Consumerism and the broadened marketing concept

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Faculty Working Papers

College of Commerce and Business Administration

University of Illinois at Urbana-Champaign

FACULTY WORKING PAPERS
College of Commerce and Business Administration
University of Illinois at Urb ana-Champaign

CONSUMERISM AND THE BROADENED MARKETING CONCEPT

Alan R. Andre as en
Professor of Business Administration

#490

Summary :

As marketing moves into new broadened domains, it risks the criticism
and public disfavor that dogs it in its traditional business milieu.
This paper explores several alternative measures of consumer and
practitioner satisfaction in one of these broadened domains, health
care. It argues that evaluations of the outcomes and process of marketing
are essential if marketing's past life cycle is not to repeat Itself
in this new area.

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Introduction

Marketing is a major force in our society. By subtly matching hetero-
geneous supplies and demands for products and services, it serves, as one
marketing sage has put it, to deliver our "standard of living." During

the 1930's and 1940's, there were many who questioned whether the marketing

2
process cost too much. With the second World War and the postwar boom,

marketing flourished with only rare suggestions that it was less than a

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wholesome force in society.

But all that changed in the early 1960's. With the rise of Naderism,
marketing again came into question, but this time on two different grounds.
First, it was argued that marketing was not really delivering products and
services of good quality; that consumers were much more dissatisfied than
market data traditionally showed. The support given to Nader airi his imi-
tators was offered as evidence that this level of profound dissatisfaction

4
did, indeed, exist.

The second charge against marketing was that not only were its outcomes
less than desirable for the society, but so too was its process. Many rose
to argue that the advertisements that were selling toilet paper to adults or
Farrah dolls to kids were turning society into manipulated mush. Others
pointed out that the same system that provided credit and low cost, honestly
promoted products to the white middle class also provided deceptively promoted
products sold at exhorbitant costs and usurious interest rates to those who
have the misfortune to be poor and/or members of racial minorities.

My colleague, Peter Webb, has argued persixasively that this criticism
of marketing was (a) inevitable and (b) desirable. The criticism was in-
evitable as marketing became more and more visible as business' interface

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with a skeptical world. The growth in per capita spending power meant that
more consumers spent more i;ime on the material dimensions of their lives.
This forced them to active.'.y seek out more contact with advertising, sales-
men, packages and the like to make purchase decisions. At the same time,
the growing ubiquity of television and other media in our leisure lives
meant that consumers were "forced" to have more passive contact with this
same voice. These contact!}, I would argue, became not only more frequent
but progressively more distasteful as increasingly well-educated consumers
felt vague guilt about the growing inroads that both materialism and tele-
vision made in their lives,. Marketing's increased visibility and its
direct link with both forces made it a natural target for consumer anger.

But the criticism thai: arose can be considered a very healthy sign,
particularly when it is directed back at business. It can be the irritant,
the flashing red light, that causes the business system to correct itself
and the consumer's frustraf.ion to be released. However, as I have noted in
another forum, business' present use of this self-corrective and frustration-
relieving feedback mechaniiim is surprisingly low. Fifty-edght percent
of all problems with products and services are never voiced to business.
And, further, of those that; are voiced, fully 44 percent are never resolved
to the consumer's complete satisfaction. This leaves both a substantial
vocal group of unsatisfied complainers who will lead the chorus of anti-
business criticisms and a tiecond non-vocal army which other researchers
have described as a "frusti'ated and even possibly an alienated group of

consumers . . . [i]n frustiation, . . . direct [ing] their anger toward the

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system, viewing both busintiss and government in very negative terms."

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Andreasen and Best have proposed that one solution to this feedback problem

is:

. . .to market the complaint-handling system to customers.
Business should encourage customers to speak out when
things go wrong — and make it more convenient for them
to do so. Through advertising, point-of-sale promotion,
and product inserts, business can tell customers that it
wants to know when things go wrong.

This feedback can not only reduce consumer frustration but improve the

information management has to correct its product and service offerings.

Broadening Marketing

It is a curious historical phenomenon that just at the point in time
when criticism of the traditional marketing system by one part of society
is most virulent, another part is just discovering that marketing has a set
of tools that are capable of having profound effects on such crucial domains
of our quality of life as health care, the arts, education and social services.
In a sense, business* whipping boy now has a chance at redemption.

But history can repeat itself. As marketing becomes more and more
visible as a tool of non-profit administrators, it may again become the
lightening rod for the frustrations of those whom these administrators are
trying to serve. The problem, obviously, is to avoid this seemingly in-
evitable outcome. The solution, equally obviously, is to develop feedback
systems that will allow non-profit administrators to improve (a) the out-
comes of their marketing systems and (b) the process whereby marketing
helps deliver those outcomes. If marketing is to continue to have a posi-
tively valued impact on these key life quality dimensions, an effective
measurement system must be devised.

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The remainder of this paper explores several of the key measure lent
issues raised by the "broadened marketing concept" with particular azten^
tion to health care. The problems of evaluating outcomes and process ar
discussed independently.

Evaluating Health Care Outcomes

To make the discussion concrete, let us suppose that the administrate
of a federal program that makes grants to medical clinics for diagnostic
equipment wishes to make those grants at least in part on the basis of how
good patient care outcomes are at various clinics. He/she wish to see
developed what Hunt calls "consumer satisfaction/dissatisfaction" (CS/D)
measures to insure both that clinics are rewarded for providing good
outcomes and that the clinics themselves get adequate feedback to c^ri-ect
their own operations and to reduce customer frustration.

Elsewhere, I have suggested that the administrator's first choice
is to specify whether he/she wishes the clinics;

1. to minimize dissatisfactions or maximize satisfactions; in neaiii
care, the analogous question is whether one merely wishes to
minimize the frequency, duration and seriousness of illness or
to optimize health;

2. accept a subjective judgment of satisfaction or dissatisfaction:
that is, should the patient or practitioner be allowed merely

to tell you how healthy or free from illness the patient is; oi

3. meas\ire satisfaction/dissatisfaction before or after the market ir
has had a chance to correct any dissatisfactions, which, of
course, presumes some system for handling patient complaiats.

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The alternative measures that this taxonomy offers in business are outlined
in Figure 1. In the main, there are six principal kinds of measures:

1. Sales;

2. Repeat purchasing (versus "brand" switching);

3. Salesmen's or middlaBen's opinions;

4. Consumer's satisfactions;

5. Voiced complaints; and

6. Reported problems.
We will consider each In turn.

(1) Sales. Sales at first evaluation is not a very useful measure to
test the effectiveness of health care systems, although it has the advan-
tage of being non-subjective and relatively easily and frequently measured.
In the first instance, if the number of customer visits or customer revenues
are used as criteria one can raise the question as to whether more is nec-
essarily better at either the individual or societal level. If individuals
visit the clinic more often, this does not necessarily mean that the clinic
is doing well or that consumers are paying more attention to their health.

It may simply mean that problems are not being resolved satisfactorily as

12
often on first visits. On the other hand, if consumers are found to

be spending more, particularly per visit, this may reflect one of two

socially undesirable outcomes:

"1. It may indicate a greater Krillingness of clinics to take

advantage of price inelasticities in a market where most

payments are by third-party insurers.

2. It may indicate a growing use of laboratory procedures to

hedge against malpractice suits.

In either case it means that the nation's health bill may be rising unnec-
essarily. In neither case does it mean that consumers are healthier.

One useful alternative may be to measure the number of customer
visits of a particular type. One could, for example, catalogue the fre-
quency with which existing patients appear for full or partial physical
examinations or for first visits for various ailments. These would appear
to be more valid indicia of improved health care behavior.

But even if such measures were developed, they only seek to evaluate
one function of health care systems, what may be called the cmrative func-
tion. Visits to clinics are to diagnose or cure problems. Yet a clinic
coxild be performing marvellously if it had a superior preventive function,
and, therefore, s eld can had to cure. Many of the marketing activities that
pursue the preventive function may be secondary to, or independent of,
clinic visits. Brochures, posters, mailers, patient education, television
talk show discussions, and other public information activities may all
serve to encourage people to take up jogging, stop smoking, practice
breast self-examination or to take their medicine (e.g., for high blood
pressure). Yet these are exchanges that, unlike curative encounters, do
not involve money changing hands. The role of the health marketer is

to get the customer to perceive that the benefits of what Kasl and Cobb

13
describe as "health behavior" exceed the costs. Indeed, the product

or service is t3^ically one that custcmers administer to themselves!

It would again appear highly useful if health care systems could

develop measures of "sales" in preventive health care, e.g., patients

taking up jogging and other health giving acts. Among other benefits.

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such a measurement device could in the long run redirect health profes-
sionals toward more preventive marketing.

(2) Repeat purchasing. Hunt has argued that:

. . .intention to repurchase is an excellent composite
measure of CS/D. The value of this measure is that it
is a composite measure getting at all the influences
affecting the decision without liaving to identify those
influences. It in essence says, given the real world
and your psychological world,, what evgr they may be,
what choice will you make next time.

Repeat visit behavior by clinic patients, however, is not a very good
measure of performance of the curative function primarily because of the
inertia that is built into doctor-patient relationships. Choosing among
alternative doctors is typically not an activity a patient undertakes at
each visit as he or she might with a toaster or a car repair shop at each
repurchase. In part this is because many patients believe that the effec-
tiveness of a medical doctor in both a psychological and medical sense is
in part a function of his/her accumulated knowledge of the patient.
Patients are reluctant to give this up even if they have misgivings about
a doctor. Further, they fear (incorrectly) that all the written minutae
of their history (x-rays, test results, etc.) cannot be transferred, thus
incurring further costs for repeat "work-ups" along with the aforementioned
risk that without these records a misdiagnosis is more likely.

Then, there is the uncertainty involved in any switch in practitioner
occasioned by the basic difficulty of acquiring the necessary information
to make an informed choice among doctors. In most cOTtnaunities (although
there are exceptions), the marketing system does not make it easy for pa-
tients to shop around. Information on a doctor^s (or clinic's) training, ex-
perience or even prices is simply hard to come by and, thus, a known mediocre

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medlcal doctor may be preferred to an unknown alternative. In sum, until
the health care marketing system is redirected to encourage easy choice
and uncomplicated doctor-switching, the absence cf "brand -switching" should
not be considered a very good measure of the curative outcomes of health
care systems. On the other Iiandj repeat "purchasing" measures may be
very useful indicators of good preventive care outcomes. In preventive
health care, one is asking people to engage in behaviors that Hochbaum
has described as "inherently unpleasant, inconvenient, humiliating and

painful; they disrupt old, accustomed living habits; and they necessitate

] 5
depriving oneself of things one wants and enjoys." " Given this char-
acteristic, Hochbaum continues:

In the health area, the concern with use after "purchase"
is as critical as and even more critical than the concern
with the purchase itself. . . . The most challenging, most
difficult, most perplexing problem is not how to sell peo-
ple on health-supporting practices, not even how to get
them to initiate such practices. We have been fairly
successful with these. It is to persuade and help them
to stick with new practices, to keep^ these up conscien-
tiously for the rest of their lives.

Again, focus on this measure of repeat purchasing appears necessary to

assume that marketing direct its efforts toward the essential preventive

health goal. If marketing focuses on the first purchase, this may lead

to greater dissatisfaction and frustration rather than less as consumers

complain that, as marketers urged, they tried to quit smoking (exercise,

brush after meals) but they couldn't stick, to it (i.e., marketing did not

follow up), rney may feel badly about themselves and, as in marketing's

business domain, take it out on the marketing community, e.g., "Why do

they keep pushing me to stop smoking; I feel guilty enough as it is?"

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(3) Salesmen's ox- middlemen's opinions. Can one ask clinicians about
how setisfled their patients are? The answer is no for two very good rea-
sons. First, the nature of the medical practitioner's job is one that re-
quires that they be very confident. People who must make daily what are

often life-and-death decisions about other human beings would sink Into

37
catatonia if they regularly questioned their skills in the field.

Second, there is the growing problem of malpractice. It is unrealistic

to expect doctors to indicate that their patients are less than fully

satisfied if this evaluation is to be written dovm. somewhere (as it pre-

stanably should) . Such data could well be grounds for a successful future

malpractice claim.

(4) Consijmers' satisfaction. A number of scales have been developed
in recent years which allow consumers to report how well they are satisfied
with the products and services they liave received. Pfaff and Blivice in

particular have sought to develop consumer satisfaction scales applicable

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to public services. Such scales could be administered annually to

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patients of various clinics. Hovjever, as Olander has pointed out, a

problem with such measures is whether health consumers really have enough

knowledge to make the appropriate judgments. Partly, this is because the

medical system has historically been less than candid with patients about

the patients' condition and/or the medical doctor's frequent uncertainties.

There are sometimes good medical reasons for this. But often lack of candor

is designed to maintain "face," to prevent time-consuming debates about

appropriate care, or to prevent malpractice claims. Thus a patient may

well feel fully satisfied with a clinic's curative function when this

merely reflects the practitiovier'e ability to maintain silence!

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A second prob3.Qn relates to standards. Patients may not really fcaow
whether a better alternative exists Bomewhere. The difficulty of directly
comparing medical doctors has already been mentioned. A second type of
ignorance is at the systems level. Most patients have little familiarity
with alternative health care systems. In North America, the medical pro-
fession is oriented toward cure and not prevention. In other countries,
such as England or Scandinavia, the orientation is much more toward pre-
vention. Someone who Is socialised to a curative system may be very
pleased with the frequent cures without questioning whether more attention

to prevention might have made the cures unnecessary.

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Then there is the matter of one's expectations. As Oliver and

others have shown, perception of system performance is a function of ex-
pectations. It may well be that a given clinic, because it sets and
vigorously advertises its high standards, may liave low consumer satisfaction
ratingf3 while having superior performance in some objective sense. On the
other hand, it may be that the medical system in general stresses too high
standards. If patients are led to expect the latest, best equipment in
every facility, the cost to society in duplication may be excessive. As
Hunt suggests, reducing expectations may be good public policy:

[Gjovemment could iixrease satisfaction just as well
by getting consumers to lower their expectations. At
first it sotinds silly, but with the conserver society
coming fast upon us it may be critical in the near
future to find ways to reduce consumer expectations
because increasing product quality will be socially
unacceptable.

A third problem is, of course, that patients are sometimes unable

to judge whether curative treatments or preventative recommendations are

successful. A case in point is the problem of educating high blood pres-

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sure patients. W:Lth this dit^eace it is very difficult to tell whether
a treatment is working since the disease has no syiaptoms. Thus a patient
told to diet, exercise and take specified piJla may not feel any different
froiD one who did not follGbr this regime. As a consequence he or she may
well feel (mistakonly) dissatisfied with the medical care received.

Finally, there is a basic nsthodolgicai probleic with satisfaction
scales that may b£; especially serious xn health care. Satisfaction scales
tend to ovrreport disnatisfaction because they often reflect inflationary
factors. Research by Andreasen and ^est reported that when people were
asked how saticfied they were xvith a product oc service, fourteen percent
of those who were dissatisfied said that high pr3.cc was their only prob-
lem. That figure rises to slraost nineteen percent for those dissatisfied

22
vrfth medical and dental care. Tne. latter is not surprising given the

very rapid increasie in heslth care costc in the last decade,

(5) Voiced coisplalatfi, A technique used by lafmy businesses to

monitor performance is to rejy on the complaints that naturally come to it

from disgruntled cu6to!E<5rj3 v^ho choase to rp&ak up either by letter or In

person. And, iijd€:edj. i-an\ ulinlcs ivad hospitals h&ve sought to generate

such co3iplait;l.s data by e.n rsbiifibin;/. "pa Lieut suvisory boards." " A

problem noted in oxir own research ovi consutaar coraplaiiitG, however, is that

voiced ccBEplaJuts imdcrraport the true level of. dissatisfaction since, as

noted earj.ier, vh^i majority of all nor.--pri.ce problciffis are never voiced.

Kot onI.y do they under rep oil probleas, i..be> present a distorted picture of

^^® JiXE££ °^ problfajce that actualJ.y exist .iiiice some types of complaints

are more likely to he voiced thars others.

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Our study sxiggests that or. bot.h coimtSj complaints data may be
especially unsatisfactory in the medical field. First » we found tliat 77
percent of all mcciical and dental problerao were unvoiced. For such an
jjaportant isBue to most consumers, this rate of voicijig Is exceedinjjiy
low. Second, our research in general showed' that the kinds of problems
that did get voiced were those where the problems were important and/or
had a hi^h likel.Lhood of resolution. While medical problems are impor-
tant, they were not very likely to be resolved satisfactorily. Our data
showed thet consumerc v;ho did voice their jaedical and dental complaints
felt that the ccKiplainta were satisfactorily resolved only 34.5 percent
of the tiioe, (THils was the second lowest figure in the entire study,)
This result laay well accurately reflect the considerable inapproachability
the laedical profession has assiduously cultivated over the years.

A third featiure of the types of problemn that were not voiced vas
that they were wliat were called ".-judgment" probleas. These vrere the eases

where ". ., .deficiencies [were] complicated or ambiguous, and therefore

25
relatively dlffi(;ult to perceive clearly fxnd state with assurances."

It is, of course., just those tynpcts of problems with which aedical encounters

abound. Consumers who are unsure of their grounds in a liighly sophisticated

and arcane subjectt as laedjcine are underntandably reluctant to challenge,

even indirectly, the usedical high priests,

^^^ Report?? of probleas. My own experience strongly argues for the

use of date geneiated from consumers in surveys on the probleras they have

26

encountered \^th goods or services as the best measure of curative outcome.

Such treasures overcome the ovfitreporting bias of simple satisfaction scales
and the underreporting bias and distortions of consumer complaints data.

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(discussed above). In our research, the rate at which Tuedical or dental
care problems involving non-price issues were laentioned was fifteen per-
cent. Given coiisunjer ignorance in this area, this figure is undoubtedly
low and I would argue vigorously for consumer education in evaluatijng
medical care. StJLil, survey reports of probieaas are at present probably
our best measure of curative outcomes.

Measures About Process

We have already seen that a major defect of the health care marketing
process in that consumers seldom liave ade<juate information to evaluate
the care they are receiving. While in t-he short run consumer expectations
can be suppressed by practitioners to keep them satisfied, in the long
run, however, adequate information is essential if customer suspicion and
frustration is to be reduced and if the self -correcting potential of an
open marketplace is to be actualized,

A second requirement for the process to work well is that it become
more consumer oriented. Tliere is considerable evidence that in curative

settings practitioners are frequently not very much concerned vlth con-

27
suiaer xntereets. And severnl authors have pointed out that even in

preventive contexts, health care specialists take the view that they know
what is best for consumers; it then become-s marketing's task to con-
vince consumers to adopt the system's view. As FJexner puts it:

One of the major reasons that preventive health
care has a relativelj' low priority among consumers
Is that all concerned entities . . . have placed
too little emphasis on the intended recipients of
the product — the consumers, their motivations,
and the 'benefits tltat attract them to certain be-
haviors.

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It Is just the kind of pifjduction orientation that characterized conciiercial
marketing of 40 years ago. A measure then of progress in tha health
ffiarketing process is tTie e35:teiit to vhich medical practit."ix>ners begin to
adopt the perspectivee, particularly i.n preventive health care, tlwt
change programs will only be raasimally ffuccessf u3 when they begin with
consuff>er neede and wants.

The product*-as~givcin approach of laost health care profp.sBionals
naturally le^de to heavy emphasis on advertising and promotion to achieve
behavior change. Kaedless to a&y^ this /approach snay be entirely appro-
priate to riiany preventive health care. raarketiiT.g programs. But even here
there is a danger. As ?foriarty notes: "Preventive health care behavior
in some cases 'hap. only long run and uncertain outcoifies for the xndivid-oal.
Advertising elates of a more healthy life associated with specific changes
in behavior will have to be dncttmented. , , ."' Monitoriiig of the
truthfulness of health care promotion therefore would also seem ianportant
if the marketing process is not to receive a black e5'e in this nen;
broadened context.

And just as we shovtld be co'Acerned aiiout the product and promotion
eleaentK of the health care sarkefcing mix, so should, we be concerned
about price and dietribfation. As noted earlier f there is very little
price competition in health eare^ In partj thio is because often the
products are liot coapsrafcle. But this is not alvreiys the case, and if
marketing is to be effectiv-e this elemeni: too rouBt becoioe more open and
flexible.

Finally, one should note th/- djj^ficulties business ruarketers have
hat by not pajing heed to tha coi^cerns of vhat 1 have called ''disadvan-

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33

t-aged consumers." ' Adftouate heaith care is soen by ir^aiiy ^r a ^igjit

of: &11 :mdividualB in na affi<j6*.nt socieliy. Health iiiar):etej.'s are in most

caoeB already sfcnsj.tized to the prohlems of t-Jje disadvantaged and are

Bttecking the©. It is, however, not: impossible that: the white middle

claes uedictl eetaW.ishKsnt (like the white middle class constjmer es-

tabllehasent) icey not be i^bII attuned to the needs of the disadvantaged.

Thus, 11 the process is to be TelatlVGly free fros? criticisiB \-f?. nnst

he Bute not only to keep the overall level of. satisfaction high but

ensure that this satiafaE-tion is ecuitably distributed across all pop--

ulation groups at riok»

The final pro'bieta sEBrl^tere should be ae.usltlve to is not to ov&T"

proBiice its coiitrihutionB to its ntltar wajor pnhilcj the henJth care

practitlonere therasftives- Ghan:berlaj3i puts it wftli:

Gar corttern should be tkaf. viiarketlaj? will not be
equipped to fulfill trie forpectations of the ht-altb
)irot'esB5.onale« Such expect^'-.tions tosy he ezeggerateci
beyond the. capRbilities of lusrketltig practitiocers.
The aarketer who achic-vee n j.5 per.cent chatsge iu
consumer behavior Tdll very likely be viewed as a
failure by heaith^profesBioDala expecting 99 per-
cent compliance, ■

If vv. do Rot jsonitor the health profe-ssiontl's ejrpectations and our

accoiapliehaients, ve rnv the difitJjact risk that they too will see UJarJceting

an a source of deception « As coie. health marketer told the authors

"Marketing to rrtany health professionals aieane putting balls and

vhlf.tlee on ecmie very bsfiic SiesssgeB," For them, raarketing^G (i-nevitable.)

failure to make large gaiiis taay indelibly iabc;! :it ss just anotlier health

laanagemenfc fad-— or worpcjt a con job by r.orie ixrory tower acadesnicR.

5:oip& ReBa&rc"b Replications

We* are clee.vly a long way Iroj. being ablle l:o rjecBure theisa luarketlnf;
outrome amd prc>f.e.8«i variabl&e. At tht- coi^sumer. lti!'el j, ve need to laiov a
goad dcfel rjor« rbout how Indiviclualo fcvaiu&te medicRl cBrt. Ke need to
know fheli" 'Know3ed.ge of the j-yfjtea aiict its. siternatives; x-»hat i:beir nx-
pectatiorts ar& cf cacb iie&lth fcacoiinter and wnal; they know of the he&3.1.}i
sypLeai tiS K wTc'.oJ.e. Vie need to l:now v)n pP.Tcexvea probiesus and v.i}jo acta
on theiii &ud vhy. We need t.o know what practitioners f.hink of mcxiuitijig
aiid what their expectations are ni its periorHaacfe. And finally wc nsieo
to know vshst will cliange the/ie vsiiahles. ±ii h iavorahle direction.

Trife fieveloicijcnt of JuiitriEnentf. sue rel^ited methodologies to assess
consoBTsr e.ud prf.ctitioner sstlsfactiouc-; vrJ.th he&lth cere outcoraftt. and thf
laari-jsting proceiis tlist brings irh&ih /should occupy ovt attention for nctvex&l
yearfj, Cvxt^iiii.y these are critir^;] ieBuefi if marketing is to serve its
fu3J pi.tQntiai in iJiiproviug the quality of lifo in this and aiM-ilui:
hrofcde.nc'>3 doissirlna .

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^i. Mark Y,. 'Kauel, Tbo J'oli^ics^^fjf Cofcai/juer J^^^ttict ion.. (ItidJ&nBpolif-j
yht Bobbi'.-frlerriii Ccu., ItTc'. ^ :ml)T"'

f«^ Evelyii Kaye, Tmj KetDl'iy G^ij.dfe to C'-xi'j/iraii^e Ueli.evi.Kiorj (Nev- York;
PsTmlhtov. Ik>o1-.Kj 2 9/^).

6. /i.laii l\, Mi&roi-.BeTi^ "Vne J>i:o^.&vanli'j^fi6 QortF-tfOier (ViP-v York; Tne Vrir.t'.
Prees» 1P75).. " " "

7. AJciiii R. .jfitwireaswi aDC' /.orthur ik^st , "'-{ioi'SOiUf-rs C;oisp:i.R5.v\-"Doei; BxisloGsr
Rftsponfl?" llsrvard -fiUBivest. Kc}^£*i< Voutm;e; SS^ Thia&c.r. 4, (July-

P. ReK H. AterJjjntlj Kfbf;rt 0, We.j.Ti.aRnr; nnd Jiioe 'wxlli-fs., "DiopstiRfie-S

iO, K, Kfcith Siwnt,, "Cfc/j!; •i'i\'> I'n-'grajr 'PJ:fim.;3 5:sB anil T^nJiuttioi- P.erfipetll^'e,"
jii Bevej-lf-e Jii. Aodereors yec^.) ^^Ysiu£€^ jl^^ J>jr)S]^t^ Vol. lil.

(Cincijruiat:i: Asisos'ifctioxi for Coii<ra:ct-.r 'keBcai-cl^ 197 6") ,. j>p. ZS^^-i&Ot

XI, Al<m 11. .;A.r«<5re&Ciet\j, "A Te^onoaiy ci! CouEsveuvr Si.(ria£ac:t.'j.on/DiyKat:icf&etJ:or!
M'ttaiUUTftfe.," .Tonrif&l _oi"^ C!ouf.-.uaar Af-f air s^t Voitane l?j Ilucibp-r 2j (V'Jntej:',
i&7?), 5.p. 11-24.

i2J,^ TJio eD.ajoj5y o^ -C:3r repsiLrK i.fc fipprc»pri/i( e. On'.-, v^ojud certainly not
j3w!cri.b.4? iiT; liici-ftase lu visdtt-. to tlit i?epfcir sLcjjj at- a slpn tbat
■ctAre vreie bciijig ludJ.t .better ot ^ uecBBjiEilly,, i'iiett people ware ftaV.iug
better cere nf, rb,eKt.

.15. Staul&iov a-^fiJ and fiafiuey Coiibj '*H£ftlth Bebr.vJ.ai , Ilinef;£ Behavior
.a.T(«3 Jiick-^.'olt' Bfch&v.ior," •/irr.hiv^es^o^^^KavjxonE.^^ Voliisae.

3.2 (I^ebruarv.. 1966).5 pp, 246-266 £m6 Voltvce 22 (hprllf 1966), pp..

-18-

14. H. Keith Hunt, "CS/D: Bits and Pieces" in Ralph L. Day (ed.).
Consumer Satisfaction, Dissatisfaction and Complaining Behavior
(Bloomington, Indiana: Department of Marketing, School of Business,
Indiana University, 1977), p. 39.

15« Godfrey M. Hochbaum, "A Critical Assessment of Marketing's Place
In Preventive Health Care," in Philip D. Cooper, William J. Kehoe
and Patrick E. Murphy (eds.). Marketing and Preventive Health Care;
Interdisciplinary and Interorganizatlonal Perspectives (Chicago:
American Marketing Association, 1978), p. 5.

16. William J. Nolen, The Making of a Surgeon (New York; Random House,
Inc., 1970).

17. Hochbaum, same reference as 15 above, p. 6.

18. Martin Pfaff and Sheldon Blivice, "Socioeconomic Correlates of Consumer
and Citizen Dissatisfaction and Activism," in Day, same reference as

In 14, pp. 115-123.

19. Folke Olander, "Consumer Satisfaction — A Skeptic's View," in H.
Keith Hunt (ed.) Conceptualization and Measurement of Consumer
Satisfaction and Dissatisfaction (Cambridge, Mass; Marketing
Science Institute, 1977), pp.

20. Richard L. Oliver, "A Theoretical Reinterpretation of Expectation
and Dlsconfirmatlon Effects on Posterior Product Evaluation;
Experiences in the Field," in Day, seune as in reference 14, pp.
2-9.

21. Hunt, same as reference 14, p. 41.

22. Andreasen and Best, same as reference 7.

23. Edmund Rlcci, Bardin Nelson and Robert Pecarchlk, "The Consumer
Movement in Health Care," paper presented at the American Sociological
Association annual meetings, Montreal, Canada, August 5, 1974.

24. Andreasen and Best, same as reference 7.

25. Arthur Best and Alan R. Andreasen, "Consumer Response to Unsatisfactory
Purchases: A Survey of Perceiving Defects, Voicing Complaints and
Obtaining Redress," Law and Society Review, Voltme 11, Number 3,
(Spring, 1977), p. 709.

26. Andreasen, same as reference 11.

27. It is recognized that Increased competition is not favorably regarded
in the medical community. However, the trend is in this direction
with the advent of generic drug prescribing and advertising of basic
medical services.

-19-

28. See, for example, Hochbaiun, same as reference 15 and M. Venkatesan,
"Preventive Health Care and Marketing: Positive Aspects," in Cooper,
Kehoe and Murphy, same reference as in 15, pp. 12-25.

29. William A. Flexner, "By Choice A Limited Government Role," in Cooper,
Kehoe and Murphy, same reference as in 15, p. 64.

30. Mark Moriarty, "Advertising Preventive Health Care: Informational,
Persuasive, Ethical?" in Cooper, Kehoe, and Murphy, same as in
reference 15, p. 57.

31* Andreasen, same as reference 6.

32, Robert M. Chamberlain, "Is Marketing Too Stigmatized to be Effec-
tively Accepted in Preventive Health Care," in Cooper, Kehoe, and
Murphy, same as in reference 15, p. 58.

M/C/75