Gestão & Produção
Gestão & Produção
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Modeling quality, satisfaction and perceived crowding in public healthcare: a study with low-income Brazilian patients

João Guilherme Marcato; Hermes Moretti Ribeiro da Silva; Octaviano Rojas Luiz; Enzo Barberio Mariano; Carlos Eduardo Paro

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Abstract: This paper is one of the first to propose a research model to assess the quality and satisfaction perceived by low-income Brazilian patients using public healthcare services, under the moderating effect of perceived crowding. The model was evaluated from data obtained from 417 patients, and its proposed relationships and statistics were tested through Structural Equation Modeling using a Partial Least Squares approach (PLS-SEM). To explore the moderating effect of perceived crowding, the sample was divided into two groups and tested by employing multi-group analysis (MGA). The results show that Reliability, Safety, Tangibles, Empathy and Responsiveness have a positive effect on Perceived Healthcare Quality (PHQ), which, in turn, has a marked effect on patient satisfaction (PS), ergo, PHQ acts as antecedent of PS. However, perceived crowding has no moderating effect on any relationship in the model.


Quality management, Public healthcare, Low-income patients, Service quality, Patient satisfaction, Perceived crowding


Akdere, M., Top, M., & Tekingunduz, S. (2020). Examining patient perceptions of service quality in Turkish hospitals: the SERVPERF model. Total Quality Management & Business Excellence, 31(3-4), 342-352.

Almeida, C., Travassos, C., Porto, S., & Labra, M. E. (2000). Health sector reform in Brazil: a case study of inequity. International Journal of Health Services, 30(1), 129-162. PMid:10707303.

Alp, S., Yilmaz, F., & Geçici, E. (2022). Evaluation of the quality of health and safety services with SERVPERF and multi-attribute decision-making methods. International Journal of Occupational Safety and Ergonomics, 28(4), 2216-2226. PMid:34556013.

Andaleeb, S. (2008). Caring for children: a model of healthcare service quality in Bangladesh. International Journal for Quality in Health Care, 20(5), 339-345. PMid:18621779.

Archibong, E. P., Bassey, G. E., Isokon, B. E., & Eneji, R. (2020). Income level and healthcare utilization in Calabar Metropolis of Cross River State, Nigeria. Heliyon, 6(9), e04983. PMid:33015387.

Babakus, E., & Mangold, W. G. (1992). Adapting the ServQual scale to hospital services: an empirical investigation. Health Services Research, 26(6), 767-786. PMid:1737708.

Badri, M. A., Attia, S. T., & Ustadi, A. M. (2009). Healthcare quality and moderators of patient satisfaction: testing for causality. International Journal of Health Care Quality Assurance, 22(4), 382-410. PMid:19725210.

Baker, J., & Wakefield, K. L. (2012). How consumer shopping orientation influences perceived crowding, excitement, and stress at the mall. Journal of the Academy of Marketing Science, 40(6), 791-806.

Baltussen, R. M. P. M., Ye, Y., Haddad, S., & Sauerborn, R. S. (2002). Perceived quality of primary health care services in Burkina Faso. Health Policy and Planning, 17(1), 42-48. PMid:11861585.

Banerjee, A., Deaton, A., & Duflo, E. (2004). Wealth, health, and health services in rural Rajasthan. The American Economic Review, 94(2), 326-330. PMid:19305517.

Barki, E., & Parente, J. (2010). Consumer behaviour of the base of the pyramid marketing in Brazil. Journal of Consumer Marketing, 25(7), 402-412.

Bernardo, J. M. S., Mendes, G. H. S., Lizarelli, F. L., & Roscani, M. G. (2022). Instruments to measure patient experience in hospitals: a scoping review. Gestão & Produção, 29, e0821.

Bhattacharjee, A., Shin, J. K., Subramanian, C., & Swaminathan, S. (2017). Healthcare investiment and income inequality. Journal of Health Economics, 56, 163-177. PMid:29055188.

Boccolini, C. S., & Souza, P. R. B., Jr. (2016). Inequities in healthcare utilization: results of the Brazilian National Health Survey, 2013. International Journal for Equity in Health, 15(1), 150. PMid:27852269.

Boyle, A., Coleman, J., Sultan, Y., Dhakshinamoorthy, V., O’Keeffe, J., Raut, P., & Beniuk, K. (2015). Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding. Emergency Medicine Journal, 32(2), 105-108. PMid:24008146.

Brady, M. K., Cronin, J., Jr., & Brand, R. R. (2002). Performance-only measurement of service quality: a replication and extension. Journal of Business Research, 55(1), 17-31.

Carrillat, F. A., Jaramillo, F., & Mulki, J. P. (2007). The validity of the SERVQUAL and SERVPERF scales: a meta‐analytic view of 17 years of research across five continents. International Journal of Service Industry Management, 18(5), 472-490.

Choi, K., Cho, W., Lee, S., Lee, H., & Kim, C. (2004). The relationships among quality, value, satisfaction and behavioral intention in health provider choice: a South Korean study. Journal of Business Research, 57, 913-921.

Dion, D. (2004). Personal control and coping with retail crowding. International Journal of Service Industry Management, 15(3), 250-263.

Donabedian, A., Wheeler, H. R. C., & Wysze-Wianski, L. (1982). Quality, cost and health: an integrative model. Medical Care, 20(10), 975-992. PMid:6813605.

Duarte, P., & Amaro, S. (2018). Methods for modeling reflective-formative second order constructs in PLS: an application to online travel shopping. Journal of Hospitality and Tourism Technology, 9(3), 295-313.

Emerson, E. J., Ford, R. C., & Simsek, K. D. (2022). The influence of baby boomers’ perceptions of well-being on their plan to age-in-place post-retirement. International Journal of Hospitality Management, 107, 103295.

Erdogan, M., & Ayyildiz, E. (2022). Comparison of hospital service performances under COVID-19 pandemics for pilot regions with low vaccination rates. Expert Systems with Applications, 206, 117773. PMid:35702379.

Erickson, D., & Andrews, N. (2011). Partnerships among community development, public health, and health care could improve the well-being of low-income people? Health Affairs, 30(11), 2056-2063. PMid:22068396.

Ferraz, D., Mariano, E. B., Manzine, P. R., Moralles, H. F., Morceiro, P. C., Torres, B. G., Almeida, M. R., Mello, J. C. S., & Rebelatto, A. N. (2021). COVID health structure index: the vulnerability of Brazilian microregions. Social Indicators Research, 158(1), 197-215. PMid:33967373.

Fornell, C., & Larcker, D. F. (1981). Evaluating structural equation models with unobservable variables and measurement error. JMR, Journal of Marketing Research, 18(1), 39-50.

Gallani, S., Kajiwara, T., & Krishnan, R. (2020). Value of new performance information in healthcare: evidence from Japan. International Journal of Health Economics and Management, 20(4), 319-357. PMid:32808057.

Guimarães, T., Lucas, K., & Timms, P. (2019). Understanding how low- income communities gain access to healthcare services: A qualitative study in São Paulo, Brazil. Journal of Transport & Health, 15, 100658.

Haddad, S., Fournier, P., & Potvin, L. (1998). Measuring lay people’s perception of the quality of primary health care services in developing countries. International Journal for Quality in Health Care, 10(2), 93-104. PMid:9690882.

Haenssgen, M. J., & Ariana, P. (2016). Healthcare access: a sequence-sensitive approach. SSM - Population Health, 3, 37-47. PMid:29349202.

Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R. E. (2014a). Multivariate data analysis. Harlow: Pearson Education Limited.

Hair, J. F., Hult, G. T. M., Ringle, C. M., & Sarstedt, M. (2022). A primer on Partial Least Squares Structural equation modeling (PLS-SEM) (3rd ed.). Thousand Oaks: Sage.

Hair, J. F., Hult, G. T. M., Ringle, C. M., Sarstedt, M., Danks, N. P., & Ray, S. (2021). Partial Least Squares Structural equation modeling (PLS-SEM) using R. In C. Homburg, M. Klarmann & A. Vomberg (Eds.), Handbook of market research. Cham: Springer.

Hair, J. F., Ringle, C., & Sarstedt, M. (2011). PLS-SEM: indeed a silver bullet. Journal of Marketing Theory and Practice, 19(2), 139-152.

Hair, J. F., Sarstedt, M., Hopkins, L., & Kuppelwieser, V. (2014b). Partial least squares structural equation modeling (PLS-SEM): an emerging tool for business research. European Business Review, 26(2), 106-121.

Heckman, S. J., & Hanna, S. H. (2015). Individual and institutional factors related to low-income household saving behavior. Journal of Financial Counseling and Planning, 26(2), 187-199.

Henseler, J., Ringle, C. M., & Sarstedt, M. (2015). A new criterion for assessing discriminant validity in variance-based structural equation modeling. Journal of the Academy of Marketing Science, 43(1), 115-135.

Henseler, J., Ringle, C. M., & Sinkovics, R. R. (2009). The use of partial least squares path modeling in international marketing. Advances in International Marketing, 20, 277-319.

Hollanda, E., Siqueira, S. A. V., Andrade, G. R. B., Molinaro, A., & Vaitsman, J. (2012). User satisfaction and responsiveness in the healthcare services at Fundação Oswaldo Cruz. Ciencia & Saude Coletiva, 17(12), 3343-3352. PMid:23175410.

Hui, M. K., & Bateson, J. E. G. (1991). Perceived control and the effects of crowding and consumer choice on the service experience. The Journal of Consumer Research, 18(2), 174-184.

Hussain, A., Sial, M. S., Usman, S. M., Hwang, J., Jiang, Y., & Shafiq, A. (2019). What factors affect patient satisfaction in public sector hospitals: evidence from an emerging economy. International Journal of Environmental Research and Public Health, 16(6), 994. PMid:30893906.

Kansra, P., & Jha, A. K. (2016). Measuring service quality in Indian hospitals: an analysis of SERVQUAL model. International Journal of Services and Operations Management, 24(1), 75761.

Kim, J. (2019). Customers’ value co-creation with healthcare service network partners: the moderating effect of consumer vulnerability. Journal of Service Theory and Practice, 29(3), 309-328.

Leguina, A. (2015). A primer on partial least squares structural equation modeling (PLS-SEM). International Journal of Research & Method in Education, 38(2), 220-221.

Li, L., Zhang, J., Nian, S., & Zhang, H. (2017). Tourists’ perception of crowding, attractiveness, and satisfaction: a second-order structural model. Asia Pacific Journal of Tourism Research, 22(12), 1250-1260.

Lien, C. H., Wu, J. J., Chen, Y. H., & Wang, C. J. (2014). Trust transfer and the effect of service quality on trust in the healthcare industry. Managing Service Quality, 24(4), 399-416.

Lin, M., Beliavsky, A., Katz, K., Powis, J. E., Ng, W., Williams, V., Science, M., Groves, H., Muller, M. P., Vaisman, A., Hota, S., Johnstone, J., & Leis, J. A. (2020). What can early Canadian experience screening for COVID-19 teach us about how to prepare for a pandemic? Canadian Medical Association Journal, 192(12), E314-E318. PMid:32144097.

Machleit, K. A., Eroglu, S. A., & Mantel, S. P. (2000). Perceived retail crowding and shopping satisfaction: what modifies this relationship? Journal of Consumer Psychology, 9(1), 29-42.

Malhotra, N. K., & Dash, S. (2009). Marketing research: an applied orientation. Delhi: Pearson.

Mashhadlou, H., & Izadpanah, S. (2021). Assessing Iranian EFL teachers’ educational performance based on gender and years of teaching experience. Language Testing in Asia, 11(1), 23.

Massuda, A., Hone, T., Leles, F. A. G., Castro, M. C., & Atun, R. (2018). The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Global Health, 3(4), e000829. PMid:29997906.

McFadyen, K., Harrison, J. L., Kelly, S. J., & Scott, D. (2001). Measuring service quality in a corporatised public sector environment. Journal of Nonprofit & Public Sector Marketing, 9(3), 35-51.

Metha, R., Sharma, N. K., & Swanmi, S. (2013). The impact of perceived crowding on consumer’s buying impulse: role of optimal stimulation level and shopping motivation. Journal of Marketing Research, 29(7), 812-835.

Moliner, M. A. (2009). Loyalty, perceived value and relationship quality in healthcare services. Journal of Service Management, 20(1), 76-97.

Murphy, K., & Creux, O. (2021). Examining the association between media multitasking, and performance on working memory and inhibition tasks. Computers in Human Behavior, 114, 106532.

Naidu, A. (2009). Factor affecting patient satisfaction and healthcare quality. International Journal of Health Care Quality Assurance, 22(4), 366-381. PMid:19725209.

Narang, R. (2011). Determining quality of public health care services in rural India. Clinical Governance: An International Journal, 16(1), 35-49.

Noone, B. M., & Mattila, A. S. (2009). Consumer reaction to crowding for extended service encounters. Managing Service Quality, 19(1), 31-41.

Noone, B. M., Kimes, S. E., Mattila, A. S., & Wirtz, J. (2009). Perceived service encounter pace and customer satisfaction: an empirical study of restaurant experiences. Journal of Service Management, 20(4), 380-403.

Osei-Frimpong, K., & Owusu-Frimpong, N. (2017). Value co-creation in health care: a phenomenological examination of the doctor-patient encounter. Journal of Nonprofit & Public Sector Marketing, 29(4), 365-384.

Pai, Y. P., Chary, S. T., & Pai, R. Y. (2018). Patient-perceived hospital service quality: an empirical assessment. International Journal of Health Care Quality Assurance, 31(1), 76-91. PMid:29504841.

Parasuraman, A., Zeithaml, V. A., & Berry, L. L. (1988). SERVQUAL: a multiple-item scale for measuring consumer perceptions of service quality. Journal of Retailing, 64(1)

Passero, L. G., Giordani, J. M. A., Hugo, F. N., Torman, V. B. L., Camey, S. A., & Hilgert, J. B. (2018). Contextual and individual factors associated with dissatisfaction with the Brazilian Unified National Health System, 2011-2012. Cadernos de Saude Publica, 34(1) PMid:27783752.

Pons, F., Giroux, M., Mourali, M., & Zins, M. (2016). The relationship between density perceptions and satisfaction in retail setting: mediation and moderation effects. Journal of Business Research, 69(2), 1000-1007.

Preacher, K. J., MacCallum, R. C., Rucker, D. D., & Nicewander, W. A. (2005). Use of the extreme groups approach: A critical reexamination and new recommendations. Psychological Methods, 10(2), 178-192. PMid:15998176.

Rathert, C., Williams, E. S., McCaughey, D., & Ishqaidef, G. (2015). Patients perceptions of patient-centred care: empirical test of a theoretical model. Health Expectations, 18(2), 199-209. PMid:23176054.

Rodrigues, L. R., Barkur, G., Varambally, K. V. M., & Motlagh, F. G. (2011). Comparison of SERVQUAL and SERVPERF metrics: an empirical study. The TQM Journal, 23(6), 629-643.

Romano, P. S., & Mutter, R. (2004). The evolving science of quality measurement for hospitals: implications for studies of competition and consolidation. International Journal of Health Care Finance and Economics, 4(2), 131-157. PMid:15211103.

Russell, R. S., Johnson, D. M., & White, S. W. (2015). Patients perceptions of quality: analyzing patient satisfaction surveys. International Journal of Operations & Production Management, 35(8), 1158-1181.

Sarstedt, M., Henseler, M., & Ringle, C. (2011). Multi-group analysis in Partial Least Squares (PLS) path modeling and empirical results. In M. Sarstedt, M. Schwaiger & C. R. Taylor (Eds.), Measurement and research methods in international marketing (Advances in International Marketing, Vol. 22, pp. 195-218). Bingley: Emerald Group Publishing.

Sarstedt, M., Ringle, C., Smith, D., Reams, R., & Hair, J. F., Jr. (2014). Partial least squares structural equation modeling (PLS-SEM): a useful tool for family business researchers. Journal of Family Business Strategy, 5(1), 105-115.

Saueressig, M. V., Larentis, F., & Giacomello, C. P. (2021). Perceived quality and loyalty in service operations: a study in banking segment’s corporate person division. Gestão & Produção, 28(1), e4983.

Sawang, S., Chou, C. Y., & Truong-Dinh, B. Q. (2019). The perception of crowding, quality and well-being: a study of Vietnamese public health services. Journal of Health Organization and Management, 33(4), 460-477. PMid:31282817.

Shafei, I., Walburg, J., & Taher, A. (2019). Verifying alternative measures of healthcare service quality. International Journal of Health Care Quality Assurance, 32(2), 516-533. PMid:31017062.

Silva, D. N. S., Jr., Braga, B. S. F., Santos, C. D. P., Borges, R. E. A., & Noro, L. R. A. (2018). Evaluation of user satisfaction from the Carta SUS, in Rio Grande do Norte, Brazil. Saúde em Debate, 42(119), 901-915.

Silva, M. Z., & Fernandes, F. C. (2019). The influence of contigencies factors strategy and structure in the enterprise risk management in a hospital. Gestão & Produção, 26(1), e2315.

Soares, A. M., & Farhangmehr, M. (2015). Understanding patient satisfaction in a hospital emergency department. International Review on Public and Nonprofit Marketing, 12(1), 1-15.

Sun, W., & Pang, J. (2017). Service quality and global competitiveness: evidence from global service firms. Journal of Service Theory and Practice, 27(6), 1058-1080.

Teshnizi, S. H., Aghamolaei, T., Kahnouji, K., Teshnizi, S. M., & Ghani, J. (2018). Assessing quality of health services with the SERVQUAL model in Iran. A systematic review and meta-analysis. International Journal for Quality in Health Care, 30(2), 82-89. PMid:29408970.

van der Linden, M. C., van Ufford, H. M. E., & van der Linden, N. N. (2019). The impact of multimodal intervention on emergency department crowding and patient flow. International Journal of Emergency Medicine, 12(1), 21. PMid:31455260.

van Duong, D., Binns, C. W., & Hipgrave, D. B. (2004). Measuring client-perceived quality of maternity services in rural Vietnam. International Journal for Quality in Health Care, 16(6), 447-452. PMid:15557354.

Verleye, K., Jaakkola, E., Hodgkinson, I. R., Jun, G. T., Odekerken-Schröder, G., & Quist, J. (2017). What causes imbalance in complex service networks? Evidence from a public health service. Journal of Service Management, 28(1), 34-56.

Walton, A., & Hume, M. (2012). Examining public hospital service failure: the influence of service failure type, service expectations, and attribution on consumer response. Journal of Nonprofit & Public Sector Marketing, 24(3), 202-221.

Wang, H., Kline, J. A., Jackson, B. E., Robinson, R. D., Sullivan, M., Holmes, M., Watson, K. A., Cowden, C. D., Philips, J. L., Schrader, C. D., Leuck, J., & Zenarosa, N. (2017). The role of patient perception of crowding in the determination of real-time patient satisfaction at Emergency Department. International Journal for Quality in Health Care, 29(5), 722-727. PMid:28992161.

Wang, W., Haggerty, J., Loban, E., & Liu, X. (2019). Evaluating primary health care performance from user perspective in china: review of survey instruments and implementation issues. International Journal of Environmental Research and Public Health, 16(6), 926. PMid:30875833.

Wei, S., Ang, T., & Anaza, N. A. (2019). The power of information on customers’ social withdrawal and citizenship behavior in a crowded service environment. Journal of Service Management, 30(1), 23-47.

Whiteside, T., Kane, E., Aljohani, B., Alsamman, M., & Pourmand, A. (2020). Redesigning emergency department operations amidst a viral pandemic. The American Journal of Emergency Medicine, 38(7), 1448-1453. PMid:32336583.

Wild, D., Grove, A., Martin, M., Eremenco, S., McElroy, S., Verjeelorenz, A., & Erikson, P. (2005). Principles of good practice for translation and cultural adaptation process for patients. Value in Health, 8(2), 94-104. PMid:15804318.

Woodworth, L. (2020). Swamped: emergency department crowding and patient mortality. Journal of Health Economics, 70, 102279. PMid:32062054.

Zekan, B., & Mazanec, J. A. (2022). Efficient satisfaction building: a comparative study of ski resorts. Tourism Analysis, 27(4), 447-465.

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