in the Indian context that has considered the IMC dimensions and its impact on Brand Image, hence this indicates a research gap which needs to be explored of. Furthermore, there is a scanty literature support on the effect of IMC mix on Brand Image specifically in the Indian healthcare backdrop, though the application of marketing communication tools and brand building initiatives is growing by leaps and bounds in the Indian hospital settings. Hence, the current paper attempts to make an original contribution to the existing literature on IMC and Brand Image by determining the impact of IMC on Brand Image in the context of Indian hospital setting.

Materials and Methods

The current paper investigated the inter-relationships among the identified constructs and therefore the present paper is descriptive and explanatory in nature. The goal of explanatory research is to determine the inter-relationships among the variables (Saunders et al., 2007) and in the present paper, the explanatory research examined the kind and the degree of relationships among the study variables and this approach is particularly highlighted in business and social sciences research. Furthermore, the present paper attempts to bring forth a lucid picture of each variable i.e., advertising, word-of-mouth, online media & brand image and hence it is also descriptive in nature (Robson, 2002).

The target respondents of the present study were the patients who availed the hospital services from one of the hospitals of Hyderabad, India & the hospital which have won the attributes in the following order: state-of-the-art medical equipment for procedures and surgeries, corporate reputation, availability of multispecialty, low-cost treatment & high volumes of patient flow have been considered as the select service brand for the current study.

An overall 400 self-administrated questionnaires were circulated to the study participants with the use of convenience sampling technique and the questionnaire comprised of the demographics and item variables (14 questions). A “critical sample size” of 200 is sufficient to produce admissible statistical power for analysing the data (Sivo et al., 2006) and hence for the present study, a sample size of 400 was considered for eliminating the human bias and the non-response rate as well as to represent the patients’ perceptions on the IMC mix and Brand Image constructs. The researcher has managed to gather all the questionnaires, as the researcher met the study participants personally. Following the data cleaning process (detection of outliers’, multicolinearity issues and data normality as suggested by, 27 questionnaires were identified as unsuitable and the remaining 373 questionnaires (response rate of 93.25%) were considered as the final sample size for data analysis and hypothesis testing.

Items measuring the study variables were operationalized on the basis of the inputs from the branding and communication departmental head of the study hospital and few items were also adopted from the existing literature with slight wording changes to fit the current study context. For example, Advertisement construct was measured using three items reflecting the medium of advertisement (print/electronic media), innovativeness of the advertising campaigns and the patient’s trust factor towards the hospital advertisement. Online media was measured using four items reflecting the patient’s awareness levels towards the health-related information, patient’s positivity towards the service portfolio information, the role of online media in strengthening the relationship between the hospital and patient, & lastly, the hospital’s social media performance in comparison to the social media platforms of other competing hospitals. Word-of-mouth was measured using four items developed by reflecting the influence of family/friends on the patient’s attitude, ideas, understanding & decision making on the hospital brand. The dependent variable Brand Image was assessed using a 4-item scale adopted from Kim et al. (2008) consisting of: the good reputation of the hospital, peaceful and comfortable environment, hospital’s genuineness towards the patients and lastly the decent atmosphere of the hospital.

The questionnaire comprised of two sections. Section-A comprised the demographic details which included name, age, sex, education, marital status, type of patient, yearly income and type of treatment availed. Section-B comprised the item variables which was a fourteen-item scale as mentioned above. According to Awang, Afthanorhan and Mamat (2016) “the researchers have to construct their questionnaire as interval scales if interested to apply the parametric test.” Thus, the present paper employed a 5-point interval Likert scale with the format extending between “strongly disagree” (1) to “strong agree” (5).

Data Analysis and Results

The study tried to balance the proportion of males and females and accounted for 56% males and 44% females. Most of the respondents were in the age category of 41-50 years (38%). Most of the patients were qualified graduates (51%). Further, 53% of the respondents were employed in the private sector and 51% of the respondents’ monthly income was above 25000. Furthermore, 29% of the respondents’ availed different types of health insurance policies and lastly 39% of the respondents’ availed cardiology services, followed by 21% for the Gastroenterology care and 18% for Orthopaedic services. Table 1 below presents the demographic characteristics of the respondents.

First-Order Confirmatory Factor Analysis (CFA): Measurement Model

The current paper employed CFA in order to attain the model fit as well as to test the convergent validity & discriminant validity of the study constructs. According to, the preferred criteria in determining the model fit includes the values of the normed chi-square (χ2/df) goodness of fit (GFI), root mean square error of approximation (RMSEA), Tucker-Lewis Index (TLI), comparative fit index (CFI) & parsimony normed fit index (PNFI). A research model with a good fit would have the following values: less than 3 for χ2/df, GFI>0.85, RMSEA<0.08, TLI>0.90, CFI>0.90, PNFI>0.50. The First-order CFA output showed that the measurement model was a good fit with the values of χ2/df =1.082, GFI = 0.971, RMSEA = 0.015, TLI = 0.997, CFI

= 0.998 & PNFI =0.758.

To examine the convergent validity of the study constructs, three criteria should be fulfilled which is as follows:

(i) Construct Reliability which is achieved by means of Cronbach’s α & Composite Reliability. The Cronbach’s α value for each of the study constructs should be higher than the cut-off value i.e., 0.7 & Composite Reliability should be higher than the threshold value i.e.,

0.6 (Fornell & Larcker, 1981).

(ii) the Average Variance Extracted (AVE) should be greater than 0.5 for each of the study constructs (Fornell & Larcker, 1981).

(iii) the standardized factor loadings should be higher than 0.50 (Fornell & Larcker, 1981).

Table 2 below depicts the Cronbach’s α for the individual study constructs which is well above the prescribed value of 0.70 & Composite Reliability for the individual study constructs which is well above the suggested value of 0.6. AVE for all the constructs exceeded the minimum value of 0.50 & the factor loadings for all the study items were more than 0.50 & therefore, the results indicate that all the study constructs attained an acceptable level of convergent validity.

Discriminant validity of the study constructs is achieved by comparing the AVE & the square of the inter-construct correlations. From the below table 2, it can be inferred that the AVE is higher than the square of the inter-construct correlations, which is the desired norm for DV according to Fornell & Larcker (1981).

Notes: ADVT = Advertisement; OM = Online Media; WOM = Word-of-mouth; BI = Brand Image. the diagonal entries (in bolds) represent the average variance extraction of the individual construct, and the off-diagonal entries are the square of the inter-construct correlations between the constructs.

On the basis of the Analysis of Moment Structures (AMOS) output, the structural model presents a good fit where χ2/df =1.475, GFI = 0.959, RMSEA = 0.036, TLI = 0.983, CFI=0.986 & PNFI=0.780. Given an adequate measurement model, the study hypotheses were tested by examining the proposed structural model. Table 3 summarizes the path coefficients for all the hypothesized paths in the model.

From the table 3, it is evident that the regression path between ADVT & BI is insignificant (p>0.05). Hence, it can be concluded that the hypothesis H1 is not supported. From the above table, it is evident that the regression path between WOM & BI is significant at 0.001 & positive. Thus, it can be concluded that the hypothesis H2 is supported. From the above table, it is evident that the regression path between OM & BI is significant at 0.001 & positive. Hence, it can be concluded that the hypothesis H3 is supported.

Discussion

The current study determined the influence of different IMC elements on Brand Image. The objective of the paper was to test the impact of IMC mix on Brand Image and from the paper it was found that, word-of-mouth and online media have a significant and positive effect on Brand Image whereas advertisement had an insignificant effect on Brand Image in the selected study hospital. From the table 3, it can be inferred that word-of-mouth had a significant & positive effect on Brand Image and these results were in-line with the findings of Ahmad (2016) & Cham et al. (2016, 2020). Second, online media had a significant & positive effect on Brand Image & these findings were congruous with the findings of Cham et al. (2016, 2020). Lastly, from the paper it was found that advertisement had an insignificant effect on Brand Image which is contrary to the findings of Ahmad (2016) & Cham et al. (2020). Since most of the paper findings were consistent with the findings of the earlier studies; we can thus conclude that the considered relationships are also valid in the Indian hospital context.

Implications

The present study provides various crucial suggestions for the hospital marketers and managers in the healthcare service context. These implications provide a base for the managers at the time of designing new corporate communication practices or restructuring the existing IMC strategies/policies. Since, from the study it was found that advertisement had an insignificant effect on Brand Image, hence hospital marketers should pay more attention towards strengthening both the traditional and extended marketing communication elements and also the marketing team have to fully understand that, the formation of a strong IMC results in a positive Brand Image which will allow a hospital to gain competitive advantage in the industry. Furthermore, the integrated IMC scale can assist the hospitals’ in knowing the patients’ pulse regarding the hospitals’ IMC practices and how these perceptions influence their attitude, association and loyalty towards the hospital brand.

Conclusion

The major purpose of the present paper was to explore the relationships between the IMC mix and Brand Image for a life caring & saving credence-dominant service. This study is assumed to be unique in terms of drawing relationships amongst the IMC mix and Brand Image in the healthcare service context especially in the Indian hospital setting (patients’ availing hospital services). Although, very few studies made an effort to determine the influence of IMC dimensions on Brand Image but the geographic context was confined and therefore, empirically testing the effect of IMC dimensions on Brand Image in the Indian hospital context has been addressed in the present study. Lastly, the study attempted to integrate a robust IMC scale to capture the patients’ perceptions on the existing IMC practices in the healthcare service settings which is a novel addition to the prevailing marketing communication literature in the Indian healthcare service context.

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Received: 22-Mar-2024, Manuscript No. AMSJ-24-14651; Editor assigned: 25-Mar-2024, PreQC No. AMSJ-24-14651(PQ); Reviewed: 10-Jun-2024, QC No. AMSJ-24-14651; Revised: 20-Jun-2024, Manuscript No. AMSJ-24-14651(R); Published: 23-Jul-2024