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A Discrepancy Model for Measuring Consumer Satisfaction with Rehabilitation Services.

The need for increased consumer involvement in rehabilitation services has often been emphasized in professional literature. Unprecedented social change, legislative initiatives, growing empowerment among consumer groups who demand informed choice, and changes in current service intervention strategies, individually and collectively, have contributed to a heightened interest in the opinions of the persons who utilize rehabilitation services. Furthermore, the long-range impact of the Americans with Disabilities Act (ADA) of 1990 on service needs of persons with disabilities is beginning to be clarified. Its impact may well prove to be as far reaching as the Rehabilitation Act of 1973. If so, a surge in consumer involvement in all areas of rehabilitation services planning is anticipated.

As empowered consumers continue to voice opinions regarding their service needs, the effectiveness of current services will be of greater interest to providers. Consumer opinion, nonetheless, should be solicited to insure that knowledgeable consumers are more involved in the assessment of current services as well as in the development of more effective services. Many researchers and practitioners are supportive of consumer opinions as a viable research option. Experts suggest that discussions continue regarding issues surrounding increased consumer involvement in service planning and how to more effectively use satisfaction research information in planning efforts (Bativia & DeJong, 1991; Fawcett, 1991; Kosciulek, Rosenthal, Vessell, Accardo & Mertz, 1997; Stubbins, 1984). Discussions on obtaining clients' perspectives in planning services and determining the usefulness of those services continue. However, two issues remain (a) agreement as to how this information can best be obtained, and (b) the usefulness of the information. The primary purpose of this paper is to explore ways that would maximize consumer participation in service planning and evaluation by more effectively assessing consumer opinions.

Increased participation of consumers in the research and exploration of more meaningful means of arriving at their opinions has been suggested by many experts in the consumer satisfaction area as viable research options (e.g. Bativia & DeJong 1990; Fawcett, 1991; Kosciulek et al 1997; Phillips, 1985; Taylor, Raccino, Knoll & Lutifyys, 1987; Williams, 1994). Historically, discussions of consumer satisfaction in human services have revolved around such questions as: (a) at what levels should clients be involved in service planning? (b) should and can, consumers be asked to determine the quality of specialized professional services such as rehabilitation services? (c) if consumers are more involved in service planning, to what extent should they be encouraged to participate in the process? and, (d) do current services meet real and perceived needs of persons receiving the services? (Johnson & Fawcett, 1987; Morrison, 1991; Stubbins, 1984). Two a priori assumptions herein, are that (a) consumers should be involved in all aspects of service planning, and (b) an initial step for researchers is to develop better measures of determining consumers' perceptions of services, planning, and evaluation of impact.

In regard to obtaining consumer opinion, social learning researchers, such as Bandura (1977) and Hawkins (1991), have stressed that the needs of persons seeking services are individualized. Consequently, their expectations and perceptions of services will likely impact the success, failure, and their opinions of services received. Research reports that dissatisfaction/satisfaction is related to individual cognitive discrepancies between a social ideal (collective expectations) and the personal experience of reality (individual perceptions) (Higgins, 1987). The social learning model has served as a theoretical base for human service satisfaction research (Bandura, 1977; Caeser, 1997; Fawcett, 1991; Gotlieb, Grewal and Brown, X1984; Higgins; 1987). This model also has served as the theoretical base for satisfaction research in the broader context of service industry marketing (Zaltman & Wallendorf, 1983).

Satisfaction Research in Human Services: Problems

The majority of satisfaction research is based on the assumption that determining consumer satisfaction is a necessary step in increasing consumer involvement in service planning and evaluation. Caeser (1997), Fawcett (1991), and Wolf (1978) recommended the use of socially valid research methods to better understand the highly individualized cognitive processes involved in the formation of opinions of satisfaction. A reasonable option is to "just ask the consumer" as a way to determine whether the consumers' needs have or have not been met. This simple question is seen as providing the cornerstone for socially valid research methods. Danek, Parker and Szymanski (1991) reported that studies, which involve consumers in research, are important steps toward forging an improved provider/consumer alliance in all areas of rehabilitation service delivery. This information is seen as valuable because it gives focus to future policy and procedural change and gives direction to research.

Patterson and Leach (1987), in a review of satisfaction literature in rehabilitation counseling, reported no conclusive evidence of client discontent. Furthermore they suggested that the research reviewed generally revealed high levels of overall satisfaction with services. For example, Hill and Hill, (1975a, 1975b, 1975c), in their studies of satisfaction with rehabilitation services in Alaska (1975a), New Mexico (1975b), and Vermont (1975c), found high levels of satisfaction among clients surveyed.

Selection of Variables

Heppner and Claiborn (1989) reported in their critical review of the human service satisfaction literature that an extremely disproportionate amount of satisfaction research in human services has emphasized constructs which professionals believe are important. However, they suggest that these variables might not necessarily be the same ones utilized by consumers in arriving at their opinions of service satisfaction. For example, Tucker, Parker, Parham, Brady, & Brown (1988), reported differences in consumer and counselor opinions concerning important counselor traits in counseling. They also found that when rehabilitation consumers and their counselors' opinions were compared regarding what were important counselor characteristics, major perceptual differences emerged. For instance, counselors reported valuing behaviors that were more task oriented, such as goal setting and problem solving. Consumers, on the other hand, believed it more important that counselors be caring, encouraging and supportive of their individual needs. Stubbins (1984) and Bativia and DeJong (1990) concurred with Heppner and Claiborn's (1990) evaluation of past research. These researchers suggested that findings yielding high levels of consumer satisfaction are likely the result of researchers' inadequately surveying the specific constructs which consumers utilize when arriving at opinions of satisfaction. These authors believed that many investigations yielding high levels of satisfaction have failed to adequately measure the specific cognitive constructs that the service recipients used to arrive at their opinions of satisfaction or dissatisfaction. These authors further suggested that professional providers have usually developed the services surveyed with little or no input from consumers. This lack of input is described as an example of how rehabilitation providers continue to devalue consumer opinion. Consequently, many satisfaction surveys may not have addressed consumer concerns about the services provided. In fact, consumers may not have perceived these services as necessary or important in the first place.

Use of Global Measures

Another issue raised with many of the research efforts in the human service satisfaction area is that studies frequently utilize instruments which define and measure satisfaction as a single and complete construct (Danek, Parker & Szymanski, 1991; Lebow, 1982). Sanbourin, LaFeiriere, Sicuro, Coallier, Cournoyer and Gendreau (1989) suggested that the use of a single global measure in satisfaction research increases the likelihood that results may be contaminated by consumers responding in a socially desirable manner. Socially desirable responding often results in inflated scores of satisfaction.

Ostrom (1989) recommended that consumer satisfaction research move beyond the limitations of highly structured instruments which have provided global indicators of cognition such as attitudes, beliefs and satisfaction. He further suggested that researchers devise or borrow tools that better measure these cognitive constructs which consumers may call upon when arriving at opinions of satisfaction. Moreover, assessments of opinions are best done in the situation in which the cognitive construct of interest is triggered, such as during service participation. This design would enable researchers to more accurately measure and better understand personal constructs used by consumers in situations of most salience.

In research efforts where satisfaction has been defined as a multifaceted or multi-dimensional construct, consumer reports of dissatisfaction appear to increase (Russell, 1990; Singh, 1990). Therefore, it has been suggested that utilization of instruments which measure multi-dimensional constructs may yield more valid information regarding consumer opinion (Bativia & DeJong, 1990; (Ostrom, 1989). The counseling literature in consumer satisfaction suggests the utilization of techniques designed or modified to address multi-factors related to satisfaction. Inquiry should start at the onset of services and continue at various points in service delivery. This would result in an enhanced ability to more accurately measure consumer opinion (Fawcett 1991; Patterson & Marks, 1992; Russell, 1990). Sabourin et al. (1988) suggested that consumer satisfaction research in human service settings should place more emphasis on exploring what specific dimensions constitute the larger construct of satisfaction. They also suggested that constructs be identified that are utilized by the recipients of the services to determine satisfaction/service quality, and not just constructs that providers or researchers of those services deem important. To account for this lack of specificity when surveying consumer satisfaction, these and other authors have suggested that future research efforts focus on identifying what factors may contribute to even moderate levels of dissatisfaction (Fawcett, 1991; Gilchrest & Stringer, 1992; Ostrom, 1989; Russell, 1990). When more specific and multiple measures have been used to assess satisfaction opinions in counseling settings, consumer reports of dissatisfaction appear to increase. Researchers indicate that this effect increases the potential for provider responsiveness to specific consumer concerns. (Reis & Brown, 1999; Russell, 1990; Singh, 1990).

Obetz, Farber, and Rosenstein (1997) examined the relationship between satisfaction and the single variable of "length of waiting time between intake and the first session" for students at a college counseling center. Their results indicated a significant relationship between length of waiting time and ensuing measures of consumer satisfaction/dissatisfaction. These authors reported that when consumers were queried on a specific dimension contributing to the global construct of satisfaction, more useful information was obtained on how service provision could be modified to increase levels of satisfaction.

Satisfaction and Attrition

Schwartz and Baer (1991) suggest that social validity research should address issues from the perspective of consumers. Furthermore, it is more than a simple matter of obtaining recipient responses when asked if they approve or disapprove of a program, but also future behaviors related to program involvement. These behaviors may include encouraging others not to participate, complaining in the community, and withdrawal from the service in question. Fawcett (1991) and Lebow (1982) believed that continuation in service is a prerequisite for a successful outcome and that a minimal level of satisfaction is necessary if a client will choose to continue in a program or service.

Fawcett (1991) and Lebow (1982) suggested that future research efforts should focus on the relationship between self-reports of satisfaction and maintenance of minimum levels of acceptability necessary for a client to continue in treatment. They also suggested that research could aid in the development of methods to identify persons who are at risk of terminating prematurely from services. If identified, then modifications in service delivery could be made to address factors that consistently contribute to attrition. Those modifications could result in enhanced treatment effectiveness because it has been demonstrated that effectiveness is dependent on client attendance and participation.

The relationship between attrition and satisfaction was investigated by McNeill, May, and Lee (1987). In their study, the satisfaction levels of premature terminators (n=56) and successful terminators (n=148) from counseling were compared. They reported that premature terminators were less satisfied with the counseling they had received than those who successfully terminated from counseling. In their study, premature terminators also reported their counselors as being; (a) less attractive, or less like themselves; (b) less expert, or lacking the skills to help them; and (c) less trustworthy, or inadequate at conveying respect, and confidence. Furthermore, they found those who remained in counseling expressed greater levels of satisfaction, regardless of initial perceptions concerning the service provider's expertness, attractiveness, or trustworthiness. Moreover, it was found that subjects who responded anonymously to the satisfaction questionnaire reported being significantly less satisfied with services.

Reported effects of increased consumer involvement in service assessment suggest that as consumers are more involved and see an affirmative response by service providers in the service planning process, there is a positive impact on the perceptions of quality. For example, Ingram, Seuser, and Owens (1988) reported that service users committed more readily to service goals in a substance abuse, setting if they perceived they had been more involved during the prescription or goal setting phase. Johnson and Fawcett (1994), in a follow up to 1987 research on consumer requests for increased courteous treatment from their rehabilitation counselors, indicated that when the behaviors consumers had identified with "courteous service provision" increased, reports of satisfaction also increased.

Consumer Satisfaction in Marketing

Much marketing research on satisfaction is based on the simple but powerful paradigm that initial expectations must be equaled or exceeded by consumer perceptions of outcome before consumer satisfaction exists (Parasuraman, Zeithaml & Berry, 1985). This discrepancy model of consumer satisfaction was developed out of social learning theory. There is agreement among marketing researchers that this theoretical assumption is a sound base from which to conduct consumer opinion research (Parasuraman, Zeithaml & Berry, 1985; Zaltman &Wallendorf, 1983). For example, Cadotte, Woodruff, and Jenkins (1987) indicated a wide acceptance of a discrepancy paradigm where satisfaction/dissatisfaction is viewed as resulting from consumers' comparisons of service expectations with their perceptions of outcome. Churchill and Surprenant (1982) argued that satisfaction could be conceived as an attitude in the sense that it is an evaluation relative to the consumption experience. This view of satisfaction as an attitude that has both cognitive and affective elements seems acceptable to marketing researchers and has been demonstrated to be useful in the development of research on the satisfaction construct. This model of consumer satisfaction is based on the discrepancy model of opinion formation previously described.

Dimensionality of Satisfaction

Marketing researchers have generally agreed that satisfaction is a multi-dimensional construct. They also have agreed that a multi-dimensional approach provides a more accurate and useful measure of generic factors that impact consumers' opinions of dissatisfaction (Gould, 1988; Pascoe, 1983; Zeithaml, Parasuraman, & Berry et al., 1990). Many human service researchers have reached agreement that the satisfaction construct should be viewed as multi-dimensional in future research efforts concurring with marketing researchers that it would provide more accurate and useful information concerning consumer opinion (Fawcett, 1991; Lebow, 1982; Wolf, 1978). Dimensionality implies that pertinent attribute dimensions are initially identified and then evaluated by a consumer. While specific dimensions could vary for different service settings, the fact that satisfaction is a construct of multiple dimensions is well supported.

The concept of "service quality" focuses on many of the same dimensions as consumer satisfaction. Definitional relations for expectations and perceptions are similar. Service quality is suggested by some researchers as a related avenue for study, however, it is unclear as to how service quality fits with consumer satisfaction (McNeill, May & Lee, 1987; Crane, 1991; Parasuraman, Zeithaml & Berry, 1991).

As summarized by Oliver (1980), satisfaction is seen as a summary psychological state resulting from emotions surrounding disconfirmation or confirmation of the consumer's expectations or prior feelings of a service and thoughts about the actual consumption experience. He suggests that satisfaction ultimately impacts one's overall attitude toward future consumption behavior.

Zeithaml, Parasuraman, and Berry (1990) believed that cognitive arrangement of satisfaction and attitude is the appropriate distinction between service quality and satisfaction. Consequently, they have argued that service quality judgments are but a higher order of the satisfaction construct. An earlier work by these authors (Parasuraman, Zeithaml, & Berry, 1985) suggested that service quality opinions and satisfaction are related. The opinion of satisfaction as experienced by a consumer also will result in positive perceptions of service quality. This model that emphasizes the distinction between perceived service quality and objective service quality, is consistent with basic differences between service and goals. This model specifies that service quality as perceived by the consumer depends on the size and direction of the gap between expected and perceived services, which in turn depends on the nature of the gaps associated with the design, marketing, and delivery of services (Zeithaml, Parasuraman, & Berry, 1990). They further suggest the utilization of multidimensional questionnaires to measure the differences between (a) what consumers expect of a service and (b) what the consumer perceives. This type of questionnaire overcomes many of the problems associated with global measures. Furthermore, this method corrects for such issues as socially desirable responses and the lack of specificity which have previously been described as contributing to inflated levels of satisfaction in human service satisfaction research.

Although participants in the original research of Zeithaml et al., (1990) were not drawn from persons in counseling, similarities between the dimensional structure of service quality and those previously reported as comprising satisfaction in human services can be noted (Fawcett, 1991; Johnson & Fawcett, 1987; Patterson & Marks, 1992; Sabourin et al., 1989; Tucker et al., 1988). Using this definition of perceived service quality as the disconfirmation/confirmation (GAP theory) between perceptions and expectations, Zeithaml, Parasuraman, and Berry (1990) developed a dual scale. The first scale measured consumers' initial expectations; the second scale determined the consumers' actual perceptions of outcome after services were received. This dual scale gives satisfaction researchers a tool that will include the opinions of those persons who terminate prematurely from counseling and thus, are most often dissatisfied with the service as provided (Fawcett, 1991; (Lebow, 1982).

In summary, the literature indicates that, for future surveys, researchers should employ a multidimensional questionnaire. Additionally, this questionnaire should measure the factors consumers utilize to arrive at their opinions of satisfaction in situations of the most salience. These surveys could overcome many of the problems associated with global measures which contribute little information to facilitate positive provider response. This method also corrects for such issues as socially desirable response and lack of specificity which have been described as contributing to inflated levels of satisfaction in human services satisfaction research. Finally, the two section SERVQUAL, given both prior to and after the initial session will enable researchers to consider opinions in relationship to expectations of all persons seeking counseling services, even those who do not keep second appointments.

Through a rigorous process of development to determine what dimensions are most often used by service industry consumers in the formation of satisfaction/service quality opinions, Parasuraman et al., (1985) reported 10 service quality determinants. These service quality determinants, later collapsed to five, are described regardless of the service type, as being used by consumers to evaluate quality of service. She reported that these dimensions, contributing to satisfaction, appear to be used by consumers in service industries regardless of the service setting. Therefore, this instrument could prove useful in providing researchers in rehabilitation settings with a more sensitive measure that utilizes dimensions of satisfaction that consumers use when arriving at their opinions of satisfaction/dissatisfaction.

Instrument

The instrument developed by Zeithaml, Parasuraman, and Berry (1990), the SERVQUAL, utilizes five dimensions. The final five quality dimensions are:

Tangibles. Tangibles are physical facilities, appearance of personnel, tools or equipment used to provide service, physical representations of the service (e.g., invoice or brochures).

Reliability. Reliability is the ability to perform the promised service dependably and accurately. It means the service provider performs the service correctly the first time. It also can mean the provider keeps promises. Specifically, it involves accuracy in billing, keeping correct records and performing the service at times designated.

Responsiveness. Responsiveness is a provider's willingness to help customers and provide prompt service. It involves timeliness of service regarding the mailing of transcription slips, returning phone calls and setting up appointments quickly.

Assurance. Assurance acknowledges courteous employees and their ability to inspire trust and confidence. This dimension contains the earlier dimensions of (a) communication, (b) credibility, (c) security, (d) competence, and (e) courtesy. Communications adjusting language for different consumers, explaining service and costs and assuring the consumer those problems will be handled. Credibility is keeping the customer's best interests, contributing to credibility of agency reputation, and personal characteristics of contact personnel. Security includes such concerns as safety, security, and confidentiality. Competence speaks to the knowledge and skill of the direct service providers as well as that of the support staff and to the capability of the organization to know the market place. Courtesy includes the politeness, considerate nature and friendliness of contact personnel.

Empathy is the caring, individualized attention the organization provides its customers. This includes preliminary dimensions of understanding/knowing the customer and, access. Understanding/knowing the customer involves an effort to learn the customer's specific requirements, to provide individualized attention, and to recognize regular customers. Access assures that the service is easily accessible by telephone (e.g., lines are not busy, etc.), that the waiting time to receive a service is not too long, and that the operating hours and location are convenient.

The SERVQUAL has proven useful in several types of service settings, such as hospital operations specific to inpatient, outpatient and emergency room services (Reidenback andFINDSanderfer-Smallwood 1990), credit card companies (Zeithaml, Parasuraman, and Berry 1990), college and university student services (Ruby, 1998) and college and university libraries (Nitecki, 1996). These studies all have indicated the instruments usefulness in identifying specific areas in which consumer expectations are not being met. It would seem beneficial to focus on issues regarding replication in rehabilitation service settings to determine the utility of the SERVQUAL. It is proposed that research be conducted to determine the SERVQUAL's utility in a variety of rehabilitation settings to discover its usefulness in predicting such outcomes relating to active participation in services, continuation in services, and early termination from services. It could also provide planners valuable input from consumers concerning their perceptions and concern regarding services provided. This information would give administrators specific information on consumer needs and service delivery could be changed accordingly. Training to change the manner in which consumers are treated by all members of an organization, the information given consumers, and a increased emphasis being placed on responsiveness are but a few examples of positive provider responses that could be taken to close the gaps between consumer expectations and perceptions. Zeithaml et al. (1990) indicated that this responsiveness to consumer input would increase perceptions of service quality and or satisfaction.

Summary

Studies indicate a strong relationship between consumer perceptions of satisfaction and attrition from counseling. Lebow (1982), Schwartz and Baer (1991), and Patterson and Marks (1992) suggested that researchers should continue to explore the relationship between satisfaction, as measured by instruments such as the SERVQUAL questionnaire, and client attrition. This article was intended as a step in the process of implementing research: (a) specific to rehabilitation service consumers, (b) to identify the factors they utilize when arriving at opinions of satisfaction or dissatisfaction, and (c) to determine how their opinions may or may not relate to premature termination. This article also provides a theoretical base to justify the utilization of an instrument in rehabilitation settings that is widely used in other service settings. Future research is proposed that will provide information which can be used to improve rehabilitation services, counselor training, and/or program design. The following are suggested future research activities:

(a) Determine the general usefulness of the SERVQUAL in identifying consumers who may be dissatisfied and whether this dissatisfaction relates to premature termination from rehabilitation services.

(b) Investigates whether consumers of rehabilitation services also relate the five dimensions of the SERVQUAL to satisfaction opinion formation.

(c) Identify, if these recommended dimensions do in fact apply to rehabilitation settings which ones are the best predictors of attrition from the service and which ones are the best predictors of successful completion.

(d) Delineate the impact of gender on the utilization of the different dimensions of the SERVQUAL when consumers arrive at opinions of satisfaction?

If the initial research with the SERVQUAL in rehabilitation service settings proves useful, then efforts can be made to make appropriate changes in the delivery of rehabilitation services so that increased consumer participation can be realized. This research can give providers information to improve the process of service delivery by identifying dimension for staff training and by directing structural changes. Thus, rehabilitation services will realize the mission to provide customer centered services and, as a result, service effectiveness will be enhanced. Rehabilitation educators will be able to stress to students' specific areas of skill development that will improve counselor effectiveness. Lastly, these changes could send a positive message to empowered consumers that rehabilitation service providers are not only interested in consumer opinion but also respond to their concerns when provided with socially valid research information.

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Michael A. Richard, Ph.D., University of South Florida at Sarasota, 5700 North Tamiami Trail, Sarasota, FL 34243-217.
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