Keywords

Hospital Service Quality, Patient-Reported Outcomes, Support services, Patient Satisfaction.

Introduction

Strategically, hospitals have competed on the basis of quality and service excellence, e.g., new technologies (Romano and Mutter, 2004) and/or price competition (Jiang, et al. 2013; MuKamel, et al. 2002). Increasingly, patient satisfaction is an important measure for healthcare organizations as they rely on patient ratings for national quality rankings and reimbursements (Fatima, et al. 2018; Hung, et al. 2015) which ultimately affect patient choice and market standing. Research on patient satisfaction indicates the patient experience is distinct from healthcare quality and strongly correlated with better health outcomes and care (Manary, et al. 2013).

More recently, competition based on the inclusion of hospital amenities (Kashkoli, et al. 2017; Mir, et al. 2023; Romano and Mutter, 2004; Severt, et al. 2008; Singh, Agarwal and Pandiya, 2022; Suri and Verma, 2022), a nonprice based business model, points to the necessity of a broader definition of patient support services in the hospital setting in order to understand patient satisfaction. The patient experience in the health care context is subject to numerous and complex interactions across the health care system (Hilligoss, McAlearney, and Song, 2019) calling for broader studies regarding quality and patient care (Brown, 2001; Hamed, El-Bassiouny, and Ternès, 2019; Romano and Mutter, 2004). Lacking this knowledge, researchers and practitioners are unable to sufficiently explain patient satisfaction, health outcomes and patient choice. Although some research has been written about the benefits of select amenities, e.g., (Smith, Stallings, Mariner and Burrall, 1999), little is known about the importance of the range of amenities available and expected by hospital patients or their association with patient satisfaction, perceptions of quality care, and patient reported outcomes. There is a gap in services marketing research as it relates to evidence based, patient-centered healthcare and empirical research on the impact of supplementary amenities, e.g., gifts and services, on satisfaction and well-being is needed (Hamed, et al., 2019; Zouni and Kouremenos, 2008).

The hospital industry in the UAE serves as the context for this research. Located in the Middle East, between Saudi Arabia and Oman, it is part of the Gulf Cooperation Council (GCC). The GCC was a political and economic alliance of Saudi Arabia, Kuwait, the United Arab Emirates, Qatar, Bahrain, and Oman. These oil-rich countries are strategically located on the largest proven oil reserves in the world. According to the International Monetary Fund, the 2003-2008 oil price boom initially led to significant GDP growth for governments in the GCC (United Arab Emirates, 2013). Like other countries in the GCC, the UAE used these revenues to invest in the healthcare infrastructure. Due to the government’s diversification efforts, the economy has remained stable and total health expenditures as a percent of gross domestic product grew from 2.3% in 2006 to 3.5% in 2016 (Global Health Expenditure Database, 2016).

The UAE has been developing the healthcare industry to provide a gold standard of care to their citizens as well as increase income from nonoil sources, i.e., medical tourism (Sahoo, 2016). In general, research in healthcare tourism, with a focus on conveniences for medical tourists, indicates that perceived quality of and value of services affects the image of the organization and intention to visit (Han and Hwang, 2018; Zouini and Kouremenos, 2008). Investments by the government in partnerships with leading global institutions such as the Imperial College London Diabetes Centre, John Hopkins Medical School, Susan G. Komen Breast Cancer Foundation, Children’s National Medical Center and Cleveland Clinic Abu Dhabi are designed to establish the country as a center of world class excellence in the medical field under the umbrella of government-owned hospitals (Health Statistics, 2015). These hospitals represent the touchstone in health care excellence.

In the Global Competitiveness Report 2017-2018 (World Bank, 2018), the UAE is classified as a high-income country that ranks in the top 10 countries in the world in agility and future-readiness, macroeconomic stability, and Information Communication Technology adoption. Although the national population in the UAE is young, demand for hospital services, fueled by rapid population growth, improved quality of care, a shift from public to private providers, expanded access to high standards of care for both expatriates and locals, mandatory health insurance since 2006, and longer life expectancies for males and females, is projected to continue to grow through 2025 (Health Statistics, 2015; Statistical Yearbook of Abu Dhabi, 2020).

The premise of this paper is that in addition to providing high quality medical care, successful hospitals n upscale markets have a compassionate patient-centric approach, i.e., broadly defined by the patient’s experience with a range of hospital services. This study examines two supplementary services, i.e., the importance of service and gift amenities for patients and their role as predictors of patient outcomes including health benefits, satisfaction and behavioral intentions. A theoretical framework has been developed for analyzing whether patients who receive gifts and services will gain benefits in the form of pain relief, stress reduction and improvement in mood, recovery and well-being. In addition, gifts and services are analyzed as predictors of patient satisfaction with the medical facility, staff and health outcomes. Last, the impact of patient satisfaction on a patient’s behavioral intentions, e.g., likelihood to return, recommend or follow doctor’s instructions, is investigated.

Literature Review

This section is organized as follows. First, a broad overview of the cultural context in the UAE is presented from an anthropological perspective of high context and collectivist cultures. Building on this framework, the symbolic meaning of gifts from a social/psychological viewpoint and the subsequent expected benefits of gifts and services follows. Last, a review of the extant literature on patient satisfaction draws from both medical and consumer research to develop the theoretical model and research hypotheses of the importance of amenities in a hospital environment to patient well-being, satisfaction and future behavioral intentions.

Cultural Context

Scholarly work by prominent anthropologists about the cultural context and communication styles of different countries provide the basis for understanding why support amenities may be important. Hall (1976) described society in the UAE as a high context culture that relies heavily on the situation to infer meaning. Words are not the primary focus. Instead, communicators rely heavily on the context to convey meaning. For example, high context cultures factor in relationships, age, and position to infer meaning (Manrai, et al. 2019). Therefore, these cultures put significant effort into fostering long-term relationships, valuing tradition and avoiding confrontational situations by using indirect communication. Examples of high context cultures include most Asian and Arab countries.

Building on Hall’s (1976) work, Hofstede (2001) defined six dimensions of culture and collected data on cultural values by surveying employees in 72 countries. He found the UAE to be a collectivist society, which means it is more interconnected and has similar characteristics of high context cultures. India, the UAE, and China all scored high as a collectivist society. These cultures value belonging to a larger group and a “we” consciousness is the norm. As such, hospital visits in high context societies can be very different from what occurs in lower context, individualist societies. Take, for example, the research by Ott, et al. (2003). They found that family members are expected to visit the sick and comfort them, e.g., be with them, ask about their well-being and pray for them to be cured. A study by Halligan (2006) describes a typical patient visit in Saudi Arabia where there is extensive family involvement in the caring of the patient’s overall health.

As it is in many faiths around the world, giving gifts to hospital patients is important. In the Muslim (Viviano, 2013) and Christian (Saarinen, 2010) religions, this is especially relevant for the sick, e.g., hospital patients. Along with visiting the sick, families and friends generally prefer to never go empty handed. Hospital patients might get a bouquet of fresh flowers, a small gift, and something to eat, e.g., chocolate. The impact of the gift giving is tied to healing. When people are sick, they tend to lean on their faith and having tangible gifts of religious significance are considered part of the healing process (Pillai and Krishnakumar, 2019).

The classification of the UAE/Emirati society as a high context, collectivist culture has important implications for this study. First, these cultures have a strong desire to create relationships and work within their groups. Group harmony is encouraged, and people generally find their identity within their group. There is an obligation to provide care for those within the in-group. The communication style is more implicit, as they rely heavily on non-verbal communication in addition to the use of words. Examples of non-verbal communication include gifts that provide the context that symbolizes the cultural values of family and support for the hospital patient. All of this contributes to a patient experience in which service provision and gift-giving is expected to add to the satisfaction and well-being of patients in UAE hospitals.

Gift Giving and Service Amenities

Gift giving has also been studied from numerous theoretical perspectives, e.g., sociology (Komter and Vollebergh, 1997), psychology (Zhang and Epley, 2012), anthropology and economics (Camerer, 1988) and marketing (Gall-Ely, 2014). While the types of gifts and motivations for giving gifts are numerous and varied, a universal underlying principle regarding gifts is that their primary function is to create and maintain social ties (Komter, 2007). Gifts symbolize our connectedness to other people and in a hospital setting, and spring from our perception that patients need to feel cared for (Branco-Illodo and Heath, 2020). Ootes,Pols, Tonkens and Willems (2013) identify a typology of gifts in the healthcare setting which include the objective of social inclusion of the giver. The sociological perspective is well suited to the hospital setting as patients are likely to receive gifts from family and friends and gift giving to the hospital patient symbolizes care and concern for the patient from the donor (Wiener, Wessely and Lewis, 1999). In a hospital, for example, the gift would not convey courtship (such as sending chocolates on Valentine’s Day) and would not imply reciprocity or repayment (such as holiday gifts). Hence, gift giving in a hospital setting is more likely to be what Komter and Vollebergh (1997) term “pure” in that it is not characterized by the sense of mutual obligation or reciprocity. Since gifts to a hospital patient can serve to symbolize the social connectedness between the giver and receiver, they are more likely to be motivated by Kim and Kim’s (2019) expressive motive.

Gifts to hospital patients may include tangible items such as flowers, plants, get well cards or other reading material (Wiener, Wessely, and Lewis, 1999; Singh, Agarwal, Pandiya, 2022) as well as intangible, nonmaterial gifts such as hospitality or service experiences. In Ootes, et al. (2013) typology of gifts in a healthcare setting, gifts to hospital patients tend to be personal and therefore emphasize the social bond between the giver and receiver. The rationale behind gift-giving is that gifts are a physical manifestation of social support and in the case where family and friends cannot be present during a patient’s hospitalization, gifts are a symbol of their care and support. Gifts are expected to provide joy or pleasure to the recipient in the hospital (Cagle, 2009) and are also a physical reminder of support from family and friends who do make visitations to the hospital. Therefore, by symbolizing social support which has been shown to reduce patients’ stress and improve well-being (Schreuder, et al. 2016), gifts provide a healing environment for the recovering patient

Gender differences have been demonstrated in gift giving behavior and attitudes. Women are more likely to give gifts and invest more time in buying a gift than men which has been attributed to their role as caretaker of the family (Cote and Deutsch, 2008; Sinardet and Mortelmans, 2009). In other words, women are more likely to care about maintaining family relations and gifts symbolize the importance of family and friends. Women have more positive attitudes about gifts (Goodwin, et al. 1990) and are more likely to receive gifts (Cote and Deutsch, 2008). Studies have shown that women are more satisfied with health services than men (Bikker and Thompson, 2006). Therefore, while both genders are expected to value gifts and services in the hospital, women are predicted to rate receiving amenities as more important than men (Jonason, et al. 2012).

In holistic medicine, the value of services such as massage and spa therapy is well established. Smith, et al., (1999) report that massage therapy for hospital patients results in numerous health benefits including increased relaxation, more energy, a positive mood, faster recovery, a sense of wellbeing and pain relief resulting in better sleep. More and more, alternative treatments are available from hospitals who claim they are in demand by patients (Keates, 2003). To illustrate, in a hospital in the US, luxurious maternity wards attempt to win patients by state of the art facilities which include whirlpool baths and free massages for women in labor (Davies, 2005). Fava (2011) found that patients who accessed complementary and alternative medicine were more likely to report higher levels of psychological wellbeing.

Therefore, several forces operate in the UAE that lead to the prediction that gifts and services will be important to hospital patients. The hospital market is upscale with the availability of a broad range of support amenities and gifts. Traditions are rooted in religious maxims to care for the sick and a collectivist, high context culture which emphasizes the importance of gifts. In a high-end hospital industry setting and based on a culture that values services and gifts, support amenities are predicted to be important to hospital patients. In addition, these amenities are expected to be valued more by women than men.

Quality, Patient Satisfaction and Behavioral Intentions

An influential report published by the Institute of Medicine (2001), a US committee on Health Care in America, defined quality of care as the extent to which health services for patient populations increase the probability of desirable health outcomes that are consistent with prevailing professional knowledge. Central to this definition is that health services encompass a wide range of services which contribute to the patient experience. Hospitalizations are well known to be stressful for patients, and social support can improve patient outcomes such as satisfaction, pain, stress, mood, recovery and well-being (Prochnow, et al. 2020). Studies by Becker, Sweeney, and Parsons (2008) indicate that patient satisfaction and improved well-being are positively correlated with better health care environments. Andrade, Lima, Devlin and Hernández (2016), looked specifically at the physical environment of the hospital and found that “patients in a health care service want to feel cared for; the hospital social environment constitutes a fundamental aspect of care” (p. 318). Similarly, Bellio and Buccoliero (2021) showed that the patient’s physical environment was associated with satisfaction and empowerment and dignity. Brown (2001) found that nonmedical amenities, such as parking, food and a pleasant environment were positively related to satisfaction with services, including medical services. At the same time, his research concluded that patients’ desires for services extended significantly beyond the quality of the medical staff and up-to-date facilities. Singh, Agarwal and Pandiya (2022) found that ancillary services, e.g., gifts and giving the patient comfort and the availability of services in diagnostic centres affected the patient experience.

There is evidence to suggest that patient expectations of private hospitals (vs. public) are higher for quality particularly regarding hotel type services (Camilleri and Callaghan, 1998; Rahman, et al. 2018). In a study of international healthcare hotels, Han and Hwang (2018) found that the travelers’ perception of quality and value had a positive impact on affective image of the facility which influenced visit intention. Similarly, Koggalage, et al. (2017) show that medical travelers are interested in high quality medical care as evidenced by internationally accredited hospitals who offer high quality services and Sadeh and Garkaz (2019) demonstrate that medical and hospitality services while independent of each other, both have an impact on perceived value, patient satisfaction and loyalty. In the UAE, an upscale market in health care, hospitals provide a range of amenities for patients and their families that go beyond what is available in traditional hospital settings. For example, at Cleveland Clinic in Abu Dhabi, patients may be treated to an ensemble of musicians playing a grand piano, flute and violin against the backdrop of a panoramic view of the Arabian Gulf. A free shuttle is provided to a nearby ritzy mall for visitors to pass the time. Healthcare markets provide an experience made up of numerous encounters from a variety of agents and activities from which patients form an overall impression or image.

In summary, previous research, coupled with more recent studies on patient satisfaction, generally posits that patient satisfaction should be defined from the viewpoint of the patient experience, expectations and context. Since a hospital offers a complex chain of service encounters, broader definitions of patient care are needed (Romano and Mutter, 2004). Moreover, patient satisfaction has important implications to future behavioral intentions (Jandavath and Byram, 2016; Lapin, et al. 2019; Prajitmutita, et al. 2016; Balqees. Almessabi, 2020), e.g., on patient intention to return and recommend the hospital to others.

Theoretical Model and Hypotheses

According to the literature reviewed in the previous sections, a theoretical model is shown in Figure 1, from which 9 hypotheses are derived. An implicit assumption of this study is that the patient, who is influenced by his/her context, is central to defining quality. Physical and psychological amenities that support the patient are predicted to increase patient satisfaction and result in health benefits. Patient satisfaction will ultimately affect behavioral intentions in the future. The following hypotheses are tested.

H1. Gift and service amenities will be rated as important during hospital stays.

H2: The mean rating for gifts and services importance for women will be greater than the mean rating for men.

H3: The benefits of gifts and services will be rated as important during hospital stays.

H4: Services benefits will be rated as more important than gifts benefits.

H5: Satisfaction with gifts and services is positively related to patient benefits.

H6: Total gifts and services is positively related to patient benefits.

H7: Satisfaction with gifts and services is positively related to patient satisfaction.

H8: Total gifts and services received is positively related to patient satisfaction.

Research Methodology

Based on the previous research and interviews in a pilot study, measurement scales were developed to assess the variables in the study. The content and clarity of the items were reviewed by faculty experts, health care practitioners and student research assistants. Based on the feedback, items were revised accordingly. The survey was then translated from English to Arabic and back translated by faculty who were fluent in both languages. The selection criteria for participation was that the respondent had experienced a hospital stay in the previous year.

Compared to previous measures (Cengiz and Fidan, 2017; Kashkoli, et al., 2017; Parasuraman, Zeithaml and Berry, 1985; Shemwell and Yavas, 1999; Wiener, et al., 1999), the present study includes a wider range of gifts and services rated on a 6-point scale ranging from very important to very unimportant. Gifts included the following items: flowers, chocolates, card, dates/fruit, books, magazines, gift vouchers, toy/stuffed animal and an other category. The gift type choices were hedonic (for pleasure vs. utilitarian as defined by Kim and Kim, 2019). Services were operationalized with 6 items: massage, spa, grooming (hair wash/shave), facial/make up and manicure/pedicure as well as other and corresponded to both hedonic and utilitarian types of gifts. Respondents were asked to rate the importance of each gift and service and to indicate the total number of each that they received while in the hospital. They were asked to rate the benefits of both gifts and services by an importance scale in five areas: pain relief or discomfort, reduced stress, positive change in mood or attitude, faster rate of recovery and sense of well-being (adapted from Smith, et al., 1999 and Rosenbaum and Van De Velde, 2016).

The total for gifts and services was summed to calculate total gifts received and total services received. Previous research on patient satisfaction (e.g., Hawthorne, Sansoni, Hayes, Marosszeky and Sansoni, 2014; Hekkert, Cihangir, Kleffstra, Van Den Berg and Kool, 2009; Turan and Bozaykut-Bük, 2016) used one item to measure overall satisfaction. Short scales for patient satisfaction show strong psychometric and discriminant validity compared to longer scales (Hawthorn, et al., 2014). To assess patients’ overall satisfaction with amenities, i.e., gifts and services, 2 items were used with a 5-point response format which ranged from very satisfied to very dissatisfied.

Overall satisfaction was assessed with 4 items which addressed nursing and doctor services, adapted from Shemwell and Yavas (1999) credence attributes and satisfaction with the hospital quality of care and health outcome (Kashkoli, et al., 2017). The satisfaction scale used 5-points ranging from very satisfied to very dissatisfied. In addition, future intentions were measured by 3 items based on Amati, Kaissi and Hannawa’s (2018) short-term individual behavioral taxonomy and included the likelihood of the patient selecting the hospital again, recommending it to family and friends and following the recommendations of the medical staff after leaving the hospital. These items used a 5-point scale ranging from very likely to very unlikely. Note that previous research indicates that about 50% of patients with a chronic illness do not take medications as prescribed (Lee, et al. 2006).

Results

Procedure and Sample

The sampling frame for this study consisted of undergraduate business students at Zayed University in Abu Dhabi enrolled in a communication course. Based on purposive sampling, 143 students were responsible for contacting individuals who had experienced a hospital stay in the previous year. The respondents were given a survey to return to the student. A total of 252 surveys were distributed and 167 useable surveys were retrieved for a response rate of 66%.

Of the 167 respondents, the majority, 92.4% were distributed across 14 large, accredited hospitals in Abu Dhabi and Dubai in the UAE. Most of the study participants were educated with some college; only 13.8% indicated they had no college. The average monthly reported income was 21,000 UAE dirham or approximately $72,000 annual income in US dollars tax free. Nationals from the UAE comprised 84.4% of the respondents. Combined with the 10.2% expatriate Arabs, the next largest group, 94.6% of the sample group was representative of Arabic nationalities. Last, the respondents indicated that the reason for the hospital stay was either surgical, internal medicine or OB/Gyn, at 50.9%, 30.4% and 7.5%, respectively.

Control variables include hospital (Jiang, et al., 2013) as well as several demographic characteristics of the patient that have been shown to impact patient satisfaction as discussed below. The majority of the studies related to age and patient satisfaction showed that elderly patients were more satisfied with health care services than younger patients (Batbaatar, Dorjdagva, Luvsannyam, Savino and Amenta, 2017; Hekkert, et al., 2009; Hung, et al., 2015). Research by Parasuraman, et al., (1985) indicates there is a positive correlation between socio-economic status on patient satisfaction.

Analysis

Exploratory factor analysis using principle component method and varimax rotation to determine the dimensionality of scales for gifts benefit, services benefit, patient satisfaction and intentions was conducted. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was statistically significant for each variable at p < .0001. The standardized factor loadings for all four variables were > .6 which is higher than the minimum threshold recommended by Hair, Anderson, Tatham, and Black (1998). Cronbach’s alpha values (> .7) demonstrate acceptable levels of reliability and validity (Nunnally and Bernstein, 1994) for gifts benefit (.857), services benefit (.885), patient satisfaction (.867) and intentions (.804). The results indicate the measurement scales are unidimensional.

The means, standard deviations and correlations for the variables are shown in Table 1.

Table 1 Means, Standard Deviations and Correlations
		Mean	Standard Deviation	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
1	Gender	na	na	1
2	Education	2.63	.85	-.23**	1
3	Hospital	na	na	-.03	-.14	1
4	Age	24.70	8.46	-.09	-.31***	-.11	1
5	Income	na	na	.15	.18*	.04	-.53***	1
6	Gifts Importance	1.81	1.12	.09	-.05	.10	.05	-0.5	1
7	Services Importance	2.12	1.24	.09	.01	.10	.09	.02	.22**	1
8	Health Benefit Gifts	2.23	.91	.17*	-.03	.17*	.00	.01	.26**	.27**	1
9	Health Benefit Service	2.12	.93	.17*	-.08	.08	.03	-.06	.19*	.22**	.70***	1
10	Gifts Received	11.47	10.72	-.11	.04	.09	-.02	.03	-.15	-.11	-.06	-.22**	1
11	Services Received	2.44	6.52	.08	.05	.06	-.01	.01	-.09	.00	-.09	-.10	.35***	1
12	Satisfaction Gifts	2.40	1.09	-.07	.04	.14	-.04	.00	.21**	.10	.24**	.18*	-.13	.03	1
13	Satisfaction Services	2.15	1.04	-.13	-.03	.14	.06	-.06	.10	.18*	.21**	.20*	-.02	.02	.48***	1
14	Patient Satisfaction	1.88	.71	-.10	-.01	.15	.03	-.03	.20*	.10	.31***	.30**	-.17*	.02	.38***	.52***	1
15	Intentions	1.96	.82	-.01	-.06	.18*	.09	-.09	.30***	.16*	.21**	.29***	-.20**	-.07	.40***	.47***	.71***	1
*Correlation is significant at the 0.05 level (2-tailed).
**Correlation is significant at the 0.01 level (2-tailed).
***Correlation is significant at the 0.001 level (2-tailed).

As shown in Table 1, the correlations between variables were below .80 indicating there was not a problem with redundancy or multicollinearity which demonstrated acceptable convergent validity (Tabachnick and Fidell, 2013). An additional check to ensure that the correlations as well as other potential sources of multicollinearity were not affecting the results, the variance inflation factor was calculated for the independent and control variables. None of the variables had a variance inflation factor above 2.1. These results are well below Kutner, et al. (2004) conservative cutoff value of 3, which establishes discriminant validity of the independent variables and satisfies the assumptions for ordinary least squares linear regression analysis.

H1 is supported, and H2 has mixed support. The mean importance of gifts was 1.85 and for services 2.31. A comparison of these averages to the scale midpoint defined as neutral, 3, indicates that both are important in a one sample t test for mean differences at p<0.001. Analyzing these means by gender, the average rating of the importance of gifts by females was 1.75, while males had an average rating of 2.32 and this difference was significant at p<0.05. There were no differences between gender regarding services.

H3 was supported. The mean value for benefits attributed to gifts and services was 2.27 and 2.12, respectively and both were significantly different from the scale midpoint at p <0.001. However, H4 was not supported as the mean difference between the gifts and services was small, .11, p < .0558. An analysis of the open-ended responses in the gifts category indicated that a cell phone was an important gift for respondents. This is supported by Amati, et al. (2018) critical incident analysis that patients “not having a cellphone to call for help” affected quality care.

H5, H6, H7 and H8 were tested with regression analysis and Table 2 shows the standardized regression coefficients for the significant predictors of patient satisfaction under Model 1. Both satisfaction with services, total services received and satisfaction with gifts were significant predictors of patient satisfaction, but total gifts received had no relationship with patient satisfaction.

Table 2 Regression Predicting Patient Satisfaction and Behavioral Intentions
Model 1			Model 2
Patient Satisfaction			Behavioral Intentions
	Coefficient			Coefficient
Variables	b	p		b	p
Gender	-.002	.977	Gender	.067	.235
Hospital	.074	.295	Hospital	.094	.094
Age	-.010	.908	Age	.047	.471
Income	.011	.898	Income	-.076	.245
Satisfaction Gifts	.157	.043	Patient Satisfaction	.692	.000
Satisfaction Services	.472	.000
Total Gifts Received	-.154	.041
Total Services Received	.078	.298
R	.600		R	.716
R2	.362		R2	.512
Adjusted R2	.324		Adjusted R2	.497

The results of the regression analysis that tested H9 are shown in Model 2 in Table 2. Hospital, as a control variable, had a significant impact on behavioral intentions indicating that behavioral intentions varied by hospital: at some hospitals, patients were more likely to return to the hospital in the future, recommend the hospital to family and friends as well as follow medical advice. H9 received strong support. In Table 1, the strongest correlation in the table is r = .704 (p < .001) between patient satisfaction and positive behavioral intentions. In addition, the standardized beta coefficient in the regression analysis in Table 3 was the highest compared to the other variables at β = .692 (p <0.001).

Table 3 Regression Analysis of Direct and Indirect Effects
			Standardized
			regression
			weights	p
Patient Satisfaction	<---	Satis Gifts	.185	.011
Patient Satisfaction	<---	Total Gifts	-.195	.007
Patient Satisfaction	<---	Total Service	.087	.249
Patient Satisfaction	<---	Satis Services	.465	.000
Behavioral Intentions	<---	Patient Satisfaction	.799	.000
Behavioral Intentions	<---	Satis Services	-.024	.741
Behavioral Intentions	<---	Satis Gifts	.097	.132

To support the previous hypotheses that amenity satisfaction had a direct effect on patient satisfaction which had a direct effect on behavioral intentions and therefore, did not have an indirect effect through patient satisfaction, the variables in the model were analyzed with SPSS AMOS structural equation modeling analysis. As seen in Table 3, the regression weights between satisfaction with services and satisfaction with gifts were not significant indicating that the effect of satisfaction with amenities is fully mediated by patient satisfaction, i.e., the direct effects were not significant.

Conclusion & Implications

The findings of this study support the hypotheses that support amenities are important during hospital stays to both males and females. Similar to Kashkoli, et al. (2017) findings, who showed that the quality of basic amenities in a hospital was significantly related to patient satisfaction with the hospital, this study demonstrates the importance of a wider range of support amenities? Whether in the form of an object or service, gifts are the physical manifestation and reminder of social support from friends and family and make a difference to well-being and recovery. Amenities improve the patient experience and predict patient satisfaction which in turn affects future intentions. These findings are supported by the socio-cultural literature, i.e., in collective, high context cultures, family and friends have a duty and religious obligation to visit the sick and spend time by their bedsides. Visitors bring gifts as a token of caring. The benefits of gifts and services include mood improvement, reduction of stress and general well-being. The hypothesis that women will rate gifts as more important to hospital stays was supported.

Gifts are important, and services received are even more important, and there were no differences found between genders regarding services. Both reported that services such as grooming, massages and other spa services are important. The importance of massage in the medical field is well documented (Grealish, et al. 2000). This investigation suggests that other forms of touch, e.g., manicure/ pedicure, are important to patient healing, wellbeing and satisfaction especially in a high context, collectivist society.

Today’s consumers seek value and choice in healthcare organizations and healthcare administrators have an opportunity to rethink the patient experience to include a wider range of solutions available to patients and families in coping and recovery. A hospital experience is a bundle of services and products and evidence-based research is required to understand patient demand across a range of contexts, e.g., cultures, types of hospitals, and different specialties. The investigation of quality and service through the eyes of hospital healthcare managers who are responsible for improvement is largely overlooked by the literature (Amati, et al., 2018).

The value in the present research is to advance earlier frameworks related to significant predictors of satisfaction and important patient outcomes in an upscale hospital setting, e.g., stress relief and faster recovery, to empirically inform healthcare managers. While nonmedical amenities are not a substitute for quality medical care, they are a complement to a patient’s overall experience (Brown, 2001). A positive patient experience is more likely to be associated with higher patient satisfaction with the hospital and staff and the patient recommending the hospital to family and friends which benefits the healthcare organization. Our study suggests a broader, multidimensional definition of support for hospital patients during hospitalization is an important part of patient outcomes.

The strategic implication of our analyses suggests that additional supplementary services augment the clinical services that can be marketed to prospective patients as a competitive tool. Severt, et al. (2008) demonstrate the importance of a hospitality centric approach to service excellence in hospitals. Hospitals who are able to communicate valued dimensions such as amenities to prospective patients can influence patients’ choices. Supplemental support services may increase patient satisfaction, health outcomes and patient choice. This conclusion supports Hilligos, et al., (2019) research that maintains it is important for health care providers to educate and equip patients with the range of health services in order to improve patients’ ability to self-manage their care. People who travel to developed countries, e.g., for medical tourism, expect benefits such as better hospitality, more personalized care, and better quality of healthcare services in general (Tontus and Nebioglu, 2018). Future studies are needed to investigate the relative importance of multiple dimensions of patient satisfaction including those related to medical care as well as support amenities across different competitive environments or hospital types, e.g., high price/high quality hospitals or nonprice based competition that draws from larger areas vs. low cost providers.

This study has several limitations. The research was exploratory, and study designs in future research are necessary to specify all the relevant constructs. As discussed earlier, gifts and services that are valued and important to hospital patients depend on the cultural context, so direct applications of our conceptual framework should be careful to consider the specific components of amenities in various cultures in future research. Expanding the study to different settings such as what factors influence medical tourists’ intention to travel to a destination would be an interesting extension of this study. Investigating additional factors that influence patient satisfaction is needed to generate a wholistic, evidence-based and interdisciplinary model of the patient experience. Like Hilligoss, et al., (2019), more research is needed on the availability and interdependencies of services such as the frequency and effectiveness of service interactions with patients.

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Received: 14-Jun-2023, Manuscript No. AMSJ-23-13697; Editor assigned: 15-Jun-2023, PreQC No. AMSJ-23-13697(PQ); Reviewed: 27-Oct-2023, QC No. AMSJ-23-13697; Revised: 03-Nov-2023, Manuscript No. AMSJ-23-13697(R); Published: 28-Dec-2023