Healthcare Branding: Developing Emotionally Based Consumer–Brand Relationships

Abstract

Purpose
– Brands can imbue unique meaning to consumers, and such meaning and personal experience with a brand can create an emotional connection and relationship between the consumer and the brand. Just as many service providers have adopted branding strategies, marketers are branding the health care service experience. Health care is an intimate service experience and emotions play an integral role in health care decision making. The purpose of this paper is to examine how emotional or affect-based consumer brand relationships are developed for health care organizations.

Design/methodology/approach
– Empirical evidence from both depth interviews and data garnered from 322 surveys were integrated into a conceptual 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 in consumer brand relationships in a health care context. Once affective commitment is achieved, consumers may come to identify with the health care provider's brand and a self-brand connection is formed. When such a phenomenon takes place, consumers can serve as advocates for the brand by actively 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 health care context.

Full text

Healthcare branding: developing emotionally
based consumer brand relationships
Elyria Kemp
Department of Marketing, University of New Orleans, New Orleans, Louisiana, USA, and
Ravi Jillapalli and Enrique Becerra
McCoy College of Business Administration, Texas State University, San Marcos, Texas, USA
Abstract
Purpose – Brands can imbue unique meaning to consumers, and such meaning and personal experience with a brand can create an emotional
connection and relationship between the consumer and the brand. Just as many service providers have adopted branding strategies, marketers are
branding the health care service experience. Health care is an intimate service experience and emotions play an integral role in health care decision
making. The purpose of this paper is to examine how emotional or affect-based consumer brand relationships are developed for health care
organizations.
Design/methodology/approach – Empirical evidence from both depth interviews and data garnered from 322 surveys were integrated into a
conceptual 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 in
consumer brand relationships in a health care context. Once affective commitment is achieved, consumers may come to identify with the health care
provider’s brand and a self-brand connection is formed. When such a phenomenon takes place, consumers can serve as advocates for the brand by
actively 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 health
care 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-war ming. 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
qEmerald Group Publishing Limited [ISSN 0887-6045]
[DOI 10.1108/JSM-08-2012-0157]
126

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 attitudes
held 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 variables
which foster emotional commitment in consumer brand
relationships with healthcare providers. Further, it proposes
that emotionally based relationships are associated such a
strong 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 to
serve as an “advocate” for the brand by actively promoting it
via word-of-mouth. For healthcare organizations, achieving
such 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 interviews
conducted with consumers as well as from surveys completed
by 322 individuals. The insights offered from these
individuals, along with theoretical insight from the
behavioral literatures, were then integrated into a conceptual
model. The model was tested using structural equation
modeling. 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 service
companies 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 characteristics
that make services distinct from goods. One distinguishing
attribute of services is that there are often fewer cues for
consumers to evaluate, which elevates purchasing risks
(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 quality
difficult 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 is
especially significant, given the changes the industry is facing.
First, as deductibles and copays increase, consumers are
becoming more selective about their healthcare and the
availability 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 into
the mature market segment and will need healthcare services
(Larkin, 2007). Additionally, the US Patient Protection and
Affordable Care Act (PPACA), enacted in March 2010, will
possibly increase the number of insured consumers by over 30
million (Sparer, 2011). Successful healthcare systems will
view these changes as catalysts for developing new strategies
that fulfill their communities’ healthcare needs.
Conceptual framework
Research suggests that high levels of commitment can be
garnered 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 proposed
relationships 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
¼11
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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 the re 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
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predicated on a number of variables. Further, interviewees
alluded to additional factors that influence commitment.
Specifically, referent influence as well as community
involvement were found to be major influences in
cultivating affective commitment between consumers and
healthcare organizations. A discussion of these precursors, or
antecedents, to affective commitment is delineated next.
Antecedents of affective commitment
Brand trust
Trust is everything when it comes to my healthcare provider (Ariel)
Brands play an integral role in service organizations because
they 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 to
the seller and in many cases even temporary lives in the
healthcare facility (Berry and Bendapudi, 2007).
Moorman et al. (1993, p. 82) defined trust as “a willingness to
rely on an exchange partner in whom one has confidence.”
Morgan and Hunt (1994, p. 23) conceptualized trust as the
perception of “confidence in the exchange partner’s reliability
and integrity.” Both definitions suggest that confidence and
reliability are essential elements of trust. Furthermore, trust is
generally viewed as an important ingredient for successful
relationships (Spekman, 1988; Berry, 1995). Morgan and
Hunt (1994) proposed that trust, along with commitment, is
essential to successful relationships. According to Morgan and
Hunt (1994) the presence of trust and commitment in a
relationship encourages marketers to work at cooperating with
exchange partners, maintain a long-term orientation with
partners, and consider high-risk actions that positively impact
the relationship. Subsequently, trust and commitment
promote efficiency, productivity, and effectiveness.
Using evidence from previous literature as well as findings
from interviews conducted in this research, it is proposed that
trust in a healthcare brand will be driven by several distinct
factors: a consumers’ attitude toward the brand, perceived
quality of the brand, prestige of the brand, and the display of
customer-oriented behavior by the attending staff and
physicians at the healthcare facility. These contributing
factors are discussed next.
Attitude toward the brand
Research from psychology suggests that when individuals
have favorable attitudes toward an entity, they are more likely
to trust the entity (Rotter, 1980). Similarly, effective services
branding is contingent on the management of consumer
attitudes (Berry, 2000). Brand attitudes refer to an affective
reaction to a brand, or a predisposition to respond in a
favorable or unfavorable manner to a brand (Lutz, 1975; Lutz
et al., 1983; Burton et al., 1998). These attitudes can be
related to not only the functional benefits of the brand, but
also the symbolic and experiential benefits, including the
sensations, feelings and cognitions evoked by a brand
(Rossiter and Percy, 1987; Zeithaml, 1988; Brakus et al.,
2009).
One of the individuals interviewed for this research
admittedly expressed apprehension about receiving
healthcare services and was often skeptical of advertising
claims 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 [...]Iwas
given immediate attention when I went there. Twelve people in the ER were
trying 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 quality
Perceived 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 was
excellent. They must have asked me over 10 times if I was allergic to any
medications and kept asking me what foot they were operating on. The nurse
had told me that they would ask me questions a number of times because
quality 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 my
physician had admission privileges. However, I did really appreciate the
anesthesiologist I had. He was very competent and I would go there again
because 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:
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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 of
the hospital means something to me. I have one of the best doctors and he is
on 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 the
quality and performance of a product are key criteria for a
brand to be judged prestigious (Lichtenstein et al., 1993; Baek
et al., 2010). Prestige brands are strongly linked to an
individual’s self-concept and social image and can create value
for the consumer through status.
Prestige and a brand’s reputation can be very important for
a brand when the product is a service since the product often
lacks search properties that can be easily evaluated (Herbig
and Milewicz, 1993). Moreover, brand prestige has been
found to decrease the information search process for
consumers because consumers may perceive brands with
high status as more trustworthy and reliable (Vigneron and
Johnson, 1999; Steenkamp et al., 2003). Accordingly, the
following is hypothesized:
H1c. Prestige for a healthcare provider’s brand is positively
related to trust.
Customer-oriented behavior
A service organization’s employees help to define and build
meaning and trust for the brand (Berry, 2000). Thus, it is
crucial 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). When
service organizations are customer oriented, they are
practicing the marketing concept (Hoffman and Ingram,
1992). Furthermore, employees’ customer-orientation
behaviors are enhanced when the leadership of the service
firmsandtheemployeesfulfill the customer-centric
organizational mission (Suh et al., 2011). These inspiring
customer-oriented behaviors of the employees reinforce the
customers’ trust towards the healthcare providers.
There was consensus among the interviewees that that the
display of customer-oriented behavior by the employees of the
healthcare 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 want
someone to be able to administer a shot, but a shot with a smile is even
better. You can have competent staff, but care delivered with a smile makes
all the difference and helps to put you at ease (Evelyn).
H1d. Customer-oriented behavior displayed by the
healthcare provider is positively related to trust.
A consumer’s attitude towards the brand, subjective
assessment of quality, level of prestige imbued by the brand
as well as the display of customer-oriented behavior by
employees can all lead to trust in the healthcare provider’s
brand. 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 responsibility
Healthcare 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).
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Healthcare providers can impact the lives of individuals in the
community by providing services that improve health,
increase access to care, save lives and train future caregivers.
Such investments in the community help to engender bonds
and attachment toward the healthcare provider. As a result,
the following is proposed:
H3. Corporate social responsibility is positively related to
affective commitment.
Outcomes of affective commitment
Affective commitment to a healthcare provider’s brand can be
fostered through trust, the influence of reference groups and
investment in the community. When affective commitment is
attained, an emotionally based relationship is established
between the consumer and the healthcare provider’s brand.
Emotionally based consumer brand relationships can result in
a strong connection between the consumer and the brand
where qualities of the brand become aligned with the
consumer’s self-concept. When such a connection develops,
a consumer is highly likely to become an advocate for the
brand and passionately promote it to others. Such outcomes
can be invaluable to the organization.
Self-brand connections
Consumers sometimes become committed to brands that help
them to create or represent their desired self-concepts
(Escalas and Bettman, 2003; Escalas, 2004). They often
construct their self-identity and present themselves to others
through their product and brand selections (Escalas, 2004;
Escalas and Bettman, 2003). As consumers discover fit
between their self-concepts and brand images, they may make
self-connections with a product or brand.
Self-connections are created when brands engender strong
and favorable brand associations from the consumer’s
perspective 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 and
Arnould, 1988). A strong self-connection with a brand allows
for easier and more frequent retrieval of thoughts and feelings
regarding the brand (Park et al., 2009).
Rachel, one of the interviewees employed as a nurse, shared
how strong emotional commitment for the hospital from some
of 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 of
the hospital and the hospital was a part of the community (Rachel).
Hence, it is proposed that when individuals become
emotionally attached to a healthcare provider’s brand, they
may come to identify themselves with that brand.
Thus, the following is predicted:
H4. Affective commitment to a healthcare provider’s brand
is positively related to self-brand connection.
Advocacy
Favorable communication about a brand from consumers can
accelerate new product acceptance and adoption (Keller, 1993).
Advocacy in the form of word-of-mouth communication can be
the most influential source of information for the purchase of
some products because it is perceived as originating from a less
biased, more trustworthy source, which helps to lessen
consumer 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 brand
and 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 is
hypothesized for consumers and healthcare brands:
H5. Affective commitment for the healthcare provider’s
brand 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 care
she received at her healthcare facility was exemplary. After
spending considerable time at the hospital during her
recovery, she began to develop a special connection to
hospital. She shares part of her experience:
I was terrified because I did not know what was happening to my body [when
I 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 the
hospital 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. As
a result, she is eager to recommend the brand to others.
Hence, individuals who develop a connection to the
healthcare 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 for
the 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 the
brand.
Finally, as indicated previously, trust is often viewed as an
essential ingredient in successful relationships. Many of our
interviewees expressed how important trust was in a
healthcare provider. Those interviewees who had confidence
in 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 model
represented in Figure 1, a sur vey was conducted. All
constructs, with the exception of referent influence, were
measured using existing scales adapted for this study. The
items 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-student
adults in a major metropolitan area in the southwestern part
of the USA. At the beginning of the survey, respondents were
Healthcare branding
Elyria Kemp, Ravi Jillapalli and Enrique Becerra
Journal of Services Marketing
Volume 28 · Number 2 · 2014 · 126 – 137
131

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
x
2
(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 and
Larcker (1981) test was performed. Discriminant validity is
demonstrated when the average variance extracted from a
construct is greater than the squared correlations between
that construct and other constructs in the model. The average
variance extracted between each construct was greater than
the squared multiple correlations for each construct pairing.
Composite reliabilities were also assessed to ensure that each
construct exhibited internal consistency (ranged from 0.87 to
0.97). All measures exemplified acceptable reliability by
exceeding the recommended 0.7 threshold (Nunnally and
Bernstein, 1994). The results for the structural model follow.
Structural model
The structural model and hypotheses were evaluated after
attaining a validated measurement model. The model
exhibited adequate fit
x
2
(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 between
exogenous and endogenous variables. Results are presented in
Table 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 effects
a
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 effect
b
H7: affective commitment on brand advocacy 0.55 **
Notes:
a
Completely standardized solution;
b
Standardized solution;
*
p
,0.05; **
p
,0.001
Healthcare branding
Elyria Kemp, Ravi Jillapalli and Enrique Becerra
Journal of Services Marketing
Volume 28 · Number 2 · 2014 · 126 – 137
132

H1a-H1d predicted that brand attitude, perceived quality,
brand prestige and customer-oriented behavior would be
positively related to trust. Results indicate that brand attitude,
perceived quality and customer-oriented behavior are
positively related to trust, but the relationship between
brand prestige and trust did not prove to be significant. Thus,
H1a,H1b and H1d were supported, but H1c was not
confirmed. Further, H1e predicted that trust would be
positively related to affective commitment. This hypothesis
was supported.
H2 proposed that referent influence would be positively
related to affective commitment; H2 was validated. Similarly,
H3 predicted that corporate social responsibility would be
positively associated with affective commitment. The
significant relationship between corporate social
responsibility and affective was verified as well. Thus,
positive links between affective commitment and its
proposed antecedents – trust, referent influence and
corporate social responsbility – were all validated.
H4-H7 addressed the outcomes of affective commitment in
consumer brand relationships. H4 predicted that affective
commitment would be positively related to self-brand
connection. This hypothesis was supported. Additionally,
H5 suggested that affective commitment would be positively
related to advocacy for the brand; H5 was confirmed. Self-
brand connection was hypothesized to be positively related to
advocacy for the brand in H6.Thispredicationwas
supported. Next, H7 suggested mediation. Self-brand
connection 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 (Cohen
and Cohen, 1983; Kenny et al., 1998). Finally, H8 predicted
that trust would be positively related to advocacy for the
brand. 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. This
research examined how emotional or affect-based consumer
brand relationships are developed for healthcare
organizations. Findings indicate that trust is a key variable
in establishing affective commitment in consumer brand
relationships. Healthcare is an intimate service. In many
cases, the individual not only surrenders very personal
information 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 and
customer-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.Prestigehasbeenusedasasurrogatefor
dependability and reliability for various products (Vigneron
and Johnson, 1999). However, since healthcare is such a
personal 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 connection
Consumer 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.
Healthcare branding
Elyria Kemp, Ravi Jillapalli and Enrique Becerra
Journal of Services Marketing
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133

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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Healthcare branding
Elyria Kemp, Ravi Jillapalli and Enrique Becerra
Journal of Services Marketing
Volume 28 · Number 2 · 2014 · 126 – 137
136

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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 adjectives
describe 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 present
myself 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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