Service Business

https://doi.org/10.1007/s11628-018-00391-0

EMPIRICAL ARTICLE

The role of customer operant resources in health care value

creation

Le Nguyen Hau1

Received: 6 November 2017 / Accepted: 26 October 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Service-dominant logic advocates that customers co-create value with a firm by
contributing operant resources. However, do their operant resources contribute to
improving the co-created value, or are they just a must? To address this question,
this research investigates the effect of different components of customer operant
resource on different forms of customer value in the context of health care service.
A structural model was developed and tested using a sample of 409 outpatients in
Vietnam. Results show that customer’s social and cultural resources (but not physi-
cal resource) have significant effects on process value, while social, cultural, and
physical resources have significant effects on outcome value. Among the three forms
of operant resource, social resource is found to have the strongest effect on both
process and outcome values. In addition, the relative effects of each form of oper-
ant resource on process and outcome values change when customers become more
familiar to the service. Finally, both process and outcome values explain an essential
part of the positive word-of-mouth behavior. Theoretical and managerial implica-
tions have then been discussed.

Keywords Customer operant resources · Health care service · Value co-creation ·

Vietnam

1 Introduction

Traditional service marketing views that the value of a service is created by a

provider and delivered to customers for money (Anker et al. 2015). However, the
emerging service-dominant logic (SDL) perspective proposes that value is not solely
created by the service provider. It is the value for customer and is created jointly by
the provider and customer (Gronroos 2008; Vargo and Lusch 2004). Scholars have

* Le Nguyen Hau
Lnhau@hcmut.edu.vn
1
School of Industrial Management, Ho Chi Minh City University of Technology, VNU-HCM,
268 Ly Thuong Kiet Str., Dist. 10, Ho Chi Minh City, Vietnam

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 L. N. Hau

further explained that the co-creation of service value is accomplished through the
interaction between the two sides and the integration of resources including operand
and operant ones (Arnould et al. 2006; Grönroos and Voima 2013; Hau et al. 2017).
This notion implies that customers must spend resources other than money if they
want to enjoy the value of a service. In other words, besides operand resources (i.e.,
money), customers must spend their operant resources in the service process to co-
create value (Mustak et al. 2013; Yi and Gong 2013). Given that value is the cus-
tomer perception about what he/she gets versus what he/she gives (Zeithaml 1988),
an arising question is that when more operant resources of a customer are utilized in
a service (more gives), does he/she feel much more benefits in return (more gets),
leading to an increase in perceived value? In other words, do operant resources of
a customer contribute to the co-created value, or they are just a must? Several stud-
ies have mentioned that customers co-create value through their participation in the
service creation, which requires the contribution of their operant resources (Bitner
et al. 1997; Joo and Marakhimov, 2018; Mahrous and Abdelmaaboud 2017; Nam-
bisan and Nambisan 2009). However, our deeper understanding of this phenome-
non is still limited. Particularly, the question about the contributive role of different
forms of customer operant resource in value co-creation is unanswered (Grönroos
and Voima 2013; Seiders et al. 2015).
Against this gap of knowledge, the main purpose of this research is to investi-
gate the effects of different components of customer operant resource on different
forms of customer-perceived value. By investigating these effects, this study pro-
vides more insights into the nature of the value co-creation in marketing literature.
It gives information for service providers about which specific forms of customer
operant resources are more or less important in a specific co-creation process, given
the notion that customers are the firm’s operant resources (Vargo and Lusch 2004).
This study also explains to customers that they need to utilize different forms of
operant resources if they want a higher service value. Moreover; different extent of
utilizations of each form of operant resources in a given service may lead to differ-
ent service value. Although there have been numerous publications on the topic of
service dominant logic and value co-creation, this research stream is, in fact, more
incomplete than complete (Vargo et al. 2010; Grönroos and Voima 2013).
Regarding the research context, as reflected by Voss et al. (2016), studies of ser-
vice is often within specific industry contexts due to the great diversity in services.
In this respect, the selected service context in this study is health care service, which
has been identified as one of the top service research priorities (Ostrom et al. 2015).
In many countries, either developed or developing ones, health care is an impor-
tant public service industry. This is a kind of transformative service aiming to create
improvements in human well-being (Anderson et al. 2013). In this service, the par-
ticipation of customer is mandatory because it is a “whole-body” service (Anderson
et al. 2013). Especially, this high-contact professional service is characterized by the
fact that health care patients are usually under stress of pain, anxiety, fear, and uncer-
tainty of the outcome. These features may affect the strength of customer operant
resources. Moreover, for many health care customers, this is the service they need
but may not want (McColl-Kennedy et al. 2017). Consequently, they may be pas-
sive, reluctant, or even refuse to participate and contribute their operant resources

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The role of customer operant resources in health care value…

during and after the direct interaction with the service provider (Gallan et al. 2013;
Hau et al. 2017; McColl-Kennedy et al. 2017; Seiders et al. 2015).
The following sections present the theoretical background and the development
of hypotheses. Next, research method is reported, which is followed by the results of
data analysis. Discussions and implications are taken up the in final sections of the
paper.

2 Literature background and hypotheses

2.1 Customer value and value creation in health care

Customer value is defined as the customer’s overall assessment of the utility of a

service based on perceptions of what is received and what is given (Zeithaml 1988).
The concept encompasses the overall “gives” versus the overall “gets” (Babin and
James 2010). Overall “gives” include factors such as money and other intangible
resources such as effort, time, opportunity, emotions, etc., while overall “gets”
include outcome quality, emotions, prestige, and convenience being experienced dur-
ing the service process. On the other hand, to explain the nature of customer value,
Holbrook (2006) defines it as an “interactive relativistic preference experience” (p.
212). Taking this view, Helkkula and Kelleher (2010) suggest that customer value
is viewed from the perspective of the consumption experience. Similarly, Heinonen
et al. (2010) argue that customer value emerges during the interactive process, when
the service becomes embedded in the customer’s activities, practices, and experi-
ences together with the service company’s activities, before it comes to the outcome
benefits at the end.
Given the aforementioned two perspectives to conceptualize service value, the
present study adopts the view that the assessment of service value must encompass
both process-outcome facets, in addition to the gets-gives principles (Hau et al.
2017; Heinonen et al. 2010). Specifically, it is operationalized as a bidimensional
construct which includes process value and outcome value (Hau and Thuy 2012;
Heinonen 2004; Luu et al. 2016). Outcome value refers to the benefits that a cus-
tomer perceives at the end of the service compared to his/her input or spending,
whereas process value refers to the value emerged due to positive experiences that
a customer perceives during the co-creation of service (Hau et al. 2017; Luu et al.
2016). These dimensions are also in line with the operationalization of service qual-
ity into functional quality and technical quality as given by Grönroos (1982).
The SDL logic advocates that value is created by customer based on the value-
in-use (Vargo and Lusch 2012; Gronroos 2008). Proponents of this perspective
explain that customer co-creates value through the dynamic interaction and resource
integration, while the firm creates and communicates value propositions (Holbrook
2006; Grönroos and Voima 2013; Gronroos 2008). Accordingly, customers are
involved in the entire process of service co-creation, even before and after the actual
consumption of service (Ballantyne and Varey 2006; Helkkula and Kelleher 2010).
Therefore, the temporal-based dimensionality of customer value as process value
and outcome value is seen appropriate to capture the notion of value-in-use, which

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emphasizes the customer’s own consumption experiences. It is also appropriate in

the health care context where the service process normally takes time before the ser-
vice outcome can be realized and assessed by the customer.
In health care, extant literature shows that the majority of studies have empha-
sized the importance of value co-creation through customer participation and inter-
action. However, as Voorberg et al. (2015) indicate, more focus has been on ante-
cedents of co-creation and less on its consequences, including customer-perceived
value. For instance, Chahal (2010) finds that frontline employee behaviors such
as caring attitude, friendliness, helpfulness, responsiveness positively affect the
patient–physician interaction. Andersson et al. (2007) discuss how mobile technolo-
gies facilitate patient involvement in the co-creation process. Nambisan and Nam-
bisan (2009) propose four models of value co-creation namely, partnership, open-
source, support-group, and diffusion. With the same focus, McColl-Kennedy et al.
(2012, 2017) explore the different styles and practices of health care customer co-
creation of value. Other scholars broaden the scope of value co-creation in health
care by taking a multiactor perspective. Based on value-creating interaction styles,
Black and Gallan (2015) provide a network view of value co-creation. Similarly,
Pinho et al. (2014) develop the value co-creation concept involving multiactors and
show how value is co-created for each actor in the complexity of interaction and
interdependencies. Zainuddin et al. (2013) find that customer resources jointly co-
create functional and emotional values for customer.
The review of previous works provides some insight into the value co-creation
in health care service. However, the involvement of customers to co-create value
requires that they must spend more operant resources to learn about the service spec-
ifications, how to use and adapt the appliances and other firm-provided resources to
their unique needs, usage situations, and behavior (Vargo and Lusch 2012). AQTo
enhance this general understanding, more insights into the role of specific type of
operant resources being deployed in this process and how they affect the customer
perception of service value are still needed.

2.2 Customer operant resources

Operant resources are those resources and capabilities that act on other resources to
produce effects (Arnould et al. 2006; Vargo and Lusch 2004). Operant resources are
often invisible and intangible. They are likely to be dynamic and infinite, meaning
that they are changeable over time and across contexts. Cultural resource-based the-
ory of the customer (Arnould et al. 2006) suggests that customer operant resources
can be classified into social resource, cultural resource, and physical resource.
Social resource is defined as networks of relationship with others over which con-
sumers exert varying degrees of command (Arnould et al. 2006). It includes relation-
ships with family members, consumer communities, and commercial relationships.
The theory of resource conservation (Hobfoll 1989) advocates that when individuals
are in shortage of resource to achieve their goals, they may rely on social relation-
ships to access others’ resources. In health care, social resource provides patients
with supports from others, especially family members, in terms of information,

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The role of customer operant resources in health care value…

sympathy, encouragement or instrumental assistants in the service process (McColl-

Kennedy et al. 2017).
The second type of customer operant resource is cultural resource, which refers
to varying amounts and types of specialized knowledge, history, and imagination
(Baron and Warnaby, 2011). Among these types, this study in health care especially
focuses on customer’s knowledge of the disease and health service procedure. This
interest in knowledge as a representative of cultural resource stems from the fact
that nowadays many patients may spend time (i.e., more resource) on internet and/
or mobile devices to learn about the service and the disease before visiting a physi-
cian (Andersson et al. 2007; Prahalad and Ramaswamy 2002). This results in the
different extent of improvement in specialized knowledge among patients. Being
more knowledgeable, they tend to be more active in the service process (Barile et al.
2014). However, whether and how the improved knowledge in the view of cultural
resource would bring them more value has not been fully investigated (Hau et al.
2017).
Finally, physical resource refers to physical and mental strength of a customer
(Arnould et al. 2006). According to Baron and Harris (2008), it includes interrelated
elements such as self-efficacy, emotion, and optimism. Among these elements, self-
efficacy is contextually changeable which may be affected by external factors, while
optimism is a personal trait of a person who tends to be a dispositional personality
(Hochhausen et al. 2007; Schwarzer et al. 1997). Moreover, according to Bandura
(1997), self-efficacy affects how people feel and act. A low level of self-efficacy is
often associated with negative emotion, while a high level of self-efficacy is consid-
ered as a major motivation to act. Because of these reasons, self-efficacy is selected
as a proxy to represent a patient’s physical resource in this study.
The customer view of value creation explains that in a need fulfillment pro-
cess involving a service exchange, customers play the role of resource integrators.
They use their wealth of operant resources including social, cultural, and physi-
cal resources to determine how their operand resources as well as the firm’s oper-
and and operant resources are employed and integrated in a way that value-in-use
emerges (Arnould et al. 2006; Baron and Harris 2008).
A review of the literature on customer operant resources in relation with value
creation reveals that the majority of the published works have focused on the
connection between customer resources with customer participation or co-crea-
tion behavior in the resource integration process and mostly been conceptual or
qualitative (Anderson et al. 2013; Ple 2016; Baron and Harris 2008; Baron and
Warnaby 2011; Xu et al. 2014). Some studies find empirical evidence to support
the relations between certain type of operant resources and service outcomes.
For instance, Bitner et al. (1997) analyze the role of customer’s knowledge and
information as resources contributed to the service process to make effects. Auh
et al. (2007) exert that expert customers have greater ability to make meaningful
contributions to service delivery. Osborn et al. (2010) find a positive effect of
patient knowledge on patient participation. Zhao et al. (2015) explore the effects
of social identity on customer knowledge contributions in online health commu-
nities. In terms of customer physical resource, Sarkar et al. (2006) and Seiders
et al. (2015) provide evidences on the role of self-efficacy in affecting patient’s

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 L. N. Hau

adherence to the physician advice. Gallan et al. (2013) find that patient’s positiv-
ity has a positive effect on the level of participation and perception of service
quality. Regarding social resources, Kang et al. (2010) and Mayberry and Osborn
(2012) provide empirical evidence to support the influence of family members’
support on customer adherence in health care. Rintala et al. (2013) shows that
family conflict and the perceived non-support from family lead to poor participa-
tion. Osborn et al. (2010) also echoed the above finding about positive correlation
between social support and patient adherence to health care professional advice.
However, except Alves et al. (2016) who investigate the influence of customer
self-efficacy, social capital, and customer expertise on co-creation behaviors in
the various services, an investigation of all three types of social, cultural, and
physical resources together and their effects on different forms of customer value
has not yet been undertaken, especially in health care service.

2.3 Proposed hypotheses on customer operant resources and perceived value

To address the mentioned research objectives, this section presents theoreti-

cal justifications for the relationships between each type of customer operant
resources and the co-created value. A model illustrating the overall picture of
these relationships is presented in Fig. 1.

Customer operant resources Customer perceived value

H1a
0.24 (0.002)

H2a Process H4
0.46 (0.002)
Cultural resource 0.10 (0.175) Value

H3a
0.40 (0.002)
Physical resource Word-of-mouth
H1b
0.20 (0.004)

Social resource Outcome

H5
H2b Value
0.16 (0.023) 0.34 (0.008)

H3b
0.40 (0.002)

Fig. 1  Customer operant resources, perceived service value, and word-of-mouth

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The role of customer operant resources in health care value…

2.3.1 Cultural resource and perceived value

As mentioned previously, in this specific study of health care, customer cultural

resource is investigated through the proxy of specialized knowledge of the patient.
This knowledge may be developed via learning or experience. In the interaction
sphere, this knowledge is very much needed for information exchange between
patient and physician in the diagnosis and treatment. The more knowledge a patient
holds about the symptom, and the disease history, the more chances are for him/her
to share relevant information with the physician. In turn, studies in health care have
shown that actively providing physician with relevant information about the disease
and patient’s personal preference is a prerequisite of a satisfied service outcome
(Bitner et al. 1997; Auh et al. 2007). Moreover, when a patient is knowledgeable
about the disease, the knowledge gap between the two interaction sides becomes
smaller, which facilitates the effectiveness of physician’s discussion and consulta-
tion, leading to the development of sympathy and social relation between patient
and physician (Seiders et al. 2015).
In the customer own sphere after meeting with the physician, knowledgeable cus-
tomers are well aware about the negative effect of non-compliance to medical treat-
ment, and understand what to do, why to do and how to do the participation tasks
within his/her own responsibility in the treatment process to ensure the service out-
come (Gallan et al. 2013; Chan et al. 2010). Moreover, it is evidenced that active
customer participation is a strong determinant of both process value and outcome
value (Hau and Thuy 2016). Thus, it is reasonable to propose the positive relation-
ship between customers’ cultural resource and their perception of service value.

H1a There is a positive effect of customer cultural resource on customer process

value in health care service.

H1b There is a positive effect of customer cultural resource on customer outcome

value in health care service.

2.3.2 Physical resource and perceived value

In this study, self-efficacy is used as a proxy to represent a patient’s physi-

cal resource. Self-efficacy is generally understood as an outcome of the equation
between the perceived complexity of an action and a person’s capability to do it. In
other words, self-efficacy exerts the perception on level of control over an action,
including motivation to perform and the enduring effort to complete it (Schwarzer
et al. 1997). Social cognitive theory posits that self-efficacy influences the proba-
bility of an individual initiating a certain behavior and then continuing the efforts
despite the presence of barriers or hardship (Bandura 1986). It facilitates not only
the persistence of action but also the spending of effort to the action (Yim et al.
2012).
Based on this theoretical basis, it is suggested that self-efficacy plays an impor-
tant role in activating patient’s participation behavior because patients with high
level of self-efficacy tend to be highly motivated to action despite their negative

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emotion and stress (Seiders et al. 2015). They have also shown that self-efficacy
is a determinant to reinforce health resilience, leading to better service outcome.
Empirically, some studies in health care have shown that self-efficacy, optimism
or positivity emotion have a positive effect on the level of participation and adher-
ence to the service (Gallan et al. 2013; Osborn et al. 2010; Sarkar et al. 2006).
In turn, patient’s participation and adherence are attributes of value co-creation
behaviors which were found to be determinants of perceived value (Yi and Gong
2013; Hau and Thuy 2016). On this basis, the following hypotheses are proposed:

H2a There is a positive effect of customer physical resource on customer process

value in health care service.

H2b There is a positive effect of customer physical resource on customer outcome

value in health care service.

2.3.3 Social resource and perceived value

In health care service, the social operant resource provides patients with sup-
ports from family, other patients, and communities at large in different aspects.
Firstly, social network is an important source of information or knowledge related
to the service. For example, market research conducted with diabetes patient in
Vietnam (TNS 2007) ranks information receiving from friends, relatives; disease
fellows as secondary reliable source after the one from healthcare professionals.
Secondly, close relationships with family members or other fellow patients are a
source of sympathy to release stress, to encourage positive emotion and to nurture
self-efficacy. Finally, family members may play the role of an assistant to patients
as physical escort or cue-to-action in the service process (DiMatteo 2004). All of
these supports are important to facilitate the active participation of patients for a
better service value.
Empirical studies have supported the influence of social resource on customer
participation in health care and behavioral science (Kang et al. 2010; Mayberry
and Osborn 2012). For example, Nicklett and Liang (2009) have shown that fam-
ily support is the strongest factor to influence the patient adherence to diabetes
regimen. In contrast, Rintala et al. (2013) shows that family conflict and the per-
ceived non-support from family lead to poor compliance with type 1 diabetes.
Becker and Maiman (1983) show a correlation between the support from relatives
or friends and the adherence to health treatment. Cárdenas et al. (1987) found that
patients who receive good supports from relatives have a good metabolic control.
Glasgow et al. (1997) also echoed the above finding about positive correlation
between social support and participation to medical service. Thus, social resource
is argued to have a positive effect on patient participation. In turn, patient par-
ticipation is shown as a driver of process and outcome value of the health care
service (Yi and Gong 2013; Hau and Thuy 2016). These analyses lead to the fol-
lowing hypotheses:

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The role of customer operant resources in health care value…

H3a There is a positive effect of customer social resource on customer process

value in health care service.

H3b There is a positive effect of customer social resource on customer outcome

value in health care service.

2.4 Customer value and positive word‑of‑mouth (WOM)

Positive or favorable WOM refers to the informal communication between private

parties concerning the favorable evaluations or suggestions of goods or services
rather than feedbacks to firms (Westbrook 1987; Anderson 1998). This voluntary
communication behavior of customer is considered as an important post-purchase
behavior which indicates the customer–firm relationship strength (Eisingerich
et al. 2014; Vázquez-Casielles et al. 2017) and brand success (Murray 1991).
Early study found WOM seven times more effective than advertising, four times
more effective than personal selling in influencing consumers (Katz and Lazars-
feld 1955).
Health care is a service for which customers need but may not want (Berry and
Bendapudi 2007). Therefore, when a customer experiences a satisfied service, repur-
chase intention is less likely a post-purchase behavior, in comparison with positive
WOM behavior. Moreover, health care is a credence service that the service quality
is difficult to observe and judge (Berry and Bendapudi 2007; Lee 2012, 2017). Con-
sequently, to make a choice decision, potential customers are likely to rely heavily
on WOM for health information and service providers. Specifically, Martin (2017)
indicates that the content of positive WOM in health care mainly relates to the posi-
tive comments on the services and/or recommendation of specific health care pro-
vider (hospital, clinic, and physician) to others. Such information can be communi-
cated via different channels such as face-to-face or electronically by social network.
Senders of these information may not only be in/outpatients, but also family mem-
bers, relatives, friends, and staff of providers. They are motivated to share positive
WOM by altruistic or egoistic motives (Hinz et al. 2012).
The relationship between customer-perceived value and WOM has been inves-
tigated in several studies (e.g., Gruen et al. 2006; Hartline and Jones 1996; Kein-
ingham et al. 2007; McKee et al. 2006). For example, Hartline and Jones (1996)
found that both service quality and perceived value increase WOM, but the effect
of perceived value is stronger than that of perceived quality. To justify for this
relationship, McKee et al. (2006) explain that customers who perceive a high
value of a service tend to become more committed to the service firm and seek to
recommend others of the reference group to the same firm.
Therefore, this study tests this relationship as a revalidation in the health care
service.

H4 There is a positive effect of customer process value on positive word-of-mouth

in health care service.

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H5 There is a positive effect of customer outcome value on positive word-of-mouth

in health care service.

3 Research method

The empirical setting of this current study is the health care service in Vietnam, an
emerging market which is transitioning from a central planning economy to a form
of market socialism. In the recent years, Vietnam has been experiencing a steady
growth of service sector from 31% of GDP in 2007 to 44% in 2014 (Alejandro et al.
2015). Moreover, Vietnam is an Eastern Confucius, collectivist culture which is
likely to affect consumers’ behaviors. Vietnamese culture is also featured by high
power distance, which implies that in the physician–patient interaction, patients are
likely to be submissive. They expect to be told what to do and physician is perceived
as a “benevolent autocrat” (Zhou et al. 2005). These key features make Vietnam an
interesting setting for this study, given the fact that most of the existing body of
research has been conducted in high income, industrialized countries, while emerg-
ing markets are natural laboratories to test and generalize theories (Burgess and
Steenkamp 2006).
The empirical data were collected using a structured questionnaire. Convenience
sampling method was applied. In this case, this method is acceptable because the
goal of this study is to test a theoretical model (Calder et al. 1981). Target respond-
ents were outpatients at several hospitals and clinics of various sizes in Ho Chi Minh
City, the largest city of Vietnam. Data collectors were five trained students who
were taking a research methods course. The data collectors approached respondents
conveniently at home or work. First, respondents were asked if they had visited a
hospital or clinic in the previous 2 weeks. If the answer was “yes,” they were invited
to proceed to answer questions about the service process and its outcome. If the
answer was “no,” the survey was ceased. The questionnaire was initially developed
in English language, which was then translated into Vietnamese via a translation and
back-translation process (Hambleton 1993). This procedure was accomplished by
two university academics. After comparing the two English versions, mismatched
points were discussed and resolved between the translators. The Vietnamese version
was then adjusted accordingly.
The scales measuring different constructs in the research model were based on
previous studies with some contextual adjustments (see Table 2). Based on the
conceptualization and specific descriptions of Arnould et al. (2006) and Baron and
Warnaby (2011), the scale for cultural resource (i.e., specialized knowledge) con-
sisted of four items asking patients about their knowledge of service procedure and
their needed activities in the service. Social resource was measured by three items
asking about assistances received from relatives, colleagues, other patients, or vir-
tual communities during the service process. Physical resource (i.e., self-efficacy)
was measured by three items adopted from Schwarzer and Jerusalem (1995), which
asked the extent to which the patient feels that he/she can manage to solve health
problems; remains calm when facing health difficulties; and is confident about the
ability to find a solution to a health problem. As for perceived value, the scale was

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The role of customer operant resources in health care value…

adopted from Hau and Thuy (2012), who developed and tested them in the health
care context in Vietnam. Accordingly, the four items measuring process value were
about the extent of positive experience, feeling of being confident, feeling of being
positive, and encouraging experience during the service process in comparison with
time, effort, and money they spent. Outcome value was measure by four items ask-
ing about perceived goodness of health outcome, valuable service received, benefits
received, and fulfillment of needs in comparison with time, effort, and money they
spent. Finally, the scale measuring positive WOM was derived from the method of
Eisingerich et al. (2014), which was based on Zeithaml et al. (1996). The three items
were about the extent of sharing experience with other people, saying positive things
about the service, and recommending the service to others. All the scales were
designed in five-point Likert type. Pretest was also conducted by means of inter-
views with five patients in order to refine and adjust the wordings of questionnaire
items to fit with the health care context.

4 Results and discussions

4.1 Sample characteristics

The sample includes 409 customers (outpatients) of health care service. This sam-
ple size is considered large enough for data analysis using SEM method, based on
Hair et al. (2017) who posit that SEM is not as sensitive to low sample size as was
thought earlier. They recommend that sample size N = 100 is sufficient for most
applications as long as measurement is good.
As shown in Table 1, the sample was fairly balanced in terms of customer famili-
arity with the service (40.6% first visit and 59.4% revisit). In terms of gender, 44.3%
of respondents were male, and 55.7% were female. Respondents in the age range of
18–25 accounted for 9.8%, with other age groups as follows: 26–35 (36.4%), aged
36–45 (28.1%) and above 45 years (25.7%). Their incomes were distributed fairly

Table 1  Sample characteristics (N = 409 cases)

Freq. % Freq. %

Frequency of visit: Income (VND Mil./month):

+ First time 166 40.6 + Low (< 5) 135 33.0
+ Revisit 243 59.4 + Upper low (5 to < 10) 141 34.5
Gender: + Medium (10 to < 15) 85 20.8
+ Male 181 44.3 + High (15 or more) 48 11.8
+ Female 228 55.7
Age group: Education:
+ 18 to 25 40 9.8 + High school (or lower) 75 18.3
+ 26 to 35 149 36.4 + College 115 28.1
+ 36 to 45 115 28.1 + University 190 46.5
+ 46 or more 105 25.7 + Post-grad 29 7.1

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 L. N. Hau

with 33% earning lower than 5 Mil. VND, 34.5% between 5 and 10 Mil. VND, and
32.6% above 10 Mil.VND per month. The education level included 18.3% high
school or lower, 28.1% college, 46.5% university, and 7.1% postgraduate level.
These characteristics represent a diversity of respondent groups which promises a
significant variation in the dataset.

4.2 Refinement of measurement scales and assessment of common method bias

First, for a preliminarily assessment, each of six scales were analyzed using explora-
tory factor analysis (EFA) in SPSS 21 software. The results showed single factor
derived for each scale indicating unidimensionality. Items loaded highly (from 0.65
to 0.96) on their factor, except that one item measuring social resource was elimi-
nated due to low loading (< 0.45).
Next, confirmatory factor analysis (CFA) was conducted using AMOS software
to assess and refine the full measurement model which included 6 constructs and 20
remaining items. These items have kurtosis values that ranged from − 0.48 to + 1.31
and skewness values from − 1.01 to − 0.30, which indicated a slight deviation from
normal distribution. In this situation, maximum likelihood (ML) was still an appro-
priate estimation method because it would exhibit minimal bias compared to other
methods (Bollen 1989). The measurement model was refined further by eliminating
three more items which had significant covariance of the error terms. The CFA of
the refined model resulted in a satisfactory fit: χ2 = 340.16; dF = 104; GFI = 0.91;
CFI = 0.95; TLI = 0.94; RMSEA = 0.07. As shown in Table 2, factor loading of
items ranged from 0.79 to 0.95, and AVE of scales ranged from 0.69 to 0.77, which
were all above 0.50, indicating satisfactory convergent validity. Correlation coeffi-
cients between pairs of constructs ranged from 0.15 to 0.82. The squares of those
values were well below the AVEs of the respective scales (see Table 3), indicating
discriminant validity of scales. Composite reliabilities were from 0.87 to 0.91 which
exceeded the threshold of 0.70. Thus, the six measurement scales were satisfactory
in terms of reliability, convergent validity, and discriminant validity.
Common method bias was assessed by the widely known Harman’s single-factor
method (Podsakoff et al. 2003). The results showed very low fit indices (χ2 = 2278;
dF = 119; GFI = 0.589; CFI = 0.586; TLI = 0.526; RMSEA = 0.211). Moreover, the
marker-variable method based on the post hoc fashion (Lindell and Whitney 2001)
was applied for double check. Accordingly, the assessment of common method vari-
ance was based on the observation of the smallest correlations among the observed
variables. In this study, they were r = 0.04 (p = 0.396 > 0.05) between the one item
measuring cultural resource and one item measuring social resource, and r = 0.06
(p = 0.181 > 0.05) between a pair of items measuring self-efficacy and WOM. These
results indicated that CMV was not the major source of bias in the observed items.

4.3 Structural model estimation and hypothesis testing

Given the satisfactory fit of the measurement model, the proposed hypotheses were
then tested by estimating the structural modeling. The ML estimation resulted

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The role of customer operant resources in health care value…

Table 2  Scale items measuring six constructs in the model

Item wordings Std. loading

Cultural resource (AVE = 0.691 Comp. reliability = 0.870)

I know well the health service procedure at X Eliminated
I know well what I need to do during the health diagnosis and treatment at X 0.81
I know how to make the diagnosis and treatment to be best benefits for myself 0.89
I understand easily the instructions at X during the diagnosis and treatment process at X 0.79
Physical resource/self-efficacy (AVE = 0.723 Comp. reliability = 0.887)
I can always manage to solve my health problems if I try hard enough 0.87
I can remain calm when facing health difficulties because I can rely on my coping abili- 0.87
ties
When I am confronted with a health problem, I can usually find a solution 0.81
Social resource (AVE = 0. 775 Comp. reliability = 0.873)
I receive useful assistance from my relatives, friends or people around during the health 0.86
treatment process.
Relatives, colleagues or friends share with me their knowledge/experience about X 0.90
I get useful information on this health service through virtual communities in the internet Eliminated
Process value (AVE = 0.752 Comp. reliability = 0.901)
In comparison with the money, time, and effort I spend…
The physician makes me feel confident during the time I am in health treatment at X 0.91
The physician gives me a positive experience during the health treatment at X 0.89
I have an encouraging time during the health treatment with X Eliminated
I have a positive feeling during the health treatment 0.80
Outcome value (AVE = 0.753 Comp. reliability = 0.901)
In comparison with the money, time, and effort I spend…
The benefits (health recovery) I receive from this health service is as good as expected 0.90
The services I receive from this health service is of high value 0.86
The physician provides me with the benefits (health recovery) I want 0.84
The physician gives me what I need (i.e., health recovery) Eliminated
Positive WOM (AVE = 0.772 Comp. reliability = 0.910)
I share my experience at X with other people 0.80
I say positive things about X with others when I have chances 0.95
I recommend X to others who seeks my advice 0.88

in a satisfactory fit: χ2 = 379.32; dF = 108; CFI = 0.95; GFI = 0.90; TLI = 0.93;
RMSEA = 0.04.
Based on the standardized path coefficients and p value shown in Table 4
and Fig. 1, it was found that all hypotheses were supported at p = 0.05, except
H2a. Particularly, H1a and H1b were supported in which customer’s cultural
resource has a significant positive effect on customer’s perception of process
value (γ = 0.24; p = 0.002) and outcome value (γ = 0.20; p = 0.004). H2a was not
supported because the path coefficient from customer’s physical resource to per-
ceived process value was not significant (γ = 0.10; p = 0.175). In contrast, the
path coefficient from customer’s physical resource to perceived outcome value

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Table 3  Composite reliability, convergent validity, and discriminant validity of scales
Construct Factor loading Composite Squared correlation and average variance extracted
(from–to) reliability
Cultural resource Physical resource Social resource Process value Outcome value Word-of-mouth

Cultural resource 0.79–0.89 0.870 0.691

Physical resource 0.81–0.87 0.887 0.197 0.723
Social resource 0.86–0.90 0.873 0.148 0.043 0.775
Process value 0.80–0.91 0.901 0.183 0.080 0.245 0.752
Outcome value 0.84–0.90 0.901 0.172 0.106 0.241 0.670 0.753
Word-of-mouth 0.80–0.95 0.910 0.159 0.021 0.260 0.542 0.517 0.772

Note: Values in the lower triangular region represent the squared correlation coefficients
Bold values in the diagonal represent the average variance extracted (AVE)
L. N. Hau
The role of customer operant resources in health care value…

Table 4  Structural model estimation and hypothesis testing results

Hypothesis Path from–to Std. coeff. p value Test result

H1a Cultural resource → process value 0.24 0.002 Supported

H1b Cultural resource → outcome value 0.20 0.004 Supported
H2a Physical resource → process value 0.10 0.175 Not supported
H2b Physical resource → outcome value 0.16 0.023 Supported
H3a Social resource → process value 0.40 0.002 Supported
H3b Social resource → outcome value 0.40 0.002 Supported
H4 Process value → word-of-mouth 0.46 0.002 Supported
H5 Outcome value → word-of-mouth 0.34 0.008 Supported
Differences between first-visit and revisit groups of patients
Relational path Unstandardized coeff. t value

First visit Revisit

Social resource → process value 0.43 0.21 2.367

Physical resource → outcome value − 0.04 0.28 2.746

was small but significant (γ = 0.16; p = 0.023) supporting H2b. Similarly, H3a
and H3b were supported because significant coefficients were found between cus-
tomer’s social resource and perceived process value (γ = 0.40; p = 0.002) and per-
ceived outcome value (γ = 0.40; p = 0.002). In turn, process value has a significant
effect on WOM (β = 0.46; p = 0.002) supporting H4, and outcome value also has
a significant effect on WOM (β = 0.34; p = 0.008) supporting H5. The results also
showed that the proportion of the variance in perceived process value explained
by the three components of customer operant resources was 31%, and that of per-
ceived outcome value was 30%. In turn, the two components of perceived value
explained 58% of the variance of positive WOM.
Moreover, to further explore if there are significant differences in the effect
size of relational paths between the first-visit and revisit patients, multiple group
comparison was undertaken. The measurement model for the two groups was first
tested, which obtained that the measurement invariance was not achieved. Thus,
unconstrained models were compared. Results indicated that between the first-
visit and revisit groups of patients, there are significant differences in the effect
sizes of two (out of eight) hypothesized paths. They are the path from the social
resource to the process value and the other from the physical resource to the out-
come value. The unstandardized path coefficients are presented in the second
part of Table 4. Accordingly, the effect of social resource on process value is sig-
nificantly stronger in the first-visit patients than that in the revisit patients (0.43
vs. 0.21, t = 2.367). In contrast, the effect of physical resource on outcome value
is significantly weaker in the first-visit patients than that in the revisit patients
(− 0.04 vs. 0.28, t = 2.746). The implications of this result are discussed in the
next section.

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4.4 Discussions

In the context of health care service, the main purpose of the current study is to
investigate the effects of different components of the customer operant resource on
different forms of the customer-perceived value. It is found that a patient’s cultural
resource, social resource, and physical resource are predictors of outcome value (the
outcome of health care treatment). It is also found that cultural resource and social
resource, but not physical resource, are antecedents of process value. Health care
is a service that customers need but may not want. That is, the ultimate need of
customers for the service is to recover from a disease, not to enjoy the service pro-
cess. However, experiencing a good service process is important because it helps
improve the quality of human life by releasing patient stress due to fear, anxiety or
uncertainty of the treatment outcome (Berry and Bendapudi 2007). Process value is
also closely associated with the service outcome value through customer positivity,
self-efficacy, and emotional state that motivate patients to actively participate in the
treatment process (Gallan et al. 2013).
Among the three components, social resource (i.e., relationships with other peo-
ple who can provide resources for the benefits of the focal customer) has strongest
effect on perceived value in both process and outcome forms. This result may be
attributed to health care service. When patients are ill and need a health care service,
many of them are not in normal physical and mental states. More often than not,
they seek the help of others in various aspects related to the service usage (seeking
information, sharing the anxiety, taking to hospital, doing personal care, etc.). Under
these circumstances, patients who are more capable of employing the resources of
others (i.e., strong social operant resource) would benefit highly from this resource
than in other normal service usages. This result is in line with that of Nicklett and
Liang (2009), which stressed the importance of social resource in health care. It also
illustrates that customer operant resources are dynamic and flexible over time and
context (Arnould et al. 2006). In contrast, physical resource (self-efficacy or a psy-
chological strength in mind) has relatively weak contribution to perceived value. In
this service, customers (patients) are often in a state of physical and mental weak-
ness due to pain, illness, fear, or anxiety. The low level of physical strength would
limit the capability of patients to mobilize their operant resource in the service pro-
cess. Consequently, the contribution of physical resource to create value is medio-
cre, and it is supplemented by social resource as mentioned above.
The above reasoning is further consolidated by the differences in the effect sizes
between groups of the first-visit patients and revisit patients. As said, in the first
visit to physician, the level of patient’s physical resource is often very low, which
cannot be mobilized and thus has a mediocre effect on value. This is indicated by
the weak effect size of physical resource on perceived value. In this very situation,
patients would rely on others in terms of social resource, according to the theory
of resource conservation (Hobfoll 1989). Consequently, the assistance of others in
the service process is perceived by patients as relatively more appreciative, which
is indicated by a stronger effect size of social resource on process value. In contrast,
when patients revisit a physician, they tend to be less anxious and more familiar to
the service. Their physical resource is therefore stronger and can be mobilized to

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contribute to co-create value. Thus, the effect size of physical resource increases
to be stronger compared to that of the first visit. Although not being hypothesized
in the mainstream of the current research, these empirical findings provide fur-
ther insights into the role of each type of customer operant resources, as well as
the dynamic and contextual nature of customer operant resources as described by
Arnould et al. (2006).
In terms of the explanatory power, the findings of this study indicate that cus-
tomer operant resources can explain a significant (around 30%) but not substantial
part of the variance of the co-created value. This implies that customers contrib-
ute their operant resources to determine the use of their own operand resources
and to act on provider’s resources, and it is the contribution of provider’s operand
and operant resources, which explains the essential part of the customer value, as
already established in the traditional marketing literature. This is the rationale for a
service exchange where customer needs service provider. Another issue worthy to
note is about the nature of operant resource. In a service exchange, customer oper-
ant resources are utilized but not transferred to service provider. Moreover, they are
dynamic and can be changed during the interaction with service provider (Arnould
et al. 2006).
In general, the current research is among the first studies to provide insights into
the specific contribution of different forms of customer operant resources to the cre-
ation of process and outcome value in health care service. Its findings contribute to
explain the mechanism of the value co-creation in which customers contribute their
cultural, social, and physical operant resources to create value (Arnould et al. 2006).
In other words, the creation of value for customer (i.e., value-in-use) needs both
operand and operant resources of both sides being deployed and integrated together.
In this resource integration process, the strength of cultural, social, and physical
operant resources of customer would determine the extent of fulfillment of custom-
er’s need as being reflected through the concept of perceived value. Despite being
conducted in the health care service, these theoretical implications can be applied
to services having features similar to health care services such as education, con-
sulting, etc. These features may include knowledge-intensive professional service,
high level of customer-provider interaction, compulsory participation, and stressed
customers.
The findings of this study and the idiosyncratic features of customer operant
resources provide the basis for managerial implications. Service providers should
not look only at the customer operand resources such as the money or other eco-
nomic power the consumer has. They need to understand different kinds of oper-
ant resources the customer can take to the exchange process because these operant
resources will enable firms to anticipate customer-desired values and to help them
create value-in-use. Moreover, upon becoming aware of the relative importance of
each component of customer operant resources in the value co-creation process, ser-
vice firms should initiate measures to improve customer operant resources in such a
way that the interaction and resource integration would occur at a high level of effi-
ciency. Particularly in health care, measures to improve patient’s operant resources
may include the provision of health consultation or instructions to increase patient’s
cultural resources, interpersonal communication, and special care to improve

13
 L. N. Hau

physical resource and social resource, to name a few. These initiations can be imple-
mented by the service firm or the service frontliners such as physicians or nurses in
the service interaction.

5 Conclusion

The current study contributes to enrich our knowledge of the service exchange to
create customer value and to fulfill customer need through the lens of service-dom-
inant logic. It is in response to the calls for more research to test hypotheses about
the roles of the customer or the nature of the value co-creation process (Vargo et al.
2010; Grönroos and Voima 2013; Gummesson and Mele 2010). In addressing the
question of how different forms of customer operant resources contribute to co-cre-
ate value in health care service, the current research shows that social, cultural, and
physical resources of customer (patients) have significant effects on outcome value,
while social and cultural resources (but not physical resource) have effects on pro-
cess value, leading to positive WOM. The sizes of effect are significant but not sub-
stantial implying a more important role of service firm’s resources in the co-creation
process. Theoretical and managerial implications have been discussed.
As with many other studies, there are still rooms left for improvement and further
research. First, the use of self-efficacy in this study as a proxy of physical resource
may not be a perfect choice, for it may not fully capture the various facets of the
highly abstract concept of physical operant resource. Further research may include
other resources such as mental strength and/or emotional state to this concept. Simi-
lar suggestion is for cultural resource such as customer’s learning capability, which
is a critical factor for enhancing cultural resource. Second, there may be some inter-
actions, nonlinear relationships, and/or moderation effects in the research model.
Exploring them (for instance, by employing the newly developed method—Univer-
sal Structural Modeling) may provide a fuller picture of the phenomenon. Third,
given that health care is a high-contact professional service, further studies to test
this theoretical model in other service industries are necessary to generalize our
knowledge in this topic. Fourth, the empirical data in this study were collected in
Vietnam, a developing country in the Southeast Asia. Further studies may validate
the proposed model and hypotheses in other countries, especially in developed econ-
omies. Finally, given that the value is co-created by the interaction and resources
integration, the issue on how customer operant resources affect customer interaction
behaviors, leading to the co-created value, is worth exploring.

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