An-Najah National University Faculty of Graduate Studies IMPACT OF MARKETING MIX (7Ps) ON HOSPITAL SELECTION AMONG PALESTINIAN PATIENTS: A CROSS-SECTIONAL STUDY By Osama Shaher Hasan Snober Supervisor Prof. Ramzi Shawahna This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master in Public Health Management, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2025 ii IMPACT OF MARKETING MIX (7Ps) ON HOSPITAL SELECTION AMONG PALESTINIAN PATIENTS: A CROSS-SECTIONAL STUDY By Osama Shaher Hasan Snober This Thesis was defended successfully on 11/02/2025 and approved by: iii Dedication This thesis is dedicated to my beloved family, whose unwavering love, encouragement, and sacrifices have been my greatest source of strength. To my parents, for their constant support and guidance throughout this journey, and for instilling in me the values of perseverance and dedication. To my siblings, for their belief in me and for standing by my side through every challenge. To my friends, thank you for your encouragement and companionship. Your humor, kindness, and steadfast support have been a source of inspiration and relief during the most demanding moments of this work. To my colleagues, for their invaluable advice, collaboration, and shared pursuit of knowledge. Your insights and shared experiences have helped shape this thesis, and I am truly grateful for your contributions. This accomplishment would not have been possible without each of you, and I am deeply appreciative of your presence in my life. Osama Shaher Hasan Snober iv Acknowledgement I would like to express my deepest gratitude to my supervisor, Prof. Dr. Ramzi Shawahna, for his invaluable guidance, patience, and encouragement throughout the development of this thesis. His insightful advice, academic expertise, and constructive feedback have been instrumental in shaping my research and bringing this work to fruition. I am deeply grateful for his constant support and mentorship. I am also profoundly thankful to all the study participants who contributed to this research. Their time, honesty, and willingness to share their experiences have provided the foundation for this study. Without their participation, this work would not have been possible. To my colleagues, I extend my sincere thanks for their collaboration, insightful discussions, and shared commitment to advancing our collective knowledge. Their support, both academic and personal, has been invaluable throughout this journey. A heartfelt thank you to my friends for their unwavering encouragement, companionship, and understanding. Your presence has been a source of strength during challenging times. Finally, to my family, words cannot express my gratitude for your endless love, patience, and belief in me. Your sacrifices and support have carried me through this journey, and I dedicate this achievement to you. Osama Shaher Hasan Snober v Declaration I, the undersigned, declare that I submitted the thesis entitled: IMPACT OF MARKETING MIX (7Ps) ON HOSPITAL SELECTION AMONG PALESTINIAN PATIENTS: A CROSS-SECTIONAL STUDY I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. Student's Name Osama Shaher Hasan Snober Signature: Date: 11/02/2025 vi List of Contents Dedication ........................................................................................................................ iii Acknowledgement ........................................................................................................... iv Declaration ........................................................................................................................ v List of Contents ................................................................................................................ vi List of Tables ................................................................................................................... ix List of Figures ................................................................................................................... x List of Appendices ........................................................................................................... xi Abstract ........................................................................................................................... xii Chapter One: Introduction and Theoretical Background .................................................. 1 1.1 A brief literature review .............................................................................................. 3 1.2 Problem statement ....................................................................................................... 4 1.3 Objectives ................................................................................................................... 5 1.4 Importance of the study .............................................................................................. 5 Chapter Two: Methods ..................................................................................................... 7 2.1 Study context .............................................................................................................. 7 2.2 Study design ................................................................................................................ 7 2.3 Study setting ............................................................................................................... 7 2.4 Population ................................................................................................................... 7 2.4.1 Inclusion criteria ...................................................................................................... 7 2.4.2 Exclusion criteria ..................................................................................................... 8 2.5 Sample size and sampling method .............................................................................. 8 2.6 Data collection and study tools ................................................................................... 8 2.7 Variables ..................................................................................................................... 8 2.7.1 Dependent variable .................................................................................................. 8 2.7.2 Background and independent variables ................................................................... 9 2.8 Reliability and validity of the study tool .................................................................... 9 2.9 Statistical analysis ..................................................................................................... 11 vii 2.10 Ethical approval ...................................................................................................... 11 Chapter Three: Results .................................................................................................... 12 3.1 Sociodemographic and health characteristics of the participants ............................. 12 3.2 Importance of the different marketing mix components .......................................... 13 3.2.1 Ratings of product components ............................................................................. 13 3.2.2 Ratings of people components ............................................................................... 14 3.2.3 Ratings of price components .................................................................................. 16 3.2.4 Ratings of process components .............................................................................. 16 3.2.5 Ratings of physical environment components ....................................................... 17 3.2.6 Ratings of promotion components ......................................................................... 18 3.2.7 Ratings of place components ................................................................................. 20 3.2.8 Ratings of the 7Ps .................................................................................................. 20 3.3 Correlation between ratings of the different components of the marketing mix ...... 21 3.4 Association between the variables of the participants and ratings of the different components of the marketing mix ......................................................................... 22 3.4.1 Association between the variables of the participants and ratings of product ....... 22 3.4.2 Association between the variables of the participants and ratings of people ........ 24 3.4.3 Association between the variables of the participants and ratings of price ........... 26 3.4.4 Association between the variables of the participants and ratings of process ....... 28 3.4.5 Association between the variables of the participants and ratings of physical environment ........................................................................................................... 30 3.4.6 Association between the variables of the participants and ratings of promotion .. 32 3.4.7 Association between the variables of the participants and ratings of place ........... 34 3.5 Predictors of important marketing mix components ................................................. 36 Chapter Four: Discussion and Conclusion ...................................................................... 37 4.1 Summary of the main findings .................................................................................. 37 4.2 Interpretation and discussion of the main findings ................................................... 37 4.2.1 Product ................................................................................................................... 37 4.2.2 People ..................................................................................................................... 38 4.2.3 Price ....................................................................................................................... 38 viii 4.2.4 Process ................................................................................................................... 39 4.2.5 Physical Environment ............................................................................................ 39 4.2.6 Place ....................................................................................................................... 40 4.2.7 Promotion ............................................................................................................... 41 4.3 Discussion of the associations .................................................................................. 41 4.3.1 Association between gender and product .............................................................. 41 4.3.2 Association between income and product, people, process, & physical environment ............................................................................................................................... 42 4.3.3 Association between governmental health insurance and product, people, and physical environment ............................................................................................ 42 4.3.4 Association between chronic disease and product, people, and place ................... 43 4.3.5 Association between age and price, place ............................................................. 43 4.3.6 Association between education level and 7Ps ....................................................... 44 4.3.7 Association between employment status and 7Ps .................................................. 44 4.4 Strengths of the study ............................................................................................... 45 4.5 Limitations of the study ............................................................................................ 46 4.6 Recommendations ..................................................................................................... 48 4.7 Conclusion ................................................................................................................ 49 List of Abbreviations ...................................................................................................... 50 References ....................................................................................................................... 51 Appendices ...................................................................................................................... 58 ب ............................................................................................................................... الملخص ix List of Tables Table 1: Detailed sociodemographic and health characteristics of the participants (n = 385) ................................................................................................................... 12 Table 2: Correlation matrix between the different components of the marketing mix ... 21 Table 3: Association between the variables of the participants and ratings of product .. 23 Table 4: Association between the variables of the participants and ratings of people ... 25 Table 5: Association between the variables of the participants and ratings of price ...... 27 Table 6: Association between the variables of the participants and ratings of process .. 29 Table 7: Association between the variables of the participants and ratings of physical environment ...................................................................................................... 31 Table 8: Association between the variables of the participants and ratings of promotion .......................................................................................................................... 33 Table 9: Association between the variables of the participants and ratings of place ..... 35 x List of Figures Figure 1: Correlations between the items in the 7Ps ...................................................... 10 Figure 2: Mean rating scores of the different product components ................................ 14 Figure 3: Mean rating scores of the different people components ................................. 15 Figure 4: Mean rating scores of the different price components .................................... 16 Figure 5: Mean rating scores of the different process components ................................ 17 Figure 6: Mean rating scores of the different physical environment components .......... 18 Figure 7: Mean rating scores of the different promotion components ........................... 19 Figure 8: Mean rating scores of the different place components .................................... 20 Figure 9: Mean rating scores of the different place components .................................... 20 xi List of Appendices Appendix A: IRB approval ............................................................................................. 58 Appendix B: Study approval 1 ........................................................................................ 59 Appendix C: Study approval 2 ........................................................................................ 60 Appendix D: Study approval 3 ....................................................................................... 61 Appendix E: Study approval 4 ........................................................................................ 62 Appendix F: Study approval 5 ........................................................................................ 63 Appendix G: Study approval 6 ....................................................................................... 64 Appendix H: Study approval 7 ....................................................................................... 65 Appendix I: Study questionnaire (Arabic) ...................................................................... 66 Appendix J: Study questionnaire (English) .................................................................... 72 Appendix K: Ratings of the participants of the different marketing mix components ... 76 Appendix L: Predictors of important marketing mix components ................................. 79 xii IMPACT OF MARKETING MIX (7Ps) ON HOSPITAL SELECTION AMONG PALESTINIAN PATIENTS: A CROSS-SECTIONAL STUDY By Osama Shaher Hasan Snober Supervisor Prof. Ramzi Shawahna Abstract Background: The influence of the marketing mix (7Ps: Product, Price, Place, Promotion, People, Process, and Physical Environment) on hospital choosing is a significant study domain, since healthcare facilities must consistently enhance their offerings to attract and keep consumers. This study was conducted to identify the key components of the marketing mix that most significantly impact patients' decision-making when choosing a hospital in Palestine. Methods: The study used a cross-sectional design to provide a snapshot on patients' preferences and decision-making criteria about hospital choosing in Palestine. The study was conducted in various regions of Palestine to ensure a representative sample that reflected the diverse socio-cultural and economic backgrounds of the population through selecting private hospitals and governmental hospitals in the north of the West Bank. Results: In this study, a total of 385 participants completed the questionnaire. The participants rated how the 7Ps (Product, Price, Place, Promotion, People, Process, and Physical Environment) influenced their choices on hospitals. Multiple linear regression showed that higher product ratings were predicted by moderate or household income (B = 2.12, p-value < 0.001) and having a governmental health insurance (B = -0.74, p- value = 0.030). Similarly, higher people ratings were predicted by moderate or household income (B = 1.57, p-value = 0.002). Moreover, higher process ratings were predicted by moderate or household income (B = -0.41, p-value = 0.048) and spending less nights at the hospitals (B = -0.83, p-value = 0.025). In addition, higher physical environment ratings were predicted by moderate or household income (B = -0.70, p-value = 0.011). Furthermore, higher place ratings were predicted by older age (B = 0.68, p-value = 0.007). Conclusions: The marketing mix (7Ps) strongly influences Palestinian hospital selection, providing healthcare providers with useful information. Patients choose hospitals based on specialist healthcare services, quality of treatment, financial accessibility, and physical xiii surroundings. Patient preferences were shaped by improved services, expert personnel, and reasonable pricing. In addition, income, health insurance status, and the absence of chronic conditions were substantially related with better marketing mix ratings, notably in product, people, and process. These results show that hospitals must strengthen specialized services, provider-patient connections, price transparency, and infrastructure to be patient-centered. Keywords: Hospitals, Healthcare, Marketing, Marketing Mix, Low-income countries, Palestine 1 Chapter One Introduction and Theoretical Background Marketing is defined as the activity conducted by organizations and individuals and a set of institutions and processes for creating, communicating, delivering, and exchanging market offerings (ideas, goods, and services) that have value for customers, clients, marketers, and society at large (1, 2). In general, marketing is regarded as a combination of elements essential for the comprehensive planning and execution of all marketing activities (1). On the other hand, the marketing mix is a set of controllable factors that are often used by marketers to influence the decisions of customers, clients, or society at large and to navigate the global competitive landscape to achieve the marketing objectives (3). For the majority of firms/enterprises/companies/institutions, the marketing mix is traditionally referred to as the 4Ps: product, pricing, place, and promotion. However, customer or client engagement, the physical environment, time, and processes are significant elements in service delivery (4-7). The "service marketing mix," or 7Ps, is comprised of the previously described 4Ps (product, price, place, promotion), together with people, physical environment, and process (4, 5). Similar to all enterprises, hospitals, as suppliers of medical and treatment services, should implement marketing strategies to attain successful performance (4, 6). Evidence indicates that the marketing mix is crucial for optimizing service pricing, expanding surgical operations, enhancing health awareness, altering service providers' attitudes, augmenting hospital financial resources, and bridging the communication gap between providers and patients/users/customers/clients (6). However, improving patient quality of life is the primary objective of hospitals and a determinant of medication adherence and the enhancement of patients' health condition; this can be a direct result of the marketing mix in healthcare facilities (4, 6). These studies have indicated favorable results for hospitals that follow marketing concepts and develop their strategies and programs based on marketing mix elements. Previous studies have examined the impact of the marketing mix elements on patients' selection of hospitals (4, 6, 7). These surveys identified staff personnel (i.e., physicians 2 nurses, and paramedics) as the most significant element in patients' selection of a private hospital, while the physical environment was deemed the least important. Other studies have highlighted "place" and "price" as the most critical marketing factors in the selection of public hospitals (4, 6, 8). A further study identified 13 determinants influencing hospital selection, categorizing them into three groups: hospital services, social factors, and hospital facilities, with hospital services being the predominant influence in the selection process (6). In industrialized nations, the primary reasons from the patients' perspective vary. A study conducted in London, England (2005), identified several critical factors influencing patient selection, including a high surgical success rate, stringent sanitary standards, effective communication between hospitals and physicians, the surgeons' reputation, post-operative home care, hospital reputation, minimal waiting times, convenient visitation for friends and family, ease of hospital access, proximity to home, complimentary transportation, amenities for the patient's companion, and the presence of private and teaching hospitals (9). Patients in poor nations reported a distinct hierarchy of causes. A study indicated that factors such as comfort, specialty, reputation, and word of mouth influence hospital selection (6). A study identified seven marketing mix elements that influence choice. Their findings indicated that at public hospitals, the pricing, products, physical assets, location, processes, personnel, and promotion were the critical determinants (4). In private hospitals, the priorities were, in order: products, physical assets, promotion, place, process, people, and price. Due to different contexts and variability of factors across studies and the potential of the marketing mix to enhance the performance of expensive hospitals, particularly in low- and middle-income nations, it is crucial to identify the primary factors influencing hospital service marketing. Therefore, this study attempted to determine the components in the marketing mix that influence patients' selection of hospitals in Palestine as there were no prior studies in this field. The findings may offer critical insights that inform the formulation of effective marketing strategies for public and private hospitals, hence improving patient satisfaction and augmenting the hospitals' market share in a competitive landscape. 3 1.1 A brief literature review The selection of a hospital is a complex choice shaped by several circumstances, illustrating the intricate relationship between healthcare providers and customers. The literature offers a variety of research that explore the complex factors influencing hospital selection, highlighting the primary criteria that assist patients in making educated decisions. Bahadori et al. (2016) examined the variables influencing patients' selections of hospital clinics from the viewpoints of both patients and management. The research elucidated the impact of many criteria, such as service quality, location, and patient satisfaction, on hospital selection. The research revealed that the primary determinants in drawing patients to a military clinic were the caliber of doctors and staff, as well as the clinic's atmosphere. The research indicates that clinic administrators have to prioritize enhancing these two characteristics and maintain uniform performance across all shifts. The research provides an extensive perspective on the intricate decision-making process by including viewpoints from both patients and management (8). Coulter, Le Maistre, and Henderson (2005) assessed patients' experiences regarding the selection of surgical interventions, specifically within the context of the London patient choice program. Their research underscored the significance of patient involvement in the decision-making process and the influence of information accessibility on patient choices. The research indicated that the majority of patients reacted favorably to the provision of an alternative hospital via the London Patient Choice initiative, with those treated at other facilities expressing greater satisfaction. The London Patient Choice program successfully fulfilled its primary goal of facilitating expedited access to high- quality treatment. This study provides important insights into the patient-centered approach to hospital selection and the importance of informed decision-making (9). Rao, Peters, and Bandeen-Roche (2006) concentrated on patient-centered healthcare services in India, creating a scale to assess patient perceptions of quality. The research established a 16-item scale to assess patient perceptions of quality in India and found that enhanced interpersonal skills of personnel and physicians, facility infrastructure, and medicine availability substantially elevate patient satisfaction in public health facilities. The data indicate that concentrating on these areas may significantly enhance patient 4 satisfaction in the Indian public healthcare system. The research acknowledged the importance of patient perceptions in influencing healthcare decisions, especially regarding service quality (10) . Hosseini, Etesaminia, and Jafari (2016) significantly contributed by finding eleven aspects of the service marketing mix (4Ps) that affect consumers' preferences for private hospitals. Their thorough analysis of marketing mix components, including product offerings, price strategies, promotional activities, and the whole service process, provides a detailed grasp of the intricate dynamics influencing patient decision-making. The research delineates eleven criteria that affect patients' selection of private hospitals, emphasizing service marketing mixes. The primary results indicate that regular attendance by physicians and nurses, operational discipline and efficiency, and suitable staff activities significantly influence patient choice for private hospitals. This research emphasizes the need for healthcare providers to implement a comprehensive marketing strategy, acknowledging the interrelation of several factors in shaping consumer preferences (11) . 1.2 Problem statement Although marketing is crucial for the success of firms/ enterprises/companies/institutions, including hospitals, via planning, promotion, pricing, and the provision of customer- oriented services, there is a significant lack of targeted study on its application to hospital selection in Palestine. The lack of locally relevant research impedes our comprehension of the critical factors in the marketing mix that substantially affect patients' decisions when choosing a hospital in Palestine. The decision-making process in this setting considers people, physical environment, location, and cost, resulting in a complex interaction of elements that has not been well investigated in the area. Multiple obstacles impede Palestinian patients' capacity to choose hospitals. Referrals are often necessary for specialist treatment, limiting choices. Geographic location and the Separation Wall segregate populations from healthcare services. Israeli checkpoints and the permission system impose movement limitations, resulting in delays and rejections for medical access, particularly for those requiring care in East Jerusalem or outside Gaza. These limitations affect access to healthcare and may result in worsening health issues. 5 The challenge is to identify and understand the critical components of the marketing mix that significantly influence patients' choices when choosing a hospital in Palestine. Despite the crucial significance of elements such as people, physical environment, location, and cost in the decision-making process, a discernible deficiency exists in region-specific research. The disparity is especially alarming because to the inconsistency in hospital selection criteria highlighted in current research, compounded by the distinct obstacles encountered by hospitals, particularly in low- and middle-income nations. To bridge this information gap and provide practical insights, it is essential to conduct a thorough study to identify and examine the critical components of the marketing mix affecting patients' hospital selection in Palestine. This research was essential for formulating effective marketing strategies that may improve patient satisfaction and bolster the competitive posture of both public and private hospitals in the area. 1.3 Objectives The general aim of this study was to identify the key components of the marketing mix that most significantly impact patients' decision-making when choosing a hospital in Palestine. The specific objectives of the study were: - To identify and prioritize the primary elements within the marketing mix that significantly influence patients' decision-making when selecting a hospital in Palestine, considering factors such as staff, physical environment, location, and cost . - To assess the associations between the sociodemographic and health characteristics with the patients' preferences of the components of the marketing mix that most significantly impact patients' decision-making when choosing a hospital in Palestine. 1.4 Importance of the study - Enhancing Healthcare Quality: Understanding the factors that shape hospital choice in Palestine is essential for elevating the standard of healthcare services. By recognizing the pivotal components of the marketing mix, healthcare providers can tailor their services to meet patient expectations, thereby enhancing the overall quality of healthcare . 6 - Enhancing Patient Satisfaction: This study seeks to boost patient satisfaction by pinpointing the elements with the most influence on patients' decisions during hospital selection. The identification of these influential factors can lead to improved patient experiences, fostering confidence in and adherence to medical institutions. - Gaining a Competitive Edge: Hospitals, whether public or private, can gain a competitive advantage by formulating marketing plans aligned with patient preferences. This alignment has the potential to increase market share and solidify a more robust position in the healthcare sector . - Informed Decision-Making: Policymakers and hospital administrators can leverage data-driven insights from this study to make informed decisions regarding resource allocation, infrastructure development, and healthcare regulations in Palestine. - Addressing Unique Challenges: By focusing on the particular challenges faced by hospitals in low- and middle- income nations like Palestine, this study can serve as a model for improving healthcare services. It offers an opportunity to adapt marketing tactics to the specific context, addressing obstacles unique to such regions. - Contributing to the Body of Knowledge : This study enriches the body of information on healthcare marketing by providing insightful data applicable not only to Palestine but also to various healthcare settings. The knowledge generated can contribute to a more comprehensive understanding of healthcare consumer behavior. 7 Chapter Two Methods 2.1 Study context The healthcare system in Palestine comprises both governmental, nongovernmental, and private providers, each delivering various healthcare services (12). Comprehending the factors influencing hospital selection is essential for augmenting healthcare service quality and elevating patient happiness in this specific setting. 2.2 Study design The study used a cross-sectional design to provide a snapshot on patients' preferences and decision-making criteria about hospital choosing in Palestine. This design was appropriate for analyzing the interactions between variables at a particular moment, facilitating data gathering from a varied participant cohort (4, 6). 2.3 Study setting The study was conducted in various regions of Palestine to ensure a representative sample that reflected the diverse socio-cultural and economic backgrounds of the population through selecting private hospitals and governmental hospitals in the north of the West Bank. The nongovernmental hospitals included An-Najah National University Hospital, Al Arabi Specialized Hospital, Nablus Specialized Hospital, Al Ittihad Women's Association Hospital, and Evangelical Hospital and the governmental hospitals included those in the main cities in the north of the West Bank, including Nablus, Tulkarm, Jenin, Tubas, and Qalqilya. 2.4 Population The study population was patients who visited nongovernmental and governmental hospitals during the study period. 2.4.1 Inclusion criteria The study participants consisted of individuals aged 18 and older who had pursued non- emergent healthcare treatments in public and private hospitals during the study period. 8 Written informed consent was obtained from each participant before their inclusion in the study. 2.4.2 Exclusion criteria The patients who were younger than 18 years were excluded. 2.5 Sample size and sampling method The sample size was calculated based on the number of patients who visited hospitals in the north of the West Bank. Based on the reports of the Palestinian Central Bureau of Statistics, 340,000 patients visited the hospitals in the north of the West Bank, accepting a margin of error of 5%, a response distribution of 50%, and using a confidence interval of 95%, the sample size needed for this study was 385 patients as calculated by RaoSoft (http://www.raosoft.com/). The study used a convenience sampling technique and accounted for representation across various demographic factors such as age groups, gender, socio-economic statuses, and geographic locations. This should have reflected the diversity within the Palestinian population. 2.6 Data collection and study tools The patients were met in person and were asked to participate in the study. Data were collected through a paper-based questionnaire. The questionnaire was designed based on previous similar studies after a thorough review of the existing literature and validated instruments used in similar studies (4, 6, 7, 9). The questionnaire covered various aspects, including demographic information, factors influencing hospital selection, and preferences regarding marketing mix elements. 2.7 Variables 2.7.1 Dependent variable - Hospital choice preferences as based on marketing mix components (product, price, place, promotion, people, process, and physical environment). http://www.raosoft.com/ 9 2.7.2 Background and independent variables - Demographic variables (age, gender, socio-economic status). - Health variables of the patients (having chronic diseases, using chronic medications). - Hospital attributes (reputation, service quality, accessibility, and cost). 2.8 Reliability and validity of the study tool The reliability and validity of the questionnaire were assessed using SmartPLS v.4.1.0.8 and IBM SPSS. The internal consistencies of the items were assessed using Cronbach’s alpha statistics. The Cronbach’s alpha values were as follows: 1) for the product (9-items) = 0.85, 2) for the place (3 items) = 0.81, 3) for the people (9 items) = 0.84, 4) for the promotion (7 items) = 0.88, 5) for the process (5 items) = 0.78, 6) for the physical environment (6 items) = 0.84, and for the price (5 items) = 0.84. These values indicated that the items in each domain were internally consistent. In addition, the correlations between the items as shown in Figure 1 indicated acceptable divergent validity. 10 Figure 1 Correlations between the items in the 7Ps 11 2.9 Statistical analysis The data were handled in Microsoft excel sheets and IBM SPSS v.21.0. Quantitative data were analyzed using descriptive statistics to summarize participant demographics and preferences. Inferential statistics, including t-tests and analysis of variance (ANOVA) were used. To control confounding variables and to identify the determinants of the most important marketing mix components, all variables were included in multiple linear regression models. A p-value < 0.05 was considered statistically significant. 2.10 Ethical approval The study adhered to ethical principles, ensuring participant confidentiality, privacy, and voluntary participation. The study was approved by the Institutional Review Board of An-Najah National University. In addition, approvals were also obtained from the Palestinian Ministry of Health, and the management of each hospital. Informed consent was obtained from all participants. 12 Chapter Three Results 3.1 Sociodemographic and health characteristics of the participants In this study, a total of 385 participants completed the questionnaire. Of those, 198 (51.4%) were male and 187 (48.6%) were female. Similarly, 187 (48.6%) of the participants were 35 years or older, 320 (83.1%) had either an undergraduate or a graduate university degree, 251 (65.2%) were employed, and 294 (76.4%) had either moderate or high household income. Of the participants, 82 (21.3%) had no health insurance and 303 (78.7%) had either a governmental or a private health insurance, 58 (15.1%) had chronic diseases, 55 (14.3%) used chronic medications, 167 (43.4%) had 2 or more hospital visits in the last year, and 114 (29.6%) spent more than 1 night at the hospital visits in the last year. The detailed sociodemographic and health characteristics of the participants are shown in Table 1. Table 1 Detailed sociodemographic and health characteristics of the participants (n = 385) Variable n % Sex Male 198 51.4 Female 187 48.6 Age (years) < 35 198 51.4 ≥ 35 187 48.6 Educational level School 65 16.9 Undergraduate 283 73.5 Graduate 37 9.6 Employment status Unemployed 134 34.8 Employed/working in a non-governmental sector 158 41.0 Employed/working in a governmental sector 93 24.2 Household income level Low 91 23.6 Moderate 269 69.9 High 25 6.5 Health insurance status No health insurance 82 21.3 A governmental health insurance 213 55.3 A private health insurance 90 23.4 Having chronic diseases No 327 84.9 Yes 58 15.1 Taking chronic medications No 329 85.5 Yes 55 14.3 Number of hospital visits in the last year < 2 218 56.6 ≥ 2 167 43.4 Number of nights spent at the hospital in the last year ≤ 1 271 70.4 > 1 114 29.6 13 3.2 Importance of the different marketing mix components Appendix 1 details the ratings of the participants on each component of marketing mix. 3.2.1 Ratings of product components In this study, availability of healthcare providers with sub-specialties in various fields of medicine/healthcare was either important or very important for 353 (91.6%) participants, introduction of updated and newly developed services was either important or very important for 338 (87.8%), quality of the provided services was either important or very important for 331 (85.9%), offering a diverse range of specialized care services was either important or very important for 328 (85.2%), length of waiting lists for needed services was either important or very important for 315 (81.8%), provision of suitable and effective preventive services was either important or very important for 304 (79.0%), provision of professional consulting services was either important or very important for 302 (78.4%), provision of home care services following patient discharge was either important or very important for 291 (75.6%), and providing remote healthcare services through technology (e.g. telemedicine) was either important or very important for 246 (63.9%). The mean rating scores of the different product components are shown in Figure 2. 14 Figure 2 Mean rating scores of the different product components 3.2.2 Ratings of people components Similarly, dedication of practitioners and their rapport with patients was either important or very important for 348 (90.4%) participants, scientific expertise and competencies possessed by physicians was either important or very important for 335 (87.0%), staff's attentiveness to addressing the mental health needs of patients was either important or very important for 314 (81.6%), sufficient staffing levels required for effective service delivery was either important or very important for 310 (80.5%), practical and beneficial advice provided to patients by healthcare providers was either important or very important for 304 (78.9%), culture of constructive criticism, optimism, and dedication was either important or very important for 299 (77.7%), positive and collaborative relationship between staff and patients was either important or very important for 292 (75.8%), staff's proficiency in scientific knowledge and skills was either important or very important for 284 (73.8%), and uniforms that align with the hospital's established dress code was either important or very important for 215 (55.9%). The mean rating scores of the different people components are shown in Figure 3. 1 2 3 4 5 Availability of healthcare providers with sub-specialties in various fields… Introduction of updated and newly developed services Quality of the provided services Offering a diverse range of specialized care services Length of waiting lists for needed services Provision of suitable and effective preventive services Provision of professional consulting services Provision of home care services following patient discharge Providing remote healthcare services through technology (e.g. telemedicine) Rating C o m p o n en t 15 Figure 3 Mean rating scores of the different people components 1 2 3 4 5 Dedication of practitioners and their rapport with patients Scientific expertise and competencies possessed by physicians Staff's attentiveness to addressing the mental health needs of patients Sufficient staffing levels required for effective service delivery Practical and beneficial advice provided to patients by healthcare providers Culture of constructive criticism, optimism, and dedication Positive and collaborative relationship between staff and patients Staff's proficiency in scientific knowledge and skills Uniforms that align with the hospital's established dress code Rating C o m p o n en t 16 3.2.3 Ratings of price components Moreover, provision for waiving fees for economically disadvantaged patients was either important or very important for 320 (83.1%) participants, competitive tariff rates in comparison to other healthcare centers was either important or very important for 316 (82.0%), provision of complimentary services was either important or very important for 312 (81.0%), clear and timely billing processes for patients was either important or very important for 308 (80.0%), and agreements established with both basic and complementary insurance providers was either important or very important for 299 (77.6%). The mean price scores of the different people components are shown in Figure 4. Figure 4 Mean rating scores of the different price components 3.2.4 Ratings of process components Additionally, ensuring promptness in service delivery by the staff was either important or very important for 329 (85.5%), providing patients with comprehensive descriptions of the services offered was either important or very important for 322 (83.6%), demonstrating discipline and attention to detail in the delivery of services was either important or very important for 321 (83.3%), giving due consideration to patients' 1 2 3 4 5 Provision for waiving fees for economically disadvantaged patients Competitive tariff rates in comparison to other healthcare centers Provision of complimentary services Clear and timely billing processes for patients Agreements established with both basic and complementary insurance providers Rating C o m p o n en t 17 feedback and concerns was either important or very important for 298 (77.4%), and using health information systems and various networks for efficient management was either important or very important for 218 (56.6%). The mean price scores of the different process components are shown in Figure 5. Figure 5 Mean rating scores of the different process components 3.2.5 Ratings of physical environment components In addition, well-suited diagnostic and treatment equipment to ensure quality care was either important or very important for 331 (86.0%), effective communication and responsiveness to patient needs was either important or very important for 324 (84.1%), effective air conditioning system and adequate lighting throughout the facility 300 (77.9%), sufficiently sized yard and parking facilities to accommodate patients and visitors was either important or very important for 266 (69.1%), aesthetic appeal and thoughtful design of the hospital's interior spaces was either important or very important for 251 (65.2%), and attractive exterior view of the hospital was either important or very important for 242 (62.8%). The mean price scores of the different physical environment components are shown in Figure 6. 1 2 3 4 5 Ensuring promptness in service delivery by the staff Providing patients with comprehensive descriptions of the services offered Demonstrating discipline and attention to detail in the delivery of services Giving due consideration to patients' feedback and concerns Using health information systems and various networks for efficient management Rating C o m p o n en t 18 Figure 6 Mean rating scores of the different physical environment components 3.2.6 Ratings of promotion components Furthermore, positive reputation within the community and among patients was either important or very important for 340 (88.3%) participants, using websites as a platform for information and engagement was either important or very important for 212 (55.0%), distributing brochures to highlight and promote the hospital's services was either important or very important for 198 (51.4%), using banners and various advertising tools for promotion was either important or very important for 197 (51.1%), generating regular reports to document and communicate successes and achievements was either important or very important for 195 (50.6%), using television advertisements and telephone communications for outreach was either important or very important for 170 (44.2%), and hosting ceremonies to showcase the hospital's capabilities and potential was either important or very important for 166 (43.2%). The mean price scores of the different promotion components are shown in Figure 7. 1 2 3 4 5 Well-suited diagnostic and treatment equipment to ensure quality care Effective communication and responsiveness to patient needs Effective air conditioning system and adequate lighting throughout the facility Sufficiently sized yard and parking facilities to accommodate patients and visitors Aesthetic appeal and thoughtful design of the hospital's interior spaces Attractive exterior view of the hospital Rating C o m p o n en t 19 Figure 7 Mean rating scores of the different promotion components 1 2 3 4 5 Positive reputation within the community and among patients Using websites as a platform for information and engagement Distributing brochures to highlight and promote the hospital's services Using banners and various advertising tools for promotion Generating regular reports to document and communicate successes and achievements Using television advertisements and telephone communications for outreach Hosting ceremonies to showcase the hospital's capabilities and potential Rating C o m p o n en t 20 3.2.7 Ratings of place components Moreover, location of the hospital was either important or very important for 289 (75.1%) participants, availability of suitable transportation options was either important or very important for 284 (73.8%), and providing mobile or portable services was either important or very important for 266 (69.1%). The mean price scores of the different place components are shown in Figure 8. Figure 8 Mean rating scores of the different place components 3.2.8 Ratings of the 7Ps The study participants rated all components of the 7Ps. The mean scores of the different 7Ps are shown in Figure 9. Figure 9 Mean rating scores of the different place components 1 2 3 4 5 Location of the hospital Availability of suitable transportation options Providing mobile or portable services Rating C o m p o n en t 0 1 2 3 4 5 Product Price Physical environment Place R a ti n g Marketing mix 21 3.3 Correlation between ratings of the different components of the marketing mix Pearson’s correlations showed that there were moderate significant and positive correlations between the ratings of the different components of the marketing mix. These correlations are shown in Table 2. Table 2 Correlation matrix between the different components of the marketing mix Product People Price Process Physical environment Promotion Place Product Pearson's r - 0.69 0.50 0.54 0.59 0.37 0.44 p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 People Pearson's r 0.69 - 0.54 0.62 0.67 0.51 0.53 p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Price Pearson's r 0.50 0.54 - 0.59 0.57 0.24 0.40 p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Process Pearson's r 0.54 0.62 0.59 - 0.61 0.39 0.35 p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Physical environment Pearson's r 0.59 0.67 0.57 0.61 - 0.39 0.43 p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Promotion Pearson's r 0.37 0.51 0.24 0.39 0.39 - 0.35 p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Place Pearson's r 0.44 0.53 0.40 0.35 0.43 0.35 - p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 22 3.4 Association between the variables of the participants and ratings of the different components of the marketing mix 3.4.1 Association between the variables of the participants and ratings of product In this study, the participants who were female (p-value = 0.037), had high household income (p-value < 0.001), had a governmental health insurance (p-value = 0.018), and did not have chronic diseases (p-value = 0.031) rated product significantly higher than those who were male, had low household income, had private health insurance, and those who had chronic diseases as shown in Table 3. On the other hand, ratings of product were not significantly affected by age, educational level, employment status, using chronic medications, number of hospital visits in the last year, and number of nights spent at the hospital in the last year. 23 Table 3 Association between the variables of the participants and ratings of product Variable n % Mean SD p-value Sex Male 198 51.4 37.3 5.2 0.037 Female 187 48.6 38.5 5.3 Age (years) < 35 198 51.4 37.9 5.0 0.868 ≥ 35 187 48.6 37.8 5.6 Educational level School 65 16.9 37.4 0.7 0.643 Undergraduate 283 73.5 38.0 0.3 Graduate 37 9.6 37.8 0.9 Employment status Unemployed 134 34.8 37.9 0.4 0.789 Employed/working in a non-governmental sector 158 41.0 38.0 0.4 Employed/working in a governmental sector 93 24.2 37.6 0.5 Household income level Low 91 23.6 35.9 0.5 < 0.001 Moderate 269 69.9 38.4 0.3 High 25 6.5 39.3 1.3 Health insurance status No health insurance 82 21.3 38.5 0.6 0.018 A governmental health insurance 90 23.4 38.9 0.5 A private health insurance 213 55.3 37.2 0.4 Have chronic diseases No 327 84.9 38.1 4.9 0.031 Yes 58 15.1 36.5 6.7 Use chronic medications No 329 85.5 38.1 5.0 0.075 Yes 55 14.3 36.7 6.7 Number of hospital visits in the last year < 2 218 56.6 37.9 5.4 0.957 ≥ 2 167 43.4 37.9 5.0 Number of nights spent at the hospital in the last year < 1 271 70.4 37.9 5.4 0.875 ≥ 1 114 29.6 38.0 5.0 24 3.4.2 Association between the variables of the participants and ratings of people In this study, the participants who had high household income (p-value = 0.001), had a governmental health insurance (p-value = 0.040), and did not have chronic diseases (p- value = 0.014) rated people significantly higher than those who had low household income, had private health insurance, and those who had chronic diseases as shown in Table 4. On the other hand, ratings of people were not significantly affected by sex, age, educational level, employment status, using chronic medications, number of hospital visits in the last year, and number of nights spent at the hospital in the last year. 25 Table 4 Association between the variables of the participants and ratings of people Variable n % Mean SD p-value Sex Male 198 51.4 36.7 5.2 0.183 Female 187 48.6 37.4 5.0 Age (years) < 35 198 51.4 36.8 4.9 0.382 ≥ 35 187 48.6 37.3 5.3 Educational level School 65 16.9 37.6 0.6 0.679 Undergraduate 283 73.5 37.0 0.3 Graduate 37 9.6 37.1 0.9 Employment status Unemployed 134 34.8 36.7 0.4 0.589 Employed/working in a non-governmental sector 158 41.0 37.3 0.4 Employed/working in a governmental sector 93 24.2 37.1 0.5 Household income level Low 91 23.6 35.4 0.5 0.001 Moderate 269 69.9 37.6 0.3 High 25 6.5 37.2 1.3 Health insurance status No health insurance 82 21.3 37.3 0.5 0.040 A governmental health insurance 90 23.4 38.1 0.5 A private health insurance 213 55.3 36.5 0.4 Have chronic diseases No 327 84.9 37.3 4.9 0.014 Yes 58 15.1 35.6 6.2 Use chronic medications No 329 85.5 37.3 4.9 0.060 Yes 55 14.3 35.9 6.2 Number of hospital visits in the last year < 2 218 56.6 37.2 4.8 0.511 ≥ 2 167 43.4 36.9 5.5 Number of nights spent at the hospital in the last year < 1 271 70.4 37.2 5.1 0.420 ≥ 1 114 29.6 36.7 5.1 26 3.4.3 Association between the variables of the participants and ratings of price In this study, the participants who were 35 years or older (p-value = 0.012) and those who had moderate household income (p-value = 0.008) rated price significantly higher than those who were younger than 35 years and those who had low household income as shown in Table 5. On the other hand, ratings of price were not significantly affected by sex, educational level, employment status, health insurance status, having chronic diseases, using chronic medications, number of hospital visits in the last year, and number of nights spent at the hospital in the last year. 27 Table 5 Association between the variables of the participants and ratings of price Variable n % Mean SD p-value Sex Male 198 51.4 21.2 3.6 0.991 Female 187 48.6 21.3 3.3 Age (years) < 35 198 51.4 20.8 3.7 0.012 ≥ 35 187 48.6 21.7 3.1 Educational level School 65 16.9 21.6 0.4 0.582 Undergraduate 283 73.5 21.2 0.2 Graduate 37 9.6 20.9 0.7 Employment status Unemployed 134 34.8 21.1 0.3 0.501 Employed/working in a non-governmental sector 158 41.0 21.2 0.3 Employed/working in a governmental sector 93 24.2 21.6 0.3 Household income level Low 91 23.6 20.4 0.4 0.008 Moderate 269 69.9 21.6 0.2 High 25 6.5 20.4 0.8 Health insurance status No health insurance 82 21.3 21.0 0.4 0.518 A governmental health insurance 90 23.4 21.6 0.4 A private health insurance 213 55.3 21.2 0.2 Have chronic diseases No 327 84.9 21.2 3.5 0.472 Yes 58 15.1 21.6 3.4 Use chronic medications No 329 85.5 21.2 3.5 0.711 Yes 55 14.3 21.4 3.5 Number of hospital visits in the last year < 2 218 56.6 21.1 3.4 0.244 ≥ 2 167 43.4 21.5 3.6 Number of nights spent at the hospital in the last year < 1 271 70.4 21.3 3.4 0.598 ≥ 1 114 29.6 21.1 3.6 28 3.4.4 Association between the variables of the participants and ratings of process In this study, the participants who had moderate household income (p-value = 0.011) rated process significantly higher than those who had low household income as shown in Table 6. On the other hand, ratings of price were not significantly affected by sex, age, educational level, employment status, health insurance status, having chronic diseases, using chronic medications, number of hospital visits in the last year, and number of nights spent at hospital in the last year. 29 Table 6 Association between the variables of the participants and ratings of process Variable n % Mean SD p-value Sex Male 198 51.4 20.4 3.1 0.802 Female 187 48.6 20.4 3.1 Age (years) < 35 198 51.4 20.4 3.1 0.930 ≥ 35 187 48.6 20.4 3.1 Educational level School 65 16.9 20.8 0.4 0.547 Undergraduate 283 73.5 20.3 0.2 Graduate 37 9.6 20.3 0.6 Employment status Unemployed 134 34.8 20.4 0.3 0.611 Employed/working in a non-governmental sector 158 41 20.3 0.2 Employed/working in a governmental sector 93 24.2 20.7 0.3 Household income level Low 91 23.6 19.7 0.3 0.011 Moderate 269 69.9 20.7 0.2 High 25 6.5 19.4 0.9 Health insurance status No health insurance 82 21.3 20.8 0.3 0.205 A governmental health insurance 90 23.4 20.1 0.2 A private health insurance 213 55.3 20.7 0.4 Have chronic diseases No 327 84.9 20.5 3.1 0.184 Yes 58 15.1 19.9 3.4 Use chronic medications No 329 85.5 20.4 3.1 0.363 Yes 55 14.3 20.0 3.4 Number of hospital visits in the last year < 2 218 56.6 20.4 3.0 0.222 ≥ 2 167 43.4 19.7 2.8 Number of nights spent at the hospital in the last year < 1 271 70.4 20.7 2.9 0.063 ≥ 1 114 29.6 20.1 3.3 30 3.4.5 Association between the variables of the participants and ratings of physical environment In this study, the participants who had moderate household income (p-value = 0.010) and those who had governmental health insurance rated physical environment significantly higher than those who had low household income and those who had private health insurance as shown in Table 7. On the other hand, ratings of price were not significantly affected by sex, age, educational level, employment status, health insurance status, having chronic diseases, using chronic medications, number of hospital visits in the last year, and number of nights spent at the hospital in the last year. 31 Table 7 Association between the variables of the participants and ratings of physical environment Variable n % Mean SD p-value Sex Male 198 51.4 24.2 4.0 0.423 Female 187 48.6 24.5 4.1 Age (years) < 35 198 51.4 24.3 3.8 0.634 ≥ 35 187 48.6 24.5 4.3 Educational level School 65 16.9 24.9 0.4 0.356 Undergraduate 283 73.5 24.2 0.2 Graduate 37 9.6 24.8 0.7 Employment status Unemployed 134 34.8 24.3 0.3 0.909 Employed/working in a non-governmental sector 158 41.0 24.4 0.3 Employed/working in a governmental sector 93 24.2 24.5 0.4 Household income level Low 91 23.6 23.5 0.4 0.010 Moderate 269 69.9 24.8 0.3 High 25 6.5 23.2 0.9 Health insurance status No health insurance 82 21.3 24.9 0.4 0.021 A governmental health insurance 90 23.4 25.1 0.4 A private health insurance 213 55.3 23.9 0.3 Have chronic diseases No 327 84.9 24.5 3.9 0.288 Yes 58 15.1 23.8 5.0 Use chronic medications No 329 85.5 24.4 3.9 0.331 Yes 55 14.3 23.9 5.1 Number of hospital visits in the last year < 2 218 56.6 24.2 4.0 0.332 ≥ 2 167 43.4 24.6 4.2 Number of nights spent at the hospital in the last year < 1 271 70.4 24.3 4.1 0.743 ≥ 1 114 29.6 24.5 4.0 32 3.4.6 Association between the variables of the participants and ratings of promotion In this study, ratings of promotion were not significantly affected by sex, age, educational level, employment status, household income level, health insurance status, having chronic diseases, using chronic medications, number of hospital visits in the last year, and number of nights spent at the hospital in the last year as shown in Table 8. 33 Table 8 Association between the variables of the participants and ratings of promotion Variable n % Mean SD p-value Sex Male 198 51.4 25.2 5.0 0.870 Female 187 48.6 25.3 5.8 Age (years) < 35 198 51.4 25.3 5.1 0.659 ≥ 35 187 48.6 25.1 5.7 Educational level School 65 16.9 26.5 0.6 0.081 Undergraduate 283 73.5 24.9 0.3 Graduate 37 9.6 25.5 0.9 Employment status Unemployed 134 34.8 25.0 0.5 0.839 Employed/working in a non-governmental sector 158 41 25.2 0.4 Employed/working in a governmental sector 93 24.2 25.4 0.6 Household income level Low 91 23.6 24.9 0.5 0.292 Moderate 269 69.9 25.5 0.3 High 25 6.5 23.9 1.3 Health insurance status No health insurance 82 21.3 25.8 0.6 0.418 A governmental health insurance 90 23.4 25.4 0.6 A private health insurance 213 55.3 24.9 0.4 Have chronic diseases No 327 84.9 25.4 5.3 0.212 Yes 58 15.1 24.4 5.8 Use chronic medications No 329 85.5 25.4 5.3 0.145 Yes 55 14.3 24.2 5.8 Number of hospital visits in the last year < 2 218 56.6 25.2 6.4 0.224 ≥ 2 167 43.4 23.8 5.4 Number of nights spent at the hospital in the last year < 1 271 70.4 25.6 5.5 0.126 ≥ 1 114 29.6 24.7 5.2 34 3.4.7 Association between the variables of the participants and ratings of place In this study, the participants who had moderate household income (p-value = 0.002), who did not have chronic disease (p-value = 0.038), and those who did not used chronic medications (p-value = 0.048) rated place significantly higher than those who had low household income, who had chronic diseases, and those who used chronic medications as shown in Table 9. On the other hand, ratings of price were not significantly affected by sex, age, educational level, employment status, health insurance status, number of hospital visits in the last year, and number of nights spent at the hospital in the last year. 35 Table 9 Association between the variables of the participants and ratings of place Variable n % Mean SD p-value Sex Male 198 51.4 11.9 2.3 0.324 Female 187 48.6 12.1 2.2 Age (years) < 35 198 51.4 11.8 2.3 0.053 ≥ 35 187 48.6 12.2 2.3 Educational level School 65 16.9 12.1 0.3 0.971 Undergraduate 283 73.5 12.0 0.1 Graduate 37 9.6 12.0 0.4 Employment status Unemployed 134 34.8 11.9 0.2 0.768 Employed/working in a non-governmental sector 158 41.0 12.1 0.2 Employed/working in a governmental sector 93 24.2 12.0 0.3 Household income level Low 91 23.6 11.5 0.2 0.002 Moderate 269 69.9 12.3 0.1 High 25 6.5 11.2 0.6 Health insurance status No health insurance 82 21.3 12.0 0.2 0.414 A governmental health insurance 90 23.4 12.3 0.2 A private health insurance 213 55.3 11.9 0.2 Have chronic diseases No 327 84.9 12.1 2.2 0.038 Yes 58 15.1 11.4 2.4 Use chronic medications No 329 85.5 12.1 2.2 0.048 Yes 55 14.3 11.4 2.4 Number of hospital visits in the last year < 2 218 56.6 11.9 2.2 0.587 ≥ 2 167 43.4 12.1 2.3 Number of nights spent at the hospital in the last year < 1 271 70.4 12.0 2.3 0.589 ≥ 1 114 29.6 12.1 2.2 36 3.5 Predictors of important marketing mix components To control potentially confounding variables and to identify the factors that can be used to predict important marketing mix components, all variables were included in multiple linear regression models. The outcomes of the models are shown in Appendix L. The multiple linear regression showed that higher product ratings were predicted by moderate or household income (B = 2.12, p-value < 0.001) and having a governmental health insurance (B = -0.74, p-value = 0.030). Similarly, higher people ratings were predicted by moderate or household income (B = 1.57, p-value = 0.002). Moreover, higher process ratings were predicted by moderate or household income (B = -0.41, p- value = 0.048) and spending less nights at the hospitals (B = -0.83, p-value = 0.025). In addition, higher physical environment ratings were predicted by moderate or household income (B = -0.70, p-value = 0.011). Furthermore, higher place ratings were predicted by older age (B = 0.68, p-value = 0.007). 37 Chapter Four Discussion and Conclusion 4.1 Summary of the main findings The influence of the marketing mix (7Ps: Product, Price, Place, Promotion, People, Process, and Physical Environment) on hospital choosing is a significant study domain, since healthcare facilities must consistently enhance their offerings to attract and keep consumers (4, 6, 7, 9-11). Comprehending the impact of these marketing components on decision-making enables healthcare managers to enhance their plans for patient happiness and operational efficacy. This study was the first investigation in Palestine to analyze the impact of the 7Ps on patients' hospital selection, offering significant insights into the regional healthcare sector. The outcomes of this study highlighted many significant findings, including: participants ranked the availability of healthcare professionals with sub-specialties and the quality of services highly, with over 85% deeming these characteristics either significant or extremely important. Product and People appeared as especially critical characteristics, with high family income and governmental health insurance serving as major drivers of superior evaluations in both categories. Price and Process also showed significance, particularly for participants with moderate incomes. Physical Environment and Place had a moderate effect, with age and income being relevant predictors. 4.2 Interpretation and discussion of the main findings 4.2.1 Product The finding that the availability of healthcare providers with sub-specialties and the quality of services was rated highly by the participants underscored the critical importance of specialized medical services in hospital selection. This result aligns with similar studies in healthcare marketing, which emphasize the role of product diversity and service quality in attracting patients (13-15). For example, research in other contexts has shown that patients prioritize hospitals with a broader range of specialized care options (4, 6, 9). However, the significance of this factor in Palestine may be heightened due to the limited availability of such services, making it a more critical determinant of choice. The fact that 38 participants with higher household income and governmental health insurance rated this dimension more favorably suggests that these groups may have higher expectations or greater access to healthcare, leading to a more discerning evaluation of the services offered. This study indicated that hospitals in Palestine have to enhance their array of specialist services and consistently update their offerings to address patient requirements. It is recommended that hospitals engage in sub-specialty training and promote the availability of these services to attract higher-income and insured patients, who are more inclined to prioritize them (16-18). 4.2.2 People The high importance attributed to the 'People' component, particularly the rapport between healthcare providers and patients, reflects the value placed on human interactions in the healthcare setting. This result was consistent with much of the literature, where patient satisfaction is closely tied to the perceived competence and empathy of healthcare staff (4, 19, 20). However, in the Palestinian context, where personal relationships often play a significant role in professional interactions, this factor may carry even greater weight. The fact that people with governmental health insurance and higher income rated this component more highly may suggest that they receive better or more attentive care, perhaps due to hospital resource allocation or staffing practices. This can be interpreted as a call for healthcare institutions to standardize the quality of patient-staff interactions across all patient groups to ensure equitable care. Building on this finding, hospitals should prioritize staff training in communication and patient care, emphasizing empathy, active listening, and mental health support (4, 21-24). A key recommendation is for hospitals to implement regular professional development programs focused on enhancing the quality of interactions between healthcare providers and patients (25-28). 4.2.3 Price The finding that price was significantly important to participants, particularly those older than 35 and with moderate household incomes, revealed that financial considerations are a central factor in hospital choice. This was consistent with global findings that price 39 transparency and competitive pricing are critical for patient decision-making, especially for middle-income groups (29-34). However, the emphasis on price in this study may also reflect the specific economic challenges faced by Palestinian patients, where healthcare costs can be a significant burden (35-40). The fact that price sensitivity was higher among older participants suggested that as individuals age, they may become more conscious of healthcare costs, possibly due to increased healthcare needs (41-43). Hospitals can build on this finding by offering more tailored pricing options or payment plans for older and middle-income patients to alleviate financial concerns. A recommendation is for healthcare providers to adopt clear and transparent billing practices and to explore partnerships with insurance companies to offer more competitive tariffs, thus making services more accessible to a broader population. 4.2.4 Process The significance of the 'Process' component, particularly the importance of timely service delivery and the efficient use of health information systems, reflected patient expectations for smooth and efficient healthcare services. This conclusion aligns with other research indicating that process efficiency was a crucial determinant of patient satisfaction in healthcare environments (4, 6). The correlation with moderate family income indicated that patients from this demographic may be more sensitive to inefficiencies in service delivery, perhaps owing to an elevated knowledge of quality standards (44, 45). Patients anticipate contemporary, efficient procedures that reduce wait times and provide transparent communication (46). Hospitals should concentrate on enhancing operational procedures, minimizing bottlenecks, and using modern health information technology to maximize service delivery. Healthcare executives should do frequent process audits and invest in solutions that improve efficiency, such as electronic health records (EHRs) and appointment scheduling systems (46-48). 4.2.5 Physical Environment The high evaluations for the physical environment, including appropriate diagnostic equipment and comfort inside hospital facilities, underscored the significance of the 40 hospital's infrastructure in patient decision-making. This aligns with research from other hospital environments, where the physical setting, including cleanliness, design, and the use of contemporary technology, significantly impacts patient perceptions of treatment quality (4, 6, 9). In Palestine, where several healthcare institutions may lack advanced infrastructure, this issue may be further exacerbated (49, 50). The higher ratings from participants with governmental health insurance and moderate incomes suggest that these patients may have higher expectations for the hospital's physical environment. Interpreting this finding, it can be concluded that patients equate a hospital's appearance and equipment with the quality of care they can expect to receive. Hospitals can build on this by investing in modern diagnostic equipment, maintaining facility cleanliness, and enhancing the overall aesthetic appeal of the environment (49-52). A recommendation would be for healthcare institutions to allocate resources to continually update their facilities and ensure that the environment is conducive to patient comfort and satisfaction. 4.2.6 Place The importance of 'Place', particularly hospital location and accessibility, reflected a universal healthcare concern: proximity to healthcare services. This result was supported by literature indicating that accessibility was a key determinant in healthcare utilization (40, 52-56). The finding that older participants and those with moderate incomes placed greater importance on this component is logical, as these groups may experience more transportation challenges or prefer hospitals that are more convenient to reach. In Palestine, where access to transportation can be a significant barrier for many patients, this finding underscores the need for hospitals to ensure they are located in accessible areas or provide transportation options for patients. Based on this, hospitals can build on this finding by offering mobile health services or shuttle services for patients who face transportation difficulties. A primary suggestion is for healthcare planners to emphasize the accessibility of healthcare services in forthcoming hospital projects, especially for groups who may have mobility difficulties. 41 4.2.7 Promotion Notably, the 'Promotion' component received a comparatively lower rating from participants, indicating that conventional promotional strategies, such as television commercials and pamphlets, may lack efficacy in swaying hospital selection within the Palestinian setting. This conclusion slightly contrasts with the literature, which often emphasizes the importance of promotional efforts in healthcare marketing (4, 6, 57-59). The diminished focus on advertising may signify the trust-centric approach to hospital selection in Palestine, where personal recommendations and experiences may have more significance than ads. This indicates that hospitals may get more advantages by establishing a robust reputation via service quality instead of depending mostly on advertising efforts. Hospitals may use this result by prioritizing community participation and patient satisfaction to enhance their reputation organically. A recommendation based on this finding is for hospitals to invest in patient experience initiatives and leverage online platforms, such as websites or social media, to enhance visibility and engagement rather than traditional advertising methods. 4.3 Discussion of the associations 4.3.1 Association between gender and product The study found that female participants rated the product component significantly higher than males. This indicated that women may place greater emphasis on the availability of specialized healthcare services and the quality of services offered. This finding aligns with literature that suggested that women were generally more attentive to healthcare details, including the range of services and service quality (60-63). However, this gender-based difference could be more pronounced in the Palestinian context, where traditional roles may involve women making healthcare decisions for their families, thus increasing their engagement with healthcare services (64, 65). This can be interpreted as a need for hospitals to focus their marketing efforts toward female patients by emphasizing the quality and variety of services offered. Building on this finding, hospitals should tailor healthcare packages and promotional efforts to highlight features that appeal to women, especially in service diversity and specialization. A 42 recommendation would be for healthcare providers to create women-targeted health awareness campaigns that emphasize quality and accessibility. 4.3.2 Association between income and product, people, process, & physical environment Higher household income was positively associated with higher ratings for product, people, process, and physical environment components. This suggested that participants with greater financial resources were likely to have higher expectations for service quality, staff professionalism, service efficiency, and hospital infrastructure. This finding was consistent with the broader literature, where income often correlates with higher expectations and access to better healthcare (66-68). In Palestine, where income disparities can limit access to high-quality healthcare, this association highlights the potential inequality in healthcare experiences. The interpretation here is that higher-income patients may be more critical of hospitals and may have the financial means to choose better-equipped and staffed facilities. Hospitals can build on this finding by offering tiered service levels that cater to different income brackets, ensuring that lower-income patients still receive quality care. A recommendation would be to improve the standard of care across all income groups while offering premium services for those who can afford them, thereby reducing inequality in healthcare experiences. 4.3.3 Association between governmental health insurance and product, people, and physical environment Participants with governmental health insurance rated the product, people, and physical environment components significantly higher than those with private health insurance. This could indicate that governmental health insurance provided access to better-quality healthcare facilities or that patients perceive the care received through governmental channels to be superior. Although this finding appears to contrast with some global studies where private health insurance is often linked to better healthcare access, however, in the Palestinian context, governmental health insurance may offer broader access to public hospitals, which could have better-established facilities in some cases. In addition, the referral system applied by the Palestinian Ministry of Health though which patients 43 are often referred to either private hospitals or abroad to receive healthcare services (37, 56, 69, 70). This can be interpreted as a reflection of the robustness of public healthcare in Palestine. Hospitals can build on this finding by continuing to collaborate with governmental insurance programs to ensure that patients feel they are receiving high-quality care. A recommendation would be for private healthcare providers to work on improving patient perceptions of their services, possibly through increased transparency and communication about the benefits of private insurance. 4.3.4 Association between chronic disease and product, people, and place Participants without chronic diseases rated product, people, and place components higher than those with chronic conditions. This suggested that those with chronic illnesses may have more frequent and perhaps more negative interactions with healthcare systems, leading to lower satisfaction with services, staff, and accessibility (20, 32, 35, 38, 41). This finding was consistent with other studies that show chronic patients often have more critical assessments of healthcare due to their prolonged exposure to services, which may highlight inefficiencies or gaps in care accessibility (20, 32, 35, 38, 41, 71). The interpretation here is that chronic patients may have unmet needs or face challenges in accessing consistent, high-quality care. Hospitals can build on this finding by implementing specialized programs for chronic patients to improve their healthcare experiences. A recommendation would be to offer chronic disease management programs that focus on continuity of care and improving patient-provider relationships to enhance satisfaction. 4.3.5 Association between age and price, place Older participants, particularly those aged 35 and above, rated the price and place components significantly higher than younger participants. This suggested that as patients age, they become more cost-conscious and place greater importance on accessibility, possibly due to increased healthcare needs and the higher likelihood of transportation difficulties. This finding aligns with existing literature, where older individuals are often more concerned about the financial and logistical aspects of healthcare (38, 72, 73). 44 In the Palestinian context, where older patients may have fixed or limited incomes, price and location become critical factors in hospital selection (38). This can be interpreted as a need for hospitals to consider the unique financial and mobility challenges faced by older patients. Hospitals may capitalize on this discovery by implementing senior- friendly pricing structures and guaranteeing that amenities are readily accessible to elderly patients. It is advisable to establish outreach programs that expressly cater to the requirements of senior patients, including transportation services and reduced fees for those on fixed incomes. 4.3.6 Association between education level and 7Ps The research revealed no significant correlation between education level and the 7Ps components, indicating that education did not influence participants' evaluations of hospital services. This finding was somewhat unexpected, considering higher education is often linked to enhanced knowledge of hospital quality and service expectations in international research (74). However, in the Palestinian context, it is possible that other factors, such as income and access to healthcare, play a more dominant role than education in shaping patient perceptions. The lack of association with education can be interpreted as an indication that healthcare preferences are more universally shared across educational levels in this setting. Hospitals can build on this by ensuring that all patients, regardless of educational background, have access to clear and easy-to-understand information about healthcare services. A recommendation would be to implement patient education programs that cater to all literacy levels to ensure equitable access to healthcare knowledge and services. 4.3.7 Association between employment status and 7Ps Employment status did not significantly affect the ratings of any of the 7Ps components. This indicated that whether a participant was employed or not did not significantly alter their perceptions of product, people, process, physical environment, price, promotion, or place. This finding diverged from some global studies where employment, and particularly the type of employment (e.g., public vs. private sector), can impact healthcare choices and satisfaction (75, 76). 45 In the Palestinian context, the universal nature of healthcare needs may overshadow employment-related factors, leading to similar experiences across both employed and unemployed individuals. This can be interpreted as a signal that hospitals in Palestine need not differentiate their services based on employment status, but rather focus on providing consistent quality care to all. A recommendation would be to maintain inclusive healthcare policies that ensure equitable access to services for both employed and unemployed individuals, possibly through subsidized care or flexible payment options for those without steady income. 4.4 Strengths of the study The study examining the influence of the marketing mix (7Ps) on hospital selection by Palestinian patients has numerous notable qualities that enhance its importance and validity. - This study was the first investigation of its sort in Palestine, filling a significant vacuum in the literature about the influence of the marketing mix on healthcare decision-making within a developing country environment. This distinctiveness offers an innovative viewpoint that might act as a benchmark for further research in Palestine and other contexts. - The use of a large, representative sample of 385 people enhanced the generalizability of the results. The research captured the viewpoints of a varied cohort of Palestinian patients, reflecting a wide array of healthcare experiences and preferences, hence strengthening the validity of the results. The sample's demographic variety, including variations in income, age, and health insurance status, allowed a significant investigation of the determinants influencing hospital selection. - The thorough investigation of the 7Ps framework—comprising product, price, site, promotion, people, process, and physical environment—provided a complete evaluation of the determinants affecting hospital selection. The study dissected each component, offering useful insights into the components that hospitals should target to enhance patient happiness and increase patient attraction. This is especially advantageous for hospital managers aiming to synchronize their services with patient requirements and anticipations. 46 - The use of several statistical techniques, such as Pearson’s correlations and multiple linear regression, strengthened the analytical rigor of the research. These methodologies facilitated the detection of substantial correlations between patient data and the 7Ps components, enhancing the comprehension of the factors influencing hospital selection. - The research ultimately has significant ramifications for healthcare practitioners and policymakers. The results provide practical insights that might assist hospitals in formulating focused marketing strategies, enhancing service delivery, and catering to the distinct demands of various patient demographics. The study provides explicit suggestions derived from the findings, so connecting academic research with practical applications, which is advantageous for stakeholders in the healthcare industry. The strengths underscore the study's contribution to the academic discipline of healthcare marketing and the practical domain of hospital administration, especially in Palestine. 4.5 Limitations of the study The study regarding the impact of the marketing mix (7Ps) on hospital selection by Palestinian patients had some limitations that must be acknowledged. - A cross-sectional study design was used. This design limited the ability to establish causation. Although the study established relationships between the characteristics of the patients and the 7Ps components; however, one cannot definitively conclude whether these factors affected the patients' hospital choices. Longitudinal studies could help in tracking shifts in the preferences of over the time and assessing the impact of marketing strategies on hospital selection. - Reliance on self-reported data could have introduced potential inaccuracies, including recall bias and social desirability bias. Participants may have provided responses they saw as expected or socially acceptable instead of their true preferences, particularly when discussing sensitive topics such as money or satisfaction with healthcare services. Furthermore, memory bias may affect patients' recollections of their hospital experiences. 47 - The study only looked at Palestine, so the results might not be applicable to other countries, especially those with different economic situations, healthcare systems, or cultural practices. Palestine's healthcare system is one of a kind. It includes state-run health insurance and easy access to medical care. It may not fully reflect the problems or chances seen in other places. Because of this, it is important to be careful when applying the results to other situations. - The small scale of some demographic categories in the study could have restricted the capacity to detect notable variations or relationships in particular analyses. Smaller subgroups categorized by educational level, occupational situation, or private health insurance may show less statistical power, therefore impeding the ability to get accurate understanding of their particular experience with hospital choice. - Though the study ignored objective assessments of hospital quality or performance, it provided insights into the patient viewpoints and preferences top priority. Although knowledge of hospital choice depends on patient preferences and satisfaction, these may not always coincide with objective measures of healthcare quality. Quality measures including treatment results and hospital accreditation status could be included into future research to provide a more complete picture of the elements influencing hospital choice. - Lack of qualitative data reduces knowledge about patient preferences. Although qualitative interviews or focus groups may provide more deep insights on the relevance of particular components of the marketing mix for patients and how hospitals should enhance these parts, the quantitative method helps to enable thorough study Including qualitative information could help to produce more complex recommendations and enhance results. These limitations highlight the necessity for additional research, encompassing longitudinal studies, cross-national comparisons, and the integration of qualitative and quantitative data to improve our understanding of the factors influencing hospital selection. 48 4.6 Recommendations In light of the findings from the research about the influence of the marketing mix (7Ps) on hospital selection by Palestinian patients, the following recommendations are proposed: - Augment Specialized Healthcare Services and Persistently Update Offerings: Hospitals must emphasize the expansion of their specialized care services and continuously integrate new and sophisticated therapies. Considering that the availability of sub-specialties and updated services received good ratings from participants, investing in proficient healthcare personnel and contemporary medical technology will meet patient demand and enhance hospital selection rates. - Enhance Patient-Centered Service Delivery: The research indicated that elements such as healthcare staff commitment, patient rapport, and consideration of mental health requirements substantially affected hospital choice. Hospitals have to prioritize the cultivation of robust patient-provider relationships, guaranteeing that personnel are well educated in communication and empathy. This may be facilitated by consistent staff training initiatives, enhanced patient feedback mechanisms, and the assurance of enough personnel numbers to provide individualized care. - Establish Competitive Pricing and Financial Assistance Programs: Given the significance of financial factors, including competitive tariffs and fee waivers for economically disadvantaged patients, hospitals should implement transparent pricing strategies and provide financial support initiatives. Partnering with insurance companies and providing tiered treatment packages may potentially draw a wider patient demographic, especially those with lower incomes or government health insurance. - Enhance Hospital Infrastructure and Physical Environment: The physical environment, including equipment quality, facility aesthetics, and sufficient parking, is vital for patients. Hospitals must devote money for the enhancement of their physical infrastructure to guarantee modern, secure, and pleasant facilities. Enhancing hospital architecture, providing efficient air conditioning, and maintaining superior diagnostic and therapeutic equipment would augment patient happiness and confidence. 49 - Utilize Technology for Service Efficiency and Marketing: Given the substantial interest in telemedicine and health information systems, hospitals have to invest in digital health platforms to facilitate remote consultations and optimize administrative procedures. Furthermore, enhancing the use of websites, social media, and digital marketing for promotion will more effectively educate consumers about hospital services and capabilities, mitigating the diminished focus on conventional promotional methods such as brochures and banners. These guidelines may assist hospitals in Palestine and analogous locations in aligning their services with patient preferences, therefore enhancing both hospital performance and patient happiness. 4.7 Conclusion In conclusion, the marketing mix (7Ps) strongly influences Palestinian hospital selection, providing healthcare providers with useful information. Patients choose hospitals based on specialist healthcare services, quality of treatment, financial accessibility, and physical surroundings. Patient preferences were shaped by improved services, expert personnel, and reasonable pricing. In addition, income, health insurance status, and the absence of chronic conditions were substantially related with better marketing mix ratings, notably in product, people, and process. These results show that hospitals must strengthen specialized services, provider-patient connections, price transparency, and infrastructure to be patient-centered. 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