Introduction
The concept of health care marketing was first introduced in 1977, when the American Hospital Association sponsored the first conference on the subject (Cazacu and Oprescu, Reference Cazacu and Oprescu2015). Since Kotler (Reference Kotler1979) emphasized the need to use marketing strategies within health care organizations, a great deal of research has been conducted (Lee et al., Reference Lee, Ginn and Naylor2009). Competition for patients is increasing, and hospitals and other providers turned to the familiar field of public relations for their promotional efforts. Communications efforts were beginning to be targeted toward patients, and patient satisfaction research grew in importance. Health marketing mainly concerns improving public health, and it uses marketing research to develop effective methods to inform, educate, and motivate the public (Gunawardane, Reference Gunawardane2020). Modern health care marketing recognizes that the present health care consumer lives in a digital and experiential economy that significantly affects his/her consumer behavior toward health and health care services (Gunawardane, Reference Gunawardane2020). The most recent definitions of health care marketing focus on information exchange between the health care institution and its customers (Gunawardane, Reference Gunawardane2020). It is important to implement the marketing of health care services accordingly by: managing relationships and building loyalty; considering patient feedback and service recovery; improving health care service quality and productivity; organizing for health care service leadership; and understanding the challenge of building relationships with patients, including preference, liking, and future intentions (Purcarea, Reference Purcarea2016). Marketing occupies a position in the field of health promotion that is ensured by marketing principles, strategies, and actions in the context of health: this includes formative research, segmentation, competitive analysis, targeting, positioning, and the marketing mix (Ayed and El Aoud, Reference Ayed and El Aoud2017). Marketing research is required to review theories of health behavior, and to incorporate the empowerment paradigm in order to further develop marketing strategies and programs (Ayed and El Aoud, Reference Ayed and El Aoud2017).
At present, patients have such a variety of options regarding the choice of primary health care service provider that the only way that health care practices can really be distinguished is by establishing well-differentiated, memorable, and unique proposals alongside their marketing strategies (Purcarea, Reference Purcarea2019). Acting in a dynamic and unpredictable environment, the health care service provider must be able to detect opportunities in, and threats to, the market in which it operates (Purcarea, Reference Purcarea2019). Marketing plays an important role in helping health care professionals to create, communicate, and provide value to their target market, and to attain a high level of patient satisfaction (Purcarea, Reference Purcarea2019). The marketing mix elements strategy is necessary in medical organizations to improve the competitive advantage of the primary health care institution, and thus to ensure their success (Purcarea, Reference Purcarea2019). For policy makers, having established the priorities of value creation at the primary health care level, it is important to develop collaborative activities by involving health care professionals in improving the quality of life and satisfaction levels of patients.
There is also a growing recognition of the significance of patient involvement and knowledge (Purcarea, Reference Purcarea2016), and consumer – patient empowerment. They work to assure voluntary consumer behavior change in health care, and permit the development of knowledge, skills, and competencies, serving both to strengthen dialogue and enhance autonomy (Ayed and El Aoud, Reference Ayed and El Aoud2017). In the marketing literature, health care services are defined as the utility obtained by the consumer as a result of some interconnected activities which are based on a supplier – client relationship, and which are materialized in physical, mental, and social welfare (Muhcina and Popovici, Reference Muhcina and Popovici2015). They are classified based on several criteria, such as the level of health care (primary, secondary, or tertiary assistance), the degree of health care services’ difficulty (routine, urgent, or chronic services), the amount of time spent by the patient in the hospital, the compulsory nature of the service, the type of consumer (individual or collective), and the nature of finances (Muhcina and Popovici, Reference Muhcina and Popovici2015). The creation and the delivery of health care services depend on creating and maintaining different types of relationships: internal relationships, relationships with collaborators, relationships with third party payers (insurance companies), and doctor – patient relationships (Cazacu and Oprescu, Reference Cazacu and Oprescu2015).
Considering the characteristics of the health care industry, health care services, and consumer behavior – alongside building relationships with patients and other parties – is critical for the success of health care institutions (Cazacu and Oprescu, Reference Cazacu and Oprescu2015). One study (n = 170) investigated the factors that influence patients’ long-term relationships with health care providers at a public regional hospital (Adomah-Afari et al., Reference Adomah-Afari, Mantey and Awuah-Werekoh2019). This study concluded that health-related factors (their reception by staff, providers’ attitudes, waiting time, competence and expertise, and the hospital environment) were statistically significant (Adomah-Afari et al., Reference Adomah-Afari, Mantey and Awuah-Werekoh2019). The primary factor in patients’ decision making is recommendation by the family physician, and e-marketing is important as the internet is the major source of information among younger respondents (Bhangale, Reference Bhangale2011).
Patients with T2DM have a significant role in the marketing of primary health care:
Value is created through patient-oriented services and health care service management. This involves meeting the needs and expectations of patients, increasing their satisfaction with primary health care institutions, providing patients with additional service choices, raising patients’ awareness about their own health, and improving communication and collaboration between patients and family physicians.
T2DM is extremely disturbing and negatively impactful on the quality of life of patients. Marketing helps better communicate to participants of the health care system regarding the disease, risk factors, and complications.
Globally, T2DM is the most important chronic disease management problem in primary health care, and patients with T2DM are regular users of the services of family physicians. Marketing activities help family physicians to better manage the progress of the chronic disease.
In previous studies, a gap is noted between health care marketing mix elements and their relationships with perceived values and satisfaction from the perspectives of patients of primary health care (Sweeney and Soutar, Reference Sweeney and Soutar2001). This research makes suggestions that relate to health care marketing mix elements and that tie into perceived values and satisfaction from the perspectives of patients with T2DM after family physician consultation at the primary health care level in Lithuania. The items studied were the opinions of respondents with T2DM regarding health care marketing mix elements and the ways in which they relate to perceived value (emotional, functional, and social) and satisfaction. Future health care marketing researchers should seek more meaningful quality improvements, a more population-specific assessment of customer satisfaction (Lim and Ting, Reference Lim and Ting2012), and to identify relationships within marketing mix elements and perceived value. The primary aim of this research is to explore marketing mix elements from the point of view of patients with T2DM after consultation with family physicians at primary health care institutions in Lithuania.
The objectives of the research can be summarized as:
To develop the hypotheses model with regards to health care marketing mix elements and perceived value dimensions, with a view towards satisfaction from the point of view of respondents with T2DM at the primary health care level.
To determine the main decisions related to health care marketing mix elements with the perspectives of respondents with T2DM at the primary health care level in mind.
To investigate the main associations of health care marketing mix elements with the perceived values of patients with T2DM and their satisfaction with primary health care services.
Development of hypothetical model for the study
The functions of the marketing of health care services are knowledge management, customer relationship management, brand image building, and internal marketing (Bhangale, Reference Bhangale2011). Organizations are increasingly focusing on building their marketing capabilities to gain a competitive advantage over their rivals (Moorman and Day, Reference Moorman and Day2016). The traditional foundation for all marketing plans is the consideration of four key elements: product (what the offering actually is and what its characteristics are), price (what the company should charge for the product in its various iterations), place (where the product is sold and the distribution channels), and promotion (advertising, public relations, sales representatives). The element of ‘principles’ become the fifth ‘P’ of health care marketing, and principles represent the means through which companies protect their reputation (Gray, Reference Gray2008). The value of an organization to customers is created through 7 Ps elements of the marketing mix that include product, price, place, promotion, people, physical evidence, and process (Kotler et al., Reference Kotler, Shalowitz and Stevens2008). During the literature analysis it was found that the 4 ‘S’ model (size, shape, share, soar) that was used in health care institutions was perceived to add significant value for entry level marketing professionals in the health care sector (Biranchi, Reference Biranchi2020). Emotional value is the utility derived from the feelings or affective states that a product generates (Sweeney and Soutar, Reference Sweeney and Soutar2001). Social value is the utility derived from a product’s ability to enhance social self-concept (Sweeney and Soutar, Reference Sweeney and Soutar2001). Functional value (price/value for money) is the utility derived from the product due to the reduction of its perceived short-term and long-term costs (Sweeney and Soutar, Reference Sweeney and Soutar2001). Functional value (performance/quality) is the utility derived from the perceived quality and expected performance of the product (Sweeney and Soutar, Reference Sweeney and Soutar2001). The results of patient satisfaction surveys allow primary health care institutions to identify service factors that need improvement (Batbaatar et al., Reference Batbaatar, Dorjdagva, Luvsannyam, Savino and Amenta2017).
The hypothetical model was built because during the analysis of other studies, it is conspicuously absent. This model constructed on the basis of separate relationships between constructs that require further testing. The primary assertion of our hypothesis is that the marketing mix elements of health care services statistically, directly, and positively relate to the perceived emotional, functional, and social value of patients with T2DM and their satisfaction with primary health care services. The results of the survey established the statistically significant positive influence of both social value and functional value on satisfaction. Conversely, emotional value was shown to decrease the satisfaction of patients with T2DM (Budrevičiūtė et al., Reference Budrevičiūtė, Kalėdienė, Bagdonienė, Paukštaitienė and Valius2019). During the theoretical discussion, the hypothesis model of research was built (Figure 1).
The hypotheses model of health care services marketing mix elements, alongside perceived value and satisfaction.
In our study, the seven key elements (service, price, promotion, people, process, place, and physical evidence) of health care marketing were investigated. Therefore, the hypotheses to be investigated were as follows:
H1: The marketing mix elements statistically, positively, and directly related to the perceived emotional value of patients with T2DM.
H2: The marketing mix elements statistically, positively, and directly related to the perceived functional value of patients with T2DM.
H3: The marketing mix elements statistically, positively, and directly related to the perceived social value of patients with T2DM.
H4: The marketing mix elements statistically, positively, and directly related to the satisfaction of patients with T2DM.
Material and methods
Research design
Before this study commenced, the Kaunas Regional Biomedical Research Ethics Committee issued permit No. BE-2-11, 2014 05 07, and the State Data Protection Inspectorate issued the preliminary data verification – permit No. 2R-5964, 2014 11 19. The design of this study was based on the survey of patients with T2DM after they had received a family physician’s services in primary health care institutions in Lithuania (Figure 2).
The research design.
The survey was conducted from October 2017 to January 2018. A questionnaire was used, which was developed following a methodological process based on three information sources that included a review of the scientific literature, consultations with researchers, the results of focus group discussions, and the survey of patients with T2DM after family physician consultation. The authors conducted a review of the scientific literature in the EBSCO and EMERALD databases and, based on the criteria, they selected 10 qualitative studies, 20 quantitative studies, 3 mixed research papers, and 10 scientific literature reviews.
Study population
National focus group discussions were conducted from May 2015 to March 2016 in the 10 counties of Lithuania. A total of 48 participants were enrolled into the qualitative study: 31 managers of public primary health care institutions and 17 managers of private primary health care institutions. The mean size of the focus group was five participants. The mean duration of the focus group discussion was 1.21 h. Participants were selected from the list composed by the Lithuanian Institute of Hygiene at the end of 2012. Selection was made following the principle of 50/50, with the intention to include the managers of both public and private primary health care institutions. A pilot study was conducted in May 2017 in Lithuania to evaluate the suitability of the questionnaire. In this pilot study, the managers of the primary health care institution were informed about the pilot study by phone and/or by email. Informed consent forms and questionnaires were then distributed to managers or heads of departments, or family physicians working in primary health care institution. The questionnaires were filled out by patients with T2DM after a consultation with a family physician. The pilot study involved 33 patients with T2DM from both private primary health care institution (eight respondents) and public primary health care institution (25 respondents). In total, 80 questionnaires were distributed, and 33 questionnaires were completed (a response rate of 41%). The reliability of the questionnaire as evaluated by the Cronbach α test was 0.920. Taking into account the respondents’ opinion, the questions on the questionnaire were then corrected and developed. From October 2017 to January 2018, the main survey was conducted and data was collected using the questionnaire given to patients with T2DM in private and public primary health care institutions in Lithuania. The inclusion criteria for this study were as follows: an age of ≥ 18 years, a diagnosis of T2DM, a treatment consisting of diet, physical activities, oral hypoglycemic agents, insulin, or any combination thereof. Those diagnosed with type 1 and gestational diabetes were excluded, because the goal of our research was to investigate the opinion and perspectives of patients with T2DM. All who met the inclusion criteria were invited to participate. The T2DM diagnosis was defined by family physician using the medical records. In total, 700 respondents were approached to take part in the survey, and 510 valid questionnaires (258 from public and 252 from private primary health care institutions in Lithuania) were collected, resulting in a response rate of 72.8%. Information regarding non-respondents is omitted from this study.
Study instrument
The questionnaire was created based on question groups that were divided into the variables of emotional value, functional value, social value, satisfaction, costs, behavioral intentions, and marketing mix elements. Table 1 (in the Annex) demonstrates factor analysis according to marketing mix elements, where ‘Service’ was comprised of 10 items, ‘Price’ 3 items, ‘Promotion’ 5 items, ‘People’ 5 items, ‘Process’ 6 items, ‘Place’ 4 items, and ‘Physical evidence’ 4 items. In questionnaire 6, the group of questions were arranged based on the Likert scale, where 13 questions were categorical and 8 questions were open (respondents added their response). Socio-demographic questions involved the gender of respondents, age of respondents, their place of residence, income, education, and occupation. In the questionnaire, respondents could choose their place of residence (urban or rural) based on the confirmed number of citizens living in that place. The question about income of respondents was categorical and divided responses into categories: less than €350 and more than €350. The low income was considered as less than €350. In the case of establishing how family physicians communicate with doctors/endocrinologists, we asked respondents about their frequency of visits to endocrinologists. In total, 35.7% of respondents mentioned that they visited a doctor/endocrinologist once per year.
Marketing mix elements’ factors, attributes, and codes
Primary health care in Lithuania
Before health care reform in Lithuania, provision of the services provided by specialist doctors predominated. In 1991, the Supreme Council of the Republic of Lithuania approved the National Health care Concept, which aimed to restructure health care services and to focus on primary health care and the primary health care institution (Resolution No. I-1939 of the Supreme Council of the Republic of Lithuania on the Lithuanian National Health Concept and its Implementation, 30 October 1991). The main objectives of the first phase (2003–2005) were to improve health care quality, improve accessibility to services, and optimize the scope and structure of health care needs (Resolution No. 335 of the Government of the Republic of Lithuania on the Approval of the Restructuring Strategy of the Health Care Institutions, 18 April 2003). The second phase (2006–2008) of the restructuring of the health care system involved the separation of primary and secondary level outpatient services, with an emphasis on primary health care institutions in rural areas and the development of the network of private primary health care institutions (Resolution No. 1020 of the Government of the Republic of Lithuania on the Approval of the 2006–2008 Program Implementation of the Government of the Republic of Lithuania, 17 October 2006). The third stage (2009–2011) of the restructuring of health care institutions aimed to provide safe, high-quality, and accessible health care services to the population, whilst ensuring the efficient use of health care resources (Resolution No. 1654 of the Government of the Republic of Lithuania on the Approval of the Third Phase Program of Restructuring of Health Care Institutions and Services, 7 December 2009). The fourth phase (2012–2016) of health care system development and hospital network consolidation involved the development of the main outpatient services, particularly the strengthening of primary health care and disease prevention (Resolution No. 1290 of the Government of the Republic of Lithuania on the Approval of the Fourth Stage Plan of the Development of the Health Care System and the Consolidation of the Hospital Network, 9 December 2015). Increasing competition among primary health care institutions gives patients the freedom to choose a health care institution and a family physician. Meeting the patients’ expectations with health care services, primary health care human resources, and patients’ communication are the main priorities in the management of primary health care institutions.
Statistical analysis
Statistical analysis was done with IBM SPSS Statistics 25. The construct validity of the questionnaire was tested with exploratory factor analysis, and the reliability of the questionnaire was tested using Cronbach α. The scores of the factor analysis were analyzed as estimates of the emotional, social, functional, and satisfaction values, marketing mix elements. The Spearman rank correlation coefficient (r s ) was used to analyze the linear relationship between factor scores and quantitative features. Linear regression analysis was used for modeling the relationship between the satisfaction of respondents and their emotional, social, and functional values. For the analysis of the relationship between factor scores and qualitative features, factor scores were grouped into two groups: weakly (those with a factor score of less than or equal to zero) and strongly (those with a factor score larger than zero) expressed emotional, social, functional, and satisfaction values. Cramer’s coefficient (rcr) and the Chi square test for independence were used to analyze the relationships between qualitative features. These associations were considered as statistically significant if a P-value < 0.05 was encountered.
Results
Among 510 respondents, 348 (68.2%) were women and 162 (31.8%) were men. As many as 77.9% and 83.3% of the women and men, respectively, indicated that they lived in urban areas. The mean age of the participants was 64.58 years (Standard deviation (SD) = 11.49), and those aged from 55 to 65 years accounted for the largest proportion of the patients with T2DM (32.00%). The mean age of the women that took part was 64.10 years (SD = 11.56), whilst for men it was 65.63 years (SD = 11.29). Table 2 shows the demographics of the study population.
Demographics of the study population
The scale of internal consistency was examined using Cronbach α, and each construct fell within the expected range. Each factor name is based on the variables with significant loadings (Cronbach α, Kaiser–Meyer–Olkin measure [KMO]) (Table 3).
Factor analysis construction
The marketing elements of ‘Service’ and ‘Process’ have the highest KMO when compared with other elements of the marketing mix. The element of ‘Place’ has the lowest KMO, and it is therefore considered not to involve this element in the following analysis. The factor analysis and Cronbach α analysis are shown in Table 4.
The results of exploratory factor analysis of the marketing mix elements
According to factor analysis, the biggest influence in the marketing mix element ‘Service’ is exerted by the responses ‘I am satisfied with my family physician’s work’ (weight 0.85), ‘My expectations with my family physician’s work are fulfilled’ (weight 0.84), ‘I am satisfied with my nurse’s work’ (weight 0.83), and ‘I am satisfied with the treatment of diabetes at primary health care institution’ (weight 0.83). The least influential statements are those where respondents felt positive when attending the primary health care institution (weight 0.58), and where the services provided by the family physician improve understanding about health (weight 0.66). The marketing mix element ‘Service’ has a statistically positive dependence on the gender of respondents with T2DM (rcr = 0.12, P = 0.007; Table 5).
The perception of marketing mix elements according to sociodemographic characteristics
* Pearson chi square test for independence, data are given as n (%).
Based on the results of factor analysis, the biggest influence in the marketing mix element ‘Price’ is exerted by the statements ‘My expenses for the medications that are prescribed by the family physician live up to my expectations’ (weight 0.88) and ‘The cost of visiting the family physician justifies the consultation’ (weight 0.8). A statistically significant association was found between primary health care institution ownership (private or public) and the marketing mix element ‘Price’ (rcr = 0.091, P = 0.040; Table 5). The occupation of respondents with T2DM (rcr = 0.151, P = 0.009) and affiliation to primary health care institution (rcr = 0.091, P = 0.040) statistically positively affect the marketing mix element ‘Price’. In the marketing mix element of ‘Promotion’, the statements with the biggest influence are ‘I would recommend my family physician to relatives and friends’ (weight 0.90), ‘I would recommend my health care institution to relatives and friends’ (weight 0.88), and ‘If I had to choose a health care facility, I would choose the same primary health care institution’ (weight 0.84). The least influential statements were ‘I would recommend my primary health care institution’ (weight 0.83) and ‘I will work harder to follow the family physician’s recommendations on how to promote health’ (weight 0.82). Statistical relationships were not identified between the marketing mix element ‘Promotion’ and the sociodemographic characteristics of respondents with T2DM (Table 5). In the marketing mix element ‘People’, the most significant opinion of respondents are related to trust in the family physician (weight 0.90) and respondent’s welcome communication with a family physician (weight 0.88) and nurse (weight 0.86). The least influential statements involved respondents’ decisions to visit the same family physician (weight 0.80) and their choice of primary health care institution due to having an experienced family physician (weight 0.56). We detected no statistically significant relationships between the marketing mix element ‘People’ and respondents with T2DM’s sociodemographic characteristics (Table 5). The most important statements in the marketing mix element ‘Process’ indicate that respondents would like to more partnership with nurse (weight 0.92) and their family physician (weight 0.90). In the opinions of respondents with T2DM, they prefer to openly discuss the best course of treatment with their family physician (weight 0.80). The least influence was exerted by the statements ‘I prepare my questions about health for my family physician in advance’ (weight 0.77), ‘The primary health care institution’s working hours are in line with my expectations’ (weight 0.72), and ‘The times of my family physician’s service fulfills my expectations’ (weight 0.67). It was found that the marketing mix element ‘Process’ had a statistically significant relationship to the income of patients with T2DM (rcr = 0.104, P = 0.019; Table 5). The marketing mix element ‘Physical evidence’ is important for respondents with T2DM because the cleanliness and maintained order at the primary health care institution live up to their expectations (weight 0.90) and the tests of laboratories fulfills their expectations (weight 0.90). The least important statements were ‘I get information about preventive programs at the primary health care institution’ (weight 0.84) and ‘I prepare the questions about health to my family physician in advance’ (weight 0.55). The marketing mix element ‘Physical evidence’ was found to be statistically significant in relation to the income of respondents with T2DM (rcr = 0.092, P = 0.038; Table 5).
Results of linear regression analysis confirmed hypothesis H4 in that the marketing mix elements of ‘Price’, ‘Promotion’, and ‘Place’ are positively, statistically significantly related to respondents with T2DM’s perceived emotional value (Table 6).
Linear regression model for values and satisfaction on marketing mix elements
There was no evidence of a statistically significant effect of the marketing mix elements such ‘Service’, ‘People’, ‘Process’, and ‘Physical evidence’ on the perceived emotional value of respondents with T2DM. The marketing mix elements of ‘Service’, ‘Promotion’, ‘Process’, ‘Physical evidence’, and ‘Place’ have positive and statistically significant links to the perceived functional values of patients with T2DM (Table 6). The marketing mix elements of ‘Promotion’ and ‘Process’ statistically significantly decrease in the perceived functional values of patients with T2DM. Results of linear regression analysis confirmed hypothesis H6 which stated that the marketing mix elements of ‘Service’, ‘Price’, ‘People’, and ‘Process’ positively and statistically significantly related to the perceived social value of patients with T2DM (Table 6). The analysis data showed that perceived social value is decreased by the marketing mix elements ‘Place’, ‘Promotion’, and ‘Physical evidence’, but the decrease is not statistically significant. The satisfaction of respondents with T2DM is decreased by the marketing mix elements of ‘Price’, ‘Place’, and ‘Physical evidence’, where the elements of ‘Service’, ‘Promotion’, ‘People’, and ‘Process’ increase the satisfaction of patients with T2DM (Table 6).
Discussion
T2DM is reported to affect 1 in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries (Ong et al., Reference Ong, Koh, Toh, Chia, Balabanova, McKee, Perel and Legido-Quigley2018). As primary health care institutions are often close to the places where people live and work, they represent the first point of contact for individuals, families, and communities and play an integral role in responding to the increasing global prevalence of this disease (Albuquerque et al., Reference Albuquerque, Cunha, Martins and Sá2014; Ong et al., Reference Ong, Koh, Toh, Chia, Balabanova, McKee, Perel and Legido-Quigley2018). Diabetes as a social problem demands a reorientation of health care professionals and health care settings, as well as the behavior of patients with T2DM (Sørensen et al., Reference Sørensen, Korsmo-Haugen, Maggini, Kuske, Icks, Rothe, Lindström and Zaletel2015; Rosiek et al., Reference Rosiek, Kornatowski, Frąckowiak-Maciejewska, Rosiek-Kryszewska, Wyżgowski and Leksowski2016). Lim (Reference Lim2020) affirms the marketing mix, noting that it encourages the desired behaviors in patients and facilitates their participation in health care by controlling a combination of the mix elements. In this study, the perspectives of patients with T2DM on marketing mix elements in the primary health care institutions of Lithuania were explored. The hypothesis model was developed and tested. We determined the main perspectives related to health care marketing mix elements with the perspectives of respondents with T2DM at the primary health care level in mind. The main associations of health care marketing mix elements with the emotional, social, and functional dimensions of perceived value and satisfaction of patients with T2DM were investigated. Our study focusing on patients’ perceived value is in line with the statement of Hirpa et al. (Reference Hirpa, Woreta, Addis and Kebede2020) that the modern health care system is moving towards patient-centered and value-based care models that prioritize health outcomes that matter to patients. However, the concept of perceived value is well known in diverse branches of the service industry, while knowledge of it in health care remains fragmented (Pevec and Pisnik, Reference Pevec and Pisnik2018). Consumer perceived value refers to consumers’ overall assessment of service utility based on benefits and sacrifices. The benefits in health care are primarily the outcomes of good service quality (i.e., satisfaction), and the sacrifices include both the monetary and nonmonetary costs (i.e., time spent, or mental and physical stress) (Chahal and Kumari, Reference Chahal and Kumari2011). Besides the concept of cost benefit analysis, customer perceived value is also defined as a multidimensional concept. In our study, we have concentrated on Sanchez et al.’s (Reference Sanchez, Callarisa, Rodriguez and Moliner2006) approach, which states that customer perceived value is a combination of three dimensions: functional value, social value, and emotional value. The ability of health care providers to operate in a highly competitive market supposes that they have to perfectly understand the needs of patients and, based on this knowledge, deliver true customer value. To do so, health care providers should effectively use their resources to maximize the perceived value of their services to target customers (Gates et al., Reference Gates, McDaniel and Braunsberger2000). Perceived value is subjective and varies based on the socio-demographic attributes of an individual. The results of our study reveal that the influence of the marketing mix elements on the dimensions of perceived value and patient satisfaction diverges from the socio-demographic characteristics of respondents. ‘Service’ as a marketing mix element is strongly expressed by gender (female), ‘Price’ by ownership (private primary health care institutions) and occupation (retired), and ‘Process’ and ‘Physical evidence’ by income (€350). The marketing mix elements of ‘People’ and ‘Promotion’ have no statistically significant relationships with the socio-demographic characteristics of the patients with T2DM involved in this study. Alongside patient perceived value, we measured how patient satisfaction is affected by marketing mix elements. Patient satisfaction is a criterion that informs whether the health care provider is successful at meeting the expectations of most relevance to the patient, and is a key determinant of the patient’s prospective behavioral intention (Xesfingi and Vozikis, Reference Xesfingi and Vozikis2016). The findings of our study indicate that a positive influence on patient satisfaction is exerted by the marketing mix elements of ‘Service’, ‘Promotion’, ‘People’, and ‘Process’, and that a negative influence is exerted by ‘Price’, ‘Place’, and ‘Physical evidence.’
Marketing is becoming increasingly important for health care institutions because competition in the health care market is ever-growing, and the pursuit of a competitive advantage in creating value for patients through marketing activities is at the heart of a company’s strategy (Elrod and Fortenberry, Reference Elrod and Fortenberry2018). Despite this, studies that concern marketing and which focus particularly on the link between marketing mix elements and patient perceived value dimensions remain scarce. Perhaps surprisingly, there is more marketing research carried out in hospitals than in the primary care sector. The major exception to this is the inquiry carried out by Račienė and Bučiūnienė (Reference Račienė and Bučiūnienė2006) in Lithuania. The findings of their quantitative study (n = 410) show that the marketing mix elements of ‘People’ and ‘Process’ play the most crucial role in the activities of primary health care institutions. Nonetheless, we were not able to locate studies aimed at how marketing mix elements as a set of tools may be used in seeking to offer better services to patients with T2DM. The research findings of Abedi and Abedini (Reference Abedi and Abedini2017) unravel the importance of two marketing mix elements – ‘Price’ and ‘Product.’ The first of these elements is actualized in public hospitals and the latter in private hospitals. A similar result was attained by Nasiripour et al. (Reference Nasiripour, Raeissi, Maliki and Akbarian Bafghi2013), wherein the researchers identified that the biggest influence on the activities of public hospitals was exerted by two marketing mix elements – ‘Place’ and ‘Price.’ Amriza (Reference Amriza2017) found that the marketing mix factors in the ‘Product’ variable have a dominant influence on the interest of patients in re-visiting national health insurance polyclinics. Zarchi et al. (Reference Zarchi, Jabbari, Rahimi, Shafaghat and Abbasi2013) disclosed how elements of the marketing mix are employed in developing medical tourism. Despite the growing amount of research into health care through the lens of marketing, the question of why health care as the world’s largest service industry is so slow to acknowledge and much less embrace the importance of marketing remains open. Marketing is widely recognized as the essence of management (Webster, Reference Webster2009), and thus using marketing in the health care sector can help to identify the health needs of society and to increase both the market share of health care institutions and their operational effectiveness (Abedi and Abedini, Reference Abedi and Abedini2017). Nitin et al. (Reference Nitin, Narendranath and Devakumar2016) point out that the marketing perspective in health care should gain more attention from both academics and practitioners. We support this approach, and affirm that Lithuanian primary health care institutions should have a deeper understanding of the role of marketing in serving groups patients, including those with T2DM.
Limitations and future research directions
A quantitative study focused on patients with T2DM in Lithuania who were asked for their opinions after using a family physician service. The strength of this study was that it examined the relationships between elements of the marketing complex and the perceived values and satisfaction of patients with T2DM in primary health care. The relationships between marketing mix elements and both the perceived value (social, functional, and emotional) and satisfaction of respondents is the basis for developing and implementing chronic noncommunicable disease intervention programs, and projects that can help manage disease outcomes and increase patient satisfaction with the delivery of health care services. We have no information about non-respondents of the study. The weakness of this study is that the methodology only used two databases of scientific publications. We did not perform a systematic review, and as such may have misses some information on the instrument and the building of the hypothesis. In future, it would be valuable to research opinions regarding marketing mix elements supplied by patients with other chronic noncommunicable diseases at the primary health care level, and to find similarities and differences with this study. The results of thisstudy can be applied both theoretically and practically to the management of chronic noncommunicable diseases at the primary health care level.
Practical implications
Suggested practical recommendations for improving value creation management and discovering competitive opportunities at the level of primary health care institution include:
The implementation of marketing principles in a primary health care institution is an important area of service management. It is recommended that health marketing programs should be designed and implemented to increase patient satisfaction and the institution’s competitive advantage. Health marketing programs could be developed by marketing professionals who have completed health management studies.
Suggested practical recommendations for improving value creation management and discovering competitive opportunities at the level of the family physician:
The largest asset of a primary health care institution is its human capital, therefore increasing employees’ motivation, improving their qualifications, and managing new competences represent the main opportunities for giving an institution a competitive advantage. Primary health care institutions should strengthen emotional intelligence management activities, as well as good staff recruitment, attraction, and retention practices.
The emotional value perceived by patients with T2DM lowers their satisfaction with the provided health care services, therefore it is recommended that a specialist lifestyle medicine position be introduced to the primary health care institution to ensure smooth patient lifestyle adjustments and the effective delivery of primary health care services.
Suggested practical recommendations for improving value creation management and discovering competitive opportunities at the patient level:
It is recommended to identify the expectations and needs of patients with chronic noncommunicable diseases and to increase their satisfaction with the provided health care services. The value created by the primary health care institution is based on health care management, that is the marketing of provided services, which are patient-oriented and aim to increase patient satisfaction and the availability of choices.
Quantitative research has identified relationships between social, emotional, and functional values, and patient satisfaction and behavioral intentions. It is recommended to segment patients with T2DM based on socio-demographic characteristics and use case management models to include collaboration between primary health care institution staff and other members of the primary health care sector in the health care system.
Patients with T2DM are concerned about their illness and how it negatively impacts the quality of their lives. They are therefore advised to communicate more closely with their family physician and other staff in the primary health care institution, and to follow the physicians’ recommendations on how to protect and improve their health. Training patients how to interact more closely with health care providers is recommended.
Conclusions
Managing the value created by Lithuanian primary health care institutions in order to improve competitiveness is a new research topic in medicine and health science. The results of this study can serve as a basis for theoretical discussion on health care management, or as a way to improve the performance of primary health care institutions.
The competitiveness of primary health care services is improved by creating value for patients with T2DM, using elements of the marketing mix, increasing patient satisfaction, reducing costs, and improving health care behavior.
Opportunities for acquiring a competitive advantage at the level of the primary health care institution can be discovered by examining patient satisfaction with health care services using a multidimensional value model analysis with an emphasis on marketing mix elements.
Acknowledgments
The authors would like to thank the participants for their views expressed in the study.
Financial Disclosure
The authors received no specific funding for this work.
Conflicts of Interest
The authors report no conflicts of interest. The authors alone are solely responsible for the content and writing of the paper.
Ethical Aspects
Approval to conduct the study was given by Kaunas Regional Biomedical Research Ethics Committee (17 April 2014, No. BE-2-11). The authors applied to the Lithuania State Data Protection Inspectorate for study’s participant personal data protection (27 November 2014, No. DVT2-2009).
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