Journal of Services Marketing

Emerald Article: Dental services marketing: do market segments based on usage rate differ in terms of determinant attributes? Zhengyuan Wang, Swinder Janda, C.P. Rao

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To cite this document: Zhengyuan Wang, Swinder Janda, C.P. Rao, (1996),"Dental services marketing: do market segments based on usage rate differ in terms of determinant attributes?", Journal of Services Marketing, Vol. 10 Iss: 4 pp. 41 - 55 Permanent link to this document: http://dx.doi.org/10.1108/08876049610124572 Downloaded on: 18-09-2012 References: This document contains references to 45 other documents Citations: This document has been cited by 6 other documents To copy this document: permissions@emeraldinsight.com This document has been downloaded 878 times since 2005. *

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An executive summary for managers and executives can be found at the end of this article

Dental services marketing: do market segments based on usage rate differ in terms of determinant attributes?
Zhengyuan Wang, Swinder Janda and C.P. Rao

Determinant attributes

Introduction Consumers form attitudes toward a product or service based on salient beliefs about the product or service (dAstous and Dubuc, 1986; Miniard et al., 1986). Alternative brands in the consideration set are viewed in terms of the associated choice criteria. Choice criteria may include aspects such as salient beliefs about product consequences, psychosocial consequences, or value consequences (Peter and Olson, 1993). However, there could be potentially a large number of choice criteria, typically product attributes, which may be considered in a particular situation, but these attributes vary in their relative contribution to the choice decision (Sinclair and Stalling, 1990). The attributes that contribute highly to choice have often been termed as determinant attributes. The decision maker must perceive large differences in the alternatives under consideration in terms of an attribute, for that attribute to be considered determinant (Myers and Alpert, 1968). Bringing about a match between a marketers offering and needs of target market segments is the essence of gaining a competitive advantage. In order for marketers to achieve and sustain long-term competitive advantage, while following the marketing concept (Kotler, 1988), they need to focus on attributes that specific market segments value the most. Parasuraman et al., (1985) have pointed out that higher complexity of services relative to tangible goods makes a matching of product offering with customer expectations more challenging in the case of services marketing. Among different types of common services, health care products may be even less amenable to a matching of services offered with customer expectations. This is because health care product offerings are often characterized by complexity, inseparability, variability and customization (France and Grover, 1992). Despite this difficulty, it is becoming increasingly imperative for practitioners to develop and maintain a strategic fit between consumers expectations of the health care offering, and the actual offering itself. This is especially true for the dental care industry which has reached a plateau in demand due to a decline in birth rate and significantly better oral hygiene (Grove et al., 1994). At the same time, the number of dentists has increased by 50 percent over the last decade (Bush and Nitse, 1992).

A strategic fit needed between consumers expectations and health care offerings

Segmented marketing strategies

Since different market segments may prefer different sets of attributes when patronizing a dentist, it becomes relevant for the practitioners to ascertain what set of attributes are determinant attributes for each specific market segment. Chakraborty et al. (1993) reviewed the dental service literature and found that market segmentation was one area where prior research could be extended. It is important for dentists to know whether different consumer
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THE JOURNAL OF SERVICES MARKETING, VOL. 10 NO. 4 1996, pp. 41-55 MCB UNIVERSITY PRESS 0887-6045

groups emphasize different determinant attributes so that dentists can employ segmented marketing strategies. Thus, the purpose of this study was to identify determinant attributes for selecting a general dental practitioner and to examine whether determinacy scores differ across market segments based on dental service usage rate. This paper first reviews the extant literature in order to determine the attributes considered relevant by consumers while patronizing a general dental practitioner. Based on the review of literature and four focus group interviews with dental service consumers, 18 attributes are then identified to be included in this study. Data pertaining to the importance of each of these attributes and the perceived differences among the various dental care providers on each attribute are collected from a nationwide sample of consumers. Using a determinant attribute approach, the data are then analyzed to obtain a smaller set of determinant attributes. Eight such attributes are isolated, and multiple discriminant analysis conducted to establish differences in attribute consideration among three a priori market segments based on usage rate (i.e. heavy, medium and light users of dental care services). Literature review Extensive work in the area of customer satisfaction with services has focussed on health care in general (Aday et al., 1980), and dental services in particular (e.g. Gopalakrishna and Mummalaneni, 1993). Prior research relating to dental services has identified relevant factors considered by patients when first choosing a dentist (e.g. Barnes and Mowatt, 1986; Hill et al., 1990), and factors influencing customer satisfaction with dental care services (e.g. Gopalakrishna and Mummalaneni, 1993). McAlexander et al. (1994) have pointed out that patient satisfaction with dental care and assessment of overall service quality contribute to intentions to patronize a dentist. Recent research (Motes et al., 1995) has attempted to uncover differences between patients search for specialized versus routine dental care. In general, the primary attributes considered by consumers when choosing a dental practitioner, or subsequently evaluating the quality of service can be grouped into three general categories: (1) Those related directly to provision of the core service offering itself, e.g. quality of service, professional competence, attitude of dentist and the support staff, methods of pain control, etc. (2) Those concerned with aspects other than the core service offering, e.g. location, parking facilities, office atmosphere, etc. (3) Consumers may also base their decisions on the reputation of the dentist and the use of advertisements. The perceived reputation could be brought about through word-of-mouth recommendations from friends and family or through advertising. Past studies have explored one or more of the above factors. These studies are now elaborated in the following sub-sections. Attributes related to core service offering These factors include characteristics inherent in the service offering, including aspects related to the dentist, the support personnel and the service offering itself. They have been found to be very important for evaluation of
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Relevant factors when choosing a dentist

Three general categories of primary attributes

dental services. Past research has found service quality to be a highly emphasized attribute in patronizing a dentist (Hawes and Prough, 1988; Sanchez and Bonner, 1989). Bush and Nitse (1992) found quality to be of very high importance irrespective of whether consumers patronize private or retail dental centers. Consumers also confer high importance to factors such as courtesy and competence (both technical and professional) of the dentist (Crane and Clarke, 1988; Gopalakrishna and Mummalaneni, 1993). Several other relevant intrinsic attributes uncovered by past research include aspects such as sensitivity of dentist, personality and attitude of dentist, attitude of support personnel, and personal attention provided (Barnes and Mowatt 1986; Chakraborty et al., 1993; Crane and Lynch, 1988; Dolinsky and Caputo, 1990; Hawes and Prough, 1988). Fee charged for dental service has been found to be a moderate determinant of satisfaction in some studies (Chakraborty et al., 1993; Gopalakrishna and Mummalaneni, 1993; Hawes and Prough, 1988; Hill et al., 1990). Other relevant attributes include the sensitivity of the dentist, personality and attitude of the dentist, attitude of support personnel, personal attention provided, methods of pain control, and availability of emergency services (Barnes and Mowatt, 1986; Chakraborty et al., 1993; Crane and Lynch, 1988; Dolinsky and Caputo, 1990; Hawes and Prough, 1988). Attributes other than those related to core service offering These attributes have been found to be of varied importance in the past literature. One of the attributes found consistently to be very important is office atmosphere and appearance including neatness, seating comfort, magazine selection and music (Andrus and Buchheister, 1985; Chakraborty et al., 1993). Other such attributes identified in the past literature include waiting time for appointment, ease of making appointments, fee payment plans, location of dentist, and attractiveness of office and facilities (Chakraborty et al., 1993; Gopalakrishna and Mummalaneni, 1993; Hawes and Prough, 1988). In general, most studies in the area of dental services marketing have found attributes related to core service offering to be very important. Attributes such as location, parking facilities, hours of operation and office atmosphere have been found moderately to minimally important as choice criteria (e.g. Chakraborty et al., 1993; Hawes and Prough, 1988). Advertising may influence customer choice Several previous studies have included advertising as one of the criteria which may influence consumers choice of a dentist. Consumers perceive advertising as less important than the other factors outlined above (Bush and Nitse, 1992; Chakraborty et al., 1993; Crane and Lynch, 1988). However, advertising plays an important role in creating awareness about different options available for dental care (Hite et al., 1988), and can also provide useful information pertaining to various dental care attributes (Sanchez and Bonner, 1989). Hite et al. (1988) found that consumers perceived advertising as playing a very constructive role in providing information about attributes pertinent to making a thoughtful dentist choice decision. Advertising also assumes importance because of its potential power to influence consumers beliefs about various dental service attributes. In addition, advertising may affect the overall reputation or image of a dentist.
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Office atmosphere

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Attributes used in a questionnaire

Method Selection of attributes and formulation of questionnaire Eighteen attributes were included in this study based on the past literature, and a series of four focus group interviews with typical consumers of dental services. Attributes pertaining to the core service offering included in the study were quality of service, professional competence, personality and attitude of dentist, attitude of support personnel, fee charged for services, methods of pain control and availability of emergency services. Attributes not pertaining directly to the service offering were location, parking facilities, hours of operation, fee payment plans, ease of making appointments, office atmosphere, nonrequirement of appointments, waiting time before treatment and services available on Saturdays. Finally, reputation of dentist and use of advertisements were the last two attributes examined in the present study. The 18 attributes outlined above were included in the questionnaire, and arranged in alphabetical order. Each questionnaire consisted of three sections. In the first section, respondents were asked to rate the importance of each attribute when patronizing a general dental practitioner. A six-point rating scale was used for this rating task, where 1 corresponded to least important and 6 corresponded to most important. In the second section, respondents were asked about their perceptions of how various alternative general dental practitioners differed in terms of each of the 18 attributes. This rating task also involved a six-point rating scale where 1 corresponded to very little differences and 6 corresponded to very large differences. The third section asked respondents about demographic information. Research design and data collection procedures The research design involved the survey method. The responses to the questions were obtained through a nationwide mailing of questionnaires. This procedure was considered appropriate in this context because it provided an opportunity to obtain geographically disperse responses at a reasonable cost within a reasonable time (Davis and Cosenza, 1988). Mailing lists of households across the USA were obtained from a reputed mailing list vendor. The initial mailing of questionnaires was followed by a second mailing after three weeks. Only heads of household who had either personally been to, or accompanied another member of household to a general dental practitioner in the last year were asked to complete the questionnaire. Altogether 1,889 questionnaires were mailed, out of which 460 consumers responded with usable responses. This is a response rate of 24 percent. Although the response rate is low, it can be considered satisfactory in this context since no financial incentives were provided to the respondents (Kanuk and Berenson, 1975; Yu and Cooper, 1983). Since the chi-square tests of early respondents versus late respondents indicated no statistically significant differences at the 0.05 level in terms of such demographic and socio-economic characteristics as age, household size and household income, there seemed to be no serious nonresponse bias in the data collected for the study. Sample description The sample of 460 respondents were heads of households. The majority of the respondents were between 36 years and 65 years (67 percent of respondents), 17 percent were over 65 years, and 16 percent below 35 years. Of the households, 25 percent had annual income greater than $30,000; 26
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The survey method

Sample demographics

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percent of households had incomes less than $15,000 and 49 percent of respondents had annual household incomes between $15,000 and $30,000. Forty-five percent of the households had two members. Three-member and four-member households each comprised 19 percent of the sample; only 9 percent of sample households had greater than four members, and 8 percent had only one member. Seventy-one percent of the households pay for dental services by cash or check, whereas 25 percent pay by insurance. The remaining 4 percent pay by other methods. The determinant attribute approach According to multi-attribute attitude models in consumer behavior (see Lutz and Bettman, 1977; Sheth and Talarzyk, 1973; Wilkie and Pessemier, 1973 for a general review) the salience of, as well as beliefs about, an objects attributes must be considered in evaluating attitude toward the object. Salience refers to the potential influence that an attribute or evaluative criterion exerts during the alternative evaluation process. Salient attributes which actually affect the evaluation process are known as determinant attributes (Alpert, 1971; Engel et al., 1993; Myers and Alpert, 1968). The notion of determinant attributes is consistent with the idea that an attribute may be important to a consumer, but if the consumer feels that alternative products are equal with regard to that attribute, then the attribute is not considered a determinant factor in consumer decision making. Take airline travel as an example. An airlines safety record is obviously important to passengers. However, because most passengers perceive all major airlines as providing relatively safe travel, safety is not a deciding factor in most airline choice decisions. Determinant attribute analysis is a technique which can assist marketers in understanding which product attributes most determine choice behavior. Prior research has used the technique to identify factors determining consumer store choice (Bearden, 1977; Lumpkin et al., 1985), bank selection (Anderson et al., 1976; Sweitzer, 1975), data terminal acquisition (Moriarty and Reibstein, 1986), and forest products purchase decisions (Sinclair and Stalling, 1990). Analysis procedures Following earlier studies with determinant attribute analysis (e.g. Moriarty and Reibstein, 1986; Sinclair and Stalling, 1990), the current study adopted the dual question method to identify determinant attributes for selecting general dental practitioners. Attribute determinacy scores were developed based on importance rating and a rating of attribute variability among dental service providers. A final set of determinacy scores was derived by multiplying, for each attribute, the importance rating by the perceived difference rating. As noted by Moriarty and Reibstein (1986), different respondents may use different intrinsic importance scales such that a rating of 4 represents high importance to one person and low importance to another. To overcome this potential bias, each respondents ratings (both importance and difference ratings) were normalized with a common mean of 6 prior to the calculation of the determinacy score (Bass and Wilkie, 1973; Moriarty and Reibstein, 1986). Normalization was performed by subtracting from each rating the mean of all 18 attribute ratings of that person and then adding the constant of 6 so that the normalized ratings had a positive value. Since the purpose of the research is to uncover the perceived relative determinacy of the dental service attributes as opposed to their absolute
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The potential influence of an attribute

Determinant attribute analysis

The dual question method

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determinacy, no information loss occurs during this normalization process (Moriarty and Reibstein, 1986). Because both the importance and difference ratings were centered around the value of 6, the resultant determinacy scores were centered about the value of 36. Thus, a determinacy value greater than 36 indicated that the attribute played a relatively more important role in the decision-making process. Likewise, a determinacy score lower than 36 indicated a less important factor. Column four in Table I (under the heading of total) ranks the 18 attributes according to their average determinacy score across the total sample of all 460 respondents. Results shown in Table I are consistent with those found in previous studies (e.g. Bush and Nitse, 1992; Chakraborty et al., 1993; Crane and Lynch, 1988; Gopalakrishna and Mummalaneni, 1993). In terms of determinacy, attributes related to core service offering such as quality of service, professional competence, reputation, personality and attitude of dentist, attitude of support personnel, and fee charged for services were most relevant factors for choosing a dental practitioner, followed by attributes other than those related to core service offering such as hours of operation, location, parking facilities, ease of making appointments, office atmosphere, and so on. Advertising was perceived as the least determinant attribute when patronizing a dental practitioner. Canonical discriminant analysis and MANOVA were used Note that mean determinacy scores under the heading of total sample in Table I represent average determinacy scores across the entire group of observations. Certain subgroups may thus differ from the averages. Average determinacy scores provide a relative ranking of each dental service attribute, but do not provide a test of differences across the three usage segments (i.e. heavy, medium and light users of dental care services). Heavy users in this study are defined as those who go to a dentist every six months or more often. Similarly, medium users visit a dentist once a year. Light users are those who visit a dentist, on an average, of less than once a year. To examine differences among heavy, medium and light users of dental care services, both canonical discriminant analysis and multivariate analysis of variance (MANOVA) were employed. The 18 dental service attributes were used as discriminating variables with dental service usage used as the grouping variable. Canonical discriminant analysis was performed to identify linear combinations of variables that best discriminate among the groups and to uncover interrelationships among predictor variables (Dillon and Goldstein, 1984). In order to detect overall differences in vectors of mean scores for the 18 attributes across the three usage segments, the MANOVA procedure was deemed appropriate. Statistically significant MANOVA results were followed up with univariate ANOVAs (Hair et al., 1992). Whenever univariate F-tests were statistically significant, Tukeys honestly significant difference (HSD) tests were then conducted to highlight differences in mean determinacy scores across the three usage segments (Hair et al., 1992). Results Table I summarizes the results of both MANOVA and canonical discriminant analysis. The overall MANOVA test was statistically significant (Wilks = 0.734, F (36, 880) = 4.09, p < 0.0001), indicating that heavy, medium and light users of dental services placed different levels of importance on the set of 18 dental service attributes. By examining the univariate ANOVA (F-test) results, one can identify those individual attributes where differences existed among the three types of users. Among
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Eleven attributes exhibited group differences

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Standardized discriminant loadings Function I Function II Total (460)a A: heavy user (153)a

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Dental service attributes

Mean determinacy scores B: medium user C: light user (178)a (129)a

F=value/ p-value (2,457)b 2.88/0.06 9.86/0.00 1.70/0.18 7.10/0.00 4.71/0.01 1.13/0.32 6.48/0.00 1.27/0.28 0.12/0.88 6.36/0.00 5.53/0.00 12.16/0.00 0.27/0.77 22.44/0.00 3.23/0.04 38.46/0.00 2.32/0.10 14.45/0.00

Tukeys HSDc NS C > A; C > B NS C > A; C > B C > A; C > B NS C > A; C > B NS NS C > A; C > B C < A; C < B C < A; C < B NS C<B<A C<A C>B>A NS C < A; C < B

Quality of service 0.021 0.250 50.53 49.41 50.18 52.41 Professional competence 0.085 0.271 49.38 47.23 49.11 52.63 Reputation 0.135 0.303 49.23 49.53 48.27 50.49 Personality and attitude of dentist 0.018 0.266 46.32 44.86 45.66 49.04 Attitude of support personnel 0.034 0.028 42.79 41.64 42.15 44.98 Waiting time before treatment 0.136 0.338 40.15 40.35 40.79 39.01 Availability of emergency services 0.023 0.352 39.88 38.95 38.83 42.34 Fee charged for services 0.235 0.205 39.55 39.25 38.89 40.67 Fee payment plans 0.078 0.079 36.08 36.40 35.99 35.85 Methods of pain control 0.070 0.087 35.08 33.12 34.60 37.60 Hours of operation 0.143 0.334 33.02 33.79 34.05 30.52 Location 0.317 0.281 32.71 35.14 33.45 29.20 Services available on Saturdays 0.013 0.085 31.60 31.98 31.66 31.04 Appointments not required 0.410 0.041 30.56 34.54 30.68 25.98 Parking facilities 0.022 0.070 29.43 30.96 29.52 27.74 Ease of making appointments 0.559 0.518 29.41 23.19 30.23 34.94 Office atmosphere 0.057 0.283 23.64 23.88 24.35 22.17 Advertisements 0.319 0.148 20.45 22.90 20.90 17.10 Group centroids A: heavy users 0.670 0.152 B: medium users 0.005 0.233 C: light users 0.771 0.148 Notes: NS stands for not significant a Number in parentheses refers to number of respondents in each group b Numbers in parentheses refer to degrees of freedom for the F-test c Groups are significantly different ( p < 0.05) for Tukeys honestly significant difference (HSD) tests for multiple comparisons of means

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Table I. Results of MANOVA and canonical discriminant analysis

the 18 attributes, 11 attributes were found to exhibit differences among heavy, medium and light users of dental services. Multiple comparisons of means using Tukeys HSD tests indicated an interesting pattern: the majority of group differences were between infrequent or light users (C) and frequent users (A and B). Compared with frequent users, infrequent users of dental services seemed to be more concerned with professional competence, personality and attitude of dentist and support personnel, availability of emergency services, methods of pain control, and ease of making appointments. They appeared to be less concerned than frequent users with hours of operation, location, appointments not required, parking facilities and advertisements. Note that most attributes important to infrequent users are attributes related to core dental care service offering while most attributes relatively more important to more frequent or heavier users are attributes other than those related to core service offering. The possible implications for dentists who want to attract light users are that they should strive to excel in such dental service attributes as professional competence, personality and attitude of both dentist and staff, availability of emergency services, and so on. On the other hand, dentists should pay attention to such attributes as hours of operation, location and parking facilities in order to have continued patronage of more frequent users. Internal validity tested Table I also provides the standardized discriminant loadings and group centroids for the two discriminant functions, which accounted for 89.97 percent and 10.03 percent of the total variance respectively. The standardized discriminant loadings represent the relative contributions of the attributes to the respective discriminant functions. In order to test for internal validity of this result, the sample was randomly split into halves and the canonical discriminant functions recomputed. Both standardized discriminant loadings and the estimate of explained variance remained stable, indicating that the results reported here are not because of chance. Figure 1 shows the plot of group centroids and attribute vectors for the between canonical discriminant loadings (Hair et al., 1992). The circles around the group centroids represent the 99 percent confidence interval of the centroids. The vectors were differentially stretched by multiplying each between canonical discriminant loading by the respective variables F-value. Hence, the longer the vector, the greater the relative importance of the variable in discriminating among the groups. Rather than plot all 18 attributes, only the most discriminating attributes those with standardized discriminant loadings greater than 0.30 are plotted in Figure 1. Heavy and light users differ on three attributes As shown in Figure 1, heavy, medium and light users formed three distinct groups: A, B and C. Since the first discriminant function explains 89.97 percent of the total variance, it provides the major distinction among the three groups. Discriminant function I separates the heavy users from the light users primarily based on three attributes, namely nonrequirement of appointments, ease of making appointments and advertisements: this is because the vectors corresponding to these three attributes fall closely along the discriminant function I (the x-axis in Figure 1). Heavy users and light users differ based on these three attributes. Medium users differ from heavy users and light users based primarily on four attributes, namely hours of operation, waiting time before treatment, availability of emergency services, and reputation of dentist (this is based on discriminant function II in Figure 1).
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Discriminant function II 0.3 0.25 0.2 0.15 0.1 0.05 0 0.05 0.1 0.15 0.2 2 1.5 1 Discriminant function I Key Groups: A Heavy users 0.5 0 0.5 1 C 7 8 A 3 5 4 2 1 6 B

Medium users 5 6 7 8

Light users

Vectors: 1 Appointments not required 2 Advertisements 3 Waiting time before treatment 4 Location

Hours of operation Ease of making appointments Availability of emergency services Reputation

Figure 1. Plot of centroids and vectors

To shed more light on how usage segments differ from one another, we examined relationships between usage segments and some demographic and behavioral variables. A series of chi-square tests involving usage rate and age of respondent, household income, household size, and level of awareness of developments in dental care services were performed. Results showed that, with the exception of age, the other variables differed significantly across usage segments. Frequent users tend to be larger households with larger incomes and higher level of awareness of developments in dental care services. Conclusions and implications With the paradigm shift in the marketing discipline from a transactional orientation to a relational orientation (Berry, 1995; Sheth and Parvatiyar, 1995; Wagner et al., 1994), usage rate as a segmentation variable becomes more significant. This is particularly true in the context of services markets in general and professional services markets in particular. Because of the complex, customized and recurring nature of most service offerings, customers may make long-term commitments in order to reduce transaction costs and uncertainty (Crosby et al., 1990). The services provider-receiver interaction will be the basis for the formation and development of relationships between the two and, thus, the usage pattern of the service receivers will prove to be a very significant segmentation variable. In this paper, such usage-based segmentation was applied in the context of dental
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Usage-based segmentation

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consumer behavior. Although the frequency of purchase of professional services will be significantly different from other frequently purchased goods and services, the relationship formation and development will have an impact on the frequency of use of professional services. From this perspective, it can be contended that the research findings reported in this paper have implications for marketing of all professional services. The eight most determinant attributes In this paper, the eight attributes considered most determinant by consumers were quality of service, professional competence, reputation, personality and attitude of dentist, attitude of support personnel, waiting time before treatment, availability of emergency services, and fee charged for services. Notice that all these determinant attributes, except waiting time before treatment, are considered attributes related directly to core service offering. The attribute of dentist reputation relates to word-of-mouth or referrals by friends and family members. It is worth noting that, although the above-mentioned eight most determinant attributes are the same regardless of usage rate segment, the determinacy value for each of these attributes differs significantly across the three usage segments. General dental practitioners would thus be well-advised to focus on these eight attributes in order to survive and grow in todays increasingly competitive environment. To the extent that other health care services share many of the attributes considered by consumers in patronizing a general dental practitioner, the eight determinant attributes identified in this study may also be applicable to other health care service providers. When using the determinant attribute approach, even minor attributes could provide significant bases for segmenting the market as these inter-segmental differences can provide firm bases for devising appropriate marketing strategies to suit each usage segment identified. Heavy users value convenience-oriented attributes Out of the total set of 18 attributes, 11 attributes were found to exhibit differences among heavy, medium and light users of dental care. The general pattern of results showed that light users differed from heavy and medium users in terms of all of these 11 attributes. Light users valued six attributes significantly more than heavy and medium users, namely professional competence, personality and attitude of dentist, attitude of support personnel, availability of emergency services, methods of pain control, and ease of making appointments. The implication for dental practitioners is that customers can be segmented in terms of frequent and infrequent users of dental care. The above six attributes, all related to aspects of core service offering except the attribute of ease of making appointments, should be emphasized while formulating marketing strategies for light users. Heavier users appeared to attach significantly more importance than light users to convenience-oriented attributes such as location, hours of operation, nonrequirement of appointments and parking facilities. One possible reason for this finding is that heavier users tend to experience more stress in time management because of the need to see their dentists more frequently than light users. As a result, heavier users tend to value convenience-oriented attributes more than light users. Apart from the eight determinant attributes, dental practitioners who want to target heavier users should, therefore, pay attention to such attributes as location, hours of operation, and parking facilities as well. In addition, heavier users seemed more favorable toward advertising than light users. In marketing their services to heavier users,
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dental practitioners might supplement their promotional strategies with proper use of advertising. Interaction with the service provider From the research reported in this paper, it seems to be evident that frequent users of dental services, who can also be expected to have greater interaction with the service provider, attach greater importance to convenience-related attributes as compared to infrequent users. This may be because of the fact that frequent users, as a result of their more involved relationship with the service provider, may focus initially on competency-related attributes, and concentrate more on convenience-related attributes in the latter stages of the relationship development process. This general hypothesis is borne out by the infrequent users, who, in the formation stage of the relationship, attach greater importance to the competence-related attributes. This general hypothesis needs to be investigated further as to its applicability in the professional services market in general. In the immediate case of dental services, this divergence between the frequent and infrequent user segments has some interesting implications. For example, many marketing-oriented dental service providers routinely send newsletters to their patrons. Instead of having one standard newsletter, perhaps making a distinction between the frequent versus infrequent segments of their patrons with regard to the type of information provided will make the newsletter a more effective marketing tool. In line with the paradigm shift in marketing discipline emphasizing relationship marketing, the research reported in this paper has significant implications for services marketing in general and professional services marketing in particular. From the perspectives of services marketing in general, it may be contended that usage rates and/or frequency proves to be a critical segmentation variable. In the services context in particular, consumer usage experience seems to influence significantly the relationship formation process between service providers and receivers. Each service encounter provides the consumer with an experiential basis for evaluating the qualitative and complex credence-related attributes of service providers. This is particularly so in the case of more complex services such as professional services. The service providerreceiver relationship In the case of complex professional services even though inter-purchase interval is longer and frequency of usage is somewhat limited, the impact of each service encounter will be very significant. As a matter of fact, one may contend that lack of frequency of usage intensifies the relative importance of each service encounter from the perspective of service provider-receiver relationship. However, the general hypothesis of relationship formation, maintenance, and commitment through a series of experiential episodes (Dwyer et al., 1987) should hold for service industries in general. In some services with greater frequency of use, there may be greater experiential bases for evaluation and relationship development. In others, the usage frequency may be less, but the experiential impact on relationship development will be greater. From these perspectives, services marketers, with both more and less frequent usage patterns, are well advised to utilize usage patterns as a segmentation variable for more effective marketing. With extensive use of information technology, such as electronic data processing, many service marketers typically have vast amounts of information about the usage
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patterns and preferences of their current customer base. By installing appropriate marketing intelligence systems, services marketers should be able to analyze the usage patterns of their existing customers and identify appropriate market segments (Wagner et al., 1994). This is being practiced in some service industries such as banking which emphasize cross-marketing of diverse banking and financial services. In other industries, if necessary, pertinent information which would enable the services marketers to segment the market on usage pattern basis may be gathered from the current customers. The emerging segmentation scheme can be utilized to target the market effectively, both the existing customers and perspective customers. Detailed future research We would like to conclude by suggesting that more detailed future research is needed to verify the applicability of our findings in other professional services. These findings will help practitioners serving markets for these services, and also shed more insights relevant to the study of development and maintenance of relationships between service providers and receivers. These future studies should consider measurement of usage rate on a metric scale, so statistical tests would have greater power. In addition, future research needs to explore the psychographic and behavioral characteristics of different usage segments for professional services.
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Dolinsky, A.L. and Caputo, R.K. (1990), The role of health care attributes and demographic characteristics in the determination of health care satisfaction, Journal of Health Care Marketing, Vol. 10 No. 4, pp. 31-9. Dwyer, R.F., Schurr, P.H. and Oh, S. (1987), Developing buyer-seller relationships, Journal of Marketing, Vol. 51, April, pp. 11-27. Engel, J., Blackwell, R.D. and Miniard, P.W. (1993), Consumer Behavior, 7th ed., Dryden Press, Fort Worth, TX. France, K.R. and Grover, R. (1992), What is the health care product?, Journal of Health Care Marketing, Vol. 12 No. 2, pp. 31-8. Gopalakrishna, P. and Mummalaneni, V. (1993), Influencing satisfaction for dental services, Journal of Health Care Marketing, Vol. 13, Winter, pp. 16-22. Grove, S.J., Pickett, G.M. and Finn, D.W. (1994), Root canals and retailing, Journal of Health Care Marketing, Vol. 14 No. 4, pp. 36-40. Hair, J.F., Anderson, R.E., Tatham, R.L. and Black, W.C. (1992), Multivariate Data Analysis with Readings, 3rd ed., Macmillan, New York, NY. Hawes, J.M. and Prough, G.E. (1988), Analyzing the market for dental services, Health Marketing Quarterly, Vol. 5 Nos 1/2, pp. 171-82. Hill, J.C., Garner, S.J. and Hanna, M.E. (1990), What dental professionals should know about dental consumers, Health Marketing Quarterly, Vol. 8 Nos 1/2, pp. 45-57. Hite, R.E., Bellizzi, J.A. and Andrus, D.M. (1988), Consumer versus dentist attitudes toward dental services advertising, Journal of Health Care Marketing, Vol. 8 No. 1, pp. 30-8. Kanuk, L. and Berenson, C. (1975), Mail surveys and response rates: a literature review, Journal of Marketing Research, Vol. 12, November, pp. 440-53. Kotler, P. (1988), Marketing Management: Analysis, Planning, and Control, 6th ed., PrenticeHall, Englewood Cliffs, NJ. Lumpkin, J.R., Greenberg, B.A. and Goldstucker, J.L. (1985), Marketplace needs of the elderly: determinant attributes and store choice, Journal of Retailing, Vol. 61, Summer, pp. 75-105. Lutz, R.J. and Bettman, J.R. (1977), Multi-attribute models in marketing: a bicentennial review, in Woodside, A.G., Sheth, J.N. and Bennett, P.D. (Eds), Consumer and Industrial Buying Behavior, North-Holland, New York, NY, pp. 137-49. McAlexander, J.H., Kaldenburg, D.O. and Koenig, H.F. (1994), Service quality measurement, Journal of Health Care Marketing, Vol. 14, Fall, pp. 34-40. Miniard, P.W., Page, T.J., Atwood, A. and Ross, R.L. (1986), Representing attitude structure: issues and evidence, in Lutz, R.J. (Ed.), Advances in Consumer Research, Vol. 13, Association for Consumer Research, Provo, UT, pp. 72-6. Moriarty, R.T. and Reibstein, D.J. (1986), Benefit segmentation in industrial markets, Journal of Business Research, Vol. 14, December, pp. 463-86. Motes, W.H., Huhmann, B.A. and Hill, C.J. (1995), Following the drill: the search for a dentist, Journal of Health Care Marketing, Vol. 15 No. 2, pp. 34-41. Myers, J.H. and Alpert, M.I. (1968), Determinant buying attitudes: meaning and measurement, Journal of Marketing, Vol. 32, October, pp. 18-20. Parasuraman, A., Zeithaml, V.A. and Berry, L. (1985), A conceptual model of service quality and its implications for future research, Journal of Marketing, Vol. 49, Fall, pp. 41-50. Peter, J.P. and Olson, J.C. (1993), Consumer Behavior and Marketing Strategy, 3rd ed., Richard D. Irwin Inc., Homewood, IL. Sanchez, P.M. and Bonner, G.P. (1989), Dental services advertising: does it affect consumers?, Journal of Health Care Marketing, Vol. 9 No. 4, pp. 27-33. Sheth, J. and Parvatiyar, A. (1995), Relationship marketing in consumer markets: antecedents and consequences, Journal of Academy of Marketing Science, Vol. 23 No. 4, pp. 255-71. Sheth, J. and Talarzyk, W.W. (1973), Perceived instrumentality and value importance as determinants of attitudes, Journal of Marketing Research, Vol. 10, February, pp. 6-9. Sinclair, S.A. and Stalling, E.C. (1990), How to identify differences between market segments with attribute analysis, Industrial Marketing Management, Vol. 19, pp. 31-40. Sweitzer, R.W. (1975), Determinant attribute segmentation, Journal of the Academy of Marketing Science, Vol. 3, Winter, pp. 85-98. Wagner, H.C., Fleming, D. and LaForge, R.W. (1994), Relationship marketing in health care, Journal of Health Care Marketing, Vol. 14 No. 4, pp. 42-8. Wilkie, W.L. and Pessemier, E.A. (1973), Issues in marketings use of multi-attribute models, Journal of Marketing Research, Vol. 10, November, pp. 428-41.

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Yu, J. and Cooper, H. (1983), A quantitative review of research design effects on response rates to questionnaires, Journal of Marketing Research, Vol. 20, February, pp. 36-44.

Zhengyuan Wang is Lecturer in Marketing at the University of Sydney, Sydney, Australia. Swinder Janda is Assistant Professor in the Department of Marketing at California State University, Dominquez Hills, California, USA. C.P. Rao is Eminent Scholar and William B. Spong Chair in Marketing and International Business at Old Dominion University, Norfolk, Virginia, USA.

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This summary has been provided to allow managers and executives a rapid appreciation of the content of this article. Those with a particular interest in the topic covered may then read the article in toto to take advantage of the more comprehensive description of the research undertaken and its results to get the full benefit of the material Executive summary and implications for managers and executives I hate going to the dentist! Mail order marketers use the segmentation of customers as an important marketing tactic. The most significant segmentation is that based on recency of purchase, frequency of purchase and value of custom. These three factors encapsulate the financial reasons for developing customer loyalty. In other words getting customers to buy more often and spend more money. Historically, mail order firms have had a head start in using this approach to segmentation because of their need to establish and maintain accurate customer records and it does not reflect any peculiarity of direct marketing. This means that the principles underlying segmentation on the basis of recency, frequency and value are transferable to other marketing situations. Wang, Janda and Rao show how one of these variables is applicable to the marketing of dental services by demonstrating that the factors influencing choice of dentist vary according to the frequency of purchase. In essence frequent users of the service place more stress on superficial elements of the service than occasional users. The implication here is that dentists should consider a different message to the two customer segments focussing on the core services (i.e. those directly related to dental surgery) in communications to infrequent users and on other aspects of the service (e.g. waiting time, opening hours and waiting room facilities) in speaking to frequent users. This finding, while bearing out the importance of separating the regular buyer from the irregular or occasional buyer, also raises some questions about dental surgery and other similar medical services. Nobody could describe going to the dentist as a pleasure. We go in the expectation that regular check ups will minimize any pain or inconvenience from our teeth and, unfortunately, when our teeth get damaged. Increasingly, dentists have added cosmetic and semi-cosmetic services such as cleaning, polishing and colouring to the range offered. People will accept a certain amount of discomfort in order to have more attractive teeth. These two types of service are only loosely related if you like we can describe one level as enabling us not to notice our teeth whereas the other concerns making our teeth more noticeable and aesthetically pleasing. In their research Wang et al. do not make any distinction between these differing reasons for using dental services yet the motivations underlying the purchase choice are different. Although I have no evidence to support the assertion, I suspect that cosmetic or vanity users of dental services are more likely to be frequent visitors whereas those who merely want to know their teeth are OK will visit less often. Cosmetic dental work buyers might also be
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more concerned about the environment in which the work is done as well as issues such as convenience, location and opening hours. For infrequent users (most of them) a trip to the dentist is viewed with a certain trepidation and, in some cases, outright fear. This concern might underlie the importance of competence, professionalism and methods of pain control. This is less likely to apply for more regular customers who might be those less fearful of dentistry and more used to the environment at the dental surgery. Whatever the reasons for variation between customer groups dentists need to appreciate that they do not deal with a homogeneous set of customers. At the same time as they seek to reassure infrequent customers about the quality of work and the level of care offered they need to reinforce the relationship with regulars through improvements to secondary aspects of the service. This might mean changing the communications approach or developments within the service environment itself. I suspect that the infrequent visitor would benefit from a changed communications approach but peripheral service improvement might help in the relationship with more regular users. In the case of the latter, improvements could include: providing toys or a childrens play area, reducing waiting times, a better range of magazines in waiting rooms, open days or evening receptions, a priority appointments system. For infrequent users changes at the surgery itself are unlikely to have the desired effect since they do not come often enough to appreciate them. However, getting the customer to attend for a nondental reason (perhaps a reception or similar) could be a way of breaking down the fear and trepidation which many feel. Carefully constructed surveys could add to this by isolating the elements of these concerns, enabling the dentist to address them either individually or through general communications. One person I know well had not been to a dentist for some years mostly out of concern about any work that might be needed. Obviously, as time passed the likelihood of work being needed increased as did the accompanying trepidation. He was finally persuaded to contact a particular dentist who said, in answer to a question about pain control, that tlc was the most important thing but that he could provide a complete range of pain control options. He realized that the fear was best addressed by the attitude of the dentist and his staff rather than by technological solutions. By providing tender, loving care he offered reluctant patients the reassurance they needed. Finally, the message here applies to others providing an essential service seen as rather a chore and especially those working in medical professions. Eventually customers will take your competence and ability for granted but, in the first instance, they need absolute assurance. I believe that the secondary service issues make a difference here as well since they help to indicate professionalism and success. They might not come across as important reasons but they reinforce the core service on offer. (A prcis of the article Dental services marketing: do market segments based on usage rate differ in terms of determinant attributes? Supplied by Marketing Consultants for MCB University Press.)
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