Abstract

Background

     Strengthening leadership and management competencies among national Expanded Programme on Immunization (EPI) teams will be critical to achieving global immunization targets and other sustainable developmental goals. However, there is little empirical evidence of the effectiveness of investments in leadership and management capacity in the context of national EPI programs. Therefore, we sought to evaluate the EPI Leadership and Management Programme (EPI LAMP), a nine-month certificate program for EPI teams in national Ministries of Health from Gavi priority countries in Anglophone and Francophone Africa and Asia.

Methods

     We used a mixed-methods longitudinal evaluation to describe EPI LAMP at four levels: (1) participant response to the training experience based on program administration records and satisfaction surveys; (2) change in management and leadership skill based on competency surveys and exit interviews; (3) change in behavior in the workplace based on exit interviews; and (4) impact of the training on EPI program performance based on the results of each delegate’s leadership project.

Results

     In the first three cohorts, the programme engaged 16 countries (63 participants) and achieved an 86% graduation rate (54 alumni). Participants demonstrated significant improvement in management and leadership competencies across eight domains with the largest improvement observed in the domain of governance and leadership. Women showed greater increases than men, especially in the domains of Operations Management and Political Advocacy and Dialogue. We observed no difference in the gains made by French-speaking delegates compared to English-speaking participants. Breakthrough projects developed by each team improved EPI program performance, as measured by metrics specific to each project.

Discussion

     Our results show that team-based leadership programs can foster improvements in management practice, collaboration, and problem-solving, and that engagement the broader policy and organizational context is needed to foster the systems thinking capacity required to address complex challenges and improve system performance.

Introduction

     Immunization is one of the most cost-effective investments in global health [1], and reaching every child with immunization is the major strategic goal of Gavi, the Vaccine Alliance. Despite significant increase in vaccination coverage in low- and middle-income countries (LMICs), 14 million children were not reached by routine immunization in 2019 [2]. EPI programs must adapt and evolve to address complexities such as reaching zero- dose children, reaching children in conflict settings and other humanitarian crises, managing an increasingly complex portfolio of routine immunizations, overcoming weaknesses in primary health care systems, and, more recently, ensuring continuity of services in light of COVID-19. Strengthening leadership and management competencies [3], [4] among national EPI teams will be critical to achieving global immunization targets and other sustainable development goals [5], [6], [7].

     In response, Gavi has developed a small but strategic portfolio of investments in leadership and management to support EPI program performance. Drawing on literature from primary health systems strengthening more broadly, leadership and management is associated with better health systems performance in LMIC settings [8], and can be improved through practical approaches to education and mentorship for healthcare professionals at all levels of the health system [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Leadership and management trainings conducted at the facility level have been linked with the reduction of wait times and patient crowdedness in hospitals in Egypt [13] and the increase in the number of women receiving counseling during antenatal care in Cameroon [14]. At the district level, a number of studies [8], [15], [16], [17], [18], [19] reported the impact of management and leadership training on primary care system performance. However, there is little empirical evidence of the effectiveness of investments in leadership and management capacity in the context of national EPI programs.

Conclusion

     Strengthening leadership and management competencies among national EPI teams will be critical to achieving global immunization targets and other sustainable developmental goals, and can be significantly improved through participation in a team-based program customized to meet the needs of immunization professionals across Gavi-eligible countries. Programs that foster development of a cross-country learning community, engage multiple levels of hierarchy, and equip teams to address complex adaptive challenges are likely to be superior to brief training programs focused on individual participants. The results of this study may be useful to educators, practitioners, and government officials seeking to strengthen EPI programme performance, as well as policymakers and global partners seeking to invest in evidence-based management and leadership development models.

Abstract

     The COVID-19 pandemic has exposed the vulnerability of frontline employee (FLEs) to infections and other hazards and highlighted the importance of workplace safety practices (WSP) for service organizations. In response to the critical issue of service safety, we developed and empirically tested a model proposing that WSPs negatively influence FLE perceptions of pandemic related threats and positively influence their perceptions of organizational supportiveness (POS). In turn, these perceptions have time-lagged effects on two aspects of FLE wellbeing—reduced emotional exhaustion and increased work engagement. Utilizing data from a two-wave (separated by a month) survey panel consisting of 310 FLEs across the United States, we found evidence for all hypothesized relationships. We discuss the practical and theoretical implications of our findings and provide suggestions for future research on service safety on the organizational frontlines.

Literature review and hypotheses

     We propose and empirically test a model of FLE workplace safety exploring the relationship between FLE perceptions of WSPs on two specific wellbeing outcomes – emotional exhaustion and work engagement, with these relationships fully mediated by job demands and resources, respectively. Our conceptual framework represented in Fig. 1 proposes that WSPs (both, essential and discretionary) negatively influence FLE perceptions of risks/hazards related to COVID-19 and positively influence their perceptions of organizational support. In other words, in workplaces where there is a focus on implementing both, essential and discretionary safety practices, FLEs perceive fewer risks/hazards and higher levels of organizational supportiveness. Consistent with JD-R theory, risks/hazards are experienced by FLEs as job demands that drain their psychological resources, while organizational support is experienced as a job resource that helps replenish this resource loss (Bakker & Demerouti, 2017). Further, job demands result in emotional exhaustion, while job resources translate into FLE work engagement. Our framework and the resultant hypotheses are described in the following section.

Results

     Descriptive statistics, reliability estimates, average variance explained (AVE), and inter-construct correlations are provided in Table 2. This data can be used to establish the integrity of the measurement model (Fornell & Bookstein, 1982). Further, Cronbach alpha statistics exceeded the 0.7 threshold recommended by Nunnally and Bernstein (1967), and AVEs associated with each latent construct (see Table 2) exceeded the recommended threshold of 0.5 (Fornell & Larcker, 1981). Discriminant validity was also observed as the bivariate correlations did not exceed the square root of the associated AVEs (Fornell & Larcker, 1981). These findings support the integrity of the measurement model.

Abstract

     Access to healthy drinking water is vital to human health and development. Bottled water consumption has been on the rise in recent years. As several chemical and bacteriological parameters affect bottled water quality, it is difficult to choose the highest-quality bottled water. Numerous studies have proposed the use of multiple-criteria decision-making (MCDM) methods to overcome this problem. Herein, the two-stage fuzzy analytic hierarchy process (FAHP) and technique for order preference by similarity to ideal solution (TOPSIS) method were adopted to rank different brands of bottled water. The FAHP approach allows working at the intervals of judgment rather than absolute values. TOPSIS is a technique for ordering performance based on its similarity to the ideal solution. An expert panel selected and classified the criteria and sub-criteria. A pairwise comparison questionnaire was then developed, and the weights of the criteria and sub-criteria were assigned by water quality experts. The data on the quality of different brands of water were collected from the Iranian bottled water database. The final data analysis and weight determination of each parameter were performed in Excel and R software Programs. Finally, the CCi (value of closeness coefficient) and rank of 71 bottled water brands were calculated, and the best brand was introduced. Among the selected criteria, carcinogenic chemical compounds with the weight of 0.368 were the most important compound in ranking bottled water brands, followed by bacteriologic, pathogenic chemical compounds, chemical compounds important in terms of toxicity, nutritious chemical compounds with a low toxicity level, chemical compounds related to esthetic effects, and chemical compounds without health effects, respectively.

Introduction

     A challenge currently faced by developing countries is the lack of access to healthy drinking water (Abuzerr et al. 2019; Cobbina et al. 2015). Based on the World Health Organization’s (WHO) report, about 663 million people worldwide do not have access to healthy drinking water (WHO 2017). The increased population growth, a lack of healthy drinking water, and the public opinion about good taste, health, and appropriate quality have increased bottled water consumption. This rise has been considered in the past three decades, with the highest consumption being reported in developing countries of Asia and South Africa (Hu et al. 2011). The bottled water sale rate was $198.50 billion in 2017, a value which is estimated to reach $307.2 billion by 2024 (Doria 2006). Therefore, access to healthy drinking water is vital to human health and development (Fisher et al. 2015).

     Natural processes (erosion) and anthropogenic activities (electroplating, metal smelting, and chemical industries) are the main sources of pollutant entrance into the water. Although a few heavy metals are essential to human health, their excess amount can have negative efects such as anemia, renal dysfunction, cancer, and brain damage (Chowdhury et al. 2016; Gharibi et al. 2012; Qu et al. 2020; Qu et al. 2021a, b; Rezaee et al. 2015; Zhang et al. 2021). The existence of numerous parameters afecting water quality complicates bottled water quality assessment and ranking and decisionmaking about the purchase of the best and highest-quality brand. Therefore, there is a dire need for precise and logical techniques for accurate and scientifc decision-making. To this end, studies have proposed various methods for choosing the best option and making the decision, among which MCDM methods have received considerable attention owing to their numerous advantages (Kou et al. 2014; Mulliner et al. 2016).

Conclusion

     The quality assessment and selection of the best bottled water brand are difcult due to the efect of various physical (temperature and turbidity), chemical (heavy metals, anions, and cations), and bacteriological (Pseudomonas and coliforms) parameters on water quality and the existence of numerous brands in the market. Herein, by using the MCDM method (FAHP-TOPSIS), the quality of 71 bottled water brands in the Iranian market was ranked. The application of MCDM approaches in various sciences indicates these methods’ strong capability in evaluating problems that possess multiple criteria. These methods accurately assess bottled water quality and aid the customer in selecting a higher-quality brand. They can, therefore, be adopted to create competition among manufacturers to produce higher-quality products. In this study, the grouping and weighting of elements were based on the opinions of Iranian experts and by taking into account the local conditions of Iran. For global applications, a comprehensive model can be proposed for water quality assessment by considering other chemical and bacteriological parameters afecting water quality and with the participation of international experts from other countries.

Abstract

     Both the healthcare and religious landscapes in the United States are rapidly changing. Despite the dynamic environment that spiritual care managers face, many do not receive management training prior to assuming their roles and many receive little or no training once they are in their roles. This study used mixed methods to examine the applicability of the National Center for Healthcare Leadership (NCHL) competency model to spiritual care manager roles. Interviews were conducted with 10 spiritual care managers across the country, using a Behavioral Event Interviewing (BEI) methodology. Interviews were quantitatively analyzed by using Natural Language Processing and qualitatively analyzed by thematic approach using NVIVO. The results found the EXECUTION domain to be the most discussed theme, followed by RELATIONS, TRANSFORMATION, and BOUNDARY SPANNING. Collectively these analyses suggest the NCHL Leadership Competency Model can provide a useful framework for understanding the roles and development needs of spiritual care managers.

Introduction

     Competent leadership is essential for any organization to achieve its mission, especially in a changing and challenging environment. We are in the midst of especially challenging times for managers of spiritual care programs in healthcare settings. The shift in healthcare delivery from in-patient services to population health is accelerating. The costs of delivering care must be contained while quality continues to improve. Every discipline must be able to show how they contribute to these goals. Spiritual care has historically been exempt from some of these pressures, but that is quickly changing (Handzo, Cobb, Holmes, Kelly, & Sinclair, 2014).

     While the healthcare landscape is undergoing rapid change, so is the religious landscape in the US. One of the most impactful changes is the increase in the proportion of people who report no religious affiliation: approximately 40% of people under 30 in some national surveys (Pew Research Center, 2019). However, on these same surveys, many people report having rich spiritual lives (Pew Research Center, 2019), and face serious spiritual/existential questions when experiencing illness or other life crises (Weber, Pargament, Kunik, Lomax, & Stanley, 2012).

Results

     Of the ten managers participating in this study, seven (70%) identified as female, and the remaining three (30%) identified as male. The average length of time in their management positions was 6.5 years. The median was 4.2 years, in a range from nine months to 24 years. Five of the managers (50%) worked at academic medical centers; the remaining five worked at faith-based health systems.

Highlights

Abstract

Keywords

1. Introduction

2. Theoretical background

3. Methodology

4. Empirical evidence

5. Results and discussion

6. Conclusions

Acknowledgement

References

Vitae

Abstract
Purpose
This research aims to increase understanding on how multilevel trust is developed as well as how trust levels are interconnected and influence international marketing strategy for healthcare services.

Design/Methodology/Approach
A comparative case study approach was applied with Elekta, a Swedish firm, operating in Brazil, the Philippines, China, Russia, and Hong Kong.

Findings
The research culminated in a multilevel trust (MLT) model comprised of three levels relating to individuals, company performance, and context.

Research implications/limitations
This study offers a context-based multilevel trust model from a process perspective focusing on healthcare. This model can be tested in other service sectors.

Practical implications
Managers should consider multilevel trust to boost relationships and achieve local acceptance.

Originality/Value
This research contributes to trust theory by constructing a context-based multilevel trust model for international healthcare marketing.

1. Introduction

This study deals with multilevel trust in healthcare services and how it affects international marketing strategy in emerging markets. Knowledge on multilevel trust is essential to understand how trust is built to facilitate development of long term relationships (Zaheer & Zaheer, 2006). Trust can be defined as the willingness to rely on an exchange partner one has confidence in (Bianchi & Saleh, 2010). Currall and Inkpen (2006) assert that trust needs to be discussed at different levels—person, group, and firm—to comprehend its role in organizational performance. They further claim that over time interpersonal trust can evolve to intergroup and then to interorganizational trust. Trust is thus dynamic, which makes multilevel trust a major issue in understanding interorganizational relationships.

Considering its importance and limited understanding on multilevel trust, a special issue in Journal of Trust Research was dedicated to this topic (Volume 8:2, 2018). Researchers have studied trust at micro levels (citizenship behavior, Mayer & Gavin, 2005; negotiation success, Lee, Yang, & Graham, 2006), and macro levels (strategic alliances, Fryxell, Dooley, & Vryza, 2002). Mouzas, Henneberg, and Naudé (2007) have discussed trust at personal and organizational levels, differentiating trust between individuals internally and representing different organizations. Lyu and Ferrin (2018) term personal trust as interpersonal trust; Zaheer, McEvily, and Perrone (1998) introduced interorganizational trust, which refers to the collective trust of members of one organization for another. Fregidou-Malama and Hyder (2015) add country-level trust to the other two levels to initiate trust discussion in international marketing.

With rising population (and healthcare issues) and a rising focus on improvement in each sector of the economy to achieve competiveness in national economy, the issues of patient satisfaction and service quality are seeking increasing interest among researchers and scholars all over the world. Developed countries are not only improving their healthcare sectors to serve their masses but also making money by promoting healthcare tourism (Lee and Fernando, 2015; Han and Hyun, 2015; Andaleeb, 2001). Developing countries can also reap these benefits by making available high healthcare quality at affordable costs (De Arellano, 2007; Horowitz et al., 2007; Lee and Fernando, 2015) which is a challenging task in countries like Pakistan where healthcare isn’t a priority and issues like patient satisfaction and service quality are receiving more attention of academicians or scholars and less of policymakers or practitioners. In service industries, the service quality always remained one of the key factors manifesting the successful management of customer relationships and value creation in the market. However, in developing countries, the health care service providers do not pay much attention to the say of service seekers and their perceptions and expectations are generally being neglected (Andaleeb, 2001). Han and Hyun (2015) reported that inviting new consumers is five times more expensive than retaining existing consumers. Thus it can be argued that by not seeking the existing consumers’ (patients’) input in improving or redesigning of value creation processes in hospitals, the service providers are not only closing the door for continuous improvement that is essential for the business survival but also loosing consumers, and thus profits, to their competitors. In case of the private hospitals this can lead to bankruptcy and for public hospitals receiving funds from the state this implies the hospitals that the poor patients consider their last resort. Pakistan is one of the few countries in the world where healthcare never remained a priority for most of the governments since its creation in 1947. The attitude of the political leadership of the country, that can be manifested though their budget allocated for healthcare and frequent visits to the healthcare facilities of the developing countries even for the smallest treatments, can add to this argument. For instance, the country spends almost 2.8% of its budget on healthcare (WHO, 2015) putting it in the basket of countries whose investment on healthcare is less compared to the most of the countries of the world. Media reports highlight that it is not rare for Pakistani politicians, bureaucrats, legislators and government officials to go overseas for treatment that not only costs millions of rupees to Pakistani taxpayers but also exposes their ‘faith in what the country has to offer’ (Siddiqi, 2016; Pakistan Today, 2016; Shehzad, 2015; Ahmad, 2011). Thus it is not difficult to comprehend why the majority of the population of Pakistan perceives that their country’s healthcare system is corrupt (Gadit, 2011). Considering all this in mind it was felt very important to seek the insight of Pakistani healthcare sector from the public’s point of view. There are not many studies conducted in the healthcare sector of Pakistan in order to examine the service quality of public as well as private hospitals in light of service-seekers’ views (see for instance, Irfan and Ijaz, 2011; Saeed and Ibrahim, 2005; Nasim and Janjua, 2014; Shabbir et al., 2016). However, there is a controversy among the studies done on Pakistani healthcare sector. For example, Irfan and Ijaz (2011) and Shabbir et al. (2016) reported that private hospitals’ patients are more satisfied with the healthcare services as compare to their public counterparts however Nasim and Janjua (2014) reported the opposite.

Healthcare is considered a ‘credence’ good – an offering that consumers will never be able to evaluate owing to deficient medical knowledge (Bloom and Reeve, 1990). Additionally, conceptualising and measuring service quality in a healthcare setting is more important and simultaneously more complex (Taner and Antony, 2006). However, researchers need to come up with ways to measure healthcare service quality, because unless we measure we cannot manage and improve healthcare services (Lohr, 2015). The literature indicates that there is a variability and confusion in how quality is conceptualized and operationalized (Sower et al., 2001). Many researchers attempt to define and conceptualize hospital service quality. Pai and Chary (2013), for example, show that the Parasuraman et al., (1985, 1988) SERVQUAL/modified SERVQUAL questionnaire is conventionally practiced in healthcare. They also pointed out studies where SERVQUAL items have not loaded onto respective dimensions highlighting a five-component structure that is lacking, suggesting a new questionnaire needs developing. New instruments, designed for healthcare setting: PRIVHEALTHQUAL (Ramsaran-Fowdar, 2008) for private and PubHosQual (Aagja and Garg, 2010) for public settings, have emerged. Studies adopting these instruments are scarce because these scales are hospital specific and not a general scale that measures hospital service quality in any hospital context. An instrument that could measure hospital service quality (HSQ) in any hospital settings has gained importance. Pai and Chary (2016) proposed their conceptual framework for measuring hospital service quality using nine dimensions. Their framework, unlike other instruments such as SERVQUAL (Parasuraman et al., 1988), PRIVHEALTHQUAL (Ramsaran-Fowdar, 2008) and PubHosQual (Aagja and Garg, 2010) has an additional dimension (relationship) in line with researchers such as Carman (1990) and Reynoso and Moore (1995), who suggested adding service specific dimensions to SERVQUAL, there exists no empirical studies to support or refute their conceptual framework. As there are no research studies that used Pai and Chary’s framework (2016), our purpose is to empirically appraise this framework and addresses literature gaps.

There is agreement among practitioners and academics that managerial competencies are useful for monitoring and improving the performance of organisational leaders and managers (Levenson et al., 2006), with useful application in healthcare (Stefl, 2008). While a wide variety of competency frameworks or models have been developed for healthcare managers around the world (Calhoun et al., 2008; Garman and Scribner, 2011; Stefl, 2008), there is strong evidence suggesting that management competencies are influenced by the industry context (Robotham and Jubb, 1996; Brownell, 2008). This limits the usefulness of competency scales developed for other industries or in other countries. In Australia, the needs of health service organisations have outpaced the science, with organisations adopting competency frameworks for which there is limited evidence and no validated and reliable measurement tools. Previous studies have suggested both a lack of leadership and management abilities in healthcare (Leggat et al., 2011; Leggat and Dwyer, 2005; Bartram et al., 2012), suggesting a need for an evidence-based competency system in Australia to inform measurement of management competence and to drive training and education requirements. This paper describes the development, testing and validation of a management competency framework relevant to the role requirements for health services managers working in Australia.

Theory

Since the concept developed by David McClelland (1973), the use of competencies to identify high-performing employees has gradually become widespread in human resource management (HRM) in both the health and non-health sectors (Rodriquez et al., 2002; Young and Dulewicz, 2008). Lucia and Lesinger (1999) defined a management competency as, “a descriptive tool that identifies the skills, knowledge, personal characteristics and behaviours needed to effectively perform a role in the organisation and help the business meet its strategic objectives” (Lucia and Lesinger, 1999, p. 5). Similarly, Hellriegel et al. (2008) viewed competence as the “sets of knowledge, skills, behaviours, and attitudes that a person needs to be effective in a wide range of positions and various types of organisation” (p. 2). A competency should predict performance on the job, be measured against well-accepted standards (Lucia and Lesinger, 1999). Competency of the management team can be achieved through recruitment and retention of competent managers, or through internal and external development activities (Cappelli, 2008). Therefore, the knowledge and utilisation of required management competencies is a critical strategic resource of an organisation (Castanias and Helfat, 2001) with evidence of a strong positive link between management competency identification and individual management performance, and a weaker relationship with unit-level performance (Levenson et al., 2006)

Lean management is a potential way to develop management practices and strategies in the health-care environment in Finland. However, further research is necessary to find out how the Lean management model manifests itself in Finland and to develop the model for this particular national context. There have been studies on the Lean method’s effectiveness in terms of management and development work in the Finnish health-care environment. In addition, there is evidence that teamwork increased in Lean workplaces (Jorma et al., 2016). There are numerous research articles about Lean thinking and plenty of literature reviews. There is also research examining evidence of outcomes of using Lean by identifying the facilitating factors in Lean initiatives (Andersen et al., 2014). Research articles also exist which focus on dividing articles according to the area of application of Lean and various study purposes and criteria (Mazzocato et al., 2010; de Souza, 2009). In Finland, we only have a few research papers regarding knowledge and understanding of managerial experience using the Lean method. The aim of this research is to discuss health service managers’ experiences of management in a special health-care unit and their development efforts from the point of view of the Lean method. Additionally, the aim is to deepen the knowledge of the managers’ work and the nature of the Lean method development processes in the workplace. The research focuses on those aspects and results of the Lean method that are currently being used in health-care environments in Finland. Health care has its own special characteristics: the work is client-oriented, different professionals work together for the benefit of the client, financial resources may vary and be limited, and medical care is improving (Stenvall and Virtanen, 2012; Clarke, 2009). There are also increases in cooperation and networking (Morrow et al., 2007) between organizations and institutions to provide public health services, and health care is always overseen and controlled by some type of steering group. In the health-care services, management is defined as the management of employees working under a manager in a unit (Aarva, 2009). This research look at specialized health-care settings in Finland in which Lean method and management principles have been implemented and applied to the delivery of health care. Management is a relatively new concept in Finnish health, and it refers to overseeing daily operations in the workplace. A manager is responsible for the services provided to customers and is, in charge of the staff, as well as having responsibility for operating budget (Aarva, 2009). According to Virtanen and Stenvall (2010), a manager oversees daily operational activities of a health-care unit while taking into consideration the whole organization through interactions at various interfaces.

Over the last two decades, remarkable progress has been made in the field of medical services and this is obvious for developed economies in terms of both economic and technological development. Lately, new drugs have been discovered, some deadly diseases have been eradicated, the population has been informed about the methods of prevention and treatment, which has led to an increase in life expectancy and quality of life in developed countries. Despite these advances in the developed world, in the case of poor countries, economic development is the first barrier that causes poor population health and low life expectancy. Economic growth is associated with the development of service economy. Among these, healthcare services are important and their development is a priority for public authorities (Andaleeb, 2001). Thus, they are experiencing rapid expansion in the context of an aging population, competitive pressures and technological developments (Dagger, Sweeney, & Johnson, 2007). Previous research on the services market confirms that ensuring the quality of the services offered is a key element for earning profitability and a good market share (Parasuraman, Zeithaml, & Berry, 1985; Parasuraman, Zeithaml, & Malhotra, 2005; Zeithaml & Bitner, 2000). Organisations improve their management strategies so that their efforts are focused on the customer (Andaleeb, 2001; Zeithaml & Bitner, 2000), meeting their requirements and needs, considering that the trust of stakeholders who are interested in service achievement is confirmed by quality assurance. In an organisation that delivers healthcare services, financial indicators or the system performance can be explained by the patients’ appreciation of service quality (Dagger et al., 2007; Naidu, 2009; Nelson et al., 1992). In order to gain competitive advantage and increase system performance on the current economic market, it is necessary to meet at least two conditions: to have satisfied clients and to provide quality services (Dagger et al., 2007). Concepts of service quality and consumer satisfaction are the target of marketing people’s concerns because they have a strong impact on many behavioural variables. In fact, these concepts are at ‘the core of the marketing concept’ (Shemwell, Yavas, & Bilgin, 1998). Therefore, there is a continuing concern within the academic environment as well as among practitioners to study these concepts. Thus, it can be explained why a large number of studies that are analysing these unique but related constructs (Cronin & Taylor, 1994; Oliver, 1993; Shemwell et al., 1998; Taylor & Baker, 1994) consider the quality of services to be objective, cognitive (attributes that correspond to a leftbrained person) while customer satisfaction is subjective, affective (attributes that correspond to a right-brained person). Some researchers argue that satisfaction is more important than service quality (Oliver, 1999) and others advocate that the service type is responsible for the salience of either components (Dabholkar, 1995; Shemwell et al., 1998).