key: cord-0841473-o501znz5 authors: Gómez-Carmona, Diego; Paramio, Alberto; Cruces-Montes, Serafín; Marín-Dueñas, Pedro P title: Impact of COVID-19 prevention measures on health service quality perceived value and user satisfaction A structural equation modeling (SEM) approach date: 2021-08-03 journal: Aten Primaria DOI: 10.1016/j.aprim.2021.102178 sha: 8d5b0402d5ead35702726b8d6234e2cb54d7bda1 doc_id: 841473 cord_uid: o501znz5 Objective: To explain using a structural equation model to patient satisfaction by analysing confidence in preventive measures against COVID-19 as an antecedent of this satisfaction and the effect that these measures have on the antecedents of service quality and perceived value. Design: An observational cross-sectional study. Site: Online survey was sent via social networks for recruiting citizens resident in Spain. Participants: The final sample consisted of 149 women and 122 men. The mean age of the participants was 36.73 years, all of whom were health service users. Interventions: No interventions were conducted in the study. Main measurements: The study variables for the development of the structural equation model were: confidence in COVID-19 safety protocol, perceived value, quality and user satisfaction. Results: The results showed a direct and positive effect of confidence in COVID-19 safety protocol on the quality of services provided, perceived value and user satisfaction. Conclusions: The study is expected to be of interest to those in charge of designing protective measures against the spread of diseases, health centre managers and marketing professionals interested in the improvement user satisfaction, affected as a result of the current pandemic. Protección de Datos Personales y garantía de los derechos digitales 3/2018. Este estudio no cuenta con financiación pública ni privada. Los autores declaran no tener conflictos de intereses que puedan haber influenciado al trabajo de investigación realizado en el presente manuscrito. What we know about the topic What does this study achieve  There is a relationship between perceived quality and patient satisfaction. Resumen Objetivo Explicar mediante un modelo ecuaciones estructurales la satisfacción de los pacientes, analizando la confianza en las medidas preventivas contra la COVID-19 como antecedente de esta satisfacción y el efecto que estas medidas puedan tener en la calidad del servicio y valor percibido. Estudio observacional transversal. La encuesta online se envió a través de las redes sociales para reclutar a ciudadanos residentes en España. La muestra final estuvo compuesta por 149 mujeres y 122 hombres. La edad media de los participantes fue de 36,73 años, todos usuarios de servicios sanitarios. No se realizaron intervenciones en el estudio. Las variables del estudio para el desarrollo del modelo de ecuaciones estructurales fueron: la confianza en el protocolo de seguridad COVID-19, el valor percibido, la calidad y la satisfacción del usuario. Governments must prioritise the health care provided to citizens. It is the state's obligation to continuously improve medical services, ensure health coverage for citizens and guarantee the safety of service provision. Since 14 March 2020, the day on which the Spanish Government declared a state of alarm, caused by the SARSCoV-2 infection (severe acute respiratory syndrome), which has led to the COVID-19 pandemic (coronavirus disease 2019), the Public Health System has experienced an overload of infected patients [1] . Although the capacity of facilities to combat the virus has been increased, it has been impossible to stop the first three waves before the first vaccines or treatment became available [2, 3] . In addition, essential services and day-to-day activities need to continue to be provided as much as possible [4] . As a consequence, care protocols have changed in all medical facilities [5] . Preventive protective measures, initially non-existent or at best insufficient, have been included for healthcare workers and for other pathologies patients. The aim is always to reduce mortality and minimise the number of people affected [4] . Through these measures, patient care coverage should be guaranteed, the risk of users attending health centres should be mitigated, and confidence in the Public Health System should be improved. However, the special characteristics of the health sector led to users being treated not as consumers, but as patients [6] . In the current context, patients perceive a risk related to their personal health each time they attend medical facilities. Overcoming these risks and improving user safety can influence service quality, perceived value and ultimately patient satisfaction. Confidence is a subjective belief, referring to the reduction of a future risk (the risk of contagion in this case) and the probability of continuing to use the service provided [7, 8] . This concept of trust applied to institutions is called institutional or organisational confidence [9] . Institutional confidence will depend on the organisational response to compliance with current regulations; this response improves the consumer's expectations of the service [10] and the trust generated. Therefore, it is logical to think that the subject, after evaluating the service provided by the institution, will increase or reduce trust in the organisation [11, 8] . In other words, patients will feel safe and trust their healthcare facility if they consider the safety measures in place to be trustworthy. Research has shown that perceived confidence is a good predictor of quality [12, 13] . In addition, trust measures have also been found to contribute to improved perceived value [14] . This relationship was demonstrated in the work of Konuck [15] , who found that increased consumer confidence in the service provider can lead to an increase in perceived value of the marketed products. In contexts such as healthcare, where relationship building becomes essential, it is possible that trust determines the quality of services and perceived value, i.e., confidence in services will be a combination of trust in the institution itself, trust in the staff working there and the technologies used by the organisation [16] , in this case by the medical centre. The work of González [17] , demonstrated this relationship between trust, service quality and user satisfaction by analysing the interactions between the client and the health services. The result of evaluating patient perceptions is an important indicator of health care [18, 19] . Specifically, patient satisfaction is one of the most widely used measures in the field of health management to gauge the effectiveness of the medical care received [20, 21] . Many studies have examined the determinants of satisfaction, showing that different variables influence this satisfaction [22] [23] [24] . Among others, previous literature suggests a relationship between quality and satisfaction [24, 25] . In this sense, consumer perceived experiential quality can be understood as the difference between expectations and performance [26] . Specifically, quality is largely a performance concept based on consumer ratings of certain criteria [25] . These evaluations of the various characteristics of a service allow the patient to rate its performance and can, in the same way, directly influence satisfaction [24] . The pandemic caused by COVID-19 has led to a series of incidents in the medical services provided. According to Smith et al., [27] , service delivery issues can derive from the process or the outcome. The process dimension is linked to how the service is received (e.g., incident caused by safety measures and protocols), while the outcome dimension involves what clients actually receive from the service (e.g., interruption of face-to-face medical service for a few months) [28] . The current healthcare environment has recovered its activity after the interruption caused by the pandemic. Medical centres have reestablished service, responding to the legal measures in place. The reestablishment of the service can reinforce customer satisfaction [29, 30] . Moreover, it is a strategic element that can increase customer satisfaction [30, 31] . According to the service recovery paradox, when an organization satisfactorily solves the problem that prevented the development of the service, users seem to be more satisfied [29] [30] [31] [32] . H4. The quality of the medical service positively influences the patient's perceived value. H5. The quality of medical service positively influences patient satisfaction. The perceived value of the medical centre experience positively influences patient satisfaction. The research complied with the requirements established by the Bioethics Committee of the University of xxx (protocol code 189). This committee regulates the rights and freedoms of the participants, the right to privacy of their personal data and the aggregate treatment of the same. As for the methodological aspects applied, a quantitative method was used by means of an online survey (see Table 1 ). The questionnaire was designed following a review of the scientific literature on the subject under study, and was reviewed by members of the research team and by 3 experts in the health field. The Google Forms tool was used to draft the questions and collect the answers sent by a random selection of subjects who have either required face-to-face health services or have needed telephone assistance in the last year. The survey was conducted online; participants accessed the questionnaire by invitation. The invitation to respond to the survey was disseminated through different social network groups. Given the great sensitivity of the population at this time with public health, an immediate response was obtained and a great social repercussion. The final questionnaire consisted of 36 items. All questions correspond to the conceptual theoretical model defined above, reflecting the hypothesised relationships. All items used Likerttype scales, with a graduation from 1 (minimum score) to 5 (maximum score). The constructs were measured using scales validated for the Spanish population. Perceived value was measured by adapting the Mitchell and Dacin [33] and Thompson [34] scale using 5 statements to assess familiarity and experience with the service. Satisfaction was assessed by adapting the 4 items from the work of Capraro et al., [35] . The scale of confidence with the service provider was adapted from Sirdeshmukh et al., [36] to the case of the COVID-19 protocol, using 4 items, related to the safety measures established in all health centres (individualised access, use of masks, distance from the health care provider and temperature taking). A structural equation modelling (SEM) approach was used to examine the measurement and structural components of the model. The validity and reliability of the scales used in the study were previously tested (see Table 2 ) using SPSS V24 software. Data analysis was carried out following a two-stage procedure based on maximum likelihood [37] . AMOS 20 was used to examine the structural model and test the research hypotheses. Confidence in the COVID-19 measures were considered as the only exogenous variable; quality, perceived value and satisfaction were considered as endogenous variables. This technique allows distinguishing between the measurement and structural model and takes into account measurement errors in the estimation of the model. Therefore, it is suitable for validating and testing causal relationships between constructs [38] . J o u r n a l P r e -p r o o f The results in Table 3 Therefore, all indicators were found to exceed the values recommended by the literature [38] , demonstrating that the model fit is efficient and reproduces the population variance-covariance matrix reasonably well. Table 5 ). The positive relationship between the confidence in safety protocols established in the health centres and quality was demonstrated, confirming the first research hypothesis (H1), with a significant standardised coefficient greater than 0.5 (β = 0.569; p<0.001). Therefore, trust in safety protocols has been found to have a positive impact on perceived quality. Hypothesis H2, which proposes that the greater the confidence in the safety measures implemented to safeguard against COVID-19, the greater the perceived value in the health centre, was confirmed with a somewhat more moderate relationship between these variables (β = 0.252; p<0.001), thus finding that the greater the confidence in the safety protocol in the medical centres, the greater the value perceived by the patient. The relationship posed by H3, between the COVID-19 safety protocol and patient satisfaction, is significant, although weaker than in the previous case (β = 0.220; p<0.001). Thus, it was found that the greater the confidence in the safety measures established in the protocol for access, treatment or protection against COVID-19, the greater the users' satisfaction with the health centre. J o u r n a l P r e -p r o o f H4, which establishes a relationship between quality and perceived value, was confirmed, showing a positive and moderate influence on the relationship (β= 0.461; p<0.001) as anticipated by previous literature. Thus, it was found that the higher the quality offered in terms of treatment, empathy, facilities or health centre staff, the higher the value perceived by the patient. The causal relationship proposed by H5 between quality and patient satisfaction was confirmed, establishing a moderate-weak relationship between the variables considered (β = 0.368; p<0.001). Thus, it was found that the higher the quality offered by the health centre, the greater the satisfaction experienced by users of the health service. Hypothesis H6, which proposes a causal relationship between perceived value and satisfaction, establishes a weak link between the two variables. The value obtained for the standardised coefficients was (β = 0.317; p<0.001). We conclude that the more value the centre places on its patients, the greater the satisfaction with the care received. The health crisis has led to a change in the way patients are treated, organised and cared for in public and private health centres. These changes in traditional healthcare patterns are affecting patient behaviour. Hence, there is a need for intervention from a management and marketing point of view to improve society's perception of current medical services. To our knowledge, this research is the first to report on the impact of trust in safety protocol on user satisfaction with medical services. It is hoped that the study will be of interest to healthcare managers and marketers interested in improving service quality, perceived value and ultimately patient satisfaction, which has been diminished as a result of the current pandemic. The results showed that the trust placed in protective measures has a direct benefit on the quality of the services provided. In line with the work of Moorman et al., [39] , our work showed that the quality perceived by patients was affected by the trust placed by users in safety protocols. It seems that the risk of contagion to which patients are exposed, make them value positively the health measures provided to safeguard personal health. Furthermore, confidence in these preventive measures seems to contribute to a higher perception of quality [40] . Our work supports those investigations that consider trust as a necessary antecedent of quality in the user-provider relationship [41] , in this case of medical services. According to the work of Dehghanpouri et al., [42] the results achieved suggest that both trust and perceived quality can improve user satisfaction. Our findings support those works that argue that quality and perceived value, anticipate user satisfaction [43, 44] . Consistent with Guenzi et al. [45] we show that higher user trust can increase J o u r n a l P r e -p r o o f perceived value. Specifically, our results confirm those achieved in the work of Hu, et al., [43] highlighting the mediating role of perceived value, in the perceived quality and satisfaction relationship. In contrast, the work of Wu et al., [44] , who found when analyzing satisfaction with medical tourism that perceived quality anticipates trust and perceived value. Although the authors support that both variables are determinants of patient satisfaction, they found no relationship between them. The results suggest that as confidence in the safety measures set out in the protocol for access, treatment or protection from COVID-19 increases, patients tend to be more satisfied with the care they receive. In line with the research of Thom, et al., [45] , our work demonstrated that trust not only determines quality of care, but also directly impacts satisfaction [46, 47] . This research reinforces the literature indicating that the higher the patients' trust in health services, the higher the satisfaction, given the existence of a positive causal relationship between both variables [48, 49] . The findings found in our work reinforce the findings of Wu et al., [44] who demonstrated that experiential quality determines perceived value. It appears that, improving the quality of the medical centre experience translates into higher levels of perceived value. Although previous literature argues for this causal relationship, in the context of healthcare management, few papers have studied the relationship between quality and perceived value [49] . In addition to influencing value perception, our work supports those researches that link the quality of the healthcare experience, with satisfaction [50] . Our data suggest that, increasing the quality of the healthcare experience, patient satisfaction can be improved. According to previous literature, service recovery per se, increases the perceived quality of the service offered and improves patient satisfaction [29, 51] . Evaluations of perceived value have demonstrated its influence on the satisfaction of health service users. Our work seems to indicate that, as patients perceive an increase in the value of the services provided, user satisfaction with the healthcare received increases. Different empirical works show that a higher perception of the value of the healthcare services offered increases the level of patient satisfaction [52, 53] . The This work, like many others, has some limitations. On the one hand, this study was carried out in a state of alarm and, therefore, some causal relationships could be questioned once the pandemic is over. Future studies could analyze these relationships over time to reaffirm the causality between variables. On the other hand, this research examines the recovery of health services in health centres, with the safety measures in place. However, the special characteristics of the medical services cannot be generalized to other research contexts, without certain nuances. Furthermore, the geographical scope of the empirical study, restricted to a region in southern Spain, also limits the generalizability of the results obtained. 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