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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 841-846
Modeling the brand loyalty of medical services in Iran's Military Hospitals


1 Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 Department of Health Management, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran
3 Health Management and Economics Research Center, University of Medical Sciences, Tehran, Iran
4 Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran

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Date of Web Publication5-Oct-2017
 

   Abstract 


Introduction: Due to growing competition among health-care institutions and increasing expectations of caregivers, hospitals need to strengthen their competitive advantages. This study aimed to determine the Dimensions of patients' loyalty in military hospitals of Tehran, Iran in 2016. Materials and Methods: A cross-sectional, analytical study was conducted among patients receiving health-care services in military hospitals affiliated by Baqiyatallah University of Medical Sciences in 2016. The survey instrument was a self-administered questionnaire included 28 questions categorized into seven sections of service quality, satisfaction, commitment to relationship, respect to patients' rights, brand trust, loyalty, and value. Collected data were analyzed using LISREL 8.8 software through structural equation modeling. Results: Analysis findings reported all fitness indices related to factor analysis of study variables in an acceptable level and affirmed the theoretical model of the research. Results revealed positive relationships between some of the constructs. The path coefficient between service quality and loyalty was (0.76) showing a positive relationship between two variables. The coefficient related to the association between brand trust and loyalty (0.5) also affirmed a positive relationship between variables (t > 1.96). Discussion: To satisfy customers and develop a competitive advantage for health-care institutions, it is suggested to improve the quality of healthcare services, focus on promoting professional skills and experience among health-care providers, compliance with ethical issues and patients' rights and generally try to develop their competitiveness by effective utilization of existing resources.

Keywords: Brand loyalty, medical service, patient

How to cite this article:
Yaghoubi M, Rafiei S, Alikhani M, Khosravizadeh O. Modeling the brand loyalty of medical services in Iran's Military Hospitals. Ann Trop Med Public Health 2017;10:841-6

How to cite this URL:
Yaghoubi M, Rafiei S, Alikhani M, Khosravizadeh O. Modeling the brand loyalty of medical services in Iran's Military Hospitals. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 17];10:841-6. Available from: http://www.atmph.org/text.asp?2017/10/4/841/215848



   Introduction Top


Due to growing competition among health-care institutions and increasing expectations of caregivers, hospitals need to strengthen their competitive advantages through recognition and proper fulfillment of consumers' attitude, values, and needs.[1] Thus, promoting effective relationships with caregivers would consequently bring about their loyalty and acts as the main factor of market survival.[2] In fact, good service quality provided for patients leads to strong relationship between providers and customers which ultimately creates user loyalty and satisfaction.[3] Such well-built relations over time not only maintain sufficient number of consumers for the hospital but also allow providers to recognize patients' expectations and make efforts to achieve them.[4] Customer loss and try to attract new ones are a costly process while investment on maintaining current consumers and catch the attention of new ones through improving hospital image are both low-cost and quick return. Satisfaction is the main direct cause of loyalty. To this fact, service providers try to understand and meet customers' expectations in a most effective way.[5],[6] Therefore, provision of health-care services has got an utmost importance due to the nature of services and the need to achieve highest level of quality.[7] Furthermore, hospitals and health-care organizations have different types of customers who often experience considerable physical or mental weaknesses and require more special attention and specialized services.[8] These factors confirm the necessity of more concentration on patient satisfaction and fulfillment of needs to gain patients' loyalty.[7] Brand loyalty is defined as “positive feelings toward a brand and dedication to purchase the same product or service repeatedly from the same brand regardless of changes in the environment.”[9] Some benefits are achieved from brand loyalty which mainly includes acceptance of provided services, attracting new consumers willing to pay high prices, and specifically retaining existing customers with long-term loyalty who need much less time and money to be served for their maintenance.[10] Factors which affect patient loyalty in health-care institutions are not the same as other industries. Sehhat et al. (2014) declared that loyalty toward hospital brand is significantly related to customer satisfaction, brand trust, and commitment to the relationship. Literature also emphasized on the importance of other factors including brand quality, image, and equity. Strong physician-patient communication builds a trusting relationship which decreases patients' concern and makes them feel safe.[11]

Another important factor which influences patients' loyalty for repurchasing health-care services and recommends it to others is patients' satisfaction. Nugraheni and Purnomo stated that patients' satisfaction can be improved through developing the quality of health services.[12] Oliver examined the relationship between satisfaction and brand loyalty and confirmed a positive relationship between two variables. He added that if consumers feel displeased with service quality, they would more probably stop using the relevant brand and complaint about it.[13] In another study, Simsek and Noyan confirmed that consumer satisfaction, trust and quality of provided services could affect loyalty and perceived value. Researches done in this respect concluded that satisfaction is not the only influencing factor on loyalty but also attention should also be paid to other affecting factors.[14]

Provision of higher quality services constantly meets patient expectations and brings about a good reputation for the hospital which increases patients' loyalty. Sidharta and Suzanto concluded that health services quality verifies patients' satisfaction.[15] Tarus and Rabach added that service quality is positively linked to patient loyalty as is critical to customers.[16] Similarly, Boshoff and Gray examined the association between loyalty, service quality, and patients' satisfaction in private health-care industry of South Africa. They affirmed that quality dimensions of services affect patients' loyalty.[17]

Brand trust is defined as “the willingness of consumer to rely on the ability of the brand to perform its stated function.” Chaudhuri and Holbrook mentioned trust as an influencing factor on loyalty which also affected consumers' satisfaction.[18] Yoon and Kim also confirmed the positive association between trust and satisfaction. He declared that customer satisfaction is difficult without making trust in them.[19]

Despite the importance of the subject, a few studies have conducted in the health sector to investigate affecting factors on brand loyalty. To gather further information in this regard, we aimed to determine the effects of brand quality, satisfaction, trust, and commitment to relationship on patients' loyalty in Military Hospitals of Tehran, Iran, in 2016.


   Materials and Methods Top


To address research objectives, a cross-sectional, analytical study was done among patients receiving health-care services in military hospitals affiliated by Baghiatollah University of Medical Sciences in 2016. To construct the questionnaire, a comprehensive literature review was done in databases of Scopus, PubMed, Google Scholar, IranMedex, SID, and Magiran with keywords including brand loyalty, influencing factors, patients' satisfaction, service quality, and hospital. A self-administrated questionnaire was used to gather data on study questions. The first part was consisted of questions about patients' demographic characteristics, and the second part included 28 questions categorized into seven sections of service quality, satisfaction, commitment to relationship, respect to patients' rights, brand trust, loyalty, and value. Items were measured using a 5-point Likert scale (from 1, strongly disagree to 5 strongly agree). The independent variables in the study were service quality, brand trust, satisfaction, and commitment to relationship while the dependent variable was loyalty. Service quality domains included in the research had five main dimensions: prompt and appropriate service provision, physical environment, medical equipment, respect to patient's rights, and experienced clinical professionals. Brand trust variable consisted of three domains: Equity inpatient admission and giving treatment, honesty of hospital staff, and feeling security while receiving medical care. Satisfaction domain of the questionnaire included main dimensions including appropriateness of diagnostic, medical and paramedical services, properness of administrative and financial services (admission, discharge, etc.) and suitability of hospital welfare services. Finally, commitment to relationship domain was consisted of questions about patient-provider communication, follow-up patients' health status after discharge, and active patients' participation in therapeutic processes. Loyalty variable also included some questions focusing on patient's willingness to recommend hospital to others, giving priority to hospital as a premium brand, and tendency to readmit in a hospital when necessary. After designing the first draft of questionnaire, its face validity was checked by a group of experts. Construct validity was also tested by correlation Pearson product moment. As all questionnaire items got correlation coefficient more than 0.3, the validity index was approved. The questionnaire reliability was also calculated by Cronbach's alpha (0.98).

The questionnaires were distributed among patients who admitted to study hospitals in a period of April to June 2016. Knowing the number of research population, sample size was calculated to be 378 patients who were included in this study through simple randomized method. Data were analyzed using LISREL 8.8 software through structural equation modeling (SEM).


   Results Top


Demographic characteristics of patients participating in the research are shown in [Table 1]. As data confirm, most of the participants were female (63%), married (85%), in the age group of 21–30 years old (31.5%) with diploma degree of education (37%) and income level between 10 and 20 million Rials (53.7%). Almost half of the patients already admitted in hospital. [Table 1] also indicates that among different demographic characteristics, only educational level, insurance coverage, history of admission, and length of stay had statistical significant relationship with brand loyalty (P < 0.05).
Table 1: Demographic characteristics of study participants and its relationship with brand loyalty

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First, measurement model was checked for validity and reliability. Analysis findings reported all fitness indices related to factor analysis of study variables in an acceptable level and affirmed the theoretical model of the research and fitness of collected data [Table 2].
Table 2: Fitness indices of the model and their level of acceptance

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The model of patient loyalty to study hospitals was analyzed using SEM. [Table 3] depicts the path coefficients of the model. Results revealed positive relationships between some of the constructs. The path coefficient between service quality and loyalty was (0.76) showing a positive relationship between two variables. The coefficient related to the association between brand trust and loyalty (0.5) also affirmed a positive relationship between variables (t > 1.96). Another positive relationship was seen between loyalty and brand value (0.95) which related t-value indicated the mentioned relationship to be significant. As data are shown in [Table 3], other relationships between latent variables and brand loyalty were not accepted.
Table 3: Path coefficients, t-statistics, and results

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[Figure 1] shows the significant level of confirmatory analysis of the variable brand loyalty. As results are observed, all paths except for the relationship between commitment to relationship and loyalty are at a significant level (t > 1.96). Thus, internal correlation between the aspects is significant.
Figure 1: Significant level of brand loyalty factor analysis

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[Figure 2] shows the estimated standard factor analysis of brand loyalty model, in which the standard coefficients of relationships between brand loyalty and its related factors were analyzed. As also depicted in [Table 3], service quality and brand trust were relatively responsible for 75%, and 50% of changes occurred in brand loyalty. In addition, brand loyalty was accountable for 95% of changes in brand loyalty.
Figure 2: Measurement and structural equation modeling results

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   Discussion Top


Research tried to find out factors influencing patients' loyalty to study hospitals. Findings revealed that patients' experience with respect to military hospitals' services had strong effect on outcome variable of loyalty and desire to reuse hospital services or recommend them to others. Results of the study added that tendency to be readmitted in the same hospital was influenced by the quality of provided services, patients' satisfaction, patient-provider communication, and trust to hospital brand. As service quality dimension was verified the most important factor affecting patient's loyalty, the military hospital managers should pay special attention to providing quality services along with raising the level of customer trust to hospital. Similarly, literature confirmed that quality services had a substantial impact on patient's loyalty. In fact, caregivers expect effective, appropriate, and timely services with the highest level of skills and expertise. Therefore, to meet patients' needs and assure their loyalty, hospitals need to emphasize on providing services in consistent with identified needs.[20]

Literature also proved the impact of other dimensions on consumer loyalty. Many studies revealed a direct relationship between satisfaction and loyalty. They pointed that satisfied patients become loyal while those displeased with provided services stop receiving medical services from previous care providers.[21] Researchers emphasized that to improve patient's loyalty; service providers should simultaneously consider two key factors, namely, service quality and patients' satisfaction.[22] Naik et al. confirmed a positive relationship between service quality and satisfaction.[23] In this regard, Kotler found that satisfied patients would make long-term bonds with providers and through meeting customer needs at an acceptable level, health providers can benefit from patients' loyalty.[24] Dagger and O'Brien, Sheng and Liu, Norizan and Asiah verified the findings and emphasized on significant positive effect of satisfaction on customer loyalty.[25],[26],[27] Ramzi and Badaruddin believed that if hospitals want to improve their patients' loyalty and retain them as permanent clients, it is necessary to develop service quality by focusing on appropriate service provision, reliability, responsiveness, assurance and empathy.[28]

Studies believed that there are also other factors besides satisfaction and service quality which have definite effect on consumer loyalty. Trust to hospital and provided services are main factors which significantly establish loyalty among caregivers. Actually, a long-term effective relationship between providers and consumers would be impossible when there is no trust in between.[29] Literature affirmed the important role of trust as a key determinant factor which forms the commitment to patient-provider relationship. A direct significant association between customer trust and loyalty was approved by several researchers. They declared that satisfied clients show higher degree of trust and loyalty in consuming services.[30] Hospitals aiming to create a sense of trust in their customers should take advantage of strategies that strengthen the effective long-term relationships between patients and providers.[8]

Furthermore, commitment to relationship has been proved to be connected to customer loyalty. Chang et al. supported the idea and stated that appropriate patient-provider relationship positively affects service quality and patient satisfaction.[30] Similar studies agreed with the previous findings and revealed that effective communication both directly and indirectly affects patient's satisfaction. Some of them mentioned patient trust as an intervening variable and declared that the better communication skills among health workforce would lead to more patient trust and satisfaction.[31],[32] Boshoff and Gray determined the importance of patient-provider relationship and stated that effective communication between these two groups would result in patients' trust and consequently lead to their loyalty.[17] Based on findings, hospitals are suggested to improve communication skills among personnel to retain loyal patients and increase their competitive advantage.

There are some limitations regarding to the current study. Since research findings are mainly related to military hospitals in Tehran; the generalizing of the results should be done cautiously. Sampling the study participants from a single city may not fully represent the whole country population. Furthermore, we applied a cross-sectional study which was conducted in a particular period without considering factors with long-term effects. Thus, to resolve such limitations and obtain more inclusive statistical data, it is recommended to analyze multiple periods of data.


   Conclusion Top


Nowadays, there are a large number of health-care institutions in a limited health market which have made strong competition in medical care industry. Thus, hospital managers and decision makers should pay special attention to the issue and consider patients' loyalty as an important concept that needs planning to be driven into action. Customer loyalty is an indication of service quality, patient satisfaction, and trust which points the importance of efforts devoted by health-care organizations to develop loyalty through meeting patients' needs properly. As a result, how effectively respond patients' needs and expectations have got a special significance. To satisfy customers and develop a competitive advantage for healthcare institutions, it is suggested to improve the quality of health-care services, focus on promoting professional skills, and experience among health-care providers, compliance with ethical issues and patients' rights and generally try to develop their competitiveness by effective utilization of existing resources.

Acknowledgments

This article is a part of project supported by Baqiyatallah University of Medical Sciences with grant number of 2016-337. Researchers are grateful to thank all the colleagues, especially mangers and personnel of studied hospitals for their cooperation and efforts.a

Financial support and sponsorship

This study was supported by Baqiyatallah University of Medical Sciences, Tehran, Iran.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yaghoubi M, Rafiei S, Khosravizadeh O. A systematic review of factors influencing healthcare services marketing in Iran. Bali Med J 2017;6:268-78.  Back to cited text no. 1
    
2.
Szczepanska K, Gawron PP. Changes in approach to customer loyalty. Contemp Econ 2011;5:60-9.  Back to cited text no. 2
    
3.
Zeithaml VA, Bitner MJ. Service Marketing: Integrating Customer Focus across the Firm. 3rd ed. Boston: McGraw-Hill; 2004.  Back to cited text no. 3
    
4.
Sachdev SB, Verna HV. Relative importance of service quality dimensions: A multi sectoral study. J Serv Res 2004;4:93-116.  Back to cited text no. 4
    
5.
Ranaweera C. Are satisfied long-term customers more profitable? Evidence from tele communication sector. J Target Meas Anal Mark 2007;15:113-20.  Back to cited text no. 5
    
6.
Bodet G. Customer satisfaction and loyalty in service: Two concepts, four constructs, several relationships. J Retailing Consum Serv 2008;15:156-62.  Back to cited text no. 6
    
7.
Baird K. Customer Service in Health Care: A Grassroots Approach to Creating a Culture of Service Excellence. United States Wiley; 2000.  Back to cited text no. 7
    
8.
Rivers PA, Glover SH. Healthcare competition, strategic mission and patient satisfaction: Research model and propositions. J Health Organ Manage 2008;22:627-41.  Back to cited text no. 8
    
9.
American Marketing Association Dictionary. The Marketing Accountability Standards Board (MASB) Endorses this Definition as Part of Its Ongoing Common Language: Marketing Activities and Metrics Project. Available from: https://themasb.org/. [Last retrieved on 2011 Jul 09].  Back to cited text no. 9
    
10.
Punniyamoorthy M, Prasanna MR. An empirical model for brand loyalty measurement. J Target Meas Anal Mark 2007;15:222-33.  Back to cited text no. 10
    
11.
Sehhat S, Otoofi A, Yusefi A. Factors influencing patient loyalty to hospitals brands using SEM. J Health Dev 2014;2:285-95.  Back to cited text no. 11
    
12.
Nugraheni TP, Purnomo A. Analysis of patient satisfaction from service quality of outpatient hospital pharmacy in Setjonegoro Wonosobo. J Management and Pharmaceutical Services 2011;1:118-25.  Back to cited text no. 12
    
13.
Oliver R. Cognitive, affective and attribute bases of the satisfaction response. J Consum Res 2003;20:418-30.  Back to cited text no. 13
    
14.
Simsek GG, Noyan F. Brand loyalty on Turkey device in the mobile phone market. ODTU Development on Derg 2009;36:121-59.  Back to cited text no. 14
    
15.
Sidharta I, Suzanto B. Satisfaction of online shopping transactions and consumer confidence in the attitudes and behavior of consumers in e-commerce. J Computech Bisnis 2015;9:23-36.  Back to cited text no. 15
    
16.
Tarus DK, Rabach N. Determinants of customer loyalty in Kenya: Does corporate image play a moderating role? TQM J 2013;25:473-91.  Back to cited text no. 16
    
17.
Boshoff C, Gray B. The relationships between service quality, customer satisfaction and buying intentions in the private hospital industry. S Afr J Bus Manage 2004;35:27-37.  Back to cited text no. 17
    
18.
Chaudhuri A, Holbrook MB. The chain of effects from brand trust and brand affect to brand performance: The role of brand loyalty. J Mark 2001;65:81-93.  Back to cited text no. 18
    
19.
Yoon S, Kim J. An empirical validation of a loyalty model based on expectation disconfirmation. J Consum Mark 2000;17:120-36.  Back to cited text no. 19
    
20.
Prakash B. Patient satisfaction. J Coetaneous Aesthet Surg 2010;3:151-5.  Back to cited text no. 20
[PUBMED]    
21.
Heskett JL. Beyond customer loyalty. Manag Serv Qual Int J 2002;12:355-7.  Back to cited text no. 21
    
22.
Spreng RA, Mackoy RD. An empirical examination of a model of perceived service quality and satisfaction. J Retailing 1996;72:201-14.  Back to cited text no. 22
    
23.
Naik CN, Gantasala SB, Prabhakar GV. Service quality (SERVQUAL) and its effect on customer satisfaction in retailing. Eur J Soc Sci 2010;16:231-44.  Back to cited text no. 23
    
24.
Kotler P. Marketing Management. 10th ed. New Jersey: Prentice-Hall; 2000.  Back to cited text no. 24
    
25.
Dagger TS, O'Brien TK. Does experience matter? Differences in relationship benefits, satisfaction, trust, commitment and loyalty for novice and experienced service users. Eur J Mark 2010;44:1528-52.  Back to cited text no. 25
    
26.
Sheng T, Liu C. An empirical study on the effect of service quality on online customer satisfaction and loyalty. Nankai Bus Rev Int 2010;1:273-83.  Back to cited text no. 26
    
27.
Norizan K, Asiah AN. The effect of perceived service quality dimensions on customer satisfaction, trust, and loyalty in ecommerce settings: A cross cultural analysis. Asia Pac J Mark Logist 2010;22:351-71.  Back to cited text no. 27
    
28.
Ramzi AM, Badaruddin M. Customer loyalty and the impacts of service quality: The case of five star hotels in Jordan. Int J Hum Soc Sci 2010;5:13.  Back to cited text no. 28
    
29.
Yaghoubi M, Amiri Fini SH, Rahmati-Najarkolaei F. The Relationship between Customer Knowledge Management (CKM) on Customer Relationship Management (CRM) Tasks in a Military Hospital. J Mil Med 2017;18:308-15.  Back to cited text no. 29
    
30.
Chang CS, Chen SY, Lan YT. Service quality, trust, and patient satisfaction in interpersonal-based medical service encounters. BMC Health Serv Res 2013;13:22.  Back to cited text no. 30
[PUBMED]    
31.
Chenet P, Dagger TS, O'Sullivan D. Service quality, trust, commitment and service differentiation in business relationships. J Serv Mark 2010;24:336-45.  Back to cited text no. 31
    
32.
Singh J, Sirdeshmukh D. Agency and trust mechanisms in consumer satisfaction and loyalty judgments. J Acad Mark Sci 2000;28:150-67.  Back to cited text no. 32
    

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Correspondence Address:
Omid Khosravizadeh
Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_137_17

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