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Preferences in health care service and treatment
Journal of Business Research 57 (2004) 1033 – 1041
Preferences in health care service and treatment A generational perspective Stephanie M. Noblea,*, Charles D. Scheweb, Michelle Kuhrc a
School of Business Administration, University of Mississippi, University, MS 38677, USA b University of Massachusetts-Amherst, Amherst MA 010032, USA c Time Inc. Home Entertainment, New York, NY 10019, USA
Abstract The American population is changing from a predominantly youth-driven marketplace to a middle- and older-aged marketplace. This trend is resulting in a greater demand for health care-related products and services and greater competition among health care providers. Increased competition among health care providers heightens the need for marketers to target their clients effectively. However, targeting health care clients is difficult because the recipient of the care is often not the decision-maker. For instance, the patients’ children often make health care decisions. Marketers, then, need to understand both parties’ preferences for health care treatment and service. These preferences often reflect underlying values, and parents and children sometimes possess different values. The goal of the current study, therefore, is to illustrate that generational differences in values influence health care preferences. Based on a national probability sample of 184 consumers the results showed that generational values have a significant impact on health care preferences. D 2002 Elsevier Inc. All rights reserved. Keywords: Generations; Baby boomers; Elderly
1. Introduction The American population is changing from a predominantly youth-driven marketplace to a middle- and olderaged marketplace (Schewe and Meredith, 1994). Two factors appear to be leading this trend. First, Americans are living longer than ever before, causing a senior boom. Second, baby boomers, the 76 million people born between 1946 and 1964, are beginning to enter their fifties (Schewe and Balazs, 1992). This changing demographic profile has important implications for health care marketers. In particular, there will be a growing demand for health care-related products and services as the boomers enter senior status. Additionally, heightened competition among health care providers increases the need for marketers to target clients effectively. Effective marketing entails understanding the factors that influence consumers’ health care preferences. Assessing
* Corresponding author. Tel.: +1-662-915-5461; fax: +1-662-9155821. E-mail address: [email protected] (S.M. Noble). 0148-2963/$ – see front matter D 2002 Elsevier Inc. All rights reserved. doi:10.1016/S0148-2963(02)00354-5
these factors in the health care industry is difficult, however, because the recipient of the health care is often not the decision-maker (Tudor and Carley, 1995). For example, Dove (1986) found that the resident’s children made over 40% of nursing home decisions. Understanding the different needs and preferences of each decision-maker, therefore, is a key task for health care marketers. Values are often cited as influencing consumers’ preferences and purchase decisions; however, less is known about how values influence health care decisions (Dolinsky and Stinerock, 1998). We propose that age-related values influence preferences for health care service and treatment. As such, the goal of this paper is to test whether generational differences in values influence these preferences. The two generations of interest for the current study are baby boomers (those 37 – 55 years old in 2001) and what we refer to as ‘‘matures’’ (those 56 and older in 2001). The dependent variables consist of five health care dimensions that were created to tap into the proposed value differences between baby boomers and mature. These dimensions include: (1) participation/information seeking—the degree to which consumers participate in their health care plan and treatment by seeking out additional information (beyond
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what their doctors give them), (2) questioning—the degree to which consumers question their health care providers regarding their care and treatment, (3) informality—the degree to which consumers desire informal attire (i.e., no suit and tie) and communications (i.e., being on a first-name basis) with their health providers, (4) flexibility—the degree to which consumers expect flexibility in scheduling appointments with health care providers, and (5) experimentation— consumers’ preferences for experimenting with alternative forms of health care treatments. A survey method is used to test whether generational differences exist for these five health care dimensions. The remainder of the paper is organized as follows. First, the process of socialization is presented to illustrate that the social, political, economic, and technological environments in which consumers come of age create unique generational values and behaviors. Second, the characteristics of the generations included in the current study are reviewed to create hypotheses. After presenting the results, the directions for future research are discussed.
2. The socialization of consumers Socialization refers to the process whereby individuals acquire various cognitions, values, attitudes, and behaviors (Goslin, 1969; Ward, 1974). This learning can take place as a result of modeling, reinforcement, and other types of social interactions at the individual level (Moschis and Moore, 1979). However, socialization can also occur at a macro level. That is, consumers acquire values, attitudes, and beliefs as a result of the larger political and social environment in which they came of age. This shared history produces unique values and behaviors that create similarities across consumers (Meredith and Schewe, 1994; Rindfleisch, 1994). Accounting for socialization at both the micro and macro level allows for differences between similarly aged consumers (due to family rearing, ethnic, or religious influences), yet can also explain general similarities between consumers within age groups (due to social or political influences). For example, baby boomers are generally characterized as the ‘‘me-generation’’ due to their individualistic tendencies, skepticism, and concern for self-indulgence. However, these similarities do not preclude other differences between members of this group. Similarly, individuals who came of age during the Great Depression tend to be compulsive savers and risk averse throughout their lives because they experienced great economic hardship in their early adulthood. At the same time, they may be very different in other aspects of their lives. Shared experiences can occur at many levels. National, regional, and religious events can influence consumers. For example, the assassination of John F. Kennedy occurred at a national level and likely influenced all Americans, especially those in young adulthood (a time frame in which individuals are thought to be impressionable to national and
world events), whereas the 1995 assassination of Yitzhak Rabin, Israel’s prime minister, likely influenced the Jewish community more than other religious groups. Similarly, the San Francisco earthquake of 1990 or the Oklahoma City Bombing of 1994 might be classified as a regional event, whereas many note that lower socioeconomic class African American men might have been influenced the most by Vietnam since they disproportionately fought in the conflict. As these examples illustrate, shared experiences can occur at many levels. The influence of national, regional, and religious events on consumers’ socialization processes is thought to be most prevalent during young adulthood. Although ‘‘young adulthood’’ is defined fairly broadly, Holbrook and Schindler (1989) found that consumers are most prone to the socialization of music around 23 years of age and movie stars at 14 years of age (Holbrook and Schindler, 1994). Similarly, the socialization of preferences for apparel occurs in young adulthood. When asked to rate their preferences for pictures exemplifying various types of women’s apparel over the decades, men showed the most preference for apparel that women were wearing when they (the men) were around 24 years of age (Holbrook, 1993). As these examples illustrate, the socialization of consumers’ preferences and attitudes spans a range of years. However, within this general period of development, consumers are thought to be susceptible to socialization processes at the macro level (e.g., national, world, and regional events). As such, age becomes a proxy variable for segmenting consumers into groups of consumers that shares common preferences, values, beliefs, and behaviors. More specifically, in the current study, age is posited to influence consumers’ health care preferences. Consumers within specified age groups, also referred to as generations (see below), should have experienced similar national and world events in their early adulthood, such that these events influenced the formation of their attitudes and values, and ultimately their preferences for health care service and treatment.
3. Generational segmentation One-way marketers can segment and target consumers is by their age. As stated above, similarly aged consumers who experienced common social, political, economic, and technological environments share similarities in their values and behaviors. This shared history and resulting commonality in values and behaviors is the basis for segmenting by age. One age-related classification is segmenting by generations. Generations are usually defined by consumers’ years of births and last approximately 20 –25 years in length, roughly the time it takes a person to grow up and have children (Rice, 1995). Generational groupings are often useful in segmenting consumers because each generation is thought to have distinct lifestyles. In particular, the
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generations commonly cited are Generation X, baby boomers, and matures. The current study examines differences between the two older generations (baby boomers and matures) and excludes Generation X because health care needs and issues were not thought to be relevant or prominent to these consumers given their age. The baby boom generation refers to those individuals born between the end of World War II (1946) and 1964. In 2001, these individuals are 37– 55 years old. They experienced John F. Kennedy’s assassination, became responsible adults during the Vietnam War, lived through Bobby Kennedy, Malcolm X, and Martin Luther King’s assassinations, witnessed the first man to walk on the moon, and suffered through Watergate and Nixon’s resignation. They questioned authority, began nationwide protests, and started the ‘‘hippie movement’’ (Auchinclo, 1969; Meredith and Schewe, 1994). The matures, also referred to as traditionalists or the depression/silent generation, are roughly individuals 56 and over. They witnessed the Great Depression, World War II, and the rebuilding of America after the war. They listened to the sounds of Glen Miller, Tommy Dorsey, Benny Goodman, and the Ink Spots. As a group, they are thought to accept authority, leadership, and structure. They won the war as a team. Thus, they believe in a sense of ‘‘we’’ over a sense of ‘‘me.’’ Finer age groupings are often helpful in the creation of marketing strategies. In the current study, it is hypothesized that generational differences yield significant and practical results that are beneficial for health care providers and marketers. As such, the age groupings used in the current study fall along generational lines.
4. Hypotheses In the previous sections, the process of socialization and the potential for unique age-related values formed from socialization at the macro level was reviewed to illustrate that consumers across generational lines are likely to have differences in values, and hence differences in preferences (due to the different social/political environment in which each group came of age). The following section builds on this review by hypothesizing value differences for the two generational groupings included in this study (see Table 1 for a comparison of generational values). The five value differences include: (1) authority vs. participation/information seeking, (2) leadership vs. quesTable 1 A comparison of generational values Mature values
Baby boomer values
Authority Institutional leadership Formality Structure Stability
Participation/information seeking Questioning Informality Flexibility Experimentation
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tioning, (3) formality vs. informality, (4) structure vs. flexibility, and (5) stability vs. experimentation. A brief review of the environment in which each generation was socialized will be presented to illustrate how these value differences might have emerged. These value differences are then applied specifically to the health care context to illustrate how consumers’ preferences in health care service and treatment (i.e., the dependent variables) stem from generational values. Only by understanding and embracing each generation’s preferences will health care providers be able to provide better care for these clients. 4.1. Authority vs. participation and information seeking Matures who grew up during the Depression and World War II respected authority. They took orders from superiors in order to work and/or fight to survive. Taking orders was their way of life and still is. On the other hand, boomers expect to participate in all decisions. They are not known for respecting authority and will not want others to make their decisions for them. Instead, boomers are likely to seek out information, beyond what authority figures give them in order to make informed, individualistic decisions. Other authors have also shown that older consumers search for information less than younger consumers do. For example, a review of the consumer behavior literature by Beatty and Smith (1987) found that older consumers are less likely to obtain information about products when making a brand choice decision than younger consumers. Cole and Balasubramanian (1993) found similar results. In both aided and unaided decision-making tasks, older consumers searched less for nutritional information than younger consumers did. One explanation for these age-related differences in information search involves the working-memory capacity of older consumers. Working memory, a part of the information processing system, is divided into storage and processing memory. There is a limited amount of working memory, therefore tradeoffs are constantly made between how much information can be stored in short-term memory and how much can be processed or manipulated at the same time. As consumers age, their capacity for working memory is thought to decline. Older subjects become taxed easier when searching for information, therefore, search less when problem solving and making purchase and brand decisions than younger consumers. Another explanation often given for this difference in information search is consumers’ familiarity and experience with brands and products. Older consumers may have more experience and knowledge in certain product categories than younger consumers, therefore the former can rely on this stored information and search less for new information when making a purchase decision. This difference in experience level was used to explain one cluster of automotive purchasers in a study conducted by Furse et al. (1984). Specifically, older consumers were thought to search
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less for automobiles when making a purchase than younger consumers because the former could use their stored knowledge and experience with past purchases to aid them in their current purchase. Both of these explanations are plausible reasons for differences in search behavior between older and younger consumers and are consistent with the directionality of our hypothesis. We suggest a third possible reason, however, for why consumers might differentially seek out information. Specifically, searching for information might be rooted in younger consumers’ desires to participate in any and all decisions rather than accept the authority of others. This view does not contradict the limited-working capacity model or consumers’ experience and knowledge explanations, however does suggest another plausible influence on consumers’ desires to seek out information. Applying this to the health care context, we believe mature patients will be much more apt to accept the prescription of a health care provider (i.e., search less for additional information regarding their care and treatment) while boomer patients will be more likely to request and seek out additional information about the health care issue. This is true also when boomers are influencers, deciders, and buyers of health care for their parents. Doctors, nurses, long-care care administrators, and the like can expect to have less authority and influence on the ultimate decisions when boomers are involved. Hypothesis 1: Baby boomers are more likely to seek out additional information (beyond what their doctors give them) regarding their care and treatment than matures. 4.2. Leadership vs. questioning Boomers have always questioned. They are the ones who challenged the government over its participation in the Vietnam War. They are the ones who said ‘‘Never trust anyone over thirty.’’ This type of skepticism is growing within the American population. That is, Americans have become increasingly skeptical about advertising, corporate activities, product claims, and the government, just to name a few examples. This questioning and antiestablishment mentality is one aspect of a movement referred to as postmodernism. Postmodernism seeks to debunk previous ideologies, philosophies, and beliefs by questioning their very existence (Watson et al., 2000). Boomers exemplify postmodernism tendencies, presumably as a result of the social and political environment in which they came of age (e.g., Vietnam, Stonewall Riots, Civil Rights movement). In addition to their questioning nature, Boomers are the most educated of any generation ever in the United States. Hence, they are armed with information to formulate solid, substantive questions. In the health care context this forces health care providers to be ready with answers, even when boomers are questioning the care of their parents. Matures, on the other hand, have accepted the voice of authority.
Doctors, to these consumers, have been viewed as god-like and the health care exchange as a sacred experience (Koerner, 1994). With matures, health care providers consistently have been put on a leadership pedestal; their word has always been final. Hypothesis 2: Boomers are more likely to question their health care providers regarding their care and treatment than matures. 4.3. Formality vs. informality Older adults embrace formality while boomers have been the forces behind casual business dress. Matures came of age during World War II, a time when men and women had undying respect for persons in military uniforms. Status, authority, and social location were all reflected in dress, style, and mannerisms—and still are for this generation. Boomers, on the other hand, broke the rules of their parents with their dress, hygiene, living habits, and general lifestyle. While such ‘‘coming of age’’ extremes are generally gone, the value of informality lives on for this generation. In the health care context, matures’ desires for formality would be exemplified by their wish to be called ‘‘mister’’ or ‘‘missus’’ by their doctors. Additionally, they should prefer a more formal dress (suit, dress, sport coat, and/or tie) on the part of their health care providers and administrators. Boomers would feel just the opposite. They would prefer being on a first-name basis with their provider and seeing them in casual attire. Hypothesis 3: Baby boomers are more likely to prefer informal attire and communications with their health care providers than matures. 4.4. Structure vs. flexibility Matures came of age at a time when structured lifestyles were the norm. People worked from 9 a.m. to 5 p.m., ate dinner as a family, took 2 weeks of vacation, and so forth. Boomers came of age with different norms and are now used to working in flextime, telecommuting, and eating on the run to provide more time for experiencing personal enjoyment. In assisted-living retirement homes, today’s residents who tend to be in their 70s welcome planned activities and set times for meals, social gatherings, and outside trips. It meshes with their ideals for a way of life. When boomers get to that stage, such facilities will have to dramatically change to accommodate a new set of preferences. Boomers will demand alternatives. This thinking will stretch to other health care contexts such as visiting hours in hospitals, clinics, and doctors’ office hours. Health care providers will have to increase their flexibility in scheduling appointments to satisfy this new breed of patient/consumer.
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Hypothesis 5: Boomers are more likely to prefer experimenting with alternative forms of health care treatments than matures.
care study. Additionally, subjects completed two openended questions that addressed their likes and dislikes about their current doctor (where ‘‘doctor’’ referred to their general practitioner). Due to the novelty of this research area all of the health care items under investigation had not received prior research attention. As such, new health care measures were created for this study and the larger one cited above. Items were generated based on a review of related literature, insights from informal interviews with aging health care patients, and discussions with academic researchers. For the current study, an initial pool of 25 items related to five constructs was generated from these sources. The items were pretested with 10 consumers ranging from 39 to 84 years old to assess their understanding and interpretation of statements. The 25 items were analyzed through a principal component analysis to purify the scales. Based on an assessment of item path coefficients, residual terms, and the overall Cronbach’s alpha for the factors, seven items were deleted. The remaining 18 items yielded a five-factor solution (varimax rotation) based on the typical 1.0 eigenvalue cutoff. These five factors explained 67% of the variance in the variables. The final item set and factor properties are shown in Table 2.
5. Methods
6. Results
5.1. Subjects
A multivariate analysis of variance (MANOVA) was performed using subjects’ mean scores for the five health care dimensions as the dependent variable and subjects’ age grouping as the independent variable. Multivariate tests indicated overall differences for the age effect were significant (Wilks’ Lambda = 10.238, P < .001). Therefore, age of respondents appears to have an influence on their health care desires. To determine the extent of these differences each of the five health care factors were examined. The results are consistent with expectations. All of the factors yielded significant results in the expected direction. See Table 3 for group means, standard deviations, and P values for each health care dimension. Consistent with Hypothesis 1, baby boomers were more likely to seek additional information about their care and treatment from sources other their doctor (mean = 5.43) than matures (mean = 4.78) [ F(1,182) = 8.56, P < .01]. This additional information should allow boomers to participate in their care and treatment decisions by being fully aware of the options available to them. Matures, on the other hand, appear more willing to accept the prescription of the health care provider without trying to find additional information regarding their care or treatment. Hypothesis 2 stated that baby boomers would question their health care providers’ decisions and suggestions more than matures. Consistent with expectations boomers were more likely to question their doctors (mean = 5.46)
Hypothesis 4: Baby boomers expect more flexibility in scheduling appointments with health care providers than matures. 4.5. Stability vs. experimentation Finally, boomers were the generation to experiment with drugs to increase their pleasure. This culture of experimentation will foster a much greater acceptance of innovative forms of medicine. We are beginning to see this with the explosion of ‘‘new age’’ and ‘‘alternative medicines’’ that are flooding the marketplace. A recent Harvard study reported that one-third of Americans have explored health care options outside traditional medicine (Gremillion, 1996). These incidences gravitate heavily to the boomer generation. Herbology, hypnotherapy, naturopathic medicine, aromatherapy, dance therapy, and light therapy are just a few of these new healing alternatives that are gaining acceptance by even traditional medicine providers, perhaps because so many of today’s health care providers are baby boomers themselves.
Consumers of a national catalog distributor were used as subjects. A stratified random sampling approach was employed to ensure an equal representation of consumers from both age groups of interest. Three hundred questionnaires were sent to baby boomers (individuals 37 – 55 years old) and 309 to matures (individuals 56 and older). Two raffle cash prizes of US$50 were offered to consumers if they completed and returned the survey by a specified date. Preaddressed and stamped envelopes were included in the mailing to facilitate the return of questionnaires. One hundred and eighty-eight surveys were returned (31%), with 184 usable responses (83 baby boomers and 101 matures). Subjects ranged in age from 37 to 89 years old. The majority of subjects were Caucasian (98%), female (76%), and educated (90% of the sample having at least some college education). 5.2. Measures Subjects rated 25 health care statements on a seven-point Likert scare (1 –7). Endpoints were from strongly disagree (1) to strongly agree (7). Respondents were asked to indicate how much they agree or disagree with each of the health care issues. The health care statements were part of a larger pool of items that were used in another health
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Table 2 Alpha coefficients and factor loadings for scale items Factor
Alpha
Item
Factor loading
Participation/information seeking
.719
– I try to obtain additional information regarding my treatment and care from sources other than my doctors. Beyond what my doctor provides me I usually search for additional information regarding my treatment or care. I frequently gather information on the Internet regarding my health care treatment or diagnosis. – I prefer that my doctor make the final decisions regarding my care/treatment.a I seem to place my doctor on a pedestal, viewing his/her words as conclusive.a I do not question my doctor’s suggestions.a – I prefer my doctor use ‘‘mister’’ or ‘‘missus’’ when addressing me.a I prefer that my doctor call me by my first name. I prefer my doctor’s attire to be casual business dress rather than something more formal. I prefer to see my doctor wearing a suit/dress rather than casual clothes.a – I expect my doctor’s office hours to be flexible to meet my changing needs. I expect my doctor to accommodate my lifestyle by being flexible about when he/she might see me. I expect my doctor to have more flexible hours of operation than 9 a.m. to 5 p.m. – I am willing to try various types of ‘‘alternative medicine.’’ Traditional medicine is the only option I would consider.a I am open to trying aromatherapy. I cannot see myself trying herbology as a treatment supplement.a I am open to trying acupuncture if it were a recommended treatment.
–
Questioning
.636
Informality
.735
Flexibility
.876
Experimentation
a
.838
.817 .777 .667 – .693 .716 .552 – .804 .755 .732 .704 – .934 .885 .823 – .868 .803 .714 .706 .702
Reverse-coded questions.
than matures (mean = 4.65) [ F(1,182) = 16.91, P < .001]. Matures, on the other hand, seemed to view their doctor’s decisions as conclusive. Subjects’ open-ended responses support this finding. When asked what they like about their current doctor, many baby boomers responded their doctor was open to answering questions and discussing their treatment with them. For example, a 46-year-old female stated, ‘‘My doctor takes the time, no matter how busy he is, to listen to my opinions and answer any questions I might have.’’ Similarly, a 45-yearold female stated, ‘‘He takes his time with me. He sits and listens to me and answers all my questions. If I ask him something he does not know he will admit he does not know the answer, but will research it and get back to me.’’ Beyond simply questioning their health care providers, baby boomers also seemed to desire and appreciate collab-
orating in their care and treatment. For example, a 44-yearold woman noted, ‘‘My health care provider presents me with a range of treatment options. Once she explains each option I can then choose which is best for me.’’ This collaborative nature was lacking in the matures’ responses. Many matures stated that their health care provider listened to them and explained procedures, diagnoses, etc., however, very few noted a collaborative environment in their treatment. These responses add additional support for Hypothesis 2. Consistent with Hypothesis 3, there were significant differences in consumers’ desires for the degree of informality provided by their health care providers [ F(1,182) = 5.99, P < .05]. Baby boomers preferred more informality (mean = 5.02) than matures (mean = 4.53). In particular, the former were more likely to prefer being called by their first name and seeing their health care provider in casual attire, whereas the
Table 3 Group means and standard deviations for the health care dimensions
Baby boomers Matures Hypothesis supported P value
Participation/information seeking
Questioning
Informality
Flexibility
Experimentation
5.43 (1.42) 4.78 (1.56) Hypothesis 1 < .01
5.46 (1.23) 4.65 (1.42) Hypothesis 2 < .001
5.02 (1.34) 4.53 (1.35) Hypothesis 3 < .05
4.91 (1.44) 3.99 (1.67) Hypothesis 4 < .001
5.33 (1.48) 4.23 (1.49) Hypothesis 5 < .001
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latter preferred their doctor to address them as ‘‘mister’’ or ‘‘missus’’ and to wear more formal attire (e.g., dresses and suits). Consistent with this finding, a 76-year-old woman stated that what she liked the least about her health care provider was that ‘‘he addresses me by my first name.’’ Many baby boomers, on the other hand, noted that they liked their health care providers’ personable personalities. As expected, the changing nature of lifestyles in the Unites States (e.g., flextime, telecommuting, two-income families) necessitates the flexibility of health care providers for younger generations. In particular, baby boomers were more likely to expect and desire flexibility in their health care providers’ hours of operations (mean = 4.91) than matures (mean = 3.99) [ F(1,182) = 15.81, P < .001]. This result is consistent with Hypothesis 4. For example, a 54year-old female stated that what she like the most about her doctor was that she could contact him by e-mail and/or at his website. Other boomers mentioned their doctors’ flexible hours of operation (including both weekend and night appointments) or that they had their doctor’s home phone number for emergencies. Finally, consistent with Hypothesis 5, there was a significant difference in the acceptance of experimentation between age groups [ F(1,182) = 24.72, P < .001]. Baby boomers were more likely to try various types of alternative treatments (mean = 5.33) than matures (mean = 4.23). In particular, aromatherapy, herbology, and acupuncture were more acceptable forms of therapy to boomers than matures. This finding received the most support in the open-ended responses. Numerous baby boomers noted that they liked their doctor’s holistic body approach to medicine. For example, a 44-year-old woman stated that her doctor will recommend alternative care (massage and acupuncture) when appropriate, whereas a 53-year-old woman noted that her doctor was ‘‘an expert in noninvasive diagnosis, acupuncture, and the use of herbs— all of which have few, if any, harmful side effects.’’ These types of responses were widespread throughout baby boomers open-ended answers, yet only two or three matures noted that they appreciated their doctor’s acceptance of alternative medications.
7. Discussion People aged 65+ represent 12% of the U.S. population, but account for over one-third of America’s total personal health care expenditures. They visit a physician eight times a year compared to five visits by the general population. They are hospitalized over three times as often as the younger population, stay 50% longer, and use twice as many prescription drugs (Aging America, 1991). These older adults are core health care consumers and come from the older age group (matures) discussed in this study. At the same time, health care decisions are increasingly a joint decision made with and by children of the health care
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user. They assist in decisions regarding type of care, provider, and ancillary services. Each person’s health care preferences often reflect their generational values and no comparison of values between generations presents a greater dichotomy than between baby boomers and their parents (i.e., the matures in the current study). As such, the purpose of this paper was to explore whether generational values influence health care preferences. The results provide strong support for this assumption. For example, baby boomers are more likely to prefer participating with their doctor in their care and treatment than matures. The former want to know their options, have their questions answered, and then be able to make their own decisions regarding which treatment option is the best for their lifestyle. Doctors, nurses, long-care administrators and the like can expect to have less authority and influence on decisions as the boomers age and become more dependent on health care services. Additionally, health care providers will need to become more receptive to intensive questioning about procedures and medications. This trend holds true both for baby boomers seeking information for their parents (i.e., about a nursing home, medical procedure) and for the case when they make decisions about their own care and treatment. Baby boomers are more likely to prefer personable, informal health care providers than matures. Boomers have valued informality in their dress, hygiene, living habits, and general lifestyles since they were teens, thus health care providers need to embrace this informality to respond to their changing clientele. One way to embrace this change is for providers to have a coat and tie in the closet at all times for mature clients, yet when caring for boomer clients they can remove these articles of clothing to appear more relaxed. This fashion trend may also be reflected in health care providers’ promotional strategies. For example, physicians could be portrayed in business casual attire in advertisements directed at boomers, but portrayed in more formal dress for those ads directed at matures. Direct mailers aimed at assisting boomers with in-home health care provisions or assisted living communities should show doctors and nurses in informal dress. Similarly, broadcast messages could illustrate providers conversing with clients on a first-name basis. These types of age-directed promotions may be effective at targeting consumers and tapping into consumers’ value orientations. Boomers also desire flexibility in office hours. These respondents valued being able to reach their health care provider by e-mail and at home. Twenty-four-hour access, if needed, was desired and even expected among many boomers. To accommodate these consumers, physicians might need to employ staff members who answer basic email questions, develop websites with the answers to the most commonly asked questions, and provide clients with beepers/home numbers in case of emergency. Health care providers promoting such services to baby boomers would likely earn their patronage.
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Finally, the desire for alternative forms of therapy and a holistic approach to medicine are evident among the boomers. Herbology, acupuncture, and aromatherapy, just to name a few, are becoming acceptable forms of therapy. As the baby boomers age and require more health care services, physicians will need to explore these types of treatment options that are outside the realm of traditional medicine. Additionally, HMO’s will need to determine what alternative treatments are covered through health care plans and which ones are not. Service providers who differentiate themselves in terms of taking a holistic approach to medicine and embracing alternative forms of therapy are likely earn the respect of baby boomers.
8. Limitations Certain limitations of this study should be noted. First, the generalizability of the results might be limited to educated female Caucasians, since they were the majority of the respondents. A more diverse group of consumers would be beneficial for replicating the results. Second, the reliability for the questioning dimension was lower than the desired .70. Although some authors suggest that .60 or above is acceptable for exploratory research (Robinson et al., 1991), alternative measures for this construct should be considered. Third, this study assessed preferences for health care services and treatments and not actual behaviors. As noted by Fishbein and Ajzen (1975), preferences do not always result in actual behaviors. Therefore, the generational preferences noted in the current study might not necessarily translate into behavioral differences. Future research is needed to assess generational differences in actual health care behaviors and choices. Similarly, the preferences noted in the current study were thought to stem from generational value differences. However, a direct test of value differences was not employed. Instead, these values were operationalized in a health care context to assess consumers’ preferences for various services and treatments. Although it is generally agreed that attitudes are a reflection of one’s values (Katz, 1960), future research needs to explore whether differences between generations actually exist at the ‘‘value level’’ instead of inferring these differences from measurement at the ‘‘attitude/preference level.’’ Finally, the results are limited to baby boomer and mature respondents and do not include an assessment of younger respondents. With Generation X (individuals 19 – 36 years old in 2001) and Generation Y (consumers younger than Generation X) entering the workforce, health care decisions will become increasingly important to these consumers (Giles, 1994; Neuborne and Kerwin, 1999). As such, health care providers will need to understand their preferences regarding treatment and care in order to provide services to meet their needs as they age.
9. Directions for future research While the most viable segment of consumers for health care providers is clearly the matures addressed in this article, younger consumers, as noted above, will be a viable segment in years to come. Simply assuming that these consumers will have the same health care preferences and desires as today’s matures would be erroneous. As such, understanding younger consumers’ preferences for health care service and treatment should be investigated in the future to provide a full array of generational differences in the health care context. Generation differences were explored in the current study; however, finer age groupings might be practical in other health care contexts. For example, grouping consumers in ‘‘cohorts’’ might prove fruitful (Meredith and Schewe, 1994; Schewe et al., 2000). Cohorts are similar to generations in that both are rooted in the process of socialization (i.e., values are formed as a result of the larger social, political, and technological environment in which they came of age); however, cohorts are not limited to 20– 25-year spans. Instead, their length depends on significant historical events experienced (Ryder, 1965). These events might split one ‘‘generational’’ grouping into two ‘‘cohorts.’’ For example, the boomer generation is often broken down into two distinct cohorts: leading edge and trailing edge boomers (Schewe et al., 2000) Some of the differences between these subgroups may hold interesting and important implications for health care marketers. For example, the trailing-edge boomers, aged 37– 46 in 2001, faced a difficult economic environment as they came of age after the energy crisis of 1973. Consequently, they may feel more deprived financially than their older boomer counterparts. This difference might have implications for elective health care procedures such as cosmetic and laser eye surgery, with trailing-edge boomers less likely to engage in elective surgeries than leading-edge boomers. Similarly, within the generation of matures, the critical health care segment, there are three proposed cohorts: Depression-scarred, World War II, and the post-War cohort (Schewe and Meredith, 1994). Significant differences might also exist between these groups in their preferences for health care services. For instance, Depression matures may be more concerned with costs of medical care than post-Wars, since the former came of age during the Depression. World War II members who sought comfort in the solace of others during the war may prefer more social interaction when incurring a stay in a hospital than other matures. Other differences might lie in deep-seated values such as death, mortality, spirituality, and religion. Certainly, these values impact the delivery of health care. As these examples illustrate, each cohort may possess a unique set of values and preferences that could translate into unique preferences in the health care context. The task of marketers, therefore, is to determine which age groupings (or other segmentation
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variables) yield practical and significant insights into the differences between consumers’ preferences for health care service and treatment. Determining the degree of information search explained by limited capacity, experience level, and socialization models is also needed in the future. All these models state that older consumers will search for information less than younger consumers (under right conditions), however each note different reasons for this finding. The current study posited this difference was due to the environment in which each age group was socialized. Future research is needed to tease apart the variation in information search explained by each model. Another area that warrants future research includes exploring the degree of intergenerational participation in health care decisions. For example, do children of older adults determine their parents’ health care provider, the procedures they will undergo, and/or the facility in which they will reside? Or are these decisions in the domain of the parent/patient? Determining who are the primary initiators, influencers, and evaluators of health care would aid providers in targeting each more effectively. Finally, future research might look at how this study’s findings can be translated into specific health care provisions. For example, what exactly constitutes informality in the health care setting? Here, we suggest communication and attire are two potential areas of informality, but does one’s desire for informality extend to the atmosphere of the facility? Should examination and hospital room walls be adorned with whimsical murals rather than staid institutional wall colorings if targeting boomers? Or should ‘‘funky’’ music be piped into birthing rooms for aging boomers? These are just some of the issues raised from the results of the current study that lend themselves to further investigation. In sum, the goal of this paper was to illustrate that the health care industry must acknowledge differences in values and preferences among clients, their children, and future generations of health care patients. By understanding and embracing these differences, health care providers will be better equipped to satisfy the preferences of each group, thus providing better care for today’s mature consumers, tomorrow’s boomers, and future generations to come.
Acknowledgments The authors thank Eric N. Berkowitz, Thomas Brashear, Charles H. Noble, and the editors of the special edition for their thoughtful comments on earlier versions of this article. We also gratefully acknowledge Commonwealth College for funding this research.
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References Aging America: trends and projections. Prepared by the U.S. Senate Special Committee on Aging, the American Association of Retired Persons, The Federal Council on the Aging, and the U.S. Administration on Aging, 1991. Auchinclo K. The 60s. Newsweek 1969;12 – 9 (December 29). Beatty SE, Smith SM. External search effort: an investigation across several product categories. J Consum Res 1987;14:83 – 95 (June). Cole CA, Balasubramanian SK. Age differences in consumers’ search for information: public policy implications. J Consum Res 1993;20: 157 – 70 (June). Dolinsky AL, Stinerock R. Cultural affiliation and the importance of health care attributes. Mark Health Serv 1998;29 – 37 (Spring). Dove RW. Exploring the selection of a nursing home: who, what, and how. J Health Care Mark 1986;6:63 – 6 (June). Fishbein M, Ajzen I. Belief, attitude, intention, and behavior. Reading (MA): Addison-Wesley, 1975. Furse DH, Punj GN, Stewart DW. A typology of individual search strategies among purchasers of new automobiles. J Consum Res 1984;10: 417 – 31 (March). Giles J. Generalizations X. Newsweek 1994;63 – 71 (June 6). Goslin DA. Handbook of socialization theory and research. Chicago (IL): Rand McNally, 1969. Gremillion J. Consumer, heal thyself. Mediaweek 1996;26 (June 17). Holbrook M. Nostalgia and consumption preferences: some emerging patterns of consumer tastes. J Consum Res 1993;20:245 – 56. Holbrook M, Schindler RM. Some exploratory findings on the development of musical tastes. J Consum Res 1989;16:119 – 24. Holbrook M, Schindler RM. Age, sex, and attitude toward the past as predictors of consumers’ aesthetic tastes for cultural products. J Mark Res 1994;31:412 – 22. Katz D. The functional approach to the study of attitudes. Public Opin Q 1960;24:163 – 91 (Summer). Koerner MM. Sacredness in service exchanges with medical underserved patients. Proc Adv Health Care Res 1994;110 – 20. Meredith G, Schewe C. The power of cohorts. Am Demogr 1994;22 – 31 (December). Moschis GP, Moore RL. Decision making among the young: a socialization perspective. J Consum Res 1979;6:101 – 12. Neuborne E, Kerwin K. Generation Y. Bus Week 1999;81 – 8 (February 15). Rice F. Making generational marketing come of age. Fortune. 1995;110 – 2 (June). Rindfleisch A. Cohort generational influences on consumer socialization. In: Allen CT, John DR, editors. Advances in consumer research, vol. 21. Provo (UT): Association for Consumer Research, 1994. p. 470 – 6. Robinson JP, Shaver PR, Wrightsman LS. Criteria for scale selection and evaluation. In: Robinson JP, Shaver PR, Wrightsman LS, editors. Measures of personality and social psychological attitudes. San Diego (CA): Academic Press, 1991. Ryder NB. The cohort as a concept in the study of social change. Am Sociol Rev 1965;30:843 – 61. Schewe CD, Balazs AL. Role transitions in older adults: a marketing opportunity. Psychol Mark 1992;9:85 – 99. Schewe CD, Meredith GE. Digging deep to delight the mature adult consumer. Mark Manag 1994;3:20 – 35 (Winter). Schewe CD, Meredith GE, Noble SM. Defining moments: segmenting by cohorts. Mark Manag 2000;9:48 – 53 (Fall). Tudor K, Carley SS. Time to choose. J Health Care Mark 1995;15:48 – 53 (Summer). Ward S. Consumer socialization. J Consum Res 1974;2:1 – 16. Watson RT, Berthon P, Pitt LF, Zinkhan GM. Electronic commerce: the strategic perspective. Fort Worth (TX): Harcourt Press, 2000.
Preferences in health care service and treatment A generational perspective Stephanie M. Noblea,*, Charles D. Scheweb, Michelle Kuhrc a
School of Business Administration, University of Mississippi, University, MS 38677, USA b University of Massachusetts-Amherst, Amherst MA 010032, USA c Time Inc. Home Entertainment, New York, NY 10019, USA
Abstract The American population is changing from a predominantly youth-driven marketplace to a middle- and older-aged marketplace. This trend is resulting in a greater demand for health care-related products and services and greater competition among health care providers. Increased competition among health care providers heightens the need for marketers to target their clients effectively. However, targeting health care clients is difficult because the recipient of the care is often not the decision-maker. For instance, the patients’ children often make health care decisions. Marketers, then, need to understand both parties’ preferences for health care treatment and service. These preferences often reflect underlying values, and parents and children sometimes possess different values. The goal of the current study, therefore, is to illustrate that generational differences in values influence health care preferences. Based on a national probability sample of 184 consumers the results showed that generational values have a significant impact on health care preferences. D 2002 Elsevier Inc. All rights reserved. Keywords: Generations; Baby boomers; Elderly
1. Introduction The American population is changing from a predominantly youth-driven marketplace to a middle- and olderaged marketplace (Schewe and Meredith, 1994). Two factors appear to be leading this trend. First, Americans are living longer than ever before, causing a senior boom. Second, baby boomers, the 76 million people born between 1946 and 1964, are beginning to enter their fifties (Schewe and Balazs, 1992). This changing demographic profile has important implications for health care marketers. In particular, there will be a growing demand for health care-related products and services as the boomers enter senior status. Additionally, heightened competition among health care providers increases the need for marketers to target clients effectively. Effective marketing entails understanding the factors that influence consumers’ health care preferences. Assessing
* Corresponding author. Tel.: +1-662-915-5461; fax: +1-662-9155821. E-mail address: [email protected] (S.M. Noble). 0148-2963/$ – see front matter D 2002 Elsevier Inc. All rights reserved. doi:10.1016/S0148-2963(02)00354-5
these factors in the health care industry is difficult, however, because the recipient of the health care is often not the decision-maker (Tudor and Carley, 1995). For example, Dove (1986) found that the resident’s children made over 40% of nursing home decisions. Understanding the different needs and preferences of each decision-maker, therefore, is a key task for health care marketers. Values are often cited as influencing consumers’ preferences and purchase decisions; however, less is known about how values influence health care decisions (Dolinsky and Stinerock, 1998). We propose that age-related values influence preferences for health care service and treatment. As such, the goal of this paper is to test whether generational differences in values influence these preferences. The two generations of interest for the current study are baby boomers (those 37 – 55 years old in 2001) and what we refer to as ‘‘matures’’ (those 56 and older in 2001). The dependent variables consist of five health care dimensions that were created to tap into the proposed value differences between baby boomers and mature. These dimensions include: (1) participation/information seeking—the degree to which consumers participate in their health care plan and treatment by seeking out additional information (beyond
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what their doctors give them), (2) questioning—the degree to which consumers question their health care providers regarding their care and treatment, (3) informality—the degree to which consumers desire informal attire (i.e., no suit and tie) and communications (i.e., being on a first-name basis) with their health providers, (4) flexibility—the degree to which consumers expect flexibility in scheduling appointments with health care providers, and (5) experimentation— consumers’ preferences for experimenting with alternative forms of health care treatments. A survey method is used to test whether generational differences exist for these five health care dimensions. The remainder of the paper is organized as follows. First, the process of socialization is presented to illustrate that the social, political, economic, and technological environments in which consumers come of age create unique generational values and behaviors. Second, the characteristics of the generations included in the current study are reviewed to create hypotheses. After presenting the results, the directions for future research are discussed.
2. The socialization of consumers Socialization refers to the process whereby individuals acquire various cognitions, values, attitudes, and behaviors (Goslin, 1969; Ward, 1974). This learning can take place as a result of modeling, reinforcement, and other types of social interactions at the individual level (Moschis and Moore, 1979). However, socialization can also occur at a macro level. That is, consumers acquire values, attitudes, and beliefs as a result of the larger political and social environment in which they came of age. This shared history produces unique values and behaviors that create similarities across consumers (Meredith and Schewe, 1994; Rindfleisch, 1994). Accounting for socialization at both the micro and macro level allows for differences between similarly aged consumers (due to family rearing, ethnic, or religious influences), yet can also explain general similarities between consumers within age groups (due to social or political influences). For example, baby boomers are generally characterized as the ‘‘me-generation’’ due to their individualistic tendencies, skepticism, and concern for self-indulgence. However, these similarities do not preclude other differences between members of this group. Similarly, individuals who came of age during the Great Depression tend to be compulsive savers and risk averse throughout their lives because they experienced great economic hardship in their early adulthood. At the same time, they may be very different in other aspects of their lives. Shared experiences can occur at many levels. National, regional, and religious events can influence consumers. For example, the assassination of John F. Kennedy occurred at a national level and likely influenced all Americans, especially those in young adulthood (a time frame in which individuals are thought to be impressionable to national and
world events), whereas the 1995 assassination of Yitzhak Rabin, Israel’s prime minister, likely influenced the Jewish community more than other religious groups. Similarly, the San Francisco earthquake of 1990 or the Oklahoma City Bombing of 1994 might be classified as a regional event, whereas many note that lower socioeconomic class African American men might have been influenced the most by Vietnam since they disproportionately fought in the conflict. As these examples illustrate, shared experiences can occur at many levels. The influence of national, regional, and religious events on consumers’ socialization processes is thought to be most prevalent during young adulthood. Although ‘‘young adulthood’’ is defined fairly broadly, Holbrook and Schindler (1989) found that consumers are most prone to the socialization of music around 23 years of age and movie stars at 14 years of age (Holbrook and Schindler, 1994). Similarly, the socialization of preferences for apparel occurs in young adulthood. When asked to rate their preferences for pictures exemplifying various types of women’s apparel over the decades, men showed the most preference for apparel that women were wearing when they (the men) were around 24 years of age (Holbrook, 1993). As these examples illustrate, the socialization of consumers’ preferences and attitudes spans a range of years. However, within this general period of development, consumers are thought to be susceptible to socialization processes at the macro level (e.g., national, world, and regional events). As such, age becomes a proxy variable for segmenting consumers into groups of consumers that shares common preferences, values, beliefs, and behaviors. More specifically, in the current study, age is posited to influence consumers’ health care preferences. Consumers within specified age groups, also referred to as generations (see below), should have experienced similar national and world events in their early adulthood, such that these events influenced the formation of their attitudes and values, and ultimately their preferences for health care service and treatment.
3. Generational segmentation One-way marketers can segment and target consumers is by their age. As stated above, similarly aged consumers who experienced common social, political, economic, and technological environments share similarities in their values and behaviors. This shared history and resulting commonality in values and behaviors is the basis for segmenting by age. One age-related classification is segmenting by generations. Generations are usually defined by consumers’ years of births and last approximately 20 –25 years in length, roughly the time it takes a person to grow up and have children (Rice, 1995). Generational groupings are often useful in segmenting consumers because each generation is thought to have distinct lifestyles. In particular, the
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generations commonly cited are Generation X, baby boomers, and matures. The current study examines differences between the two older generations (baby boomers and matures) and excludes Generation X because health care needs and issues were not thought to be relevant or prominent to these consumers given their age. The baby boom generation refers to those individuals born between the end of World War II (1946) and 1964. In 2001, these individuals are 37– 55 years old. They experienced John F. Kennedy’s assassination, became responsible adults during the Vietnam War, lived through Bobby Kennedy, Malcolm X, and Martin Luther King’s assassinations, witnessed the first man to walk on the moon, and suffered through Watergate and Nixon’s resignation. They questioned authority, began nationwide protests, and started the ‘‘hippie movement’’ (Auchinclo, 1969; Meredith and Schewe, 1994). The matures, also referred to as traditionalists or the depression/silent generation, are roughly individuals 56 and over. They witnessed the Great Depression, World War II, and the rebuilding of America after the war. They listened to the sounds of Glen Miller, Tommy Dorsey, Benny Goodman, and the Ink Spots. As a group, they are thought to accept authority, leadership, and structure. They won the war as a team. Thus, they believe in a sense of ‘‘we’’ over a sense of ‘‘me.’’ Finer age groupings are often helpful in the creation of marketing strategies. In the current study, it is hypothesized that generational differences yield significant and practical results that are beneficial for health care providers and marketers. As such, the age groupings used in the current study fall along generational lines.
4. Hypotheses In the previous sections, the process of socialization and the potential for unique age-related values formed from socialization at the macro level was reviewed to illustrate that consumers across generational lines are likely to have differences in values, and hence differences in preferences (due to the different social/political environment in which each group came of age). The following section builds on this review by hypothesizing value differences for the two generational groupings included in this study (see Table 1 for a comparison of generational values). The five value differences include: (1) authority vs. participation/information seeking, (2) leadership vs. quesTable 1 A comparison of generational values Mature values
Baby boomer values
Authority Institutional leadership Formality Structure Stability
Participation/information seeking Questioning Informality Flexibility Experimentation
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tioning, (3) formality vs. informality, (4) structure vs. flexibility, and (5) stability vs. experimentation. A brief review of the environment in which each generation was socialized will be presented to illustrate how these value differences might have emerged. These value differences are then applied specifically to the health care context to illustrate how consumers’ preferences in health care service and treatment (i.e., the dependent variables) stem from generational values. Only by understanding and embracing each generation’s preferences will health care providers be able to provide better care for these clients. 4.1. Authority vs. participation and information seeking Matures who grew up during the Depression and World War II respected authority. They took orders from superiors in order to work and/or fight to survive. Taking orders was their way of life and still is. On the other hand, boomers expect to participate in all decisions. They are not known for respecting authority and will not want others to make their decisions for them. Instead, boomers are likely to seek out information, beyond what authority figures give them in order to make informed, individualistic decisions. Other authors have also shown that older consumers search for information less than younger consumers do. For example, a review of the consumer behavior literature by Beatty and Smith (1987) found that older consumers are less likely to obtain information about products when making a brand choice decision than younger consumers. Cole and Balasubramanian (1993) found similar results. In both aided and unaided decision-making tasks, older consumers searched less for nutritional information than younger consumers did. One explanation for these age-related differences in information search involves the working-memory capacity of older consumers. Working memory, a part of the information processing system, is divided into storage and processing memory. There is a limited amount of working memory, therefore tradeoffs are constantly made between how much information can be stored in short-term memory and how much can be processed or manipulated at the same time. As consumers age, their capacity for working memory is thought to decline. Older subjects become taxed easier when searching for information, therefore, search less when problem solving and making purchase and brand decisions than younger consumers. Another explanation often given for this difference in information search is consumers’ familiarity and experience with brands and products. Older consumers may have more experience and knowledge in certain product categories than younger consumers, therefore the former can rely on this stored information and search less for new information when making a purchase decision. This difference in experience level was used to explain one cluster of automotive purchasers in a study conducted by Furse et al. (1984). Specifically, older consumers were thought to search
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less for automobiles when making a purchase than younger consumers because the former could use their stored knowledge and experience with past purchases to aid them in their current purchase. Both of these explanations are plausible reasons for differences in search behavior between older and younger consumers and are consistent with the directionality of our hypothesis. We suggest a third possible reason, however, for why consumers might differentially seek out information. Specifically, searching for information might be rooted in younger consumers’ desires to participate in any and all decisions rather than accept the authority of others. This view does not contradict the limited-working capacity model or consumers’ experience and knowledge explanations, however does suggest another plausible influence on consumers’ desires to seek out information. Applying this to the health care context, we believe mature patients will be much more apt to accept the prescription of a health care provider (i.e., search less for additional information regarding their care and treatment) while boomer patients will be more likely to request and seek out additional information about the health care issue. This is true also when boomers are influencers, deciders, and buyers of health care for their parents. Doctors, nurses, long-care care administrators, and the like can expect to have less authority and influence on the ultimate decisions when boomers are involved. Hypothesis 1: Baby boomers are more likely to seek out additional information (beyond what their doctors give them) regarding their care and treatment than matures. 4.2. Leadership vs. questioning Boomers have always questioned. They are the ones who challenged the government over its participation in the Vietnam War. They are the ones who said ‘‘Never trust anyone over thirty.’’ This type of skepticism is growing within the American population. That is, Americans have become increasingly skeptical about advertising, corporate activities, product claims, and the government, just to name a few examples. This questioning and antiestablishment mentality is one aspect of a movement referred to as postmodernism. Postmodernism seeks to debunk previous ideologies, philosophies, and beliefs by questioning their very existence (Watson et al., 2000). Boomers exemplify postmodernism tendencies, presumably as a result of the social and political environment in which they came of age (e.g., Vietnam, Stonewall Riots, Civil Rights movement). In addition to their questioning nature, Boomers are the most educated of any generation ever in the United States. Hence, they are armed with information to formulate solid, substantive questions. In the health care context this forces health care providers to be ready with answers, even when boomers are questioning the care of their parents. Matures, on the other hand, have accepted the voice of authority.
Doctors, to these consumers, have been viewed as god-like and the health care exchange as a sacred experience (Koerner, 1994). With matures, health care providers consistently have been put on a leadership pedestal; their word has always been final. Hypothesis 2: Boomers are more likely to question their health care providers regarding their care and treatment than matures. 4.3. Formality vs. informality Older adults embrace formality while boomers have been the forces behind casual business dress. Matures came of age during World War II, a time when men and women had undying respect for persons in military uniforms. Status, authority, and social location were all reflected in dress, style, and mannerisms—and still are for this generation. Boomers, on the other hand, broke the rules of their parents with their dress, hygiene, living habits, and general lifestyle. While such ‘‘coming of age’’ extremes are generally gone, the value of informality lives on for this generation. In the health care context, matures’ desires for formality would be exemplified by their wish to be called ‘‘mister’’ or ‘‘missus’’ by their doctors. Additionally, they should prefer a more formal dress (suit, dress, sport coat, and/or tie) on the part of their health care providers and administrators. Boomers would feel just the opposite. They would prefer being on a first-name basis with their provider and seeing them in casual attire. Hypothesis 3: Baby boomers are more likely to prefer informal attire and communications with their health care providers than matures. 4.4. Structure vs. flexibility Matures came of age at a time when structured lifestyles were the norm. People worked from 9 a.m. to 5 p.m., ate dinner as a family, took 2 weeks of vacation, and so forth. Boomers came of age with different norms and are now used to working in flextime, telecommuting, and eating on the run to provide more time for experiencing personal enjoyment. In assisted-living retirement homes, today’s residents who tend to be in their 70s welcome planned activities and set times for meals, social gatherings, and outside trips. It meshes with their ideals for a way of life. When boomers get to that stage, such facilities will have to dramatically change to accommodate a new set of preferences. Boomers will demand alternatives. This thinking will stretch to other health care contexts such as visiting hours in hospitals, clinics, and doctors’ office hours. Health care providers will have to increase their flexibility in scheduling appointments to satisfy this new breed of patient/consumer.
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Hypothesis 5: Boomers are more likely to prefer experimenting with alternative forms of health care treatments than matures.
care study. Additionally, subjects completed two openended questions that addressed their likes and dislikes about their current doctor (where ‘‘doctor’’ referred to their general practitioner). Due to the novelty of this research area all of the health care items under investigation had not received prior research attention. As such, new health care measures were created for this study and the larger one cited above. Items were generated based on a review of related literature, insights from informal interviews with aging health care patients, and discussions with academic researchers. For the current study, an initial pool of 25 items related to five constructs was generated from these sources. The items were pretested with 10 consumers ranging from 39 to 84 years old to assess their understanding and interpretation of statements. The 25 items were analyzed through a principal component analysis to purify the scales. Based on an assessment of item path coefficients, residual terms, and the overall Cronbach’s alpha for the factors, seven items were deleted. The remaining 18 items yielded a five-factor solution (varimax rotation) based on the typical 1.0 eigenvalue cutoff. These five factors explained 67% of the variance in the variables. The final item set and factor properties are shown in Table 2.
5. Methods
6. Results
5.1. Subjects
A multivariate analysis of variance (MANOVA) was performed using subjects’ mean scores for the five health care dimensions as the dependent variable and subjects’ age grouping as the independent variable. Multivariate tests indicated overall differences for the age effect were significant (Wilks’ Lambda = 10.238, P < .001). Therefore, age of respondents appears to have an influence on their health care desires. To determine the extent of these differences each of the five health care factors were examined. The results are consistent with expectations. All of the factors yielded significant results in the expected direction. See Table 3 for group means, standard deviations, and P values for each health care dimension. Consistent with Hypothesis 1, baby boomers were more likely to seek additional information about their care and treatment from sources other their doctor (mean = 5.43) than matures (mean = 4.78) [ F(1,182) = 8.56, P < .01]. This additional information should allow boomers to participate in their care and treatment decisions by being fully aware of the options available to them. Matures, on the other hand, appear more willing to accept the prescription of the health care provider without trying to find additional information regarding their care or treatment. Hypothesis 2 stated that baby boomers would question their health care providers’ decisions and suggestions more than matures. Consistent with expectations boomers were more likely to question their doctors (mean = 5.46)
Hypothesis 4: Baby boomers expect more flexibility in scheduling appointments with health care providers than matures. 4.5. Stability vs. experimentation Finally, boomers were the generation to experiment with drugs to increase their pleasure. This culture of experimentation will foster a much greater acceptance of innovative forms of medicine. We are beginning to see this with the explosion of ‘‘new age’’ and ‘‘alternative medicines’’ that are flooding the marketplace. A recent Harvard study reported that one-third of Americans have explored health care options outside traditional medicine (Gremillion, 1996). These incidences gravitate heavily to the boomer generation. Herbology, hypnotherapy, naturopathic medicine, aromatherapy, dance therapy, and light therapy are just a few of these new healing alternatives that are gaining acceptance by even traditional medicine providers, perhaps because so many of today’s health care providers are baby boomers themselves.
Consumers of a national catalog distributor were used as subjects. A stratified random sampling approach was employed to ensure an equal representation of consumers from both age groups of interest. Three hundred questionnaires were sent to baby boomers (individuals 37 – 55 years old) and 309 to matures (individuals 56 and older). Two raffle cash prizes of US$50 were offered to consumers if they completed and returned the survey by a specified date. Preaddressed and stamped envelopes were included in the mailing to facilitate the return of questionnaires. One hundred and eighty-eight surveys were returned (31%), with 184 usable responses (83 baby boomers and 101 matures). Subjects ranged in age from 37 to 89 years old. The majority of subjects were Caucasian (98%), female (76%), and educated (90% of the sample having at least some college education). 5.2. Measures Subjects rated 25 health care statements on a seven-point Likert scare (1 –7). Endpoints were from strongly disagree (1) to strongly agree (7). Respondents were asked to indicate how much they agree or disagree with each of the health care issues. The health care statements were part of a larger pool of items that were used in another health
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Table 2 Alpha coefficients and factor loadings for scale items Factor
Alpha
Item
Factor loading
Participation/information seeking
.719
– I try to obtain additional information regarding my treatment and care from sources other than my doctors. Beyond what my doctor provides me I usually search for additional information regarding my treatment or care. I frequently gather information on the Internet regarding my health care treatment or diagnosis. – I prefer that my doctor make the final decisions regarding my care/treatment.a I seem to place my doctor on a pedestal, viewing his/her words as conclusive.a I do not question my doctor’s suggestions.a – I prefer my doctor use ‘‘mister’’ or ‘‘missus’’ when addressing me.a I prefer that my doctor call me by my first name. I prefer my doctor’s attire to be casual business dress rather than something more formal. I prefer to see my doctor wearing a suit/dress rather than casual clothes.a – I expect my doctor’s office hours to be flexible to meet my changing needs. I expect my doctor to accommodate my lifestyle by being flexible about when he/she might see me. I expect my doctor to have more flexible hours of operation than 9 a.m. to 5 p.m. – I am willing to try various types of ‘‘alternative medicine.’’ Traditional medicine is the only option I would consider.a I am open to trying aromatherapy. I cannot see myself trying herbology as a treatment supplement.a I am open to trying acupuncture if it were a recommended treatment.
–
Questioning
.636
Informality
.735
Flexibility
.876
Experimentation
a
.838
.817 .777 .667 – .693 .716 .552 – .804 .755 .732 .704 – .934 .885 .823 – .868 .803 .714 .706 .702
Reverse-coded questions.
than matures (mean = 4.65) [ F(1,182) = 16.91, P < .001]. Matures, on the other hand, seemed to view their doctor’s decisions as conclusive. Subjects’ open-ended responses support this finding. When asked what they like about their current doctor, many baby boomers responded their doctor was open to answering questions and discussing their treatment with them. For example, a 46-year-old female stated, ‘‘My doctor takes the time, no matter how busy he is, to listen to my opinions and answer any questions I might have.’’ Similarly, a 45-yearold female stated, ‘‘He takes his time with me. He sits and listens to me and answers all my questions. If I ask him something he does not know he will admit he does not know the answer, but will research it and get back to me.’’ Beyond simply questioning their health care providers, baby boomers also seemed to desire and appreciate collab-
orating in their care and treatment. For example, a 44-yearold woman noted, ‘‘My health care provider presents me with a range of treatment options. Once she explains each option I can then choose which is best for me.’’ This collaborative nature was lacking in the matures’ responses. Many matures stated that their health care provider listened to them and explained procedures, diagnoses, etc., however, very few noted a collaborative environment in their treatment. These responses add additional support for Hypothesis 2. Consistent with Hypothesis 3, there were significant differences in consumers’ desires for the degree of informality provided by their health care providers [ F(1,182) = 5.99, P < .05]. Baby boomers preferred more informality (mean = 5.02) than matures (mean = 4.53). In particular, the former were more likely to prefer being called by their first name and seeing their health care provider in casual attire, whereas the
Table 3 Group means and standard deviations for the health care dimensions
Baby boomers Matures Hypothesis supported P value
Participation/information seeking
Questioning
Informality
Flexibility
Experimentation
5.43 (1.42) 4.78 (1.56) Hypothesis 1 < .01
5.46 (1.23) 4.65 (1.42) Hypothesis 2 < .001
5.02 (1.34) 4.53 (1.35) Hypothesis 3 < .05
4.91 (1.44) 3.99 (1.67) Hypothesis 4 < .001
5.33 (1.48) 4.23 (1.49) Hypothesis 5 < .001
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latter preferred their doctor to address them as ‘‘mister’’ or ‘‘missus’’ and to wear more formal attire (e.g., dresses and suits). Consistent with this finding, a 76-year-old woman stated that what she liked the least about her health care provider was that ‘‘he addresses me by my first name.’’ Many baby boomers, on the other hand, noted that they liked their health care providers’ personable personalities. As expected, the changing nature of lifestyles in the Unites States (e.g., flextime, telecommuting, two-income families) necessitates the flexibility of health care providers for younger generations. In particular, baby boomers were more likely to expect and desire flexibility in their health care providers’ hours of operations (mean = 4.91) than matures (mean = 3.99) [ F(1,182) = 15.81, P < .001]. This result is consistent with Hypothesis 4. For example, a 54year-old female stated that what she like the most about her doctor was that she could contact him by e-mail and/or at his website. Other boomers mentioned their doctors’ flexible hours of operation (including both weekend and night appointments) or that they had their doctor’s home phone number for emergencies. Finally, consistent with Hypothesis 5, there was a significant difference in the acceptance of experimentation between age groups [ F(1,182) = 24.72, P < .001]. Baby boomers were more likely to try various types of alternative treatments (mean = 5.33) than matures (mean = 4.23). In particular, aromatherapy, herbology, and acupuncture were more acceptable forms of therapy to boomers than matures. This finding received the most support in the open-ended responses. Numerous baby boomers noted that they liked their doctor’s holistic body approach to medicine. For example, a 44-year-old woman stated that her doctor will recommend alternative care (massage and acupuncture) when appropriate, whereas a 53-year-old woman noted that her doctor was ‘‘an expert in noninvasive diagnosis, acupuncture, and the use of herbs— all of which have few, if any, harmful side effects.’’ These types of responses were widespread throughout baby boomers open-ended answers, yet only two or three matures noted that they appreciated their doctor’s acceptance of alternative medications.
7. Discussion People aged 65+ represent 12% of the U.S. population, but account for over one-third of America’s total personal health care expenditures. They visit a physician eight times a year compared to five visits by the general population. They are hospitalized over three times as often as the younger population, stay 50% longer, and use twice as many prescription drugs (Aging America, 1991). These older adults are core health care consumers and come from the older age group (matures) discussed in this study. At the same time, health care decisions are increasingly a joint decision made with and by children of the health care
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user. They assist in decisions regarding type of care, provider, and ancillary services. Each person’s health care preferences often reflect their generational values and no comparison of values between generations presents a greater dichotomy than between baby boomers and their parents (i.e., the matures in the current study). As such, the purpose of this paper was to explore whether generational values influence health care preferences. The results provide strong support for this assumption. For example, baby boomers are more likely to prefer participating with their doctor in their care and treatment than matures. The former want to know their options, have their questions answered, and then be able to make their own decisions regarding which treatment option is the best for their lifestyle. Doctors, nurses, long-care administrators and the like can expect to have less authority and influence on decisions as the boomers age and become more dependent on health care services. Additionally, health care providers will need to become more receptive to intensive questioning about procedures and medications. This trend holds true both for baby boomers seeking information for their parents (i.e., about a nursing home, medical procedure) and for the case when they make decisions about their own care and treatment. Baby boomers are more likely to prefer personable, informal health care providers than matures. Boomers have valued informality in their dress, hygiene, living habits, and general lifestyles since they were teens, thus health care providers need to embrace this informality to respond to their changing clientele. One way to embrace this change is for providers to have a coat and tie in the closet at all times for mature clients, yet when caring for boomer clients they can remove these articles of clothing to appear more relaxed. This fashion trend may also be reflected in health care providers’ promotional strategies. For example, physicians could be portrayed in business casual attire in advertisements directed at boomers, but portrayed in more formal dress for those ads directed at matures. Direct mailers aimed at assisting boomers with in-home health care provisions or assisted living communities should show doctors and nurses in informal dress. Similarly, broadcast messages could illustrate providers conversing with clients on a first-name basis. These types of age-directed promotions may be effective at targeting consumers and tapping into consumers’ value orientations. Boomers also desire flexibility in office hours. These respondents valued being able to reach their health care provider by e-mail and at home. Twenty-four-hour access, if needed, was desired and even expected among many boomers. To accommodate these consumers, physicians might need to employ staff members who answer basic email questions, develop websites with the answers to the most commonly asked questions, and provide clients with beepers/home numbers in case of emergency. Health care providers promoting such services to baby boomers would likely earn their patronage.
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Finally, the desire for alternative forms of therapy and a holistic approach to medicine are evident among the boomers. Herbology, acupuncture, and aromatherapy, just to name a few, are becoming acceptable forms of therapy. As the baby boomers age and require more health care services, physicians will need to explore these types of treatment options that are outside the realm of traditional medicine. Additionally, HMO’s will need to determine what alternative treatments are covered through health care plans and which ones are not. Service providers who differentiate themselves in terms of taking a holistic approach to medicine and embracing alternative forms of therapy are likely earn the respect of baby boomers.
8. Limitations Certain limitations of this study should be noted. First, the generalizability of the results might be limited to educated female Caucasians, since they were the majority of the respondents. A more diverse group of consumers would be beneficial for replicating the results. Second, the reliability for the questioning dimension was lower than the desired .70. Although some authors suggest that .60 or above is acceptable for exploratory research (Robinson et al., 1991), alternative measures for this construct should be considered. Third, this study assessed preferences for health care services and treatments and not actual behaviors. As noted by Fishbein and Ajzen (1975), preferences do not always result in actual behaviors. Therefore, the generational preferences noted in the current study might not necessarily translate into behavioral differences. Future research is needed to assess generational differences in actual health care behaviors and choices. Similarly, the preferences noted in the current study were thought to stem from generational value differences. However, a direct test of value differences was not employed. Instead, these values were operationalized in a health care context to assess consumers’ preferences for various services and treatments. Although it is generally agreed that attitudes are a reflection of one’s values (Katz, 1960), future research needs to explore whether differences between generations actually exist at the ‘‘value level’’ instead of inferring these differences from measurement at the ‘‘attitude/preference level.’’ Finally, the results are limited to baby boomer and mature respondents and do not include an assessment of younger respondents. With Generation X (individuals 19 – 36 years old in 2001) and Generation Y (consumers younger than Generation X) entering the workforce, health care decisions will become increasingly important to these consumers (Giles, 1994; Neuborne and Kerwin, 1999). As such, health care providers will need to understand their preferences regarding treatment and care in order to provide services to meet their needs as they age.
9. Directions for future research While the most viable segment of consumers for health care providers is clearly the matures addressed in this article, younger consumers, as noted above, will be a viable segment in years to come. Simply assuming that these consumers will have the same health care preferences and desires as today’s matures would be erroneous. As such, understanding younger consumers’ preferences for health care service and treatment should be investigated in the future to provide a full array of generational differences in the health care context. Generation differences were explored in the current study; however, finer age groupings might be practical in other health care contexts. For example, grouping consumers in ‘‘cohorts’’ might prove fruitful (Meredith and Schewe, 1994; Schewe et al., 2000). Cohorts are similar to generations in that both are rooted in the process of socialization (i.e., values are formed as a result of the larger social, political, and technological environment in which they came of age); however, cohorts are not limited to 20– 25-year spans. Instead, their length depends on significant historical events experienced (Ryder, 1965). These events might split one ‘‘generational’’ grouping into two ‘‘cohorts.’’ For example, the boomer generation is often broken down into two distinct cohorts: leading edge and trailing edge boomers (Schewe et al., 2000) Some of the differences between these subgroups may hold interesting and important implications for health care marketers. For example, the trailing-edge boomers, aged 37– 46 in 2001, faced a difficult economic environment as they came of age after the energy crisis of 1973. Consequently, they may feel more deprived financially than their older boomer counterparts. This difference might have implications for elective health care procedures such as cosmetic and laser eye surgery, with trailing-edge boomers less likely to engage in elective surgeries than leading-edge boomers. Similarly, within the generation of matures, the critical health care segment, there are three proposed cohorts: Depression-scarred, World War II, and the post-War cohort (Schewe and Meredith, 1994). Significant differences might also exist between these groups in their preferences for health care services. For instance, Depression matures may be more concerned with costs of medical care than post-Wars, since the former came of age during the Depression. World War II members who sought comfort in the solace of others during the war may prefer more social interaction when incurring a stay in a hospital than other matures. Other differences might lie in deep-seated values such as death, mortality, spirituality, and religion. Certainly, these values impact the delivery of health care. As these examples illustrate, each cohort may possess a unique set of values and preferences that could translate into unique preferences in the health care context. The task of marketers, therefore, is to determine which age groupings (or other segmentation
S.M. Noble et al. / Journal of Business Research 57 (2004) 1033–1041
variables) yield practical and significant insights into the differences between consumers’ preferences for health care service and treatment. Determining the degree of information search explained by limited capacity, experience level, and socialization models is also needed in the future. All these models state that older consumers will search for information less than younger consumers (under right conditions), however each note different reasons for this finding. The current study posited this difference was due to the environment in which each age group was socialized. Future research is needed to tease apart the variation in information search explained by each model. Another area that warrants future research includes exploring the degree of intergenerational participation in health care decisions. For example, do children of older adults determine their parents’ health care provider, the procedures they will undergo, and/or the facility in which they will reside? Or are these decisions in the domain of the parent/patient? Determining who are the primary initiators, influencers, and evaluators of health care would aid providers in targeting each more effectively. Finally, future research might look at how this study’s findings can be translated into specific health care provisions. For example, what exactly constitutes informality in the health care setting? Here, we suggest communication and attire are two potential areas of informality, but does one’s desire for informality extend to the atmosphere of the facility? Should examination and hospital room walls be adorned with whimsical murals rather than staid institutional wall colorings if targeting boomers? Or should ‘‘funky’’ music be piped into birthing rooms for aging boomers? These are just some of the issues raised from the results of the current study that lend themselves to further investigation. In sum, the goal of this paper was to illustrate that the health care industry must acknowledge differences in values and preferences among clients, their children, and future generations of health care patients. By understanding and embracing these differences, health care providers will be better equipped to satisfy the preferences of each group, thus providing better care for today’s mature consumers, tomorrow’s boomers, and future generations to come.
Acknowledgments The authors thank Eric N. Berkowitz, Thomas Brashear, Charles H. Noble, and the editors of the special edition for their thoughtful comments on earlier versions of this article. We also gratefully acknowledge Commonwealth College for funding this research.
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