Journal of Services MarketingHealthcare branding: developing emotionally based consumer brand relationshipsElyria Kemp Ravi Jillapalli Enrique Becerra

Article information:To cite this document:Elyria Kemp Ravi Jillapalli Enrique Becerra , (2014),"Healthcare branding: developing emotionally based consumer brand relationships",Journal of Services Marketing, Vol. 28 Iss 2 pp. 126 - 137Permanent link to this document:http://dx.doi.org/10.1108/JSM-08-2012-0157

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Healthcare branding: developing emotionallybased consumer brand relationships

Elyria Kemp

Department of Marketing, University of New Orleans, New Orleans, Louisiana, USA, and

Ravi Jillapalli and Enrique BecerraMcCoy College of Business Administration, Texas State University, San Marcos, Texas, USA

AbstractPurpose – Brands can imbue unique meaning to consumers, and such meaning and personal experience with a brand can create an emotionalconnection and relationship between the consumer and the brand. Just as many service providers have adopted branding strategies, marketers arebranding the health care service experience. Health care is an intimate service experience and emotions play an integral role in health care decisionmaking. The purpose of this paper is to examine how emotional or affect-based consumer brand relationships are developed for health careorganizations.Design/methodology/approach – Empirical evidence from both depth interviews and data garnered from 322 surveys were integrated into aconceptual model. The model was tested using structural equation modeling.Findings – Results indicate that trust, referent influence and corporate social responsibility are key variables in establishing affective commitment inconsumer brand relationships in a health care context. Once affective commitment is achieved, consumers may come to identify with the health careprovider’s brand and a self-brand connection is formed. When such a phenomenon takes place, consumers can serve as advocates for the brand byactively promoting it via word-of-mouth.Practical implications – The findings provide insight for marketing managers in developing successful branding strategies for health care organizations.Originality/value – This research examines the advantages of cultivating meaningful brand connections and relationships with consumers in a healthcare context.

Keywords Affective commitment, Health care, Branding

Paper type Research paper

An executive summary for managers and executive

readers can be found at the end of this issue.

I must say that I have a special connection – even an emotional tie to my

hospital. Every time I drive by the hospital with my three year old in the car,

she says “that’s where I was born.” This is heart-warming. Besides, they have

great milkshakes there (Lauren).

Healthcare is one of the most important, yet personalized

services a consumer experiences. In the US, it is expected that

the healthcare industry will encounter unprecedented change

and growth as Baby Boomers mature and governmental

healthcare reform results in millions of newly insured patients

(Weiss, 2010; Sparer, 2011). Further, as more healthcare

options become available to consumers (e.g. minute clinics in

drug stores, after-hour urgent care clinics), more competition

will exist within the industry. Marketing will play an integral

role as hospitals compete on care and quality outcomes.

Effective marketing strategy will require organizations to

develop a strong brand identity.In response to this growing challenge, preeminent

healthcare organizations, including the Mayo Clinic,

Cleveland Clinic, Johns Hopkins, Memorial Sloan-Kettering

and Massachusetts General Hospital have increased efforts to

reinforce their brands (Thomaselli, 2010). A brand is a

promise to consumers that the hospital will deliver on the kind

of care needed. It can drive business and growth for the

organization, especially when high levels of satisfaction and

emotional commitment are present. Healthcare branding

requires a solid, organized commitment to delivering unique

standards of consistency through the institution’s products

and services. A successful branding strategy must address how

to preserve equity and leverage equities to build trust as well

as how to manage consumer perceptions and emotions

regarding the healthcare organization (Speak, 1996; Mangini,

2002).As aforementioned, healthcare is a highly personalized

service. Just as brands for products comprise socio-

psychological attributes, brands for services and healthcare

can imbue unique meaning to consumers. Such meaning and

personal experience with a brand can create a connection, or

relationship, between the consumer and the brand. Fournier

(1994, 1998) was one of the first to conceptualize consumer

brand relationships. In this metaphor, a consumer and a

brand are theorized as being in a dyadic relationship similar to

a relationship between two people. Developing consumer

brand relationships can be a challenging and complex process.

Brand relationships can take various forms. For example, a

consumer brand relationship may be cognitively-based and

simply habitual, or it can be emotionally based (Park et al.,2009; Thomson et al., 2005; Brakus et al., 2009; Grisaffe and

Nguyen, 2011). When an emotionally based relationship

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0887-6045.htm

Journal of Services Marketing

28/2 (2014) 126–137

q Emerald Group Publishing Limited [ISSN 0887-6045]

[DOI 10.1108/JSM-08-2012-0157]

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exists between a consumer and a brand, it can give an

organization a competitive advantage, making the brand

resistant to competitive attacks because of robust attitudesheld toward the brand by the consumer.

The purpose of this research is to examine how emotional,or affect-based brand relationships, are developed for a

service-based product – specifically healthcare. It contributes

to the existing literature by identifying important variableswhich foster emotional commitment in consumer brand

relationships with healthcare providers. Further, it proposes

that emotionally based relationships are associated such astrong connection to the healthcare brand that the brand can

come to be aligned with the consumer’s self-concept. When

such a phenomena takes place, the consumer may begin toserve as an “advocate” for the brand by actively promoting it

via word-of-mouth. For healthcare organizations, achievingsuch status with consumers will be invaluable in the growing

competitive environment.The subsequent research explores the phenomena of

developing emotionally based brand relationships in a

healthcare context by using both qualitative and quantitative

empirical evidence. Data were gathered from depth interviewsconducted with consumers as well as from surveys completed

by 322 individuals. The insights offered from theseindividuals, along with theoretical insight from the

behavioral literatures, were then integrated into a conceptual

model. The model was tested using structural equationmodeling. Findings are discussed and implications for

marketing managers in developing successful branding

strategies for healthcare organizations are enumerated.

Branding services and healthcare

A service brand is a promise of future satisfaction, and servicecompanies build strong brands through distinctiveness,

performance, message consistency and by appealing to

consumers emotionally (Berry, 2000; Berry and Seltman,2008). Berry (2010) suggested that branding services is

different from branding goods because of the characteristicsthat make services distinct from goods. One distinguishing

attribute of services is that there are often fewer cues for

consumers to evaluate, which elevates purchasing risks(Murray and Schlacter, 1990; Zeithaml, 1988). As a result,

Onkvisit and Shaw (1989) suggest that branding is critical in

services because the intangibility of services makes qualitydifficult to evaluate. Branding a service can help consumers

by assuring them of a uniform level of service quality (Berry,

2000; Krishnan and Hartline, 2001).Consequently, the development of effective branding

strategies is important for healthcare organizations. This isespecially significant, given the changes the industry is facing.

First, as deductibles and copays increase, consumers are

becoming more selective about their healthcare and theavailability of options makes this possible (Sparer, 2011).

Secondly, a growing and new market for healthcare services

will exist. Almost 60 million Baby Boomers have moved intothe mature market segment and will need healthcare services

(Larkin, 2007). Additionally, the US Patient Protection andAffordable Care Act (PPACA), enacted in March 2010, will

possibly increase the number of insured consumers by over 30

million (Sparer, 2011). Successful healthcare systems willview these changes as catalysts for developing new strategies

that fulfill their communities’ healthcare needs.

Conceptual framework

Research suggests that high levels of commitment can begarnered from consumers by engaging them in emotionally

based brand relationships (Allen and Meyer, 1990; Park et al.,2009). Firms focusing on cultivating meaningful brand

connections with consumers can achieve differential and

competitive advantage in the marketplace. In the research to

follow, an exploratory investigation was first performed in

order to gain an understanding of how emotionally based

brand relationships are formed in the healthcare environment.

Semi-structured interviews were conducted with individuals

throughout the USA who had enlisted the services of a

healthcare provider/organization within the past three years.

The information garnered from these interviews provided a

deeper understanding of what individuals viewed as important

in a healthcare provider/organization (McCracken, 1988;Ryan and Bernard, 2000). Similar to previous studies with

qualitative elements, emergent patterns in the text from the

interviews helped to inform the theoretical and conceptual

underpinnings of this research (Hudson and Ozanne, 1988;

Wallendorf and Arnould, 1988; Hirschman, 1992). For the

purposes of this research, healthcare providers/organizations

were limited to hospitals. A total of 11 consumers were

interviewed. Interviews lasted approximately 30 minutes. All

consumers were assigned aliases to ensure anonymity;

individual information about the respondents is included in

Table I. Following an iterative process, the qualitative data

garnered from these interviews were methodically integrated

it into an emerging theoretical argument (see Figure 1). A

discussion of the conceptual model, including proposedrelationships within the framework, follows.

Affective commitment in consumer brand relationships

There is consensus among marketing academics as well as

practitioners that building a valuable brand goes beyond

specific product features and benefits, but also includes the

ability of the brand to penetrate people’s emotions (Berry,

2000; Aiello, 2010). When consumers connect emotionally

with a brand, a relationship of attachment and commitment

develops between the consumer and the brand (Park et al.,2009).

Research in the behavioral sciences suggests that individuals

are inherently motivated to become attached to entities

(Bowlby, 1973). Subsequently, they may become attached, or

Table I Interviewees

Name (alias) Age Ethnicity/race Gender Marital status Children

Lauren 39 African American Female Married Yes

Ariel 33 White/Caucasian Female Married No

Vera 73 African American Female Widowed Yes

Evelyn 51 African American Female Single No

Gabrielle 52 White/Caucasian Female Married No

Mark 55 White/Caucasian Male Divorced No

Faith 37 African American Female Single Yes

Rachel 55 Asian American Female Married Yes

Kay 52 White/Caucasian Female Divorced Yes

Eric 52 Hispanic/Latino Male Single No

Nicole 38 White/Caucasian Female Single No

Note: n ¼ 11

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committed, to brands (Park et al., 2009). Brand commitment

is an enduring desire to maintain a valued relationship with a

brand (Lacy, 2007; Moorman et al., 1992). It refers to the

economic, emotional and psychological connections that the

consumer may have toward a brand (Evanschitzky et al.,

2006). Committed consumers are often willing to stay in an

exchange relationship as well as put forth effort to maintain

the relationship. Commitment is recognized as an essential

ingredient for successful long-term relationships (Beatty and

Kahle, 1988; Morgan and Hunt, 1994).Researchers have identified distinct components of

commitment – one dimension is more emotional in nature

and the other is more economic in structure (Allen and

Meyer, 1990; Bansal et al., 2004). The economic type of

commitment is known as calculative, or continuance

commitment and the emotional type is called affective

commitment. Continuance commitment stems from cost-

based calculations and results in commitment because of a

need to stay in the relationship when no other comparable

alternatives exist, or the costs of switching to other options are

too high (Allen and Meyer, 1990). However, affective

commitment differs from continuance commitment in that

the customer develops an emotional attachment to the brand

or organization (Allen and Meyer, 1990). Affective

commitment involves the desire to maintain a relationship

that the customer perceives to be of value (Morgan and Hunt,

1994). Consumers who are affectively committed to a brand

are less expensive to retain; less vulnerable to loss from

competitive efforts, brand blunders, or service failures; and

are willing to pay a price premium (Bolton et al., 2000).

Establishing affectively committed consumers in a

healthcare marketing context can be invaluable. Many of the

individuals that were interviewed who expressed favorable

attitudes about their hospital alluded to an emotional bond or

attachment they had developed with the hospital:

Now that I think about it, I guess you could say that I have an emotional

attachment to my hospital. My children were born there and our family has

gone there when the situation demanded it. We have been through some

good times and some difficult times there [. . .] I guess deep down there is a

connection there. I guess it was latent, but yes, when I think it over, there is

that special feeling I have towards the hospital and how it has served my

family (Kay).

Also, one of the interviewees was a nurse and commented on

how her patients had vocalized an emotional attachment and

commitment to the hospital where she worked:

I have had patients tell me that their entire family was born at a hospital.

They have a special tie to the hospital and they also feel the hospital has a

special tie to the community (Rachel).

Healthcare is a very intimate and personalized service

experience. Narratives from the individuals interviewed for

this research underscore the importance of connecting

emotionally with consumers. Such a connection can lead to

affective commitment and strong brand relationships.

However, several factors contribute to the development of

affective commitment between consumers and a brand.

Evidence from the marketing literature as well as findings

from the interviews conducted in this research identified

various factors. For example, trust, which has been well-

supported in the literature, plays an important role in the

foundation of a strong relationship (Morgan and Hunt,

1994). In a healthcare context, trust is essential and is

Figure 1 Healthcare branding model

Healthcare branding

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predicated on a number of variables. Further, intervieweesalluded to additional factors that influence commitment.Specifically, referent influence as well as communityinvolvement were found to be major influences incultivating affective commitment between consumers andhealthcare organizations. A discussion of these precursors, orantecedents, to affective commitment is delineated next.

Antecedents of affective commitmentBrand trust

Trust is everything when it comes to my healthcare provider (Ariel)

Brands play an integral role in service organizations becausethey foster trust from consumers for intangible performances(Zeithaml, 1981; Berry, 2000; Gummerus et al., 2004).Branding in healthcare is very dependent on trust (Berry,2000; Beckham, 2000). The buyer surrenders completely tothe seller and in many cases even temporary lives in thehealthcare facility (Berry and Bendapudi, 2007).Moorman et al. (1993, p. 82) defined trust as “a willingness torely on an exchange partner in whom one has confidence.”Morgan and Hunt (1994, p. 23) conceptualized trust as theperception of “confidence in the exchange partner’s reliabilityand integrity.” Both definitions suggest that confidence andreliability are essential elements of trust. Furthermore, trust isgenerally viewed as an important ingredient for successfulrelationships (Spekman, 1988; Berry, 1995). Morgan andHunt (1994) proposed that trust, along with commitment, isessential to successful relationships. According to Morgan andHunt (1994) the presence of trust and commitment in arelationship encourages marketers to work at cooperating withexchange partners, maintain a long-term orientation withpartners, and consider high-risk actions that positively impactthe relationship. Subsequently, trust and commitmentpromote efficiency, productivity, and effectiveness.

Using evidence from previous literature as well as findingsfrom interviews conducted in this research, it is proposed thattrust in a healthcare brand will be driven by several distinctfactors: a consumers’ attitude toward the brand, perceivedquality of the brand, prestige of the brand, and the display ofcustomer-oriented behavior by the attending staff andphysicians at the healthcare facility. These contributingfactors are discussed next.

Attitude toward the brandResearch from psychology suggests that when individualshave favorable attitudes toward an entity, they are more likelyto trust the entity (Rotter, 1980). Similarly, effective servicesbranding is contingent on the management of consumerattitudes (Berry, 2000). Brand attitudes refer to an affectivereaction to a brand, or a predisposition to respond in afavorable or unfavorable manner to a brand (Lutz, 1975; Lutzet al., 1983; Burton et al., 1998). These attitudes can berelated to not only the functional benefits of the brand, butalso the symbolic and experiential benefits, including thesensations, feelings and cognitions evoked by a brand(Rossiter and Percy, 1987; Zeithaml, 1988; Brakus et al.,2009).

One of the individuals interviewed for this researchadmittedly expressed apprehension about receivinghealthcare services and was often skeptical of advertisingclaims from healthcare providers. However, in one instance,the situation mandated it that he receive healthcare attention.He had to be rushed to the hospital because he was having

problems breathing and chest pains. He recounts his

experience:

What can I say – [my hospital] gives and stands for excellent care [. . .] I wasgiven immediate attention when I went there. Twelve people in the ER weretrying to figure out what was wrong with me [. . .] Excellent care (Mark).

After such an experience, Mark only had positive attitudes

about the hospital he attended.He indicated that if he needed immediate attention again,

he would select the same hospital without equivocation.

Subsequently, it is proposed that when individuals have

favorable attitudes about a healthcare provider and its brand,

this will be positively related to feelings of reliability and

confidence in the brand. Thus, the following is predicted:

H1a. Attitude toward the healthcare provider’s brand is

positively related to trust.

Perceived qualityPerceived quality is the consumer’s subjective assessment

about a product’s overall excellence in reference to

competitive offerings (Zeithaml, 1988; Aaker, 1991).

Similarly, service quality perceptions are generally defined as

a consumer’s judgment of, or impression about, an entity’s

overall excellence or superiority (Bitner and Hubbert, 1994).

A number of factors can influence a consumer’s assessment of

quality, including personal product experience, special needs

and consumption (Yoo et al., 2000). High perceived quality

will foster trust in a brand and motivate a consumer to choose

a brand over competing products (Dodds et al., 1991;

Netemeyer et al., 2004).According to Babakus et al. (1991), one form of quality in

the healthcare environment refers to the manner in which the

healthcare service is delivered to the patient. Often patients

are unable to accurately assess the technical quality of a

healthcare service, thus “functional” quality is usually the

primary determinant of patients’ quality perceptions

(Babakus and Mangold, 1992; Donabedian, 1982).One of the interviewees was impressed with the way in

which service was rendered to her during one of her visits to

her healthcare facility. This experience impacted her

perception of the quality of care she received:

You can find the nicest people [at my hospital]! The care I received there wasexcellent. They must have asked me over 10 times if I was allergic to anymedications and kept asking me what foot they were operating on. The nursehad told me that they would ask me questions a number of times becausequality control was so important to them (Gabrielle).

Research has shown that perceived quality is a primary

variable influencing the value perceptions of consumers

(Zeithaml, 1988). These value perceptions, in turn influence

consumers’ intentions to purchase products or services. One

of the interviewees expressed intentions to return to the

facility where she had surgery because of her favorable

assessment regarding the care she received:

I had my surgery performed at [my hospital] mostly because it was where myphysician had admission privileges. However, I did really appreciate theanesthesiologist I had. He was very competent and I would go there againbecause of him (Ariel).

As indicated, a consumer’s subjective assessment of quality

for a brand can influence perceptions of value as well as

purchase intentions. Fundamentally, perception of quality is

related to confidence in the brand. As a result, the following is

proposed:

Healthcare branding

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H1b. Perceived quality of the healthcare provider’s brand is

positively related to trust.

Brand prestige

I don’t select hospitals just based on proximity – the standing and prestige ofthe hospital means something to me. I have one of the best doctors and he ison staff at my hospital because of the great hospital that it is (Vera).

Brand prestige refers to a high status positioning of a brand(Steenkamp et al., 2003). A unique competency as well as thequality and performance of a product are key criteria for abrand to be judged prestigious (Lichtenstein et al., 1993; Baek

et al., 2010). Prestige brands are strongly linked to anindividual’s self-concept and social image and can create valuefor the consumer through status.

Prestige and a brand’s reputation can be very important fora brand when the product is a service since the product oftenlacks search properties that can be easily evaluated (Herbigand Milewicz, 1993). Moreover, brand prestige has been

found to decrease the information search process forconsumers because consumers may perceive brands withhigh status as more trustworthy and reliable (Vigneron andJohnson, 1999; Steenkamp et al., 2003). Accordingly, the

following is hypothesized:

H1c. Prestige for a healthcare provider’s brand is positivelyrelated to trust.

Customer-oriented behaviorA service organization’s employees help to define and build

meaning and trust for the brand (Berry, 2000). Thus, it iscrucial that service firms’ employees exhibit customer-oriented behavior (Hartline et al., 2000; Kim et al., 2004).Customer-orientation is the set of beliefs that puts the

customer’s interest first (Brady and Cronin, 2001). Whenservice organizations are customer oriented, they arepracticing the marketing concept (Hoffman and Ingram,1992). Furthermore, employees’ customer-orientation

behaviors are enhanced when the leadership of the servicefirms and the employees fulfill the customer-centricorganizational mission (Suh et al., 2011). These inspiringcustomer-oriented behaviors of the employees reinforce thecustomers’ trust towards the healthcare providers.

There was consensus among the interviewees that that thedisplay of customer-oriented behavior by the employees of thehealthcare provider – from the administrative staff to

attending nurses and physicians – was an essential trust-building factor:

At [my hospital] they were very patient-oriented. It is all about attitude.Competence is great, but competence with a smile is even better. I do wantsomeone to be able to administer a shot, but a shot with a smile is evenbetter. You can have competent staff, but care delivered with a smile makesall the difference and helps to put you at ease (Evelyn).

H1d. Customer-oriented behavior displayed by thehealthcare provider is positively related to trust.

A consumer’s attitude towards the brand, subjective

assessment of quality, level of prestige imbued by the brandas well as the display of customer-oriented behavior byemployees can all lead to trust in the healthcare provider’sbrand. Relationships characterized by trust will often result in

the desire for long-term commitment between two parties(Hrebiniak, 1974; Morgan and Hunt, 1994). Moreover,

enduring relationships are often based on emotional

attachment (Gournaris, 2005). Thus, it is proposed that

trust in a healthcare provider’s brand can foster high levels of

affective commitment:

H1e. Trust is positively related to affective commitment for a

healthcare provider’s brand.

Referent influence

We went to my hospital as children. I go there as an adult, and other

members of my family go there for care (Faith).

Most of my colleagues at work patronize my hospital (Rachel).

Social scientists have long recognized the importance of group

membership in influencing behavior. For example, people

may conform with a frame of reference produced by the

groups to which they belong (Bearden and Etzel, 1982). Such

referent influence can impact behavior and lifestyles, influence

self-concepts, contribute to the formation of values and

attitudes and create pressure for conformity (Bearden and

Etzel, 1982).Specifically, emotional ties and intimate bonds can form

around a product or brand that may be used by members of a

group. Group members can provide mutual endorsement and

social support in the usage of a product or brand (Schouten

and McAlexander, 1995). Many of the interviewees who

spoke favorably about their current healthcare provider

indicated that another family member, friend or colleague

also patronized their provider. Further, groups can help to

create attachment and engender a shared consciousness for a

brand (Schouten et al., 2007; McAlexander et al., 2002;

Muniz and Schau, 2005). Thus, it is proposed that referent

influence, specifically word of mouth and advice from

“important others,” will impact affective commitment to a

healthcare provider:

H2. Referent influence for a healthcare provider’s brand is

positively related to affective commitment.

Corporate social responsibilityHealthcare providers (e.g. hospitals) view their community

roles – both as employer and provider of medical services – as

investments. Healthcare organizations have a responsibility to

society, the environment and their own prosperity (Bowen,

1953). Responsible, sustainable and transparent approaches

by healthcare providers can help to build their brand and

strengthen the community.Whether the hospitals are providing charity care, mobile

medical services, specialized treatment programs or secure

jobs, improvements in facilities and property, and community

event sponsorships, the community reaps the benefit of such

investments through improved health and economic stability.

Two of the interviewees commented on the involvement of

their healthcare providers in the community:

I see the hospital sponsoring events for underserved individuals in the city’s

low-income neighborhoods [. . .] like picnics in the park. I think others have

taken notice and this has helped the hospital within the community (Evelyn).

My hospital was very involved in the community and had all kinds of

outreach programs – including blood drives and health fairs. I remember

that once the hospital sponsored a project to encourage adoption. They took

pictures of children in foster care and featured the pictures of the children in

the lobby of the hospital in hopes of encouraging adoption. The children so

enjoyed having their pictures taken! (Rachel).

Healthcare branding

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Healthcare providers can impact the lives of individuals in thecommunity by providing services that improve health,increase access to care, save lives and train future caregivers.Such investments in the community help to engender bondsand attachment toward the healthcare provider. As a result,the following is proposed:

H3. Corporate social responsibility is positively related toaffective commitment.

Outcomes of affective commitment

Affective commitment to a healthcare provider’s brand can befostered through trust, the influence of reference groups andinvestment in the community. When affective commitment isattained, an emotionally based relationship is establishedbetween the consumer and the healthcare provider’s brand.Emotionally based consumer brand relationships can result ina strong connection between the consumer and the brandwhere qualities of the brand become aligned with theconsumer’s self-concept. When such a connection develops,a consumer is highly likely to become an advocate for thebrand and passionately promote it to others. Such outcomescan be invaluable to the organization.

Self-brand connectionsConsumers sometimes become committed to brands that helpthem to create or represent their desired self-concepts(Escalas and Bettman, 2003; Escalas, 2004). They oftenconstruct their self-identity and present themselves to othersthrough their product and brand selections (Escalas, 2004;Escalas and Bettman, 2003). As consumers discover fitbetween their self-concepts and brand images, they may makeself-connections with a product or brand.

Self-connections are created when brands engender strongand favorable brand associations from the consumer’sperspective and can be used to satisfy psychological needs,reinforce identity and allow an individual to connect to others(Escalas, 2004; Escalas and Bettman, 2003; Wallendorf andArnould, 1988). A strong self-connection with a brand allowsfor easier and more frequent retrieval of thoughts and feelingsregarding the brand (Park et al., 2009).

Rachel, one of the interviewees employed as a nurse, sharedhow strong emotional commitment for the hospital from someof her patients had resulted in them becoming aligned with,and in many ways, identifying with the institution:

I have had patients tell me that their entire family was born at a hospital.They have a special tie to the hospital. They felt as though they were a part ofthe hospital and the hospital was a part of the community (Rachel).

Hence, it is proposed that when individuals becomeemotionally attached to a healthcare provider’s brand, theymay come to identify themselves with that brand.

Thus, the following is predicted:

H4. Affective commitment to a healthcare provider’s brandis positively related to self-brand connection.

AdvocacyFavorable communication about a brand from consumers canaccelerate new product acceptance and adoption (Keller, 1993).Advocacy in the form of word-of-mouth communication can bethe most influential source of information for the purchase ofsome products because it is perceived as originating from a lessbiased, more trustworthy source, which helps to lessenconsumer anxiety (Herr et al., 1991).

When a consumer becomes affectively committed to a

brand, this connection can lead to brand advocacy (Fullerton,

2003). The consumer becomes an “evangelist” for the brandand spreads positive word-of-mouth about the brand as well

as recruits others to become purchasers and users of the

brand (Chakravarty et al., 2010). Hence, the following ishypothesized for consumers and healthcare brands:

H5. Affective commitment for the healthcare provider’sbrand is positively related to advocacy for the brand.

A powerful endorsement was made by one of our interviewees

after she had been hospitalized for a stroke. She felt the careshe received at her healthcare facility was exemplary. After

spending considerable time at the hospital during her

recovery, she began to develop a special connection tohospital. She shares part of her experience:

I was terrified because I did not know what was happening to my body [whenI had my stroke], but the care I received at [my hospital] was top-notch.That hospital saved my life. It is a part of me now. I would recommend thehospital to others because of the service that was given to me (Vera).

Clearly, Vera is now an evangelist for the healthcare provider.

She has a developed a personal connection with the brand

because of the life-saving treatment and care she received. Asa result, she is eager to recommend the brand to others.

Hence, individuals who develop a connection to thehealthcare provider may also be more likely to become

advocates for the brand. In fact, individuals that have formed

a connection to the brand may become fervent advocates forthe brand. Ergo, the following is proposed:

H6. Self-brand connection is positively related to advocacy

for the brand.H7. Self-brand connection mediates the relationship

between affective commitment and advocacy for thebrand.

Finally, as indicated previously, trust is often viewed as an

essential ingredient in successful relationships. Many of ourinterviewees expressed how important trust was in a

healthcare provider. Those interviewees who had confidencein their healthcare provider were willing to recommend their

provider to others. As a result, it is also predicted that trust in

the healthcare provider’s brand is related to advocacy:

H8. Trust in the healthcare provider’s brand is positively

related to advocacy.

Method

Measures

In order to test the proposed hypotheses and the modelrepresented in Figure 1, a survey was conducted. All

constructs, with the exception of referent influence, were

measured using existing scales adapted for this study. Theitems for referent influence were developed specifically for this

research, and the construct was measured using three items

(e.g. I patronize my hospital because my family has for years).All scale items appear in the Appendix. Age and level of

education were measured and controlled for in the study.

Procedure and sample

A convenience sample was obtained consisting of non-studentadults in a major metropolitan area in the southwestern part

of the USA. At the beginning of the survey, respondents were

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asked to list the hospital they and their immediate family

currently attend for healthcare needs. After listing this

information, respondents were asked specific questions that

related to, and operationalized the constructs presented in

Figure 1.A total of 322 completed surveys were obtained; 40 percent

of respondents were male and 60 percent were female. The

mean age was 44. Mean household income was $103,134. A

total of 6 percent of the respondents were high school

graduates, 36 percent reported having attended college, 44

percent were college graduates and 14 percent held graduate

degrees.

Results

The data were subjected to structural equation analysis in

Lisrel 8.72. As recommended by Anderson and Gerbing

(1988), a two-step procedure was used to first assess the

model for construct and discriminant validity and then

hypotheses were tested in the structural model. Additionally,

statistical techniques, including the marker variable technique

(Lindell and Whitney, 2001; Malhotra et al., 2006), were

applied to ensure that findings were not inflated due to

common method bias.

Measurement model

Standard statistical techniques, including performing

exploratory factor analysis and examining item-to-total

correlations, were conducted. Exploratory factor analysis

confirmed that each item loaded on the appropriate factor.

The measurement model was further validated for construct

and discriminant validity by performing confirmatory factor

analysis. The final measurement model exhibited adequate fit

x2 (1151.06); p-value (0.01); CFI (0.98); NNFI (0.98);

RMSEA (0.05); and SRMR (0.04).To test for convergent validity, factor loadings, along with

the average variance extracted were calculated for each latent

variable. Standardized factor loadings exceeded the 0.6

threshold as recommended by Hair et al. (2006).

Additionally, as seen in Table II, the average variance

extracted (ranged from 0.58 to 0.93) for each construct

exceeded the recommended rule of thumb of 0.5 (Hair et al.,

2006), which is an indication that the variance captured by

the construct is greater than the variance due to measurement

error.

In order to assess discriminant validity, the Fornell andLarcker (1981) test was performed. Discriminant validity isdemonstrated when the average variance extracted from aconstruct is greater than the squared correlations betweenthat construct and other constructs in the model. The averagevariance extracted between each construct was greater thanthe squared multiple correlations for each construct pairing.Composite reliabilities were also assessed to ensure that eachconstruct exhibited internal consistency (ranged from 0.87 to0.97). All measures exemplified acceptable reliability byexceeding the recommended 0.7 threshold (Nunnally andBernstein, 1994). The results for the structural model follow.

Structural model

The structural model and hypotheses were evaluated afterattaining a validated measurement model. The modelexhibited adequate fit x2 (1309.41); p-value (0.01); CFI(0.98); NNFI (0.98); (RMSEA (0.05); and SRMR (0.06).Both direct and indirect effects were predicted betweenexogenous and endogenous variables. Results are presented inTable III.

Table II Means, standard deviation, reliability, average variance extracted and Pearson correlations

Means SD Reliability AVE BAtt BP PQ COB T CB CI AC SBC BA Ed

Brand attitude (BAtt) 5.86 1.67 0.97 0.91 1.00

Brand prestige (BP) 4.38 1.45 0.89 0.70 0.19 1.00

Perceived quality (PQ) 5.64 1.05 0.98 0.93 0.53 0.28 1.00

Customer-oriented behavior (COB) 5.28 1.13 0.89 0.73 0.37 0.34 0.59 1.00

Trust (T) 5.80 0.95 0.90 0.74 0.38 0.23 0.52 0.593 1.00

Co-behavior (CB) 3.71 1.64 0.88 0.71 0.00 0.15 0.02 0.044 0.02 1.00

Community investment (CI) 4.63 1.24 0.94 0.79 0.10 0.15 0.16 0.144 0.18 0.06 1.00

Affective commitment (AC) 3.93 1.48 0.96 0.89 0.04 0.22 0.08 0.152 0.09 0.29 0.14 1.00

Self-brand connection (SBC) 3.23 1.51 0.94 0.80 0.03 0.2 0.06 0.09 0.05 0.29 0.12 0.59 1.00

Brand advocacy (BA) 3.93 1.52 0.90 0.73 0.05 0.26 0.07 0.102 0.08 0.34 0.19 0.49 0.56 1.00

Education (Ed) 3.69 0.78 N/A N/A 0.00 0.02 0.00 0.00 0.00 0.01 0.00 0.02 0.00 0.02 1.00

Table III Results of structural equations modeling (SEM) analysis

Effects

Direct effectsa

H1a: brand attitude on brand trust 0.14 *

H1b: perceived quality on brand trust 0.23 * *

H1c: brand prestige on brand trust 0.01

H1d: consumer oriented behavior on brand trust 0.23 * *

H1e: brand trust on affective commitment 0.50 * *

H2: referent influence on affective commitment 0.17 * *

H3: community investment on affective commitment 0.48 * *

H4: affective commitment on self-brand connection 0.20 * *

H5: affective commitment on brand advocacy 0.55 * *

H6: self-brand connection on brand advocacy 0.78 * *

H8: trust on brand advocacy 0.71 * *

Age 0.02

Education 20.10 * *

Indirect effectb

H7: affective commitment on brand advocacy 0.55 * *

Notes: aCompletely standardized solution; bStandardized solution;*p , 0.05; * *p , 0.001

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H1a-H1d predicted that brand attitude, perceived quality,

brand prestige and customer-oriented behavior would bepositively related to trust. Results indicate that brand attitude,

perceived quality and customer-oriented behavior are

positively related to trust, but the relationship betweenbrand prestige and trust did not prove to be significant. Thus,

H1a, H1b and H1d were supported, but H1c was notconfirmed. Further, H1e predicted that trust would be

positively related to affective commitment. This hypothesiswas supported.

H2 proposed that referent influence would be positivelyrelated to affective commitment; H2 was validated. Similarly,

H3 predicted that corporate social responsibility would bepositively associated with affective commitment. The

significant relationship between corporate socialresponsibility and affective was verified as well. Thus,

positive links between affective commitment and its

proposed antecedents – trust, referent influence andcorporate social responsbility – were all validated.

H4-H7 addressed the outcomes of affective commitment inconsumer brand relationships. H4 predicted that affective

commitment would be positively related to self-brandconnection. This hypothesis was supported. Additionally,

H5 suggested that affective commitment would be positivelyrelated to advocacy for the brand; H5 was confirmed. Self-

brand connection was hypothesized to be positively related toadvocacy for the brand in H6. This predication was

supported. Next, H7 suggested mediation. Self-brandconnection was predicted to mediate the relationship

between affective commitment and advocacy for the brand.Results indicate that self-brand connection mediates the

relationship between affective commitment and advocacy for

the brand, given the significance of the indirect effect (Cohenand Cohen, 1983; Kenny et al., 1998). Finally, H8 predicted

that trust would be positively related to advocacy for thebrand. This relationship was supported. Age as a control

variable in the analysis did not prove to be significant;however, the effect on education was significant and negative.

Discussion

Summary of findings

Creating emotionally based consumer brand relationships can

result in substantial reward for service organizations. Thisresearch examined how emotional or affect-based consumer

brand relationships are developed for healthcareorganizations. Findings indicate that trust is a key variable

in establishing affective commitment in consumer brandrelationships. Healthcare is an intimate service. In many

cases, the individual not only surrenders very personalinformation to the healthcare provider, but also his or her

physical and psychological well-being; therefore, trust is

essential.Results demonstrate that trust is predicated on a

consumer’s attitude toward the brand, perceived quality andcustomer-oriented behavior. Findings were not significant for

the proposed relationship between brand prestige and trust.The lack of significance may have been due to the product

category. Prestige has been used as a surrogate fordependability and reliability for various products (Vigneron

and Johnson, 1999). However, since healthcare is such apersonal sometimes vital service, variables related to actual

performance may be stronger antecedents of trust.

Especially germane in a healthcare context, this research

identified two important constructs – reference influence and

corporate social responsibility – that were also positively

related to affective commitment. Group members can provide

ratification and support regarding usage of a product or

brand. Further, a hospital’s contribution, or investment in the

community, was critical in developing emotional bonds with

consumers. Such actions help to signal to the consumer that

the healthcare provider cares about the community.Further, results suggest that cultivating affective commitment

in consumers is associated with the healthcare provider’s brand

becoming aligned with the consumer’s self-concept, creating a

self-brand connection. When a self-brand connection is formed,

an individual comes to identify with the institution. Moreover,

results indicate that the consumer may also begin to serve as an

advocate for the brand by actively promoting, and even

defending it to others. Thus, developing strong, emotional

attachments with consumers will be invaluable to healthcare

providers in the growing competitive marketplace.

Managerial implications

This research demonstrates the advantages of cultivating

meaningful brand connections and relationships with

consumers. Findings from this research can assist marketers

in strategic planning. In the healthcare industry, proximity has

been a major driver of utilization (Beckham, 2001). However,

as healthcare costs increase and more healthcare options

become available, marketers can be more strategic in their

efforts to target desired consumer segments and differentiate

their organizations by delivering valued brand experiences

(Brakus et al., 2009).In delivering unique and differentiated brand experiences,

healthcare providers should effectively position the

organization and its brand as a valued contributor to health.

As suggested in this research, ensuring consumer engagement

and an enduring emotional connection to the organization is a

vital part of achieving this task.

Emotional connectionConsumer sensitivity and emotional response play a major

role in healthcare where trust and caregiving must co-exist.

Emotions are inherent in the type of buying decisions that

individuals make for their family and themselves in the

healthcare marketplace. Thus, effective marketing for

healthcare organizations should consider consumer emotions.This research demonstrated that trust, referent influence and

corporate social responsibility are positively related to

consumer emotional commitment for a healthcare provider’s

brand. Marketing communications that appeal to consumers’

attitudes about the organization by communicating

competence and patient-centric qualities will be effective in

cultivating trust and thus, emotional connections with

consumers. Further, given the importance of referent

influence, promoting a family-friendly environment

(e.g. flexible visiting hours, comfortable rooms) and

emphasizing the importance of family and friends in the

healing process may also help to foster emotional commitment

from consumers. Hospitals have created maternity wards which

exemplify the family-friendly philosophy. Such an emphasis is

important since women make approximately 80 percent of

healthcare decisions for their families (US Department of

Labor, 2012), and are thus a viable consumer segment to target

for healthcare services.

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Finally, events sponsored by healthcare providers such as

health fairs, picnics in the park, working with underserved and

disadvantaged members of the community are activities that

signal to the consumer that the hospital cares about their

home – their community. Such efforts are effective at creating

bonds between the brand and the consumer.As marketers engage in endeavors to understand and

improve the experience their brand provides for their

customers, operative implementation and controls systems

will be required. However, such effective marketing will help

differentiate healthcare brands and allow them to achieve

competitive advantage in the marketplace.

Limitations and future research

Although this research makes important contributions to

understanding how emotionally based consumer brand

relationships are formed in healthcare, future research is

warranted. First, given the cross-sectional nature of the data

in this study, no causal relationships could be established.

Future studies might assess the link between performance and

actual satisfaction and how such outcomes contribute to the

creation of consumer brand relationships.Additionally, respondents for the quantitative component of

this research were from one geographical area. They were also

highly educated, with 58 percent of the sample having

attained a college degree. Future research might survey

individuals from various regions of the country with more

diverse educational backgrounds. Furthermore, given the

comparisons that have been made between healthcare systems

in the USA and other countries, a cross-cultural study might

yield additional insight.In this research, the healthcare provider was limited to

hospitals. Future research might examine how emotionally

based consumer brand relationships are developed for other

entities in the healthcare industry, including pharmacies,

clinics, and the group practices of physicians and dentists.Healthcare is a service that most consumers will have to

enlist at some point in their lives. It is a very personal service

experience where relationship building is important. As the

landscape for healthcare services undergoes significant change

in the USA, research opportunities abound for exploring

effective marketing and branding strategies for healthcare

providers.

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Marketing Health Services, Summer, pp. 3-5.

Healthcare branding

Elyria Kemp, Ravi Jillapalli and Enrique Becerra

Journal of Services Marketing

Volume 28 · Number 2 · 2014 · 126–137

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Appendix. Measures

Brand attitude (Lichtenstein and Bearden, 1989)

(7-point scale)My overall attitude towards the hospital I currently attend is:. Good/bad.. Pleasant/unpleasant.. Favorable/unfavorable.. Positive/negative.

Perceived quality (Keller and Aaker, 1992)

(7-point scale)Please indicate the extent to which the following adjectivesdescribe the quality of care you receive at your hospital:. Inferior/superior.. Low quality/quality.. Excellent/poor (R).

Brand prestige (Kirmani et al., 1999)

(Likert seven-point scale). I enjoy the prestige that comes with going to my hospital.. I think my hospital is exclusive.. I think my hospital has high status.

Customer-oriented behavior (Kim et al., 2004)

(Likert seven-point scale). The staff at my hospital is always willing to help patients

and/or their guardians.. The staff at my hospital is willing to cheer up patients

when they are down.. The staff at my hospital is always willing to resolve

patients’ complaints.. The staff at my hospital is willing to consider the things

not requested by patients and/or their Guardians.

Brand trust (Chaudhuri and Holbrook, 2001)

(Likert seven-point scale). I trust the care that I receive from health professional at

this hospital.. I rely on the care I receive from this hospital.. I feel safe at my hospital.

Referent influence

(Likert seven-point scale). I patronize my hospital because my friends use it.. I patronize my hospital because my family has for years.. I use my hospital because people who are important to me

use it.

Community investment – corporate social

responsibility (Turker, 2008)

(Likert seven-point scale). My hospital emphasizes the importance of its social

responsibilities to the society.. My hospital contributes to campaigns and projects that

promote the well-being of the society.. My hospital targets sustainable growth which considers

future generations.. My hospital makes investment to create a better life for

future generations.. My hospital implements special programs to minimize its

negative impact on the natural environment.

Affective commitment (Meyer and Allen, 1991)

(Likert seven-point scale). I feel emotionally attached to my hospital.. I feel like part of the family at my hospital.. I feel a strong sense of belonging to my hospital.

Self-brand connection (Escalas and Bettman, 2003)

(Likert seven-point scale). My hospital reflects who I am (not at all/extremely well).. I can identify with my hospital (not at all/extremely well).. I feel a personal connection to my hospital (not at all/very

much so).. I (can) use my hospital to communicate who I am to other

people (not at all/extremely well).. I think my hospital (could) help(s) me become the type of

person I want to be (not at all/extremely well).. I consider my hospital to be “me” (it reflects who I

consider myself to be or the way that I want to presentmyself to others) (not “me”/“me”).

. My hospital suits me well (not at all/extremely well).

Advocacy (Phillips et al., 2011)

(Likert seven-point scale). I try to get my friends and family to patronize my hospital.. I seldom miss an opportunity to tell others good things

about my hospital.. I would defend my hospital to others if heard someone

speaking poorly about my hospital.. I would bring friends/family to my hospital if they needed

care because I think they would like it.

Corresponding author

Professor Elyria Kemp can be contacted at: ekemp@uno.edu

Healthcare branding

Elyria Kemp, Ravi Jillapalli and Enrique Becerra

Journal of Services Marketing

Volume 28 · Number 2 · 2014 · 126–137

137

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