Han H. & Hwang J., 2016 Investigating Healthcare Hotel Travelers’ Overall Image Formation Impact of Cognition, Affect and Conation


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  Article  Investigating healthcare hotel travelers’overall image formation: Impact ofcognition, affect, and conation Heesup Han College of Hospitality and Tourism Management, Sejong University, Seoul, Korea Jinsoo Hwang College of Hospitality and Tourism Management, Sejong University, Seoul, Korea Abstract Since there has been little empirical research on the phenomenon of healthcare hotels, this study examinedthem in order to provide a clear understanding of these facilities and international medical/healthcare tour-ists’ overall perspectives on them. A model was developed and tested that integrated conation into an existingtheoretical framework related to image. A field survey was conducted to collect data. A confirmatory factoranalysis was used to evaluate measurement quality, and a structural equation modeling was utilized to testresearch hypotheses and achieve study objectives. A series of modeling comparisons using a structuralanalysis were conducted. The test results verified the completeness of the proposed model and demonstratedthe superiority of the proposed research framework, which comprises conative image factors as the mostproximal determinants of overall image, over alternative models. In addition, the results of the structuralanalysis suggested that cognitive image involving perceived quality and value has a positive impact on affect-ive image; affective image forms conative images involving visit intention and commitment, and conativeimage exerts a positive impact on overall image. Moreover, an examination of the indirect impact of studyvariables suggested that affective image and conative image components are necessary mediators in themodel. Theoretical implications and the advertising and marketing implications for practitioners arediscussed. Keywords Healthcare hotel, medical tourism, overall image, medical treatment, intention to visit Introduction The medical tourism industry is nearly $60 billion-plus annually, primarily involves international trav-elers, and has experienced growth of approximately20% each year (Heung et al., 2011; Yu and Ko,2012). While medical travel is becoming more andmore popular, medical/healthcare tourists whoengage in it express concerns relating to conveni-ences (e.g., access to a variety of medical treat-ment/healthcare clinics from the hotel, languageissues), privacy/confidentiality, medical safety (e.g.,follow-up care, malpractice), quality of care, qualityof accommodations, and food and beverage (F&B)for themselves as well as accompanying family/friends/others (Gan and Frederick, 2011; Reddyet al., 2010). The healthcare hotel, which is alsoknown as a medical hotel or Meditel, can be agreat facilitator of international medical tourism(Han, 2013). Corresponding author: Jinsoo Hwang, Faculty of College of Hospitality and TourismManagement, Sejong University, 98 Gunja, Gwanjin, Seoul143-747, Korea.Email: jinsoohwang@hanmail.net Tourism and Hospitality Research0(0) 1–11 ! The Author(s) 2016Reprints and permissions:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1467358416670936thr.sagepub.com  Although the phenomenon of the healthcare hotel isnot well documented in the academic literature, it hasmade inroads into the popular press. Accounts in thesepublications report that this destination is believed tosignificantly increase patient travelers’ physical andpsychological conveniences, feelings of privacy/confi-dentiality, safety, quality of care, comfort, and services(Han, 2013; Han and Hyun, 2014; Hwang, 2011).The notion of the healthcare hotel is not yet a heavilystudied topic in the academic literature and, to the bestof our knowledge, little empirical study has appearedin the hospitality and tourism literature.It is generally believed that a firm’s overall image isone of the vital elements in increasing a firm’s com-petitiveness and encouraging continuous repurchase(Lee et al., 2010; Lin et al., 2007). Therefore, anumber of studies have dealt with customers’ percep-tions and images of a product or service. Previous stu-dies have generally indicated that overall image formsthrough two major stages: cognitive and affectiveimage (Baloglu and McCleary, 1999; Lee et al.,2010; Lin et al., 2007). That is, the perceptual, cog-nitive, and affective steps taken by customers in eval-uating a product or service are essential to shapingtheir overall beliefs, ideas, and impressions. However,it has been argued that overall image formation ignoresindividuals’ conative process by mainly involvingintention/commitment (Oliver, 1997), which is avital/valuable concept in consumer behavior, and thatconation is occasionally believed to be an outcomerather than a contributor/predictor of conation. Inaddition, in the hospitality industry, even though thesignificance of image and conation in explaining cus-tomer behaviors is well recognized, few studies haveexamined overall image formation. For this reason,there are no detailed explications of how conation pro-duces customers’ overall image of a product/service.Further, while previous studies have identified compo-nents of cognition and conation, cognition and con-ation were normally utilized in the hospitality/tourismliterature as uni-dimensional constructs in explainingconsumer behaviors.Considering the points outlined above, in the pre-sent study, the main purpose was to develop a robustmodel that provided a deeper understanding of inter-national medical travelers’ overall image formation of ahealthcare hotel. In particularly, the present studyattempted to: (1) integrate the conative stage into anexisting socio-psychological theory about overall imageformation, which mainly consists of cognitive andaffective stages; (2) compare the proposed modelwith alternative models only involving the originalphases of the existing theory (i.e., cognitive and affect-ive) and theorizing conation as a function of overallimage; (3) examine the detailed relationships amongcomponents of cognition, affect, and conation, and theimpact of such associations on overall image forma-tion; and (4) investigate mediating roles of study vari-ables in generating customers’ overall image of ahealthcare hotel. Overview of the literature Healthcare hotels  A healthcare hotel refers to a lodging establishmentthat contains a variety of medical/healthcare/aestheticfacilities and hospitals (Han, 2013). In the increasinglycompetitive lodging industry, simply changing ahotel’s accommodations to make them more appealingand improving services cannot be the ultimate strate-gies followed to ensure continued customer attractionand retention. In recent years, the healthcare hotel hasemerged as a niche market in the lodging industry,mainly targeting international visitors who want toobtain medical treatment and healthcare/aesthetic ser-vices along with traveling opportunities (Han, 2013;Han and Hyun, 2014). Although the perfect health-care hotel rarely exists, an increasing number of hotels,particularly in developing/less developed countries, areeager to integrate healthcare/medical facilities and ser-vices into their operations as well as to improve exist-ing facilities with advanced technology to activelyattract more international medical tourists (Han,2013; Han and Hyun, 2014). A healthcare hotel pro-vides not only diverse types of rooms—just like a con-ventional hotel—but a variety of medical treatment,healthcare, or aesthetic services for international tour-ists (KTMA, 2011; Han, 2013; Han and Hyun, 2014). Overall image formation and its components  Retaining existing customers and attracting new cus-tomers are hospitality/tourism marketers’ goals sincecustomer retention and attraction are directly asso-ciated with a firm’s profit and success (Lee et al.,2010; Han and Hyun, 2012; Han et al., 2011).Researchers agree that overall image can have amajor impact on attaining this goal. The topic of over-all image is, therefore, often preferred in manyresearchers. For example, Baloglu and McCleary(1999) found that, in the tourism context, the percep-tual/cognitive stage and affective phase, which are theoutcomes of the perceptual/cognitive stage, generateindividuals’ overall conception of image. Lin et al.(2007) have consistently shown that cognitive andaffective components of image influence travelers’overall images and their association with a productpreference in natural, developed, and theme park des-tination settings. In a hotel setting, Lee et al. (2010) 2  Tourism and Hospitality Research 0(0)   reported that cognitive factors of image and affectiveimage impact customers’ overall image of a hotel prod-uct/service. These studies all centered on previousknowledge/information and pleasurable feelings of ful-fillment about a product/service in shaping overallnotions of image. Many researchers in diverse fieldshave agreed that such perceptual/cognition stagemainly comprises the functional and psychologicalaspects of perceived value and quality (Back, 2005;Han and Hyun, 2012; Han et al., 2011), and affectmainly involves one’s emotional responses that containfeelings or pleasurable fulfillments of a specific prod-uct/service (Bagozzi, 1978; Oliver, 1997, 1999).However, the common agreement among manyresearchers in diverse fields is that the conativeaspect is also critical in shaping individuals’ psycho-logical processes—this includes decision/image forma-tion (Evanschitzky and Wunderlich, 2006; Han andHyun, 2012; Han et al., 2011; Oliver, 1997, 1999).Conation can be described as ‘‘intention or commit-ment to behave toward a goal in a particular manner’’(Oliver, 1997: 393). Such conation contains two majorfactors (i.e., commitment and intention) (Han et al.,2011; Oliver, 1997, 1999). Researchers have verifiedthat employment of three phases, including cognitive,affective, and conative, is essential to understandingcustomers’ psychological process/decision/behaviorrelated to various products/services. These researchershave insisted that conation is a direct function of affectin shaping attitudes and individuals’ purchasing-related psychological processes. Specifically, in exam-ining customers’ attitude development structure,Oliver (1997, 1999) theorized that one’s attitudetoward a product/service develops through cognitive,affective, and conative manners. This conative phase,which is mainly comprised of intentions/commitment,is a vital element in attitudinal structure along withcognitive and affective phases. His finding was sup-ported by many recent studies. For instance,Evanschitzky and Wunderlich (2006) and Han et al.(2011) stated that considering cognition and affect aswell as conation are vital to explicitly comprehendingcustomers’ psychological processes related to a prod-uct/service. Their findings implied the conceptual ade-quacy of comprehensively integrating conation into anexisting bi-dimensional image model that involves cog-nitive and affective components. Cognitive dimension and its impact  The term, cognition, refers to one’s perceptions/know-ledge/beliefs about a particular product, its attributes,and its performances (Baloglu and McCleary, 1999;Oliver, 1997). This cognition mainly comprises such fac-tors as functional and psychological facets of value andperceived quality (Back, 2005; Han et al., 2011).Zeithaml (1988) indicated this value as one’s comprehen-sive evaluation of the utility of a product/service rooted inthe perceptions of what is obtained and given; Bitner andHubbert (1994) described this perceived quality as one’soverall perception of the relative superiority or inferiorityof a product and the performances of its attributes. Thecriticality of cognition and its constituents in product/ser-vice consumers’ psychological process is often stressed byresearchers. For instance, Baloglu and McCleary (1999)asserted that cognitive factor and its components aredirect drivers of affective image. Lee et al. (2010) alsoindicated that cognition exerted a significant influenceon affective image playing a vital role in generating hotelcustomers’ eco-friendly purchasing behaviors.Consequently, it was hypothesized that: H1 : Increases in perceived value lead to increasedaffective image. H2 : Increases in perceived quality lead to increasedaffective image. Affective factor and its impact  Affect is another crucial construct in one’s image for-mation. According to Lee et al. (2010) and Lin et al.(2007), affective image is central in building one’sfavorable overall image and decision for a firm.Affect comprises individuals’ emotional responses,which include pleasurable fulfillments/feelings whenusing a specific product/service (Bagozzi, 1978;Oliver, 1999). Lin et al. (2007) demonstrated thataffect generates overall image and contributes tobetter predicting travelers’ choice/preference acrossnatural, developed, and theme-park destinations. In agreen lodging sector, Lee et al. (2010) also verifiedthat affect, which is a significant function of cognitiveimage, has a key role in triggering patrons’ overallimage and behavioral intentions. Moreover, in a res-taurant sector, Han et al. (2011) demonstrated thataffective process exerted a significant influence onpatrons’ commitment and revisit intention. Theseresearchers’ general agreement is that conative imageconstituents (e.g., intention, commitment, choice, andpreference) in the overall image (or decision) forma-tion for a product/service are often induced by affect.It was therefore hypothesized that: H3  : Increases in affective image lead to increased visitintention. H4 : Increases in affective image lead to increasedcommitment. Han and Hwang   3  Conative dimension and its impact  Theterm,conation,isalsoanessentialconceptinexplain-ing one’s psychological decision-making process related toconsumption (e.g., Han and Hyun, 2012; Oliver, 1999).Oliver (1997) defined conation as one’s commitment orintention to act toward a goal in a specific manner. As thisdefinition indicates, intention and commitment are twocore components of conation (Han et al., 2011; Oliver,1999). While some researchers utilized conation as a uni-dimensional construct (Back and Parks, 2003), a two-dimensional view of conation comprising commitment,and intention is believed to capture the construct moreexplicitly (Han et al., 2011). The conative process con-taining both commitment and intention is often found tobe influenced by affect (Han et al., 2011). According toHan and Hyun (2012), conation is a significant and posi-tive function of affect in one’s decision-making processrelated to consumption. Their finding also indicatedthat cognition also significantly influences conation indir-ectly through affect. Similarly, in building a theoreticalframework explicating tourists’ behavioral intention,Baloglu (1999) identified that cognitive evaluation deter-mines tourists’ affective evaluation (e.g., feelings-relatedevaluation) about travel destination, and this affectivefactor increases their intention to travel to the place,which is a vital constituent of conative image. Therefore,it was hypothesized that: H5  : Increases in visit intention lead to increased over-all image. H6  : Increases in commitment lead to increased overallimage. Conceptual model  According to the view in the literature discussed above,individuals’ psychological decision-making process orthought development process related to consumptionproceeds through cognitive stage, affective phase, andconative stage in a sequential manner. Hence, we putforth that the overall image forms through cognitive,affective, and conative processes. The proposed modelis exhibited in Figure 1. This model comprises a totalof six hypotheses. Methods Measures and questionnaire development  The initial questionnaire comprised an introductorycover letter, definition of the concept of a healthcarehotel, questions relating to the variables to be studied,and questions for a demographic profile of each par-ticipant. The questionnaire was based on the existingliterature (e.g., Baloglu and McCleary, 1999; Hanet al., 2010; Kim and Han, 2008; Lee et al., 2010;Morgan and Hunt, 1994; Oh, 2000; Varki andColgate, 2001) and refined to be adequate in a health-care hotel setting. Multi-item scales were consistentlyused to measure study variables. In addition, a seven-point Likert-type scale from ‘‘Extremely disagree’’ (1)to ‘‘Extremely agree’’ (7) was used for cognitive com-ponents of image, conative image components, andoverall image. For affective image, four bipolar scaleswere used (e.g., ‘‘Arousing’’ – ‘‘Sleepy’’). The initialquestionnaire was altered and perfected through a hos-pitality and tourism expert review and a pre-test. As a H1H2H4H3H5H6Perceived ValuePerceived QualityAffective ImageIntention to Visit Commitment Overall Image about a HealthcareHotel Conative Image Cognitive Image Figure 1.  Proposed model. 4  Tourism and Hospitality Research 0(0) 
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