Norfolk State University Scent Marketing Marketing Director Essay

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bs_bs_banner International Journal of Consumer Studies ISSN 1470-6423 The effects of scent on consumer behaviour Justina Rimkute1, Caroline Moraes2 and Carlos Ferreira2 1 2 Birmingham Business School Graduate, University of Birmingham, University House, Birmingham, UK Centre for Business in Society (CBiS), Faculty of Business, Environment & Society, Coventry University, Coventry, UK Keywords Consumer behaviour, scent, sense of smell, sensory marketing, systematic literature review. Correspondence Caroline Moraes, Centre for Business in Society (CBiS), Faculty of Business, Environment & Society, Coventry University, Priory Street, Coventry CV1 5FB, UK. E-mail: [email protected] doi: 10.1111/ijcs.12206 Abstract This article presents a systematic review of extant research on the effects of scent on consumer behaviour for readers of the International Journal of Consumer Studies. Although many articles have been published on this topic in recent years, there is a need for a comprehensive summary of up-to-date findings in this area of research. A systematic literature review is conducted with selected Chartered Association of Business Schools-ranked journals in the fields of marketing and psychology, covering the period between 1980 and 2015. Thematic areas include the impact of scent on consumers’ cognitive and affective responses, attitudes and perceptions, as well as memory and behaviours. Relevant mediators and moderators of the effects of scent on these variables include affect, cognition, awareness and individual or environmental stimuli. Gaps for future research are identified and include the role of consumer awareness of scent and its influence on behaviour. Although this article provides a systematic review of the literature within the fields of psychology and marketing, it acknowledges that a large body of research regarding human responses to odours exists within other disciplinary fields such as neuroscience. The potential for, as well as the ethical caveats of, using scent stimuli for marketing purposes are also considered. This article makes a significant contribution to the consumer behaviour literature given its systematic article selection and review process, encompassing the most up-to-date research and focusing on all key thematic areas related to scent and consumption. Introduction Marketing communications are usually designed to appeal primarily to consumers’ senses of vision and hearing. Yet, consumers’ decision-making processes are also influenced by other sensory information. Marketers understand that auditory and visual influences alone can be insufficient to persuade consumers and that increased persuasiveness can be achieved by targeting the senses of touch, taste and smell (Milotic, 2003; Lwin and Morrin, 2012). The marketing strategy of appealing to all five senses is referred to as sensory or experiential marketing (Hulten et al., 2009). This approach to marketing is especially relevant in the services industries, which offer goods with high experiential and credence properties, although the evaluation of which is often difficult before consumption takes place. For this reason, service businesses are investing in enhancing their physical environment, or atmospherics, as it is believed that the perception of the environment can be transferred to the perception of the service itself (Ellen and Bone, 1998). Scent is a very important aspect of sensory marketing and is considered to be one of the key elements of the service’s physical environment (Hulten et al., 2009). The effectiveness of ambient scent (also referred to as atmospheric odour or olfactory cue) in influencing consumer behaviour has received support from 24 academic research. However, the ambiguity regarding the effectiveness of scent calls for a review of the extant literature in this field of research. Although some reviews in the area of scent have already been published (Davies et al., 2003), they suffer shortcomings such as a focus on one particular type of response to odour such as memory (i.e. Schab, 1991), while others fail to state the criteria used for article selection in their reviews and are not up-to-date (i.e. Davies et al., 2003). Therefore, this article aims to address such shortcomings by conducting a systematic literature review on the effects of odour on consumer behaviour for readers of the International Journal of Consumer Studies, in order to map out future research directions and discuss potential managerial implications in this area of marketing. More specifically, the objectives of this article are: to explore the key thematic areas and findings of the selected literature on scent in the fields of marketing and psychology; to discuss the potential mediating and moderating variables on the effects of scent on consumer behaviour; to explore and evaluate the methodologies used in the selected studies; and finally to identify gaps in the literature and provide suggestions for future research. This article adds to the extant literature and existing literature reviews in the field in that it covers all effects of scent, clarifies the criteria used to select International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V J. Rimkute et al. The effects of scent journal articles for the systematic review and uses updated resources to build on the literature reviews done over a decade ago. The first section of the article provides some background information on the research area by exploring the concept of sensory marketing. The following sections present the methodology used for this literature review, as well as the main findings and implications. Background to sensory marketing research The application of multisensory appeals in marketing has received significant research attention, as sensory cues influence consumer decision making processes by creating mental associations that strengthen the recall of brands and products. Multisensory appeals also provide multiple options for creating and modifying quality perceptions, as one sense may cue quality perceptions more strongly than others (Hulten et al., 2009). Of all the senses, the sense of touch is the least researched area, with only limited support regarding its persuasive nature in sensory marketing (Peck and Childers, 2005). Vision has received the most attention from consumer researchers and examples of visual appeals include design of brands, products, packaging and interior (Hulten et al., 2009), colours (Bellizzi et al., 1983) and lighting (Golden and Zimmerman, 1986). A number of studies have also explored how auditory cues influence consumer behaviour. Music was found to influence mood (Bruner, 1990), to condition consumer responses to products (Gorn, 1982; Macinnis and Park, 1991), and to increase consumption and time spent in store (Milliman, 1982). In contrast, research on integration of the sense of taste in sensory marketing has not been as extensive, focusing mainly on how in-store sampling of products can influence consumer choice (Nowlis and Shiv, 2005), and on how the perception of taste is subject to bias (Hoyer and Brown, 1990). The application of olfactory cues in sensory marketing is an under-researched area in comparison to vision and hearing, but more widely researched than taste and touch. However, the increasing amount of published research in this area highlights the need to review and summarise some of the findings, which is the main objective of this article. The following section describes the methodology used. Systematic literature review methodology A literature review was used to examine existing studies on scent in the area of sensory marketing. Following Leonidou and Leonidou’s (2011) guidelines for systematic literature reviews, article selection was based on three criteria: quality (articles published in peer-reviewed journals, graded 3 and 4 stars in the Association of Business Schools Academic Journal Quality Guide 2010, in the fields of psychology and marketing); time period (1980–2015); and variables under study (effects of scent on human affect, cognition and/or behaviour). The literature search focused on papers published in the fields of marketing and psychology, as these are the main disciplines publishing research on the effects of scent on consumer behaviour. The search was conducted using electronic databases including ProQuest, EBSCO, ISI and Ovid. Keywords used to retrieve articles included ‘scent’, ‘odour (odor)’, ‘smell’, ‘olfactory cues’, ‘environmental fragrance’, ‘environmental cues’, ‘atmospherics’ and ‘environmental stimuli’. A total of 45 articles from 18 journals were selected as a result (Table 1). Out of all articles, five focused on atmospherics, with scent mentioned as one of the environmental cues but not investigated separately; six were literature reviews of previous studies on odours and 35 included primary research. Only 9% of articles were published during the 1980s and more than 56% since the year 2000, which reveals an increased interest in the field. A bibliographical analysis procedure (Leonidou and Leonidou, 2011) was adopted, where selected papers were coded according to the variables that are impacted by the sense of smell. The review findings are presented in the next section. Literature review results The systematic review showed that ambient scents are addressed in the literature as being part of the overall atmospherics within the service environment. Atmospherics is concerned with how environmental cues affect the behaviours of consumers by appealing to their senses. Several studies of atmospherics refer to scent (i.e. Bitner, 1992; Turley and Milliman, 2000; Baker et al., 2002; Walsh et al., 2011), but none of them investigate scent in much depth. Other studies that focus primarily on scent reveal that odour has an impact on consumers’ affective, behavioural and cognitive responses. Nonetheless, to fully understand the Table 1 Selected journals and articles retrieved Marketing Psychology Journal name No. of articles Grade 4 Journal of Marketing Journal of Marketing Research Journal of Consumer Research Journal of Retailing European Journal of Marketing 5 1 3 2 2 Grade 3 Psychology and Marketing Journal of Advertising Journal of Business Research Marketing Letters Journal of Marketing Management 3 1 7 1 1 International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V Grade 4 Grade 3 Journal name No. of articles Psychological Bulletin Journal of Applied Psychology Journal of Personality and Social Psychology Personality and Social Psychology Bulletin Psychological Science 2 2 1 3 4 Journal of Consumer Psychology Journal of Psychology British Journal of Psychology 1 2 4 Total 45 25 The effects of scent J. Rimkute et al. Table 2 Summary of the effects of scent on consumer and mediating/moderating variables Consumer responses to scent Mediating variables Moderating variables Attitudes Affect Cognition Consumer Perceptions Memory Behaviour More positive evaluations of the environment, products and their quality Better overall evaluations of shopping experience More positive ratings of people Perception to have spent less time in store Scent Enhances memory for products Improved recall and recognition for familiar and unfamiliar brands Cue to activate information More happy memories retrieved Context-dependent memory effects Short-term memory and long-term memory More time spent in the environment More money spent Increased gambling rates Pro-social behaviour Impulsive buying more likely More time examining products More willing to pay a higher price Desire to consume food significance of scents in the service environment each effect has to be explored in more detail (Table 2). Table 2 summarises the content of this systematic literature review in that the effects of scent on consumer behaviour as well as the mediating and moderating variables in such relationships are addressed. The main thematic areas are discussed below. Key thematic areas The analysis of the papers yielded five main thematic areas of research on the effects of scent including cognitive responses, affective responses, attitudes and perceptions, memory and behavioural responses as detailed below. Cognitive responses A few studies’ results suggest that exposure to olfactory cues influences cognitive processes (Table 3). Such exposure increases attention and results in greater elaboration effort in consumers’ product considerations (Morrin and Ratneshwar, 2000; Krishna et al., 2010). Gender Scent preferences Awareness of scent and its influence Perceived pleasantness Intensity Congruence Mitchell et al. (1995) referred to this phenomenon as cognitive enrichment: when exposed to a scent that is perceived to be congruent with the product class, consumers tend to spend more time processing information and developing inferences, which in turn leads them to rely on their experiences to make a decision. In contrast, incongruent scents were found to act as cognitive interference, evoking irrelevant information in the consumer’s memory and impeding decision making (Mitchell et al., 1995). In contrast, Bosmans (2006) suggests that it is enough for an ambient scent to be perceived as pleasant in order for it to enable positive cognitive reactions, and that congruence is an insignificant factor. However, a more recent study conducted by Olofsson et al. (2012) has found that congruence takes precedence over valence (pleasantness) in the cognitive processing of scents. Therefore, findings in this area seem somewhat inconclusive. Affective responses Affective responses to odour have received more research attention than cognition (Table 4). Affect is a general term used to describe the mix of moods and emotions, with two dimensions: Table 3 Cognitive responses to scent Authors Approach Findings Krishna et al. (2010) Mitchell et al. (1995) Laboratory experiment Laboratory experiment Morrin and Ratneshwar (2000) Olofsson et al. (2012) Laboratory experiment Distinctive product scent attracts attention and results in greater elaboration effects. Congruent odour influences consumer decision making processes (various information processing measures). Presence of pleasant ambient scent influences the processing effort involved with unfamiliar brands. Object evaluation (congruence) was faster and more accurate than valence evaluation (pleasantness). Responses were quicker for odours preceded by semantically matching, rather than nonmatching, word labels. However, results showed no evidence of interference from valence. 26 Laboratory experiment International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V J. Rimkute et al. The effects of scent Table 4 Affective responses to scent Authors Approach Findings Baron (1997) Field experiment Bosmans (2006) Laboratory experiment de Groot et al. (2015) Ehrlichman and Halpern (1988) Laboratory experiment Laboratory experiment Ellen and Bone (1998) Laboratory experiment Fiore et al. (2000) Laboratory experiment Knasko et al. (1990) Laboratory experiment Lee et al. (2011) Field experiment Morrin and Ratneshwar (2003) Laboratory experiment Morrin and Ratneshwar (2000) Laboratory experiment Much higher levels of positive affect were reported when participants were exposed to pleasant ambient scent. Ambient scents act as affective cues, providing information for product evaluation. A positive state (happiness) can be transferred by means of odours. Odour can have an influence on mood that may work as a mediator to evoke affectively congruent memories. Better fitting or no scent had no impact on consumer mood, but badly fitting scent negatively affected consumer mood. Scent had an effect on affective state that partly mediated the effect on attitudes towards products and approach behaviours. Suggestion of a pleasant ambient odour enhanced positive mood in participants. Exposure to soothing scent reduces the anxiety caused by stereotypes in the marketplace. Mood and arousal were not impacted by sent, but this study was based on self-reported measures. Ambient odours did not affect consumer mood or arousal. pleasantness (or valence) and arousal (Feldman Barrett and Russell, 1998). According to Hirsch (1995), the smell is the sense most directly linked to emotions, as the centre of smell in the brain has a direct link to the brain part responsible for emotions. As a result, an affective response to odour can be generated before cognitive processes take place. Much research suggests that scents can alter the affective state of humans (Ehrlichman and Halpern, 1988; Baron, 1997; Lee et al., 2011; Morrison et al., 2011). In a study of emotion transfer between humans through smell, de Groot et al. (2015) found that happiness can indeed be transferred among humans by means of odours. Nevertheless, Ellen and Bone (1998) suggest that only negative effects on affect are possible when the scent is incongruent with the product, whereas no positive effects have been observed with congruent scent. Morrin and Ratneshwar (2000, 2003) also found that mood and arousal levels of participants in scented and unscented conditions do not differ, which consequently reveals no relationship between scent and affect. However, the latter findings were obtained through selfreported measures, which are problematic because changes in mood can be too subtle for consumers to reflect on them. This issue was raised in an experiment by Mitchell et al. (1995), where the participants reported a more positive mood by just believing that pleasant odour is present in the room. Though these findings seem to be in favour of an existing relationship between odour and affect, determining the actual effects of scent on the state of affect may be a complex task. Attitudes and perceptions The potential for odours to change attitudes and perceptions is comparatively the most researched area in scent research as demonstrated through Table 5. As shown in Table 5, ambient scents have been found to bias the evaluations of the retail environment (Spangenberg et al., 1996; Chebat and Michon, 2003; Madzharov et al., 2015), products (Bone and Jantrania, 1992; Spangenberg et al., 1996; Fiore International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V et al., 2000; Chebat and Michon, 2003) and their quality (Spangenberg et al., 1996; Chebat and Michon, 2003). When paired with congruent music, ambient odours also help to achieve more positive overall evaluations of a shopping experience (Spangenberg et al., 1996; Mattila and Wirtz, 2001; Morrison et al., 2011). Further, scent congruency with product class (Bone and Jantrania, 1992; Bosmans, 2006) and gender (Spangenberg et al., 2006) are found to enhance attitudes. When scents are perceived as incongruent with the product they have no effect on judgements, as consumers treat them as an extraneous influence on their judgements and try to correct for the influence (Bosmans, 2006). Thus, it seems that for attitude and perception shift to occur, a condition of scent congruency has to be met. The type of scent in a retail environment also impacts the experience: a warm scent is associated with a denser social environment, resulting in a greater need for power, with the opposite effect resulting from cool scents. Indeed, a warm scent results in an increased preference for, and purchase of, premium and luxury brands (Madzharov et al., 2015). Additionally, number of studies suggest that scent is capable of affecting the ratings of people, impacting the likeability of faces (Li et al., 2007), the attractiveness ratings of the opposite sex (Baron, 1981; Foster, 2008), as well as the ratings of job applicants (Baron, 1983). Pleasant odours can also alter perceptions, as Spangenberg et al. (1996) show that consumers perceived to have spent less time in store and found prices lower in the presence of pleasant ambient odour. Therefore, it is possible to infer that odour affects attitudes and perceptions, although such effects may be indirect as discussed later on in the article. Memory Various studies have focused on the impact of scent on memory as illustrated through Table 6. Although some studies focus exclusively on the memory of odours (Richardson and Zucco, 1989; Perkins and Cook, 1990; Annett, 1996; White and Treisman, 27 The effects of scent J. Rimkute et al. Table 5 Effects of scent on attitudes and perceptions Authors Approach Findings Baron (1981) Laboratory experiment Baron (1983) Bosmans (2006) Laboratory experiment Laboratory experiment Chebat and Michon (2003) Field study Ellen and Bone (1998) Laboratory experiment Fiore et al. (2000) Foster (2010) Li et al. (2007) Laboratory experiment Laboratory experiment Laboratory experiment Madzharov et al. (2015) Laboratory experiment Mattila and Wirtz (2001) Field study Morrison et al. (2011) Field study Spangenberg et al. (2005) Spangenberg et al. (1996) Field experiment Laboratory experiment Exposure to pleasant scent affected social perception through increased attraction to opposite sex. Scent biased ratings of job applicants. Ambient scents had a strong influence on product evaluations. Congruence was a necessary condition. Scent indirectly influenced a more favourable perception of a shopping centre and product quality. Unless congruent scent provides perceived relevant product information, it does not enhance attitudes. Attitudes towards product were enhanced by scent. Scent influenced attractiveness ratings of men by women. Scent affected likeability ratings of people even though it was operating at subconscious levels. In a warm-scented and thus perceptually more socially dense environment, people experience a greater need for power, which manifests in increased preference for, and purchase of, premium products and brands. The opposite applies to coolscented environments. When scent and music were congruent in terms of arousing qualities, more positive ratings of environment and shopping experience were achieved. Overall evaluations of shopping experience were more positive when consumers were exposed to scent and music. Evaluations were biased when scent was thematically congruent with music. Exposure to pleasant scent influenced more positive evaluations of store environment and, in general, of the merchandise and product quality. Perceptions of time spent in store were also biased. 1997), much research centres on how scent can improve memory of other information. Indeed, several researchers suggest that odour can enrich the memory of specific information if the same odour is present during both the encoding and retrieval of such information (Ball et al., 2010; Morrin et al., 2011). Aggleton and Waskett (1999) suggest that ambient scent can help retrieve memories of real world experiences. In their experiment, they found that participants who were exposed to a particular scent of a museum and who visited such a museum (on average around 6 years before the experiment) retrieved much more information about its contents than participants in a non-scented condition. With regards to recall of product information, Morrin et al. (2011) argue that scented products may only have an advantage over similar but unscented products when the scent is present at retrieval. If this condition is not met, information about scented and unscented products has the same chance of being retrieved (Morrin et al., 2011). Conversely, Morrin and Ratneshwar (2000, 2003) note Table 6 Effects of scent on memory Authors Approach Findings Ball et al. (2010) Laboratory experiment Aggleton and Waskett (1999) Field study Ehrlichman and Halpern (1988) Laboratory experiment Krishna et al. (2010) Laboratory experiment Mitchell et al. (1995) Morrin and Ratneshwar (2003) Laboratory experiment Laboratory experiment Morrin and Ratneshwar (2000) Morrin et al. (2011) Perkins (1990) Laboratory experiment Laboratory experiment Laboratory experiment White and Treisman (1997) Laboratory experiment Some odours can produce reliable effects on environmental contextdependent memory. Odours were found to act as contextual retrieval cues for a real-world experience. When exposed to pleasant scent, participants retrieved more happy memories than the ones under unpleasant odour condition. Product scent is more effective in enhancing product memory than ambient scent. Ambient odours can help access information in the memory. Ambient scent improved recall and recognition of familiar and unfamiliar brands. Scent increased recall of unfamiliar brands. Scent can be effective in enhancing long-term product memory. Olfactory memory can be suppressed by the encoding of visual and verbal information. There is short-term memory for odours. However, short-term odour memory is more effective when odours are labelled verbally. 28 International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V J. Rimkute et al. The effects of scent that scent is only necessary at the encoding phase, as the same results were obtained when odour was present and not present at the retrieval phase. In their studies, the authors found that pleasant ambient scents enhance recognition and recall of familiar and unfamiliar brands (Morrin and Ratneshwar, 2000, 2003). Other studies suggest that exposure to any pleasant ambient scent is enough for consumers to access information such as attitudes to product class or brands (Mitchell et al., 1995), or to retrieve a larger number of happy memories than in non-scented conditions (Ehrlichman and Halpern, 1988). Therefore, in general it seems that odours facilitate formation and retrieval of memories. However, the evidence remains mixed in terms of the necessity of odour’s presence at retrieval and encoding phases. Behavioural responses A substantial body of research suggests that, within services settings, pleasant ambient scents are capable of influencing certain types of consumer behaviour. These behaviours are referred to as approach responses, or positive responses to the stimuli in the environment (Mehrabian and Russell, 1974). Studies summarised in Table 7 have found a number of scent-induced approach responses, such as stronger intent to visit a store (Spangenberg et al., 1996), spending more time in it (Spangenberg et al., 1996; Morrin and Ratneshwar, 2003), seeking variety (Mitchell et al., 1995), willingness to pay a higher price (Fiore et al., 2000) and spending longer examining products (Vinitzky and Mazursky, 2011). Approach behaviours are also enhanced when ambient scent is combined with music which is considered arousing and congruent with the product (Mattila and Wirtz, 2001; Morrison et al., 2011). Other researchers have found that exposure to scents can cause pro-social behaviours (Baron, 1997; Holland et al., 2005). Additionally, one study has found that imagining what a food product smells like can also produce a behavioural response. Referred to as “smellizing” a given food product, the effect of imagining the smell of food results in increased salivation, actual food consumption and self-reported desire to eat (Krishna et al., 2014, p.18). Research has also found that consumers are likely to spend more money (Chebat and Michon, 2003; Spangenberg et al., 2006; Vinitzky and Mazursky, 2011), and engage in impulsive buying (Mattila and Wirtz, 2001), when exposed to ambient scent. According to Chebat and Michon (2003), affective responses to scent lead to a more positive perception of an environment, which subsequently influences consumer spending. For instance, Hirsch (1995) found that ambient scent increased gambling rates, resulting in 45% more revenue being generated by slot machines in scented areas of casinos. The author explains the results as a product of olfactory-evoked recall, which takes place when scent evokes associations that enhance gambling mood. Findings from the reviewed studies suggest that, in most cases, olfactory cues do not directly influence consumer behaviour. Although the evidence from published research is not definitive in terms of the impacts of olfactory cues on the five thematic areas identified, the review suggests that the apparent incongruences may be due to the existence of differing mediating and moderating variables (Baron and Kenny, 1986), which influence the various relationships. Such mediators and moderators are explored in the following section. Table 7 Behavioural responses to scent Authors Approach Findings Baron (1997) Field experiment Chebat and Michon (2003) Field study Fiore et al. (2000) Laboratory experiment Hirsch (1995) Field study Holland et al. (2005) Laboratory experiment Krishna et al. (2014) Laboratory experiment Mattila and Wirtz (2001) Field study Morrin and Ratneshwar (2003) Laboratory experiment Morrison et al. (2011) Field experiment Spangenberg et al. (1996) Laboratory experiment Vinitzky and Mazursky (2011) Laboratory experiment Exposure to pleasant ambient odour in a large shopping centre induced prosocial behaviours. Scent enhanced shopping centre perception, which enhanced mood, which in turn influenced consumer spending. Ambient scent was found to enhance approach behaviours, such as intention to buy the product and willingness to pay a higher price for it. Ambient scent increased gambling rates at the casino by increasing slot machine revenue by 45% in scented condition. An exposure to the subliminal scent of a cleaning product had a direct influence on the performance of a cleaning task (eating biscuit and removing crumbs). Imagined scent can enhance consumer response, but only when the consumer creates a vivid visual mental representation of the object emitting the odour. When scent and music were congruent in terms of arousing qualities, more approach behaviours were exhibited, such as impulsive buying. Ambient scent encouraged approach behaviours such as consumers spending more time in the environment. Ambient scent together with music created an affectively pleasing environment, which subsequently positively influenced approach behaviours such as time and money spent. Approach behaviour also positively influenced (i.e. stronger intent to visit the store under scented condition). Ambient scent induced approach behaviours in online shopping: participants spent more time browsing, examined more brands, and spent more money than participants in the non-scented condition. International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V 29 The effects of scent Relevant mediating and moderating variables The systematic literature review suggests that the primary impact of scent is on the affective state or cognitive processes of the consumer, which in turn mediates the effects in terms of consumer behaviour. In addition, research has shown that moderating variables such as awareness of scent and its perceived pleasantness can alter consumer responses to scent. Affect The literature on atmospherics considers mood as a mediating factor between environmental cues and behaviour. This is based on the stimulus–organism–response theory (Mehrabian and Russell, 1974), which argues that environmental cues influence affective responses, which are subsequently turned into approach or avoidance behaviours. Examples of approach behaviours in this context include consumers spending more time in the outlet and purchasing more due to scent, whereas avoidance behaviours encompass the intention to leave the store and a range of negative attitudes also due to scent. A number of studies partially support the mediating role of affect between scent and attitude change, improved memory and behavioural responses (Ehrlichman and Halpern, 1988; Baron, 1997; Fiore et al., 2000), and sometimes specify arousal as the mediator (Mattila and Wirtz, 2001). In terms of attitudes, pleasant scents create a more emotionally satisfying environment and lead products in such environments to be perceived more positively (Chebat and Michon, 2003). This is because attitude towards the store is sometimes regarded to be more important than attitude towards the merchandise itself when determining consumer choice (Spangenberg et al., 1996). This, in turn, helps to explain the relevance of in-store scent. Several studies claim that scent-induced behaviours are mediated by affect (Baron, 1997; Fiore et al., 2000; Morrison et al., 2011; Vinitzky and Mazursky, 2011). If on exposure to a scent consumers experience a shift of affect, they are likely to recall information encoded in a similar affective state (Ehrlichman and Halpern, 1988), or that provoked by a similar affective response (Aggleton and Waskett, 1999). Thus, odours are likely to evoke memories that are affectively congruent. Despite this evidence, other findings reject the theory of the mediating role of affect on perception and behaviour (Chebat and Michon, 2003). The partial support for the mediating role of affect and the contradictory evidence suggests that another mediating variable must be examined, that is, cognition. Cognition Several papers suggest that cognitive processes can mediate the effects of scent. Olfactory cues were found to increase attention, resulting in greater elaboration effort by consumers, as well as enhanced memory for products (Krishna et al., 2010), and brands (Morrin and Ratneshwar, 2000). Cognitive effort and increased attention are necessary conditions for a more effective encoding of information and are enhanced when scent is perceived to be distinctive (Morrin and Ratneshwar, 2000, 2003; Ball et al., 2010). Krishna et al. (2010) report that scents relating to specific products are more effective in improving memory than ambient scents, as the former are perceived as 30 J. Rimkute et al. more distinctive than the latter. Cognitive responses were also found to mediate the effects of scent on shaping attitudes and inducing behaviours (Fiore et al., 2000; Vinitzky and Mazursky, 2011). Odours are capable of influencing consumer attitudes by evoking associations in the memory of consumers (Ellen and Bone, 1998). Moreover, if the olfactory cue is considered to provide relevant product attribute information, it enhances consumer attitudes (Ellen and Bone, 1998). Overall, evidence suggests that both affect and cognition work as mediators of the effects of scent. Awareness Consumer awareness of the presence of scent and its potential influence can be a crucial moderating variable when determining relevant consumer response. The perception of odours is different from perception of other environmental cues, since scent can be processed without consumer awareness (Davies et al., 2003). The sense of smell is exceptional because it is able to trigger an automatic response to stimuli before the consumer is aware of what is causing it (Hirsch, 1995). Scents which operate below the level of perception are referred to as covert or subliminal scents (Bradford and Desrochers, 2009), and their effectiveness is supported by several experimental findings as exhibited through Table 8. Table 8 shows a study by Li et al. (2007), which found that only subliminal scents were capable of affecting likeability ratings of faces. The ratings were more positive on the exposure to a pleasant scent, but only when participants were not aware of its presence. Awareness was also found to moderate the impact of odours on evaluations of products (Bosmans, 2006), and people (Baron, 1983). Further, a number of studies indicated that the effects of scent on consumer behaviour were significant when consumers were not conscious of its presence. However, similar responses to odour were observed in studies where consumers were aware of the presence of scent, which suggests either a need for further research or that awareness of odour may not be such an important variable after all. Nevertheless, an important distinction must be made when discussing consumer awareness of scent. Consumers may not be aware of the presence of the olfactory cue because it operates below the level of perception or at very low concentration. Even if consumers are able to detect the scent, they may still not be aware of its influential nature. When consumers are aware of the persuasive power of an environmental cue, they tend to apply defensive mechanisms towards it to correct for its extraneous influence (Bosmans, 2006). This was evident in Baron’s (1983) study, where perfume biased the ratings of job applicants. However, more positive ratings were only obtained with female evaluators; male evaluators were more aware of perfume as a mechanism to bias their judgement and tried to correct for this influence by giving lower ratings. This means that participants seemed to defend themselves against environmental influences, but only if they were able to recognise and interpret them as persuasive. Therefore, it is possible that in the studies where consumers were conscious of scent, they were not actually aware of its persuasive nature. This is consistent with the theory of affect as information (Pham, 1998), which postulates International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V J. Rimkute et al. The effects of scent Table 8 Consumer awareness of scent in primary studies Awareness Author Main areas investigated Comments regarding awareness of scent Studies conducted with participants who were aware of the scent. Baron (1981) Baron (1983) Foster (2010) Mattila and Wirtz (2001) Spangenberg et al. (2005) Baron (1997) Vinitzky and Mazursky (2011) Ellen and Bone (1998) Bone and Jantrania (1992) Chebat and Michon (2003) Attitudes and Perceptions N/A Behaviour N/A Attitudes and Perceptions Scent Variables Behaviour Fiore (2000) Behaviour Knasko et al. (1990) Affect Mitchell et al. (1995) Memory Morrison et al. (2011) Attitudes and Perceptions Smelling the ad was part of the task. N/A The study ensured that scent intensity reached the thresholds of perception, but participants were not questioned about it. Participants asked to rate the appropriateness of the scent. No scent was actually present, but the findings suggest that participants were aware of the influence of scent. Participants were asked to rate scents after experiment. Participants were asked to identify the aroma, therefore directing attention to its presence. Bosmans (2006) Attitudes and Perceptions Li et al. (2007) Attitudes and Perceptions Hirsch (1995) Behaviour Holland et al. (2005) Behaviour Krishna et al. (2010) Memory Morrin and Ratneshwar (2003) Memory Morrin and Ratneshwar (2000) Memory Spangenberg et al. (1996) Attitudes and Perceptions Spangenberg et al. (2006) Consumer variables Ehrlichman and Halpern (1988) Perkins (1990) White and Treisman (1997) Aggleton and Waskett (1999) Ball et al. (2010) Morrin (2010) Lee et al. (2011) N/A Studies conducted with participants who were both aware and unaware of the scent. Studies with participants who were unaware of the scent. Participant awareness either not relevant or not specified in the studies. International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V When the influence of scent is made salient to respondents, discounting of the influence occurs. Likeability ratings of faces were biased only when consumers did not perceive the presence of scent. Concentration of odour quite low; participants not questioned on awareness. Only a few participants were aware of the scent, but none were aware of the potential influence of scent on their cognition and behaviour. Scent was not referred to during the test. Fewer than three participants reported noticing scent (low awareness). Subjects were questioned regarding their scent awareness after the experiment. Not much scent was noticed and only one participant believed to be affected by it. Most participants were not aware of the scent and scent intensity was quite low. None of the participants noticed the presence of scent during the experiments; scents were not mentioned. Scent intensity mild in order to avoid the scent getting unpleasant. Participants were not aware of the scent. N/A 31 The effects of scent that consumers draw conclusions based on the observations they have made on their feelings. Thus, if the mood change is tacitly caused by scent rather than the product, a consumer’s judgement can be biased. However, when the ‘driver’ of the mood change becomes salient (i.e. when the scent is noticed), such biasing effects become weak or disappear (Pham, 1998). Cues within the environment can also activate relevant concepts and associations in the mind, a process referred to as priming (Bargh, 2002). Priming can subconsciously activate the pursuit of a certain goal, without the individual being fully aware of what is causing their behaviour. A study by Holland et al. (2005) revealed that exposure to covert odour enhanced a given pro-social behaviour of participants, namely cleaning crumbs from a table. One explanation for this is that the smell of citrus cleaner subconsciously activated relevant knowledge structures associated with cleaning, subsequently influencing the cleaning behaviour (Holland et al., 2005). Nevertheless, Bargh (2002) argues that non-conscious influences can only activate existing goals, not create new ones. As with affective biases, priming manipulation can diminish when scent and its influence become salient. Therefore, consumer awareness of scent has the potential to alter the consumer’s initial response to that scent. Factors related to individual and environmental stimuli Consumer responses to scent were found to vary depending on specific consumer and scent factors. With regards to consumer factors, gender (Spangenberg et al., 2006) and scent preferences (Breckler and Fried, 1993) were identified as the most influential variables in determining the effects of scent on consumers. Furthermore, it was found that the relationship between imagining food smell and the associated behavioural responses (increased salivation, food consumption and reported desire to eat) depends on the consumer creating a vivid mental image of the scent of food (Krishna et al., 2014). With regards to scents, the perceived congruency of odour with product class (Bone and Jantrania, 1992; Mitchell et al., 1995; Ellen and Bone, 1998; Fiore et al., 2000; Bosmans, 2006), gender (Spangenberg et al., 2006) and music in terms of arousing qualities (Mattila and Wirtz, 2001; Morrison et al., 2011) were considered essential conditions for olfactory effects to occur. Another important attribute of scent is its intensity, as intensity determines the perceived pleasantness of odour, which is a key factor in positively influencing consumers (Fiore et al., 2000). Spangenberg et al. (1996) found that the relationship between perceived pleasantness of scent and its intensity is negative for neutral scents, but follows an inverted U-shaped function for pleasant scents. Thus, the qualities of scent such as its congruency and perceived pleasantness, together with general consumer preferences of scent, act as moderating variables, which influence affective, cognitive and behavioural responses to scent. Methodologies within the reviewed studies A few final points must be made in relation to the methodologies used by the papers addressed in this systematic literature review, as a means to provide further insights into the results of such studies on consumer responses to scent. A summary of such methodologies is provided in Table 9. 32 J. Rimkute et al. Table 9 Methodologies used in research on scent Research environment Data collection method Research design Total (n 5 41) % Field study Laboratory experiment Non-empirical Questionnaire Observation Structured Interview Non-empirical 14 72 14 68 14 5 13 As demonstrated above, it is evident that most experimental studies were conducted within laboratory environments and such studies account for two thirds of all research on the impact of scent on consumers. About 13% were non-empirical studies in the form of literature reviews. Only 14% of researchentailed field studies and the first was done by Hirsch (1995). These facts suggest a strong preference for laboratory over field settings, possibly because field studies have intrinsic disadvantages related to consumer exposure to uncontrollable variables (i.e. exposure to unintended environmental cues), which can make it difficult for researchers to make definitive conclusions about the effects of scent on consumers. Nevertheless, one could question whether the responses to scent achieved within laboratory settings would occur within ‘real-life’, marketplace situations. Given that field studies are more resonant with the lived experiences of consumers, their use in future studies may shed some new light on this area of research. Another important issue to consider is that the majority of studies reviewed here used similar experimental designs. The procedure in most cases involved a pre-test of scent, followed by the creation of several different environmental conditions where consumer responses to scent were tested. All of the primary studies used quantitative data collection measures, with questionnaires being used in 68% of all articles. Observation was rarely used in studies of scent, accounting for only 14%, and focused on monitoring consumers’ behavioural responses to odours. The points above raise several issues. First, researchers seem to be over-reliant on experimental designs and usage of selfreported measures, which are problematic in such contexts where participants may not be able or willing to reflect on mood changes, for example. In fact, only a few studies within the area of consumer responses to odour used objective measures, such as collecting consumption data (i.e. Hirsch, 1995). Indeed, although self-reported measures are suitable for assessing the effects of scent on memory, investigation of other consumer responses to scent may require more objective measures as discussed below. Conclusions This systematic literature review explored the effects of an important aspect of sensory marketing (i.e. scent) on consumer behaviour. Exposure to scent was found to positively influence attitudes towards service environments and enhance memory for brands, ultimately resulting in increased likelihood of purchase. The effects of scent on consumer behaviour were found to be mediated by other variables, such as affect and cognition, International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V J. Rimkute et al. and moderated by consumer factors (gender and scent preferences), scent properties (intensity, pleasantness, congruence) and consumer awareness of scent and its influence. Although this article provides a systematic review of the literature within the fields of marketing and psychology, it acknowledges that a large body of research regarding human responses to odours exists within other disciplinary fields such as neuroscience. Nevertheless, this review has identified several gaps in the literature which can be addressed by future research. The first issue is the ambiguity of the mediating role of affect and cognitive processes in determining consumer responses to scent. Lack of clarity also exists with regards to how marketers can determine the perceived congruency of scent and a product if, for instance, the scent is emitted within an environment containing a variety of other products. With regards to moderating variables, it is important to further investigate whether and how consumer awareness of scent and its influence can alter consumer responses. Another issue concerns the consumer’s ability to report the influences on their decisions, as self-reported measures can be subjective. Since self-reported measures were the most common data collection method within the reviewed studies, it is suggested that future research could use different measures such as facial electromyography and magnetic resonance imaging. However, we acknowledge that such measures may also present their own limitations. Finally, future research could seek to investigate whether scents are as effective in influencing purchase decisions for high involvement goods and services as they are in influencing low involvement purchases. Managerial implications Scent is an important part of atmospherics and has been widely used in retailing, restaurants and other service contexts (Morrin and Ratneshwar, 2003). The most common type of scent in these settings is ambient scent. An advantage of ambient scent over product scent is that it can influence consumer reactions to all the products within the service environment, which is especially useful for products that are difficult to scent (Spangenberg et al., 1996). Service providers and retail businesses can benefit from ambient scent when trying to enhance consumer attitudes towards the environment and products, and to create better recognition and recall of their brands, which ultimately should lead consumers to make resonant purchasing decisions. Small changes in the environment, such as adding low intensity odours, can also increase feelings of novelty and pleasantness among consumers (Spangenberg et al., 1996), which in turn would encourage approach behaviours by consumers. The perceived pleasantness of odours can also induce affective reactions that could create positive perceptions of the service (Ellen and Bone, 1998). Therefore, well selected ambient scent can be a cost-effective way to create a competitive advantage for service providers. However, this practise may have some ethical implications. Not being aware of the influential nature of scent may make consumers vulnerable to manipulation (Bradford and Desrochers, 2009). Since consumers cannot turn their sense of smell off and may not be aware of its influential nature in a retail setting, the use of scent can be seen as a form of subliminal nudging. 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International Journal of Consumer Studies 40 (2016) 24–34 C 2015 John Wiley & Sons Ltd V Copyright of International Journal of Consumer Studies is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Health Marketing Quarterly, 27:86–96, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 0735-9683 print=1545-0864 online DOI: 10.1080/07359680903519826 Customer Advisory Groups: Another Way to Listen to the Marketplace WILLIAM R. GOMBESKI, JR. Strategic Marketing, UK HealthCare, Lexington, Kentucky JAN TAYLOR Communications and Advertising, UK HealthCare, Lexington, Kentucky JASON BRITT Market Research, UK HealthCare, Lexington, Kentucky KAREN RIGGS Physician Marketing, UK HealthCare, Lexington, Kentucky TANYA WRAY Service Line Marketing, UK HealthCare, Lexington, Kentucky SUZANNE SPRINGATE Customer Service, UK HealthCare, Lexington, Kentucky GEOFF BLAIR Internal Communication Manager, UK HealthCare, Lexington, Kentucky PHIL BERNARD University of Kentucky College of Medicine, Lexington, Kentucky Customer advisory groups (CAGs) are formal groups of customers (referring physicians, patients, health insurance brokers, etc.) who meet regularly to share their ideas and to provide feedback to proposed or existing marketing strategies, programs, and activities. While CAGs are very prevalent in other industries they appear to be relatively underutilized in health care. This article provides an overview of how CAGs work, their advantages and disadvantages, tips on how to make them work better, and insights from interviews with 39 healthcare chief marketing officers on their use of CAGs. Address correspondence to William R. Gombeski, Jr., UK HealthCare, 2347 Sterlington Rd., Suite 100, Lexington, KY 40517. E-mail: [email protected] 86 Customer Advisory Groups 87 KEYWORDS competitive advantages, customer advisory groups, leadership, marketing effectiveness, market research Marketers in all industries are always looking for new, more effective ways to listen, obtain ideas and feedback from customers and potential customers. One approach, customer advisory groups, has been around in other industries and is now catching some attention in health care. Customer advisory groups (CAGs) are formal groups of customers who meet regularly with marketers to share their ideas and to provide feedback to proposed or existing marketing strategies, programs and activities. The primary advantage of CAGs is that through the education of a consistent group of customers and by building their trust with the organization over a period of time, deep, more honest conversations are possible and more insightful opportunities can be identified. Marketers in many organizations have been using CAGs for some time. A 2006 survey of 550 chief marketing officers (CMOs) across all U.S. industries noted that 25% of the organizations used CAGs (CMO Marketing Council, 2006). Commenting on this study (Gillin, 2007) felt the low percentage of marketers having customer advisory groups was due to an intense pressure on generating leads and sales in the short-term and less understanding or focus on the value of more long-term conversations. Interestingly, interviews with 39 CMOs of large academic medical organizations conducted by the authors in 2007 showed that while 51% of the organizations had CAGs, only 13% of the CAGs were led or managed by marketing; the rest were managed by clinical areas and their primarily purpose was to raise money or provide political advocacy for issues. The purpose of this article is to help health care marketers: (a) become more familiar with CAGs and how they are used in health care; (b) understand the advantages and disadvantages of CAGs; (c) learn how to recruit members, operate and use CAGs to benefit your marketing and organization; (d) review the results of interviews with 39 CMOs on their use of CAGs; and (e) share insights from six different kinds of CAGs used at UK HealthCare, the clinical enterprise of the University of Kentucky. BACKGROUND In health care, the application of CAGs began with the use of family advisory groups associated with children’s hospitals. CAGs are now becoming more important as the growing consumer movement continues to empower health care consumers (Halm, 2006). Customer advisory groups belong to an integrated set of strategies used to both instill a patient-centered care philosophy and one of a continuum of tactics to obtain information about customers (Halm, 88 W. R. Gombeski, Jr. et al. Sobo, & Rudiger, 2006). CAGs are also becoming bigger and moving online and the ‘‘hawthorne effect’’ of being involved in an organization’s marketing can lead to significant positive word-of-mouth marketing (Marsden, 2006). CAGs are especially good for emerging or transforming market segments where organizations need to stay in touch with quickly changing dynamics of the marketplace (Geehan & Sheldon, 2005). One use of CAGs is to share survey data to identify broad areas of opportunity and to generate insights about the data through deep conversations with customers in face-to-face situations (Fleming & Asplund, 2007). Specific uses of CAGs outside of marketing include input to (a) design new facilities; (b) set hiring standards; (c) interview job candidates; (d) design clinical trials; (e) evaluate hospital equipment; (f) review medical safety measures; and (g) help train medical students (Landro, 2007). Management is more likely to accept new measurement metrics when an advisory group has recommended those values (Devlin & Dong, 1994). Because CAGs are usually comprised of current customers (patients, referring doctors, health insurance brokers), obtaining ideas on how to attract and acquire nonusers or prospects can be difficult and is one negative of CAGs (Carter, 2004). UK Healthcare Experience UK HealthCare, with over 8,000 employees, is the clinical enterprise arm of the University of Kentucky. UK HealthCare consists of Albert B. Chandler and Good Samaritan Hospitals, Kentucky Clinics, and the clinical activities of the colleges of Medicine, Dentistry, Pharmacy, Health Sciences, Nursing and Public Health. Since 2004, the organization has increasingly spent more and more energy on better serving more patients and referring physicians. The development of customer advisory groups is a recent continuation of that effort. At UK HealthCare, the marketing department manages or supports UK physician, referring physician, employee, patient, health consumer and community advisory groups (see Figure 1). The six advisory groups provide a mechanism to brainstorm ideas and obtain feedback on new programs and market industry developments. A short summary of each CAG is provided in Figure 2. Benefits of these customer advisory groups to date include: (a) many new ideas leading to enhanced effectiveness and efficiency of UK HealthCare marketing efforts; (b) increased UK physician and employee awareness; understanding, support and satisfaction with marketing programs; and (c) growth in number of referrals, transfers, new patients, reputation, income and market share. In this article, an overview of UK HealthCare’s advisory groups is provided and a study of CMOs from academic medical centers and their use of advisory groups are also shared. Customer Advisory Groups 89 FIGURE 1 UK HealthCare marketing review process. UK HealthCare Advisory Groups PHYSICIAN MARKETING ADVISORY GROUP The physician advisory group is directed by a senior physician and the Director of Marketing is the co-director. The group consists of 12 UK physicians, chosen with the help of the various clinical department chairmen to represent the various specialties and areas of the organization. The directors of product line marketing and physician liaison also are members along with the director of strategic planning. The group meets monthly to provide advice to the marketing department and among its other duties serves as an editorial advisory group for the organization’s referring physician publications. See Table 1 for examples of agenda topics. FIGURE 2 Advisory group information. 90 W. R. Gombeski, Jr. et al. TABLE 1 Examples of Physician Marketing Advisory Group Agenda Topics Improving patient satisfaction with UK physicians Physician behavior expectations Market share discussion Growing internal familiarity with all UK docs Review of publications aimed at referring physicians Advertising concepts and campaign direction Improving service to referring physicians Clinical annual reports as a direct mail piece to referring physicians Review of dress code Influencing patient=referring physician decision-making Increasing referring physician satisfaction with UK doctors Growing numbers of Medicare patients Developing patient satisfaction tips for UK physicians EMPLOYEE MARKETING ADVISORY GROUP The Employee Advisory Council consists of 15 employees representing different components of the 8,000-person UK HealthCare enterprise. Employees are chosen to represent a variety of levels of employees to provide a broad grass roots level of perspectives. Ideal candidates for the committee (a) have a sincere desire to understand and advance UK HealthCare’s marketing efforts; (b) agree to attend scheduled meetings; and (c) commit to active participation within the group. See Table 2 for examples of employee marketing group agenda topics. CONSUMER ADVISORY GROUP The Consumer Advisory Group consists of a mixture of 30 current and past patients and members of the community who use other medical organizations. This group provides both feedback from patients and nonpatients. TABLE 2 Examples of Agenda Topics With the Employee Marketing Group Advertising concept review Physician behavior expectation Marketing overview and suggestions Employee appreciation day feedback Feedback on Medicare patient records binder 100 Top Hospital campaign idea feedback Ways to capitalize on county extension agents Employee shuttle bus communication Physician liaison program feedback Advertising plan review Marketing outcomes Internal and external communications regarding new parking options Tobacco Free campus implementation Feedback on promotional items Market research findings and what they mean Customer Advisory Groups 91 The group is designed so that all or a segment (recent inpatients, families with children) can be created. The panelists have primarily been recruited from UK HealthCare’s marketing database, which consists of callers to the organization’s consumer call center. Screening of participants was negligible during early creation of the advisory panel, thus limiting representation of key groups. After creating a core group of 20 active participants, recruiting efforts were designed to ensure panelist representation in key groups of interest. Other recruiting sources include respondents from patient satisfaction surveys, new patient surveys, and health lectures attendees and referrals from current members. See Table 3 for consumer advisory group agenda examples. COMMUNITY INTERNET PANEL This group is an e-mail advisory group that periodically assists in responding to questions. Approximately five to six times a year specific topic questions are identified and sent out to a growing population of more than 2,000 members. Response rates vary based on topic but are between 9.4% and 12.5%. No more than three questions are sent at any one time. Questions are usually open-ended (see Table 4). Patient Advisory Group UK HealthCare has a patient advisory group consisting of current and former Medicare patients. Medicare patients were chosen because they represent an important group that underutilizes UK HealthCare. See Table 5 for patient advisory group agenda examples. REFERRING PHYSICIAN ROUNDTABLE A group of six community physicians were recruited and meet every one to two months to discuss ideas and issues related to use of UK Chandler TABLE 3 Examples of Consumer Advisory Group Agendas Newspaper banner advertisement assessments Yellow pages usage Creative=copy testing Web site usability testing Health care purchase habits Tag line feedback Advertising concepts Organizational outreach clinics Health lectures Attributes of a good or bad physician Familiarity with Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) and likelihood of use. 92 W. R. Gombeski, Jr. et al. TABLE 4 Examples of Community Internet Panel Agendas Medical campus terminology: academic medical center vs. regional referral center Advertising concept evaluation Web site usage habits Awareness of and suggested uses for children’s hospital mascot New hospital construction and traffic issues Consumer driven health care Difference between ambulatory and outpatient. Hospital and Kentucky Clinics. The group is led by a UK pediatrician and supported by the physician liaison department within marketing. Depending on the topic(s) chosen by the referring physicians, other UK physicians are brought in to facilitate appropriate exchange of concerns and information (see Table 6). While there are many benefits to CAGs, there are several limiting factors to address. First, recruiting participants can be difficult and time consuming. Second, managing the groups requires time and resources. Third, the groups often raise issues that require follow-up and significant effort. Recruiting participants is often difficult and time consuming. When recruiting physicians, scheduling concerns often arise because physicians at UK HealthCare often juggle patient loads and faculty responsibilities. The process of recruiting for the employee group raised the issue of staff scheduling, often requiring the employee to obtain supervisor approval. Because many of the employees on an advisory group have patient care responsibility, getting away during a busy period can be difficult and can affect attendance. Along with scheduling issues, consumer and patient groups present the challenge of incentivizing participation. Often, consumers and patients are reluctant to participate or drop out because they misunderstand their role in the advisory group or fail to see the results of their participation. To address these issues, before each meeting the individual and group roles are reinforced, minutes from the last meeting are reviewed and TABLE 5 Examples of Patient Advisory Group Agendas HCAHPS awareness, use Quality measures patients would like to see What makes a good volunteer experience? Issues=frustrations patients face with healthcare Tobacco-free campus initiative Use of UK Website Medical binders, how to improve Has consumer=patient power changed? How to capitalize on World Equestrian Games Sponsorship Emergency department patient guide, how to improve Customer Advisory Groups 93 TABLE 6 Examples of Physician Roundtable Agendas Criteria for discharge from NICU to home Hospitalists role with inpatient pediatric patients Evaluation and treatment for congenital malformations of the heart Advanced radiology service available When to refer diabetic children New surgical capabilities organizational uses of the advisory group’s opinions and suggestions are shared. Additionally, following each meeting, participants are contacted and thanked for specific insights they provided. A very useful workbook on how to establish and operate customer advisory groups developed by the University of New Mexico offers additional insights (Stevens & Ibenez, 2004). Despite the recruiting and management issues, there are many advantages of CAGs. From a tactical marketing perspective the insights generated from a regular meeting group are stronger and have more impact than ad hoc input from focus groups, etc. One reason for that is as the CAGs mature and the members become more familiar with each other, there is more comfort disagreeing and more comfort sharing one’s position on a topic leading to more open discussion. Additionally, members become comfortable with the organization and often share delayed reactions with organizational contacts or, because members know they will see each other and marketing each month, they often save ideas about strategies and topics that have been or will be discussed leading to many more new and good ideas than a just assembled group would generate. Perhaps the most valuable benefit of a CAG is the new agendas or topics introduced that were not on the marketing department’s radar screen. Another important benefit is the identification of operational side effects from a proposed marketing recommendation. What are some lessons we have learned? First, get buy in and approval from management. Work CAGs into your marketing plans so that your organization understands their role and importance. Recruiting internal members is most effective when the members’ supervisor has approved and helped select the member. For external audiences, generally a screening process is best. It is not necessary to compensate members; however, food and gifts enhance goodwill and encourage participation. Internal members at UK often meet over a nice lunch and are given UK HealthCare promotional items to test and evaluate. External members are also provided with food and promotional items in addition to compensation in the form of a gas card for travel expenses. It is important while recruiting, at the first meeting and periodically to remind the group that they are an advisory group and that not all recommendations can be used. Orientation usually consists of a short overview of UK HealthCare’s marketing plan and current goals. Ongoing replacement is normal as members leave but provide an opportunity to 94 W. R. Gombeski, Jr. et al. FIGURE 3 Have regular marketing-sponsored advisory groups? freshen the group and bring in an individual representing a different segment. It usually takes at least three meetings before a group begins to become comfortable with each other and their roles. From a strategic perspective CAGs allow marketers to test ideas and draft programs so that how to package and sell ideas are carefully worded and organized to insure key internal stakeholder buy in. Recommendations from CAGs provide valuable input for senior management and a level of comfort that key customer groups have bought in. Finally, CAGs tell management that marketing is listening. Having CAGs lets the public and community leaders know that the organization is including community input into its efforts. It is also an avenue to make sure marketing is included at the organization’s decision-making committees. A tactical benefit is the wordof-mouth marketing and communication that takes place between members and other similar customers. Survey of Academic Medical Centers CMOs Between July 2007 and September 2007, the CMOs of 51 academic medical centers active in the UHC were contacted by one of the authors to understand their use of customer advisory groups. Thirty-nine were interviewed. Interviews were not completed with the remaining due to nonresponse, CMO position vacant or unwillingness to participate. Of the 39 interviewed, five had marketing-managed CAGs, however none included external customers (see Figure 3). Most of the CAGs identified by the AMC survey were primarily patient advisory groups for children’s FIGURE 4 Other common approaches to obtaining ‘‘customer’’ input and feedback. Customer Advisory Groups 95 FIGURE 5 Interesting approaches. hospitals or community advisory groups managed by other departments or areas of the organization. Figure 4 shows the many ways the 51% of AMCs with CAGs use them to obtain some input. In some cases marketing was allowed to participate to place an item on the agenda. Figure 5 shows the variety of other ways AMCs seek customer input. Reasons offered for marketing not having CAGs included not enough time, advisory groups can micromanage marketing’s efforts, hard to keep attendance up=members motivated, groups got off tract=not that helpful, need new members to maintain freshness. Some of the benefits identified were (a) advisory groups can help you acquire resources; (b) help decisions happen more quickly. Surprisingly, given the size and sophistication of many academic medical center marketing departments customer advisory groups are not used significantly. CONCLUSIONS Physician, patient, and family advisory councils should be part of a marketing strategy to understand customer needs. For marketers wanting to listen more closely to customers and prospects, becoming more involved in CAGs is one way to get new insights. Today’s health care organizations need to bring their customers into the marketing conference room to develop the most customer-focused strategies and to have a competitive advantage. Having CAGs provides strong evidence to the organization that marketing management is providing market leadership. Finally, CAGs provide the opportunity to market with consumers instead of at them. 96 W. R. Gombeski, Jr. et al. REFERENCES Carter, T. (2004). Customer advisory boards: A strategic tool for customer relationship building. Competitive Review, 14, 109–111. CMO Marketing Council. (2006). Select and connect. Strategies for targeted acquisition and retention. Chicago, IL: American Marketing Association. Devlin, S. J., & Dong, H. K. (1994). Service quality from the customer’s perspective. Marketing Research, 6(1), 5–13. Fleming, J. H., & Asplund, J. (2007). Human sigma. New York, NY: Gallup Press. Geehan, S., & Sheldon, S. (2005). Connecting to customers. Marketing Management, 14(6), 37–42. 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