CONCEPTUAL FRAMEWORK

AND
THEORETICAL PERSPECTIVE

40
 CHAPTER-III

CONCEPTUAL FRAMEWORK AND THEORETICAL

PERSPECTIVE
3.1. INTRODUCTION

The first part of this chapter provides a thorough sketch about the disease cancer,
its symptoms, the causes, the health problems associated with it, the warning signs, and
throws light on the prevention and also on the treatment aspects. In the second part of
this chapter, a brief profile of Kerala and Ernakulam district where this study was
primarily conducted is provided. Third part of this chapter, then discusses the hospitals
that were selected for the purpose of this study, and the considerations associated with it.
Finally, the conceptual model of service quality perception and satisfaction as supported
with theoretical perspective are presented.

3.2. BRIEF OUTLINE OF THE DISEASE CANCER

Cancer is a result of uncontrolled cell division, in any part of the body, and these
cells continue to divide and a mass of cells are produced as a result of it..There are
literally hundreds of cancers known today, and irrespective of the type of cancer, all of
them occur due to the uncontrolled growth of some abnormal cells. It is part of the
natural life cycle of a cell to grow, divide and die, as per its life span, under normal
circumstances. All multicellular organisms, start from a single cell and the cells, continue
to grow and divide and continues to grow and divide, thereby enabling the growth from
an infant to an adult. Once the person becomes an adult, the cells divide only in order to
replace the work out tissues or in other words, to replace the dying cells or under special
circumstances, required to repair injured cells. Cancer cells on the other hand, are
abnormal cells, which continue to divide and outlive normal cells, and have lost the
control regulation like normal cells. It has been shown that, mutations or damage to the
DNA in the cells causes cancer cells. DNA is present in every cell of the individual, and
this is the central most genetic material, and the information in the DNA of the cell, is
responsible for all the activities of the cell. Most often, when there is damage to the
DNA, the body is able to repair it and restore the balance. Sometimes, the damage goes

40
unnoticed or unattended to or, the body is not in a position to repair it. Then, this
damaged DNA containing cell, turns out to be the abnormal cancer cell. Since, DNA is
the genetic material, this damage DNA passes from one generation to the other, which
causes cancer to be an inheritable disease. The damage to the DNA is caused by a virus, a
mutagen or a carcinogen or a chemical, from the environment. Most prevalent and
generally known cause is the damage caused by smoking.

Cancer cells divide continuously and form a mass of cells, which are usually
termed as a tumor. Tumor is a solid mass of cells and can occur in any organ. There is
also a form of cancer, termed as leukemia, where the damaged cell is a blood cell. In this
case, there is no formation of tumor, but the abnormal cells are present in the circulating
blood. As the cancer tissue begins to grow in size, some of the cells loosen up and travel
to other parts of the body, and establish a new mass of cells there. This process of
movement of cancer cells from the place of origin to other tissues is termed as metastasis.
Irrespective of where the cancer cells are found spread, the cancer is always named after
the tissue of origin. For example, there breast cancer cells might have spread, and be
present in the liver. But the cancer is still termed as breast cancer and not liver cancer.
Another caveat is, not all tumors or the mass of cells are cancers. There are sometimes, a
mass of tissues that form in some part of the tissue, but they don’t grow beyond a stage
and these tumors are called Benign tumors. These don’t spread from one tissue to other,
and hence, they are not life threatening. Every cancer is unique in its own way, and
different cancer cells have different behavioural features. For instance, lung cancer and
breast cancer are very dissimilar and are two different unique diseases. There are lots of
differences between them, in terms of rate of growth of the cells, the way they respond to
the treatments and so on. Hence, the treatment for cancer has to be customized for the
individual, for a particular kind and case of cancer.

Cancer is one of the leading causes of death all around the globe, and it is second
most leading cause of death in the United States of America. It has been documented that
more than fifty percent of all men and about thirty percent of all women, in this country,
will develop one type or the other of cancer during their lifetimes. It is a sad scenario

41
today that millions of people around the globe, live with cancer. This is a very easily
preventable disease though, and the risk towards the development of cancer in an
individual can be reduced several fold by changes in life style, by engaging in a better
diet, and quitting smoking. Early detection of cancer enables that this disease is
controlled quickly and it enhances the chance of living longer for the individual.

¾ Symptoms of Cancer

There are about eighteen or so symptoms for cancer. One of the sure shot way to
cure and treat cancer effectively is it early detection. It is crucial that cancer is detected
early, ideally before its spreads, thereby enhancing the survival of the patient. Most
common symptoms are:

• A lump or tissue, under the skin anywhere in the body, especially in the breast or
testicles.
• Persistent cough, and at times, saliva that is blood-tinged when coughing or
spitting.
• Very thin stool or blood in the stool, with changes in the bowel habits of the
individual, and in a few cases diarrhea.
• A change in a wart or mole present in any part of the body.
• A skin sore or a persistent sore throat that does not heal.
• Low blood cell count or an unexplained anaemia
• A lump in the breast or unusual discharge from the breast
• Constant indigestion or trouble in swallowing.
• A change in urination, or unusual bleeding or vaginal discharge
• Chronic fatigue, along with excessive body temperature.

3.2.1. CAUSES OF CANCER

3.2.1.1. Tobacco
Tobacco is one of the most commonly known substances to cause cancer. This
can be substantially prevented by the individual, by abstaining from nicotine containing
food and consumables.

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3.2.1.2. Alcohol
It has been documented that, individuals, who consume more amounts of alcohol, put
themselves at a moderate to higher levels of risk of cancer.

3.2.1.3. Industrial Chemicals

Many chemical substances have been shown to be carcinogenic. The list includes
industrial agents such as asbestos coals, tar chromate and pesticides. As mentioned
previously, many of the cancers caused by such agents are inheritable. Evidences clearly
suggest that there is a higher personal risk in individuals, who are predisposed genetically
to cancer.

3.2.1.4. Other causes

The individual’s food habit has been proven to be one of the source of cancer.
Along with them, radiations like Ultraviolet radiation, gamma rays and exposure to
radioactive substances are also known causes for cancer. There are also certain viruses
which can cause cancer, and these are termed oncogenic viruses.

3.2.2. PROBLEMS OF CANCER PATIENTS

• Morbidity or Fear of death
• Changes as social role and life style
• Interception of life plans
• Changes in body image and self esteem
• Money and legal concern

3.2.3. CANCER’S SEVEN WARNING SIGNALS

CAUTION is the abbreviation term that is used to indicate the seven major warning
signals of cancer. (Source: https://www.webmd.boots.com/cancer/cancer-symptoms)
• Change in bowel or bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump in breast or elsewhere
• Indigestion or difficulty in swallowing.
• Obvious change in crust or mole
• Nagging cough or hoarseness.

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3.2.4. TREATMENT
Three most common modes of treatment for cancer involves: a) Surgery, b)
Radio-therapy and c) chemotherapy. These treatments may be given separately or as a
combination to treat the cancer in a patient. The regime to be administered would be
decided upon the various tests prescribed by the clinician, the age of the person, general
health status, the type and size of tumor, the morphology of the tumor as observed under
the microscope, and whether the tumor is present only at the primary region or it has
spread or metastasized.

3.2.4.1. Surgery
Most preferred method of treatment when it is found that the tumor is a localized
lump, and the cancer has not spread or has only limited spread. This mode is chosen,
depending on the size of the tumor and its location. Surgery can’t be used, if the cancer
has metastasized or spread from its primary origin. Normally, it takes a few weeks for the
patient to recover from the surgery. This is subjective, and different individuals respond
differently, and recover sooner too.

3.2.4.2. Radiotherapy
This method involves the usage of high-energy radiation to destroy the cancer
cells, while minimizing the harm to the normal/healthy cells. This therapy can be used
alone or post-surgery, to treat the cancer. Normally, this is the preferred mode of
treatment for the non-tumorigenic cancer like leukemia. Here again, the dosage, the
length of the treatment, the duration of it, is dependent on the type and size of the cancer.
Most crucial part of the radiation therapy is the Treatment planning, and this can be an
elaborate process, and may require the patient to visit the radiotherapist several times,
and this also depends on the radiation source that is used for the treatment. This mode of
treatment is not painful to the patient, and it takes a few minutes for administration, once
the initial planning is performed based on the reports.

3.2.4.3. Chemotherapy
As indicated by the name, this method deals with the usage of chemicals or anti-
cancer drugs for the treatment or the destruction of the cancer cells in the individual.

44
These chemicals disrupt the abnormal cancer cells growth and destroy them. This is the
most preferred method of treatment if metastasis of the cancer is observed. The drugs are
administered as tablets or given intravenously. Duration of the treatment lasts for a few
days to few months. After the first round of administration, the patient is allowed to rest
for a few weeks, allowing the body to recover from the side effects of the drugs. The
number of such cycles administered depends upon the type of cancer and the way the
patient responds to the treatment.

3.2.4.4. Cancer Global Scenario

According to the World Health Organization WHO, cancer is the second most
leading cause of death globally, and it has become one of the most important health
issues of the world. It has been estimated that about one in six death globally are due to
cancer. Cancer is a serious threat in most of the developed countries, and is tending to
grow in the developing countries too. International Agency for Research in Cancer IARC,
the specialized cancer agency of the WHO, is involved in the constant monitoring of the
global scenario, has published the reports related to 28 different cancers across the globe
in about 184 countries, as a comprehensive review of cancer in the Globocan 2012 report.
( Source: www.science.nmims.edu/docs/01-editorial). According to the report, about
14.1 million new cases (with the 2008 estimates being 12.7 million new cases), 8.2
million cancer deaths, and five-year prevalence of 32.6 million cancers in individuals
above the age of 15 years. The estimates of the Globocan 2012 point out that there will be
an increase to approximately 20 million new cases of cancer by the year 2025. It has also
been documented that there is a significant contributions to the new cancer cases from the
developing countries, with India being one of them.

Indian scenario reads as follows in the report. About 1.1 million new cancer cases
were estimated in the year 2012, and this suggests that out of the 184 countries surveyed,
approximately, 8% of the global burden is caused or shared by India, with the morality
rates in the country being 8.3%, on the global scale.

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3.2.5. PREVENTION
3.2.5.1. Primary prevention
The best action towards cancer is prevention. The earlier the disease is diagnosed,
the better it can be managed, and dealt with. Prevention is the best policy, and it can be
achieved by abstaining from the use of certain drugs and potential carcinogens.

• Topmost in the list is: Control of tobacco intake and alcohol consumption
• Personal hygiene – includes diet patterns of the individual
• Radiation – Exposure to high doses, places a person at risk. It is important to
reduce or avoid occupational exposure
• Preventation of intake of certain chemicals, through food, or through breathing
the pollutants and carnicogens.
• Control of air pollution is a very good way
• Awareness about the disease causing agents amongst the general populace and
people should be motivated to approach the health care centres for early
diagnosis and early treatment.

3.2.5.2. Secondary Prevention

It includes the following

¾ Cancer Registration
This step is part of the initiative from the government, and this enables the
collection of data, in order to ascertain the magnitude of the problem in the country and
for the planning necessary action plan and implementation.

¾ Early Detection Cases

Only plausible solution is the Cancer screening, for those who are genetically
predisposed or those who exhibit risky behaviour. This enables the early detection of
cancer, when the cancer is at its pre-malignant stage or before the cells invade the other
tissues further away from the primary source of origin.

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3.2.5.3. Treatment

One of the most promising news in cancer treatment is, if it is detected early and
if proper treatment is administered, it is possible to save over two-thirds of all patients.
They can be cured of the cancer and they can get back to their normal lives. As
previously mentioned, the three most common methods of treatment are a) Surgery b)
Radiation Therapy, and c) Chemotherapy.

3.3. BRIEF PROFILE OF THE STATE AND STUDY AREA

3.3.1. PROFILE OF KERALA

Kerala is a south Indian state, located at the south-western tip of India, on
the Malabar Coast. The state was formed on the first of November in the year 1956,
following the States Reorganisation Act by combining Malayalam-speaking regions. The
state occupies about 38,863 km2 (15,005 sq mi). On to the north and north east boundary
of this state is the state of Karnataka, and the state of Tamil Nadu forms its boundary on
the east side and in the south. To the west of this state, is the Arabian sea, and the islands
of the Lakshadweep Sea are present in the proximity to this state. The state has 14
districts and the capital city of the state is Thiruvananthapuram, which incidentally is the
largest city in the state. The official language of the state is Malayalam, and it is also the
most widely spoken language in this state.

Kerala has the lowest positive population growth rate in India, 3.44%; the
highest Human Development Index (HDI), 0.712 in 2015; This state is known for its
highest literacy rate in the country, and is placed at 93.91% as of 2011 census; The data
on expectancy, is placed at 77 years, which is also the highest value documented in the
country; along with the highest sex ratio, 1,084 women per 1,000 men. During the Gulf
boom of the 1970s and during the early 1980s, many keralites emigrated to Arab
countries and the economy of the country is driven significantly by the remittances from
a large Malayali expatriate community. The religion that is practiced by more than 50%
of the population is the Hinduism, and this is followed by Islam and Christianity, in the
mentioned order. The culture of this state has a good deal of influence from the Aryan,
Dravidian, Arab, and European cultures, which has developed over many centuries.

47
 Kerala is also known for having the lowest proportion of homeless people in rural
India – 0.04%, which is the lowest in the country, and the state is very soon set to achieve
the target of becoming the first "Zero Homeless State", in addition to its acclaimed "Zero
landless project", with private organisations and the expatriate Malayali community
funding projects for building homes for the homeless. The state was also among the
lowest in the India State Hunger Index next only to Punjab. The state also became the
first "complete digital state" in the year 2015, due to its implementation of several e-
governance initiatives.

Kerala, has many more such honours. The state has been found to be a lot more
healthier in comparison to many states of the developed nation like United States of
America. This status for the state has been achieved due to its pioneering efforts towards
the implementation of the the universal health care programme. There are more laurels to
the state. In a recent study conducted by Lien Foundation, a Singapore-based
philanthropic organisation, Kerala has been ranked as one the best place to die in India
based on the excellent facilities provided in the palliative care for patients, with serious
illness, in this state..

In 2014, Kerala government started the program called “Sukrutham”, which offers
free cancer treatment to the poor, and thereby it stands as the first state in India to do so.
It has been documented that there is an elevated level of cancer incidences in kerala,
especially those related to liver and kidneys. The Economic Times has documented that
about two and half lakhs of patients are treated for cancer in this state, as on April 2015.
There is a greater number of liver transplants that are being conducted in this state and
the numbers range from about 150 to 200 liver transplants annually. The incidence of
new cancer cases in this region is about 42,000 cancer cases.

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3.3.2. PROFILE OF ERNAKULAM DISTRICT

One of the most developed districts in the state of kerala is the Ernakulam district,
which spans about 3068 square kilometres, which translates to about 7.9% of the total
area of the Kerala state. The district lies between 9o47' and 10o18' north latitudes and
76o9' and 77o 6' east longitudes. It is bounded on the west by Lakshadweep Sea, south
by Kottayam and Alappuzha districts, east by Idukki district and on the North by Thrissur
district. Physiographically, the district is divided into three broad divisions - lowland,
midland, and highland. The lowland includes the coastal plains, coastal depressional
lands with swales and marshes and the fluvial transitional plains. The midland constitutes
the undulating to rolling terrain. The upland comprises of the rolling to hilly terrain with
elongated ridge, scarp slopes and isolated rocky cliffs. Kochi and Paravur taluks and
western part of Kanayannoor taluk constitute the low land while Aluva, Muvattupuzha,
Kothamangalam and eastern portion of the Kanayannur taluk come under the midland
region. The major part of the Kunnathunadu taluk also is in the midland region. Eastern
part of Kunnathunadu and Kothamangalam taluks come under the highland region. The
lowest elevation of nearly Mean Sea Level (MSL) is noticed in the western coastal area
and the highest elevation of 534 metres above MSL is at Sulu Medu.

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3.3.3. ERNAKULAM DISTRICT AT A GLANCE

Ernakulam at a Glance
District Name Ernakulam
Headquarters Kakkanad
Goegraphical Area 3068 Sq.kms
Coastal line 46 Kms
Water bodied area 12,700 Hectares
Forest Land 8,123 Hectares
Location Latitude : 9o57’ N; Longitude 76 o15’ E
Boundaries North – Thrissur District, East – Idukki District, West Arabian
Sea, South –Kottayam & Alappuzha Districts
Time Indian Standard Time +5:30 hours GMT
Altitude Sea Level

Population details
Male 16,17,602
Female 16,62,258
Total 32,79,860
SC 2,68,411
ST 16,559
Sex ratio 1028
Density of population 1069
Per capita income Rs.23020

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 Literacy Rate
Male 97.14%
Female 94.27%
Total 95.68%

Administrative setup
Taluks 7

Villages 124
Blocks 14
Panchayats 84
Corporation 1 (Kochi)
Municipalities 11
Assembly Segments 14

Parliament Constituencies Ernakulam, Part of Chalakkudy, Idukki and

Kottayam

Emakulam district was one of the areas where the Community Development
Programme was originally introduced on experimental basis. The Community
Development Programme started in 1951, aimed to integrate developemntal activities
through community action in rural areas. The entire 1 rural area of the district was
divided into 15 commmunity development blocks. During the first and second five year
plans activities under agriculture in rural areas were mainly carried out through the
blocks. The district showed comparatively good result in the implementation of various
programmes. In 1963, the Intensive Rice Cultivation Programme was introduced in a few
blocks of Emakulam district.(17) This was followed by the introduction of Intensive
Agricultural Area Programme, which aimed at provision of credit facilities, technical
know how and package of practices to cultivators for increasing production of all major
crops.

51
 With the spread of educational opportunities an.d redistribution of land, an
influential strata of people emerged from the lower sections of the population, and
became active in economic and political life. This helped them to initiate reforms in their
communities. Despite their belated positions, the lower castes encouraged by these
reforms tumed to education to better their social ranking. Also the activities of Christian
missionary societies in educational and health services helped the lower sections. Over
the years, considerable progress has been achieved in providing educational facilities to
Scheduled Castes and Scheduled Tribes in the district.

Agriculture is the mam occupation of the rural folk of the district and agricultural
labourers form an important segment of the working population. The workers are mainly
engaged in agricultural operations connected with paddy, coconut, tapioca etc., which are
the main agricultural crops grown in the district. Most of the agricultural workers live in
small huts built in the plots belonging to big cultivators.

The district has prospered in the distribution of basic amenities such as roads,
electricity and fmancial institutions. The availability of superior advantages with regard
to raw materials, fuel and skilled labour, plentiful supply of water for industrial purposes,
easy access to electric power stations etc., make the Alwaye-Emakulam area as a major
industrial belt. The advantage is even greater due to location of the Cochin Harbour in the
district.

The district of En1akulam could be regarded as an excellent n1iniature example

of what is now popularly called as the 'l(erala n1odel of development'. This type of
laboratory of development emerged through intense political participation and
consciousness of the people. In particular, a large number of associations, missionary
societies, grass root voluntary organisations helped to remove the old form of favouritism
and patronage. Thus Ernakulam, a district with a tradition of religious orthodoxy of
primordial loyalties, has undergone social and political transformation: the result is the
political development of its population. The traditional rules of power relation have
vanished and majority of people from lower strata get opportunity to improve their social
and economic status.

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3.3.4. HEALTH CARE FACILITIES IN ERNAKULAM DISTRICT

Healthcare facilities are the most important parameter from the administrative
point of view in any city, district or state. It is one of the primary requirements of people
and that is why special care is taken to make it absolutely the best in every way..
Ernakulam is a district spread over an area of 2068 sqkm with a total population of
3279860. The city administration understands its responsibility to this huge population
and that is why Ernakulam is equipped with excellent medical services with the joint
efforts of government and private hospitals. The efforts are also nurtured by most
efficient and expertise from the country as well as abroad making the medical facilities
stronger and useful. The amenities used in these hospitals are all modern and latest
technology based and the treatment procedures are at par with the leading countries. In
Ernakulam, medical treatment are conducted through allopathic treatment, homeopathic
and ayurvedic treatment. In all types of treatment there are government supports for the
people who are in absolute need of it.

3.3.5. HOSPITALS IN ERNAKULAM

In Ernakulam district, there are several government hospitals, primary health care
centers and community health centers which altogether takes care of the health care
requirements of the district. General Hospital Ernakulam is a state-owned hospital which
started its operation in the year 1845. It may be noted that the services of the hospital is
highly subsided and it remains funded by the State Government. Even the person who
falls under Below Poverty Line gets medical facilities absolutely free. Almost all kinds of
medical treatment are done here under the supervision of highly qualified doctors in
every genre. There are separate departments or wards like cardiology, eye, children,
oncology, orthopedic, gastroenterologist, ENT and maternity wards where crucial cases
are taken into consideration and specialized doctors in these fields provides medical
treatment. There are pathology labs at the government hospital where all kinds of tests
are done free or at much subsidized rates. Several health schemes introduced by the
Government Public Health system are also maintained here and the benefits given.

53
 Apart from usual medical care and treatment, the public health department in
collaboration with the private hospital administration, organize health camps as well as
public health awareness camps to impart knowledge on several critical diseases, on
healthy living and hygienic environment. They often arrange for free health camps to
help people faster with their health issues. Several vaccinations are also done in these
camps to prevent any spreading diseases.

Just like the government hospitals there are plenty of private reputed hospitals and
Nursing Homes which also take part in curing the people of the district. These private
organizations are costlier as compared to the government ones but they have huge
facilities which are not always available in Government Hospitals. They have extreme
modern treatment facilities along with assistance of high-end doctors which make
treatment in these hospitals extremely good.

Apart from general private hospitals which are equipped to treat all kinds of
health issues, there are specified hospitals and nursing homes which caters to integral
health issues of a particular type or organ and have doctors specialized and super
specialized in that subject only. For example for eye treatment there is KPM Eye
Hospital, Vasan Eye Care Hospital etc, for ENT GV ENT center, Vijaylakshmi ENT
center, for orthopedic problems there is Devi Hospital Pvt Ltd, for mental problems there
Bethseda Mental Hospital, Kusumagiri Mental Health Center etc, for children there is
Evershine Hospital and for Maternity one can refer to Salys Surgical Maternity Hospital.

3.3.6. ABOUT LAKESHORE HOSPITAL

VPS Lakeshore has been recognized globally as one of the largest, most
comprehensive, independent multi-specialty hospitals in the state of Kerala. It is also
considered to be a leader in the area of medical education, and groundbreaking research.
This place is known for its innovative patient-centered clinical care, all over the globe to
the extent that, this hospital has become the hospital of choice to patients worldwide, in
almost every field of medicine, including emergency treatments, primary and multi-
specialty care. .

54
 The advanced hi-tech healthcare facility ushers in world class standards in
healthcare and offers diverse medical specialties, including Multi Organ Transplantation,
Gastroenterology, G.I Surgery, Medical, Surgical Oncology, Joint Replacement, Accident
& Trauma Orthopedics, Sports Medicine, Neurology, Neurosurgery Surgery, Cardiology,
Cardiovascular Surgery, Gynecology & more...

VPS Lakeshore was incorporated as a public limited company in 1996 and in

January 2003 the hospital officially opened its doors to integrated healthcare. Over the
years, the hospital has emerged as a centre of international healthcare excellence for
patients in India & abroad through a broad range of advanced clinical programs and the
most cutting-edge treatments and diagnostic services.

3.3.6.1. Exemplary Professional Expertise

VPS Lakeshore aspires to be the destination of choice for people seeking superior
healthcare through leading-edge treatments and research. This has been made possible by
the talented medical professionals on board with expertise in many fields providing,
courteous compassionate care with a personal approach.

3.3.6.2. Cutting Edge Technologies

The strength of the hospital is the synthesis of several innovative diagnostic and
therapeutic medical technologies that are current in the world of science. The hospital is
constantly keeping pace with the amazing new inventions that are happening in the field
of medical science, and all of this has taken VPS Lakeshore Hospital into one of the top
academic medical centers in the country, and these have also secured it a position in the
global scenario.

3.3.6.3. Courtesy & Efficiency personified

A patient centered culture exists at VPS Lakeshore and they are the focus of
everything we do! Every patient receives warm and personal attention and service with a
smile has been our motto always.

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3.3.6.4. Research
At VPS Lakeshore, research is given prime importance, and the hospital
management provides support towards pioneering research and treatments for many life-
threatening diseases. The backbone of the research is the core facilities present in the
hospital, along with the various services offered here, which also includes the formal
academic programs and public education programs. The hospital also pays special
research attention to those diseases that are endemic/found only in the state of Kerala,
thereby contributing to the betterment of health in Kerala.

3.3.7. WELCARE HOSPITAL PROFILE

Welcare hospital has been functioning since the year 200, and it has established
itself as one of the most well-equipped and premier hospitals in the city of Ernakulam.
The hospital has been known for the commitment and passion of their healthcare
professionals, and for the provision of patient centred treatment and care. The hospital is
also known for its adherence to high quality standards in both healthcare and medicine.
Welcare Hospital is a 100 beded multispeciality hospital located in SA Road very near to
Vyttila Junction. Total build up area is 60000 sq. feet with necessary convenience and
equipments to give efficient medical treatment. There are four operation theatres and
labour room.

3.3.7.1. Medical Services

The hospital provides various medical services to its patients, and their services
include general analysis, medical treatment and so on. The following is a brief list of the
facilities provided.
¾ General Analysis
¾ Medical Treatment
¾ Emergency Help
¾ Advanced Technology
¾ Laboratory Test
¾ Symptom Check

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3.4. CONCEPTUAL MODEL

3.4.1. INTRODUCTION

A conceptual model is proposed to measure the Service quality with respect to

Patients Perception and Satisfaction on Services provided by Lakeshore and Welcare
Hospitals in Ernakulam District. The mediated effect is measured with respect to
Affordability of cost aspects and the dependent factor is Overall Satisfaction of the
patients about the services provided by the select hospitals which are examined using
Structural Equation Modeling (SEM) with the help of AMOS 16 to provide statistical
significance of the proposed model.

FIGURE 3.1: MODEL MEASURING DIRECT EFFECT OF SERVICE QUALITY

AND PATIENTS SATISFACTION MEDIATED BY AFFORDABILITY

Affordability

Empathy

Tangibility

Assurance SERVQUAL SATISFACTION

Timeliness

Responsive

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3.5. THEORETICAL PERSPECTIVE

Over the past couple of decades or so, there has been a huge growth in the area of
health care on a global scale and this industry has become highly competitive. In the
health care industry, patient observations are a focal point of service quality. Contentment
of the Patient should be the prime focus, and the central most point for all decision
making in the health care services, and it is imperative that the quality of services
provided meets or exceeds the expectations of the customers. SERVQUAL, is an
amazing tool, that has been created by Parasuraman et al, and this tool has been widely
used scale for measuring service quality in the service sector, and has come to be
accepted as almost the gold standard for the assessment of service quality. Aghamolaei et
al have suggested in strong terms, that this particular model is definitely suited for the
measurement of service quality in hospitals; They did provide a rider stating that the
suitability of this model should be evaluated under different scenarios, since it is but
natural for the people or patients in different parts of the world, having different
expectations due to their social, cultural, and economic conditions in which they live.

The health care facility has been classified into two equally important quality
dimensions namely:1) Technical quality and 2) Functional quality. As the term indicates,
Technical quality deals with the techniques used in the health care industry, and it deals
with the technical correctness and medical analyses and techniques used. The second
dimension, namely functional quality deals with the manner in which the services are
rendered to the patients. In other words, we can state that the technical quality deals with
what the customers get, while the functional quality deals with how they get it. Ware and
Snyder clearly point out in their article that, although it is understandable that patients
give a great deal of significance to the technical quality, this trait is not present in all the
patients. He also adds that this is due to the reason that most patients lack the required
information and the understanding to assess efficiently the quality of the investigative and
relaxing involvement procedure or material needed..

It is but natural for the customers to assess the service quality on the basis of both
on the outcome of the service and also the delivery process involved. Amongst the
various service industries, health care services do occupy a distinct position since it is

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directly involved with the health of the individual, and also the risky nature of the
services that are offered under this umbrella. Added on to this is the additional feature
that the consumers do not possess sufficient knowledge about this most critical aspect of
their life. All of these parameters, make the conceptualization and also the measurement
of customer services and their quality, very difficult. The only source of information the
management had are those feedback surveys from the patients in order to make any
modifications either to the clinical or the economic side of the equation under question.

Although there are sufficient efforts expended by the government towards the
betterment of the public health sector, with all the efforts being guided in the right
direction, it is unfortunate that this public sector is perceived poorly by the people, since
it is usually met with uneven demand on one hand, and the perceptions of poor quality of
service on the other (Andaleeb et al. 2007). In fact, this poor service quality has been the
very reason, which has caused a huge decline in the utilization of public health care
facility in India. This is also the similar case amongst the cancer patients in Kerala too,
involved in the area of study in this research project. Elsewhere it has also been
documented that the overall percentage for the utilization rate for public health care
services is as low as 30% (Ricardo et al. 2004). Since there is a huge level of
dissatisfaction with regards to the public health care sector, this is channeling a greater
demand for the private health care sector in the country. There is a clearly documented
evidence of this happening in Bangladesh between 1999 and 2003, where the utilization
of public sector health care went stooping down, with a clear cut increase in the rate of
utilization of private health care facilities (CIET Canada, 2003). It has been debated all
over the world that the private health care sector should be closely monitored, since about
as about 70% of the patients are obtaining and seeking medical care from the private
sector all around the globe (World Bank, 2003). It has been reported that about 15% per
annum has been the growth of the private hospitals between the years 1996 and 2000,
(HEU, 2003b). The growth in this sector is boosted by massive investments that are
taking place in this sector. In the year 2005, a single player, namely Apollo hospital alone
had invested about $35 million into the private sector healthcare (People’s Daily Online,
2005). Many such corporate groups have been involved in making such similar

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investments in the recent past, and all of this has contributed towards the growth in the
private sector health care centres.

3.5.1. CONCEPTS OF SERVICE QUALITY IN HEALTHCARE

Health care service providers need to constantly expend effort towards

determining and also improving the weaker aspects in their service delivery system, in
order to have an edge over their competitors. This therefore calls forth for the need of
better understanding of their customers, as to how their consumers evaluate health care
service quality. One of the simplest way to enhanced service quality is to monitor the
patient perceptions and following it up with the implementation of action plan based on
feedback obtained from the patient themselves. The SERVQUAL framework has been
very successful in guiding several studies in the service sector including banks, repair and
maintenance services, telephone companies, physicians, hospitals, hotels, academic
institutions and retail stores (Parasuraman et al. 1988; Carman 1990; Boulding et al.
1993). Parasuraman et al. (1988) was the first person to propose the SERVQUAL
framework with five dimensions of service, which was a refinement from the ten
dimensions, they previously proposed. Currently, the SERVQUAL framework deals with
the following five dimensions:

(1) Empathy – This deals with the service provider being caring, and offering
individualized attention;
(2) Tangibles – This deals with the physicality of the set-up, namely the physical
appearance of the facility, instrumentation/equipment and it also includes the
appearance of personnel;
(3) Assurance – This parameter deals with the knowledge and courtesy of service
personnel and their ability to instill trust and confidence;
(4) Reliability – This dimension deals with the ability to perform the promised
service dependably and accurately, in order words, deals with consistency;
(5) Responsiveness – This dimension is about the willingness of the personnel to
help customers and provide prompt service.

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3.5.2. Empathy: This parameter deals how sympathetic is the service provider towards
the patient. Does the. Health care providers’ sympathizes and shows understanding of the
needs and problems of the patient? This parameter has a great amount of influence on the
satisfaction of the patient. It is natural for the patients to expect that the doctors and
nurses are observant, attentive and understanding towards them, and they are willing to
provide them with personal care and mental support to them. Thus this parameter
showcases the service providers’ empathy.

3.5.3. Tangibles: This deals with the Appearance (tangibility) of the physical facilities.
This includes the physical space in which the facility is set up, the equipment or the
instruments available, the staff/personnel, their attire, and the various quotes and posters,
and the written notices, and forms that are present in the facility. All of these have been
shown to have an effect on the patients’ satisfaction. It has also been documented that a
very systematic, ordered and clean appearance of hospital premises, clean restrooms, high
quality and hi-tech modern equipment, clean wards, beds and the whole construction or
infrastructure can all influence patients’ impressions about the hospital.

3.5.4. Assurance: Every patient seeks this when they come to the hospital. One, that they
are sure of getting well, and that the personnel involved possesses the required
knowledge and skill, to deal with the situation at hand. Assurance effectively deals with
the knowledge, skill level and the courtesy of the service provider which can inspire and
instill trust and confidence in consumers’ mind. In the health care setting, assurance deals
with the competencies of diagnosis of the doctor, skills to interpret laboratory report by
the clinician, and provision of satisfactory and appropriate explanations to the questions
that customer poses to the personnel. Amongst the things that also reassures patients is
the presence of well-trained nurses and other support staffs in the facility.

3.5.5. Timeliness: Timeliness is a straight forward interpretation of this parameter. It

simply points out, whether the service provider performs or completes his promise tasks
on time, and is they able to perform it dependably and accurately, and on time. The
actions that enhance the perceptions of reliability with the patients: a) the doctors

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diagnose on-time b) the reports are delivered on time c) the required attention was
provided during emergencies and d) timely treatment following the diagnoses.

3.5.6. Responsiveness: It is but natural that the patients or any consumer would expect
that the service personnel respond to the queries, promptly and when required. In the
hospital set up, this would deal with the hospital staff exhibiting their willingness and
their promptness towards responding to the patients’ questions. Also added to this
dimension is the presence of experts, and the required infrastructure and equipment in the
facility, which can enable a speedy diagnosis.

3.5.7. Cost: This can be a very sensitive dimension in most cases and the treatment cost
is an important factor affects the patients’ expectation a great deal and thereby influences
the patients’ satisfaction. This is especially so in a country like India, where there is a
great deal of concern related to the cost, since the economic stature of most of the
consumers are not very sound, and they fall into the lower income brackets. In health care
setting costs normally encompass the doctor’s consultation fees, the laboratory test
charges, travel, the prescribed medications and the accommodation/stay in the hospital.
There is a great range of costs which vary among the private hospitals.

3.5.8. Medication and support: This parameter from the patients perspective dels with
the level of access, they have to health care, and this means, the presence of the required
personnel, either the doctors or nurses, the presence of required facilities like hospital
beds and most importantly the availability of the required information round the clock
with minimum hassle, to the patient.

3.5.9. Treatment outcome: Treatment outcome as the term clearly indicates, what are
the results or effects post the medical care. Did the patient get well? Did they get cured of
whatever it is they were suffering? It has been shown in several studies, that if the
patients don’t feel cured mentally, they don’t feel cured physically. In terms of cancer
treatment, due to the associated morbidity and mortality, this parameter has a huge say.

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3.5.10. Patient satisfaction: This is the final verdict which encompasses the above
discussed dimensions. This deals with the person’s feeling of pleasure or disappointment
resulting from service perceived and outcome of the performance of a hospital in relation
to the patient expectations. There are three scenarios that are possible. If the service falls
short of the expectation, it leaves the patient completely dissatisfied. If it meet or exceeds
the patients’ expectations, it will leave the patient happy and greatly satisfied
respectively.

3.6. SUMMARY

Third chapter discussed about the details of the disease, profile of the study area,
profile of the select hospitals followed by Conceptual Model and Theoretical Framework
to conclude the chapter. In the fourth chapter is the data analysis and interpretation
conducted to furnish the survey results.

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