Influence of cultural factors and user engagement motives on value co-creation dynamics between healthcare service providers and users

Healthcare systems are increasingly expected to promote well-being and cost-effective service delivery, making value co-creation an important area of inquiry. (See: Glassman and Temin, 2016; Haenssgen, 2023; Sachs and Ban, 2015; United Nations, 2025: Goal 3). Value co-creation can contribute to the effectiveness of healthcare services and user well-being. Value co-creation in health services is defined by McColl-Kennedy et al. (2012, p. 375) as “the benefit realized from integration of resources through activities and interactions with collaborators in the customer’s service network.” This process involves interactions between healthcare service providers and users involving communication, collaboration, and resource sharing, enabling mutual learning and the co-creation of value that can contribute to positive health outcomes and user well-being (Enam et al., 2022; McColl-Kennedy et al., 2017a, b; Sweeney et al., 2015).

An emerging body of research applies value co-creation to healthcare contexts, highlighting its relevance for service delivery and user engagement (Grindell et al., 2022; Janamian et al., 2016; Keeling et al., 2021; McColl-Kennedy et al., 2017a, b; Osborne, 2018; Osei-Frimpong et al., 2018; Vargas et al., 2023). At the same time, there are multiple calls for increased adoption of value co-creation in healthcare research to improve practice (Hasan et al., 2024; Poblete et al., 2023; Rosengren et al., 2021; Voyer, 2022). Vafeas et al. (2026) note that much of the existing debate examines value co-creation primarily from the service user perspective rather than that of providers. Within healthcare, patients often interpret value as the achievement of quality outcomes and positive experiences (Landon et al., 2021), whereas healthcare providers typically consider process and cost efficiencies in addition to the outcomes in terms of treatment effectiveness (Best et al., 2022). While these existing value co-creation studies in the healthcare sector significantly contribute to our knowledge, several gaps in our understanding remain.

First, due to previous contradictory research findings regarding user motives for co-creation, calls were made to consider the role of cultural values in the co-creation process and their impact on healthcare service user motives for co-creation (e.g. Bhatti et al., 2021; Chwialkowska, 2022). Existing research focusing on the outcomes of healthcare service user value co-creation does not account for the importance of healthcare service users’ cultural background (e.g. Kremer et al., 2007; Loh et al., 2007; McColl-Kennedy et al., 2017a, b; Manias and Williams, 2008; Stewart and Napoles-Springer, 2000; Sweeney et al., 2015). This is of importance as culture affects healthcare service provider-healthcare service user interactions (Hofstede et al., 2001, 2010).

While previous studies identified motives for value co-creation in the healthcare service sector (Neghina et al., 2014), recent studies yielded contradictory findings regarding the importance of various user motives across countries. For instance, studies by Bhatti et al. (2021) and Chwialkowska et al. (2022) point to differences in the significance of ethical, individualizing, and concerted motives (found to be significant in the U.S. and Pakistan but not in Germany. Moreover, when we contrast the results by Chwialkowska et al. (2022) and Neghina et al. (2017), we discover differences in the significance of relating motives and knowledge sharing, which were not significant in the US sample, but were significant in the study conducted in the Netherlands. Taken together, these findings suggest that the importance of co-creation motives cannot be assumed to be generalizable across healthcare contexts, pointing to national culture as a plausible but under-theorized explanatory factor. These contradicting results point to the limitations of the service-dominant logic (S-D logic) (Vargo and Lusch, 2004; Karpen et al., 2012; Neghina et al., 2014) in explaining differences in value co-creation motives across national cultures: “value co-creation research needs to go beyond commonly applied service-dominant logic and account for the context in which this co-creation takes place” (Chwialkowska et al., 2022, p. 1).

Second, the existing literature identifies a variety of healthcare service user co-creation activities (Gonzales, 2019; Bashar et al., 2020; McColl-Kennedy et al., 2012; Sweeney et al., 2015). We thus differentiate between active (intense mutual communication and actors’ involvement) versus passive co-creation behaviors (low mutual interaction degree among the involved actors, such as healthcare service users) (Lee, 2019; Kaartemo and Känsäkoski, 2018; Zhang et al., 2015). However, existing studies do not acknowledge that the degree of healthcare service user involvement is a culture-dependent construct (Hofstede, 2001; Hofstede et al., 2010; House et al. 2004) and do not explore how cultural and relational contexts shape the extent of user engagement. Thus, to bring a more nuanced understanding of the value co-creation between healthcare service users and providers, we believe it is essential to study healthcare service users' motives and the dynamics of the healthcare service user-expert relationship within the cultural context in which this interaction occurs (See Figure 1 below).

Therefore, this study adopts a conceptual research approach and is positioned as an integrative, theory-extending framework. Our primary objective is not to develop a new standalone theory, but to integrate and organize existing theoretical perspectives relevant to co-creation in healthcare services that were rarely examined jointly. In particular, our framework synthesizes service-dominant logic (Vargo and Lusch, 2004), value co-creation motives (Neghina et al., 2014), healthcare service provider–user relationship models (Emanuel and Emanuel, 1992), and cultural value dimensions framework (Hofstede, 2001), to address inconsistencies in prior research on healthcare service user engagement. At the level of analysis, our framework focuses on micro-level interactions between healthcare service users and providers. These interactions, which are critical to treatment effectiveness, service efficiency, and user well-being, are situated within a macro-level national cultural context which greatly shapes expectations regarding authority, autonomy, coordination, and ethical conduct.

The purpose of this study is twofold: (1) To explore the importance of cultural values in shaping the healthcare service user's motives to co-create and propose how these values impact the healthcare service provider-healthcare service user relationship dynamics. (2) To propose practical implications for the healthcare actors (e.g., medical experts, physicians, hospitals, pharmaceutical firms) striving for healthcare service user satisfaction (patient well-being). This study therefore aims to encourage the development of culturally sensitive healthcare services and treatment processes that will improve healthcare service users' well-being. This is important as long-lasting development approaches hold promise in tackling global health challenges (McKee, 2021). Based on the identified theoretical tensions and gaps, we address the following research questions:

Table 1 summarizes the theoretical foundations of value co-creation constructs and motives. This study adopts Hofstede’s (2001) cultural value framework, which conceptualizes culture as collective mental programming shaping expectations and behavior. Alternative approaches, such as the GLOBE framework (House et al., 2004), focus primarily on leadership within organizations and are therefore less suited to examining interactions between healthcare service providers and users, who are not members of the same organization.

Our main contribution lies in developing an integrative conceptual framework that combines insights from marketing, healthcare, and cross-cultural research to explain how cultural value dimensions shape healthcare service users’ motives for value co-creation, their expectations of relationship dynamics with healthcare professionals, and their propensity to engage in active versus passive participation. This integration responds directly to calls within healthcare management research to better contextualize service interactions and patient engagement across diverse populations.

In doing so, we extend service-dominant logic by conceptualizing national culture as a contextual boundary condition shaping established co-creation mechanisms. Specifically, we integrate power distance (Hofstede, 2001) with the healthcare service provider–user relationship model proposed by Emanuel and Emanuel (1992) to explain how authority expectations and role perceptions influence healthcare service user engagement. We further incorporate individualism–collectivism and uncertainty avoidance to explain variation in the salience of co-creation motives across contexts, thereby addressing contradictory findings in prior research (Bhatti et al., 2021; Chwialkowska et al., 2022; Neghina et al., 2017). Overall, these inconsistencies suggest that prevailing theoretical explanations—particularly those embedded in service-dominant logic—do not fully capture how culturally embedded expectations regarding authority, autonomy, and relational roles shape healthcare service users’ participation in value co-creation.

Although value co-creation research in healthcare has expanded rapidly, the literature remains theoretically fragmented. While service-dominant logic emphasizes active participation as a normative ideal, empirical studies suggest that there exist major differences in healthcare service user engagement, ranging from active collaboration to passive compliance. These inconsistencies point to unresolved tensions concerning when, why, and how value co-creation occurs in healthcare services.

To address these tensions, in what follows, we synthesize interdisciplinary insights to develop a conceptual framework linking national cultural values, healthcare service provider–user relationship dynamics, and value co-creation behaviors. We advance research propositions (P1–P9) and differentiate between active and passive co-creation behaviors, proposing that healthcare service users’ engagement patterns are shaped by culturally embedded expectations regarding authority, autonomy, and interaction. In doing so, the study extends service-dominant logic by incorporating culture as a contextual boundary condition.

Healthcare literature and practice emphasize the significance of user-centered care over viewing the patient as a passive recipient. Key dimensions include meaningful engagement, the establishment of trust, and the promotion of an active patient role. Consequently, the participatory patient is increasingly described as a co-creator (Janamian et al., 2022; McColl-Kennedy et al., 2017a, b; Vafeas et al., 2026). Unlike traditional coordination or collaboration, co-creation emphasizes the generation of innovative solutions (Von Krogh et al., 2020) and can help ensure that health service solutions align with end users’ preferences (Mimoso et al., 2024). While some scholars argue that healthcare services are inherently co-created through interactions between providers and recipients (Enam et al., 2022), others suggest that co-creation is not automatic and requires active facilitation to occur (Willumsen and Kjeldstadsli, 2020).

At its current stage, the value co-creation literature in healthcare primarily focuses on three major research areas. The first research stream examines outcomes of healthcare service user involvement, such as enhanced well-being and quality of life (McColl-Kennedy et al., 2017a, b; Sweeney et al., 2015), among other outcomes (Manias and Williams, 2008; Kremer et al., 2007; Loh et al., 2007; Stewart and Napoles-Springer, 2000). These studies share a strong emphasis on the benefits of value co-creation but largely overlook the role of healthcare service users’ cultural background in the interaction process. The second research stream provides insights into the co-creation activities of healthcare service users (Gonzalez, 2019; Bashar et al., 2020). McColl-Kennedy et al. (2012) differentiate between various co-creation activities. Sweeney et al. (2015) propose a hierarchy of co-creation activities based on the degree of effort exerted by the healthcare service user. These studies demonstrate that value co-creation behaviors vary substantially in their degree of user involvement. Given the knowledge- and communication-intensive nature of healthcare services, it is important to distinguish between active co-creation behaviors, which are characterized by intense mutual communication and involvement, and passive co-creation behaviors, which are marked by low interaction and simple compliance (Lee, 2019; Kaartemo and Känsäkoski, 2018; Zhang et al., 2015).

More recent research highlights organizational and contextual constraints on healthcare service user engagement (e.g. Aljafari et al., 2024; Binsar et al., 2024). Value co-creation depends on the availability of resources and the willingness and ability of actors to integrate them. This integration requires not only expertise but also enabling mechanisms such as organizational structures, systems, and practices. In the absence of these elements, efforts to co-create value are likely to be unsuccessful (Echeverri and Skålén, 2021).

The fourth research stream, drawing on service-dominant logic (Karpen et al., 2012; Neghina et al., 2014; Vargo and Lusch, 2004; Vargo et al., 2020), emphasizes that healthcare service users engage in value co-creation for different motives, including individualizing, relating, developmental, empowering, ethical, and concerted motives (Bhatti et al., 2021; Chwialkowska et al., 2022). However, this stream has largely neglected the cultural context in which value co-creation unfolds. Taken together, these gaps suggest that the importance and salience of co-creation motives should not be assumed to be generalizable across healthcare contexts, pointing to national culture as a plausible but under-theorized explanatory factor. We discuss these motives in greater detail in the next section.

McColl-Kennedy et al. (2012, p. 370) define customer value co-creation as a “benefit realized from integration of resources through activities and interactions with collaborators in the customer’s service network.” Table 2 summarizes the co-creation motives (Neghina et al., 2014) that are the healthcare service users’ “why” for their participation in the first co-creation experience.

Service-dominant logic (S-D logic) provides a foundation for understanding value co-creation in healthcare by emphasizing interaction, resource integration, and reciprocal value creation between service providers and users (Vargo and Lusch, 2004, 2017). However, its application in healthcare has largely assumed that service users are willing and able to participate actively in co-creation processes. This assumption does not fully capture the context of healthcare characterized by professional authority, asymmetrical expertise, and patient vulnerability. As a result, S-D logic offers a limited explanation for observed differences in healthcare service user engagement across cultural contexts. Addressing this limitation requires extending S-D logic to incorporate how culturally embedded expectations regarding authority, autonomy, and uncertainty shape value co-creation dynamics.

Physiotherapy service is characterized by relatively high potential for value co-creation and SD-logic, as the recovery heavily depends on the healthcare service user performing exercises at home. Thus, the healthcare service user actively and consciously co-creates the value of the physiotherapy treatment. In comparison, in a trauma scenario in an emergency room, there is neither the time for the communication phase nor is the healthcare service user in a mental and physical condition to actively participate through communication during the healthcare treatment. Consistent with the expectancy theory (Mitchell, 1974; Vroom, 1964), value co-creation activities represent the expected values derived from the interaction, which are translated into motives to engage in co-creation. SD-Logic emphasizes the importance of interaction and the exchange of knowledge, skills, and technological innovations. Therefore, (See Figure 2 below) the underlying healthcare service user’s cultural attitudes drive their willingness to engage in value co-creation processes (Osei-Frimpong et al., 2018; Vespestad and Clancy, 2019; Peltier et al., 2020).

The six motivations for value co-creation presented above have been suggested as critical drivers of value co-creation behaviors in various industries (Karpen et al., 2012; Neghina et al., 2014; Bhatti et al., 2021). However, future research studies should account for differences in customers' propensity to actively engage in value co-creation, as well as consider relationship dynamics and attitudes toward authority, which we discuss in the following section. In what follows, we elaborate on how insights from the healthcare service literature can complement the S-D logic. In particular, we propose that the dynamics of medical expert-healthcare service user interaction will affect the expectations of value co-creation (P1) and healthcare service user involvement regarding the types of value co-creation behaviors healthcare service users want to adopt (P2). Value co-creation happens within service-systems, which, are driven by social norms, politics, laws, and regulations that govern healthcare systems (Vargo and Lusch, 2018). Thus, in what follows, we take a more specific look at the role of culture in shaping the relationship dynamics.

Taken together, the reviewed literature highlights unresolved tensions concerning authority, autonomy, and uncertainty in healthcare service interactions. The following propositions are developed to address these tensions and discuss how cultural values and relationship dynamics jointly shape healthcare service users’ value co-creation motives and behaviors. More specifically, existing healthcare research acknowledges differences in patient engagement but offers a limited explanation of how expectations regarding decision-making authority are formed. Relationship dynamics are often treated as outcomes rather than explanatory mechanisms, leaving a gap in understanding how different relationship models shape healthcare service users’ willingness to engage in value co-creation and the degree of such engagement. To address this gap, we theorize relationship dynamics as a central mechanism translating authority expectations into engagement behaviors.

The relationship dynamics between the healthcare service provider (medical expert or physician) and the service recipient (healthcare service user) influences the healthcare service user’s expectations and willingness to participate in the value co-creation process (Cossío-Silva et al., 2016). To account for the specific relationship dynamics in healthcare, the study integrates Emanuel and Emanuel’s (1992) model of the healthcare service provider-healthcare service user relationship. This model identifies four modes: paternalistic, informative, interpretive, and deliberative, which vary based on the degree of collaborative care and healthcare service user-centrism (Emanual and Emanuel, 1992) as presented in Table 3. These relationships should be viewed as a continuum, ranging from paternalistic to deliberative, with an increasing degree of collaborative care and healthcare service user-centered service.

The paternalistic relationship mode is expert-centered, characterized by top-down decision-making and limited expectations for value co-creation among the involved parties. The deliberative relationship mode is the most healthcare service user-centered and characterized by high expectations of value co-creation from both actors (Emanuel and Emanuel, 1992).

Prior studies distinguish passive and active co-creation behaviors, but do not explain how relationship dynamics shape service users’ propensity to engage in each. However, as we argue, we should differentiate between these degrees of involvement, as the healthcare service user's propensity to passively or actively engage in co-creation is influenced by the dynamics of healthcare service provider and healthcare service user interaction. Thus, more passive behaviors correspond with paternalistic relationship dynamics, whereas more active behaviors correspond with informative relationship mode (Emanuel and Emanuel, 1992; Vargo et al., 2020). Therefore, we propose the following.

Propositions 1–2 present relationship dynamics as the key mechanism through which expectations about authority and decision-making translate into healthcare service users’ engagement extent, shaping whether co-creation unfolds through passive compliance or active participation. The model can be further complemented to provide a more nuanced understanding of the impact of relationship dynamics on co-creation when we consider insights from the cross-cultural literature. Thus, in what follows, we elaborate on how the expectations and preferences regarding the relationship dynamics between the healthcare service provider and healthcare service user are influenced by the cultural value orientation of power distance, which reflects attitudes toward inequality, authority, and expertise.

Although power distance has been widely used to explain communication patterns in healthcare, its role in shaping co-creation expectations has not received due attention. Previous studies revealed that there are significant differences in deference to medical authority across cultures, but do not theorize how these differences fundamentally alter preferred relationship dynamics and engagement. This gap obscures the cultural foundations of healthcare service user participation.

As a cultural value orientation, power distance (PD) reflects societal attitudes toward inequality, authority, and experts (Hofstede, 2001). PD is defined as “the extent to which the less powerful members of institutions and organizations within a country expect and accept that power is distributed unequally” (Hofstede et al., 2010, p. 61). High-PD cultures accept inequality as a natural order of the world, while low-PD cultures seek equality (House et al., 2004). These two opposites represent a continuum of societies with varying degrees of acceptance of inequality (Hofstede, 2001). For example, people in high PD cultures expect the decisions to be made top-down and do not expect to be consulted or asked about their opinions. On the other hand, in low PD cultures, even relationships between supervisors and subordinates or parents and children are based on equality and interdependence, which results in people in these cultures expecting collaborative decision making (House et al., 2004; Hofstede et al., 2010).

PD is relevant to this study because this cultural value affects the relationships between medical experts and healthcare service users, as well as their expectations of mutual behavior during the healthcare treatment process (Chwialkowska et al., 2022; Hofstede, 2001; Hofstede et al., 2010). Therefore, it impacts the expected roles in the interaction and treatment motivations. In high PD cultures, medical experts spend less time with each healthcare service user as both parties perceive the hierarchical distance as significant (Goodyear-Smith and Buetow, 2001). They share less information with the healthcare service user than in low PD cultures (Meeuwesen et al., 2009). The healthcare service provider controls the interaction and is treated as a superior and a knowledge owner. The subordinate (healthcare service user) is expected to follow directions without questions, just as a subordinate would follow a manager in an enterprise (Hofstede et al., 2010). People in high PD cultures do not expect the consultation time to be spent building rapport or an emotional connection between the two actors in this exchange (Meeuwesen et al., 2009; Goodyear-Smith and Buetow, 2001).

On the other hand, in low PD cultures, the two actors are considered equals (Hofstede, 2001), more time is spent on consultation, and the medical experts share more information with their healthcare service users (Meeuwesen et al., 2009). Healthcare service users are expected to actively participate in the communication, consultation, treatment and feedback process (Mead and Bower, 2000; Hofstede et al., 2010). Figure 3 shows how PD influences expectations and preferred relationship dynamics between the expert and healthcare service user’s (and experts’) attitudes toward inequality and authority.

Therefore, the degree of PD (Hofstede, 2001) impacts the preferred relationship dynamics style (Emanuel and Emanuel, 1992) between the healthcare service provider and the healthcare service user. Emanuel and Emanuel’s (1992) paternalistic relationship dynamics align with healthcare service users' expectations in high PD cultures, as these cultures rely on authority, expert opinion, and top-down decision-making. On the other hand, the deliberative relationship dynamics will be most prevalent in low PD cultures, which expect decisions to be made collaboratively and where both the healthcare service user and the healthcare service provider are responsible for the well-being of the healthcare service user and the success of the treatment. Consequently, the increasing extent to which the two actors engage in value co-creation activities corresponds to lower levels of power distance.

Therefore, as power distance affects the expectations and preferred relationship dynamics between the expert and healthcare service user (service recipient), we propose:

Proposition 3 discusses how power distance operates as a cultural mechanism that structures perceived legitimacy of authority, thereby predisposing healthcare service users to accept paternalistic or expect deliberative relationship dynamics during the service interaction.

Next, we discuss how co-creation motives identified by Neghina et al. (2014) and Karpen et al. (2012), i.e. individualizing, relating, and developmental motives, are influenced by healthcare service user’s self-concept and autonomy reflected in the cultural value dimension of individualism versus collectivism (Hofstede et al., 2010).

In the existing research on individualizing, relating, and developmental motives, there is a tension between autonomy-centric models of engagement and empirical findings showing limited personalization or knowledge-seeking behavior in many healthcare contexts. While past studies report cross-national differences, they rarely discuss what are the cultural mechanisms through which self-concept and autonomy norms shape our motivations to co-create. Without theorizing this, we lack the understanding of the reasons behind the contradictory findings.

The cultural values of individualism and collectivism pertain to how an individual’s self-concept and autonomy depend on their group membership (Hofstede et al., 2010). Previous service literature has established that cultural values, including individualism-collectivism (Hofstede, 2001), influence service recipient satisfaction and, most notably for this study, the beliefs and expectations regarding the service (Mattila and Patterson, 2004; Chen et al., 2015; Lamb et al., 2020; Mai et al., 2020; Li and Cai, 2012; Rahman, 2019). In the context of value co-creation, Bhatti et al. (2021) suggest that research should consider the cultural values of individualism and collectivism, and how they impact individualizing motives for co-creation. In addition, Chwialkowska et al. (2022) call for studies to consider the potential influence of these cultural values on related motives.

Individualistic and collectivistic cultures vary in their expectations of autonomy (Oishi et al., 1999). People in individualistic cultures expect to make independent decisions, whereas those in collectivistic cultures are more satisfied with decisions made by others (Iyengar and Devoe, 2003; Iyengar and Lepper, 1999). Moreover, these cultures define autonomy differently (Oishi et al., 1999). People in collectivistic societies often feel that they are making autonomous decisions when, in reality, they are following the advice of others and are more susceptible to interpersonal influences (Mourali et al., 2005; Bond and Smith, 1996). For example, using the word “no” or disagreeing with someone would be seen as a confrontation in collectivistic cultures (Hofstede et al., 2010).

On the other hand, people in individualistic societies tend to seek self-expression and make decisions independently (Chen et al., 2015). Not speaking one’s mind would be considered dishonest in these cultures (Hofstede et al., 2010). Individualistic cultures also believe that individuals are capable of assessing their circumstances and the consequences of their intended actions (Mai et al., 2020) and thus know what is best for themselves. In collectivistic cultures, one’s social network is the primary source of important information, whereas people in individualistic cultures also seek other sources of knowledge outside their social network (Hofstede et al., 2010). The latter also emphasized the importance of asking questions in educational settings and continued learning across later life stages (Hofstede et al., 2010). This is most relevant for healthcare service users' propensity to seek individualizing and developmental co-creation goals (individualistic cultures). On the other hand, healthcare service users relying on the advice of others (collectivistic cultures), including the medical expert, will not seek to customize their treatment plan. In contrast, those who want to be in charge of making decisions and believe they know what is best for themselves (individualistic cultures) will be motivated by individualizing co-creation goals and developmental goals to make a more informed decision. Therefore, we propose the following:

The cultural values of individualism and collectivism also influence how much people value personal interactions (Marcus and Le, 2013; Mourali et al., 2005; Oyserman, 1993). While people in individualistic cultures value their independence, those in collectivistic societies often rely on interpersonal relationships for their life satisfaction (Uchida and Kitayama, 2009; Uchida et al., 2004). While people in individualistic cultures perceive themselves as unique and separate from others, and engage in voluntary relationships, those in collectivistic cultures emphasize group membership (Mai et al., 2020) and often have predetermined relationships (Hofstede et al., 2010). Moreover, people in individualistic (collectivistic) societies are encouraged (discouraged) to present themselves as happy, but are discouraged (encouraged) from displaying sadness (Matsumoto, 1989; Markus and Kitayama, 1991; Watkins and Liu, 1996; Oyserman et al., 2002). This is most relevant for healthcare service users' propensity to seek related co-creation goals. Healthcare service users who rely on their group identity for self-worth are more likely to share their value co-creation experiences with others.

In contrast, those in individualistic cultures perceive engaging in healthcare treatment as a personal experience that does not support their self-enhancement motives. For instance, Bhatti et al. (2021) demonstrate that physiotherapy healthcare service users in Germany (a country with an individualistic culture) prefer to keep their co-creation experience private from other healthcare users. These results were echoed by the study by Chwialkowska et al. (2022, p. 20) on U.S. healthcare service users (individualistic culture), who write that the insignificance of the related motives “can be attributed to a very personal nature of physiotherapy and well-being and healthcare users not wanting to disclose such intimate information on social media, which are generally used for self-promotion and self-enhancement in terms of image building.” Therefore, we propose the following:

Propositions 4-6 explain how culturally embedded conceptions of the self and autonomy activate different co-creation motives by shaping whether healthcare service users interpret engagement as a personal decision-making task or a socially embedded relational obligation.

In what follows, we discuss the remaining co-creation motives identified by Neghina et al. (2014) and Karpen et al. (2012), i.e. empowering, ethical, and concerted motives, and how they are influenced by the cultural value dimension of uncertainty avoidance (Hofstede et al., 2010), which reflects healthcare service users’ tolerance of ambiguity.

Existing research acknowledges that healthcare involves uncertainty, yet we lack understanding of how that tolerance for ambiguity influences engagement behavior. Studies emphasize ethical concerns, desire for coordination, or demands for empowerment, but treat these motives independently. A coherent theoretical account is needed to explain how uncertainty avoidance shapes engagement as a strategy for anxiety regulation in healthcare interactions.

Chwialkowska et al. (2022) call for studies to consider the potential influence of uncertainty avoidance (UA) on concerting and ethical motives to co-create value. The cultural value of UA relates to differences in “tolerance of the ambiguous and the unpredictable,” defined as “the extent to which the members of a culture feel threatened by ambiguous or unknown situations” (Hofstede et al., 2010, p. 189, 191). Low UA cultures accept ambiguity as a normal part of life, whereas high UA cultures meet such uncertainty with anxiety (Hofstede, 2001).

Previous research suggests that this cultural value has implications for healthcare (Hofstede et al., 2010; Neghina et al., 2014). For example, in high UA cultures, more time is spent building rapport between the healthcare service user and the medical expert, who is more attuned to recognizing various warning signs (Meeuwsen et al., 2009). Moreover, people in high UA cultures prefer more structured activities with detailed schedules and precise objectives (Hofstede et al., 2010). This is particularly relevant to healthcare user propensity to engage in value co-creation for concerted motives, as people in these cultures tend to seek structure (House et al., 2004; Hofstede et al., 2010). Thus, not acting concertedly, as outlined in the procedures, would introduce too much ambiguity in a high UA context. On the other hand, people in low UA cultures are more comfortable acting spontaneously and without a script (Hofstede, 2001).

This cultural dimension is also relevant to ethical co-creation motives. To decrease perceived uncertainty, cultures with high UA establish rules, laws, and policies, and people expect that these rules will be respected (Ho et al., 2012; Hofstede et al., 2010). They also tend to be more suspicious of others as children learn that the world is a hostile place full of threats (Hofstede et al., 2010). Moreover, many of their consumption decisions are influenced by ethical motives (Special Eurobarometer, 2008). Even though high UA cultures have many formal rules, this could be explained by that. They are frequently not followed, as stringent regulations often result in lenient practices and increased corruption (Rallapalli et al., 1994; Hofstede et al., 2010). Thus, a fear of the expert not following the ethical rules might prompt the healthcare service user to “supervise” the treatment to ensure that any ethical guidelines are followed.

Expressing negative emotions is also more accepted in high than low UA cultures (Hofstede et al., 2010). Thus, individuals in high UA societies will actively seek to provide feedback, feeling in charge of their experience. In high UA cultures, people are also more attuned to their health and expect medical drugs to be prescribed even for conditions not considered a disease in low UA cultures (Payer, 1989; Hofstede et al., 2010). People in high UA cultures also take proactive actions to reduce anxiety (Chwialkowska et al., 2020; Choi and Bazarova, 2015; Goodrich and de Mooij, 2013). This is relevant for healthcare service user propensity to engage in value co-creation for empowerment motives. They can also reduce their anxiety by taking concerted actions and engaging in value co-creation for ethical motives, ensuring that all guidelines are followed. Therefore, we propose the following:

Propositions 7-9 deal with how Uncertainty avoidance functions as an anxiety-regulation mechanism that strengthens the motivation of healthcare service users’ to seek structure, oversight, and control through ethical, concerted, and empowering co-creation behaviors.

The next section focuses on interpreting how the proposed framework advances theory and resolves prior inconsistencies in the existing literature.

This study advances healthcare service research by responding directly to theoretical tensions identified in the existing literature. By integrating culture, relationship dynamics, and co-creation motives, our framework explains why healthcare service user engagement varies across contexts and why co-creation motives produce inconsistent empirical findings. Existing studies yielded contradictory findings regarding the importance of value co-creation motives across different countries. Following prior calls, our framework incorporates individualism–collectivism, power distance, and relationship dynamics to explain differences in healthcare service user engagement across cultural contexts.

To further increase our understanding of the cultural influences on healthcare user propensity to co-create value and the motives and expectations that drive both passive and active value co-creation behaviors, we conceptualize (Figure 4), a model of cultural influences on value co-creation in the context of well-being experiences. To achieve this, the research draws on a range of disciplinary perspectives. We integrate the S-D logic (Vargo and Lusch, 2004) and the typology of co-creation interaction motives (Karpen et al., 2012; Neghina et al., 2014) with the cultural framework of Hofstede (2001) and the relationship dynamics model from healthcare literature (Emanuel and Emanuel, 1992). By incorporating these interdisciplinary insights, we help advance value co-creation research by highlighting how culture and relationship dynamics impact the significance of value co-creation motives across cultures. By doing so, we advance the discussion of our understanding of what drives value co-creation in different cultural settings.

Viewed against the existing healthcare value co-creation literature, the framework developed in this study offers a way to reconcile several persistent inconsistencies rather than adding another set of isolated explanations. Existing research either portrays a healthcare service user as an increasingly active co-creator (e.g. McColl-Kennedy et al., 2017a, b) or as mostly constrained by professional authority and institutional structures (e.g. Goodyear-Smith and Buetow, 2001). Moreover, while studies grounded in service-dominant logic emphasize participation as a normative ideal, empirical findings repeatedly demonstrate stark differences in engagement intensity and motive salience across healthcare contexts and cultural origins of subjects (Bhatti et al., 2021; Chwialkowska et al., 2022; Neghina et al., 2017). Our framework suggests that these discrepancies are to a large extent a reflection of culturally embedded expectations of authority, autonomy, and uncertainty that shape healthcare relationships. Thus, we argue that engagement motives and behaviors are not universally activated but become salient only when they are in alignment with culturally informed relationship norms and expectations. Therefore, the same co-creation practice could foster empowerment and collaboration in one healthcare setting, but generate discomfort, passivity, or resistance in another.

Table 4 summarizes the proposed propositions by highlighting their underlying mechanisms and clarifying their theoretical contributions, illustrating how national culture and relationship dynamics jointly shape healthcare service user engagement.

Taken together, Propositions 1–9 demonstrate how healthcare service users’ engagement in value co-creation is shaped by culturally embedded expectations regarding authority, autonomy, and uncertainty. Specifically, the framework shows how relationship dynamics influence the type and intensity of co-creation behaviors, and how national cultural values condition the salience of different co-creation motives. Rather than treating engagement as a uniform or purely individual-level phenomenon, the propositions highlight the joint role of culture and relationship dynamics in shaping active and passive participation in healthcare service interactions.

This study contributes to healthcare service and organization research by advancing a set of theoretically integrative propositions that move beyond treating healthcare service user engagement as a uniform or purely individual-level phenomenon. Rather than offering isolated associations, the propositions collectively articulate how cultural values shape engagement motives through relationship dynamics and expectations about authority, autonomy, and coordination.

We make several contributions to the existing value co-creation literature. First, we integrate insights from the healthcare service provider and healthcare service user relationships (Emanuel and Emanuel, 1992) within the S-D logic framework (Vargo and Lusch, 2004; Karpen et al., 2012; Neghina et al., 2014). Previous value co-creation research treated healthcare service users as a single undifferentiated segment and did not account for the fact that the relationship dynamics between healthcare service users and medical experts are heavily influenced by culture. The four relationship dynamics modes (Emanuel and Emanuel, 1992) presented in this paper vary in the degree of healthcare service user - and expert-centrism. Thus, they determine the expectations of healthcare service users and experts regarding mutual behavior in this exchange process. These expectations are internalized as social and behavioral norms (Ajzen, 1991, 2002). They also shape the expectations about healthcare service users' active involvement in the treatment process and the expectations of the medical expert’s role and obligations.

Consequently, our study contributes to the literature by advancing the value of co-creation literature in terms of the impact of culture, thereby increasing the predictive power of S-D logic. In addition, we shed light on potential reasons behind contradictory findings in academic healthcare research by Bhatti et al. (2021) and Chwialkowska et al. (2022). We propose that future research test the model of cultural influences on value co-creation related to healthcare services and the well-being experience of the healthcare service users through quantitative empirical studies in countries representing different levels of uncertainty avoidance, power distance, and individualism-collectivism.

Propositions 1–3 make a distinctive contribution by positioning healthcare service provider–user relationship dynamics as a central explanatory mechanism linking national culture with engagement behaviors. This shifts the analytical focus from patients’ willingness to participate to the relational and organizational conditions under which participation is enabled or constrained, thereby extending prior healthcare engagement research that has largely overlooked cultural variation in authority expectations. Propositions 1–3 extend healthcare service research by theorizing relationship dynamics as a mechanism through which organizational and cultural contexts shape engagement, rather than treating patient participation as an individual-level disposition.

This framework extends service-dominant logic by specifying how cultural context conditions healthcare value co-creation. Propositions 4–9 contribute to this discussion by specifying how different cultural dimensions systematically condition the salience of co-creation motives, helping to resolve contradictory empirical findings in prior cross-national studies. By theorizing culture as a contextual boundary condition rather than a background variable, these propositions clarify why identical engagement practices may be effective in some healthcare settings but ineffective or even counterproductive in others.

In terms of future research directions, taken together, propositions 1–9 provide a structured agenda for future empirical research at the intersection of national culture, relationship dynamics, and healthcare service engagement. The propositions specify theoretically grounded mechanisms that can be examined using multilevel and cross-national research designs, including moderation models in which cultural value dimensions shape the relationship between healthcare service provider–user interaction modes and co-creation behaviors. In particular, the framework invites empirical testing at the micro level of service encounters, while accounting for macro-level cultural contexts, thereby enabling researchers to move beyond treating patient engagement as a universal construct. By delineating distinct clusters of propositions related to authority, autonomy, and uncertainty management, the model also offers a basis for developing context-sensitive measurement instruments and comparative studies across healthcare systems.

Although most prominent, we are aware of the conceptual limitation of Hofstede’s cultural dimension model (Hofstede, 2001). Critics argue that IBM’s corporate culture might have influenced the results of Hofstede’s study concerning national cultures. The Hofstede model tends to ignore subcultures, ethnic diversity, and regional differences, e.g. the difference between Northern and Southern Italy or Eastern versus Western regions in Germany) (McSweeney, 2002). Consequently, as a follow-up to our research, we invite scholars to deepen this theoretical discussion as well as to initiate empirical studies, addressing S-D logic and culturally biased value co-creation processes in the healthcare industry. Alternatively, as not considered in our current study, due to its research design complexity, further studies shall address whether the dimension of masculinity vs. femininity (Hofstede, 2001) is relevant in this context.

In terms of managerial implications, Propositions 1–9 provide a theoretically grounded basis for differentiating engagement strategies across healthcare organizations serving culturally diverse populations. In high power-distance contexts, healthcare organizations may need to prioritize clear professional roles, structured guidance, and reassurance, recognizing that expectations for active co-creation are shaped by authority norms. In contrast, in low power-distance and individualistic contexts, organizations can design care pathways that explicitly support shared decision-making, personalization, and skill development. In high uncertainty-avoidance settings, healthcare organizations may benefit from reinforcing ethical transparency and procedural clarity rather than relying solely on empowerment initiatives. Overall, patient engagement should be viewed as an organizational capability that must be configured in alignment with cultural context and relationship governance.