How the Intervention of Treatment Effectiveness and Patient Satisfaction Affects Patients' Behavioral Intentions in Relation to Perceived Service Quality

Recent developments in health care services have drawn significant attention for dealing with the effects of pandemics on patients' perceptions (Hernández-Peña, 2020; Paspuel et al., 2021; Shirazi et al., 2020; Tripathi & Siddiqui, 2020). Quality healthcare services have become an imperative phenomenon in both developing and developed countries. The developed countries reap the benefits of having unrivalled medical services in the form of a healthier population, while economically depressed countries struggle to raise the living standards of their citizens (Javed & Liu, 2018).

 

 Given the aforementioned factors, healthcare has remained a major issue in Southeast Asia. South-East Asia accounts for only 2% of global healthcare spending (Hernández-Peña, 2020). Previous empirical studies on service quality with a direct relationship and intervening variables (patient satisfaction, loyalty, customer gratitude, hospital image) are recommended for future research (Agyapong et al., 2018; Hasan et al., 2020; Ullah & Shabbir, 2020). Furthermore, active empirical studies have identified the role of treatment effectiveness and patient satisfaction in their intervention between perceived service quality and behavioral intentions (Nguyen & Nagase, 2021; Samyadip Chakraborty, 2021; Singh & Dixit, 2022).

 

Therefore, the need to explore the role of perceived service quality in designing patients’ behavior towards hospital services and business esteem is increasing day by day. However, the particular explanation of how perceived service quality affects the behavioral intentions of patients still needs to explore further. Research in this dimension is still at its initial level in Pakistan. As these dimensions are studied in other service sectors but not in the healthcare sector. So there is a room for further elaboration of this concept and to evaluate the contextual factors that play a distinguished role in affecting the behavioral intentions of patients with intermediation of patient satisfaction and treatment effectiveness.

 

The purpose of this study is to investigate how perceived service quality influences patients' behavioral intentions through the intermediation of treatment effectiveness and patient satisfaction. This study specifically investigates the relationships of PSQ with BI, PS, and TE, the association of PS with BI and TE, the relationship of TE with BI, and the mediation of PS and TE in the direct relationship of PSQ and BI. The study adds to the literature on service quality and behavioral intentions, with the intervening role of patient satisfaction and treatment effectiveness in Pakistan's public healthcare sector.

Healthcare delivery system in Pakistan remained is in progress from the day of its inception. The country has tried too much to improve the healthcare delivery system and brought out many reforms (Kurji et al., 2016). The goal of the "No one must be left behind" campaign is to lessen the health disparities and vulnerabilities that prevent people from reaching their full potential and threaten humankind as a whole. Given that human progress and well-being depend on good health, the government remained dedicated to enhancing population health by offering Universal Health Coverage (UHC) to all societal segments. The resources were diverted to stop the spread of the fourth and fifth waves of the pandemic, but COVID-19 had halted the significant advancements in the health sector. The Government successfully minimized the threat to the health system, people's lives, and their way of life through prompt procurement and a significant immunization effort (Ahmad et al., 2022).

 

Health subject was also transferred to the provinces with the 18^th constitutional amendment of 2011. Although it is evident from previous researches and government statistics, in Pakistan healthcare never remains a priority in last few decades which is apparent from low budget allocation for this sector in every successive financial year’s budget (Ahmad, 2021; M. Ali, 2017; Kurji et al., 2016; Safi et al., 2021; Shabbir et al., 2017).  However, many positive initiatives were being taken in the last year for improvement of healthcare service delivery and to achieve UHC, the Sehat Sahulat Card was introduced in order to lessen health inequity in the nation and improve everyone's well-being. To accommodate the rising demand for health services, the government also increased the number of hospitals, Rural Health Units (RHUs), Basic Health Units (BHUs), doctors, dentists, and dispensaries in 2022  as well as a rise in health sector budget allocation in every consecutive year is also noticed as shown in figure 1 (Ahmad et al., 2022).

 

Figure 1: Total Public Sector Health Expenditures

 

Source: Pakistan Economic Survey 2021-22

 

However, the scope of all of these programmes is quite limited, which is why Pakistan's healthcare system is still inefficient. The rising concern of population and the awareness towards their constitutional rights; the picture has now change and government is taking effective steps in lifting up the health service provision process. 

 

Service quality is the most widely discoursed topic in the literature of service marketing (Clottey et al., 2008; T. L. H. Nguyen & Nagase, 2021; Shirazi et al., 2020; Singh & Dixit, 2022). Service quality is defined as how well a service consistently meets or exceeds the expectations of its consumers (Aliman & Mohamad, 2013; Parasuraman et al., 1985). Perception is the process of observing and creating a sense of information. The analysis based conclusion of end user about the preeminence of service performance is known as perceived quality (Zeithaml et al., 1988). Therefore, in their groundbreaking paper of 1985, Parasuraman et al., proposed the SERVQUAL model which is the most extensively used conceptual model of service quality in quality research paradigm.

 

The positive association between service quality and consumers' behavioral intentions has piqued the interest of both academics and practitioners in service quality (Fullerton, 2003). Patient satisfaction can be regarded as a significant component and metric of care quality in the health-care industry (Lee, 2019; Salisbury et al., 2005). Patient satisfaction with medical care is a complex concept with dimensions that correspond to primary provider and service features (Kalhor et al., 2020; Ware et al., 1983).  It is the most important aspect of developing customer relationships, which is crucial for customer retention and increasing customer loyalty for value-added organizational performance (F. Ali et al., 2017; Hasan et al., 2020; Kim et al., 2017).

 

In the association of service quality and satisfaction treatment effectiveness holds a considerable importance to validate this relationship in medical service studies (Magill et al., 2010). The majority of studies focus on the overall services while ignoring the relationship between medical service-specific variables such as patient satisfaction and treatment effectiveness (Pakdil & Harwood, 2005). Treatment outcomes have an impact on the perceived service quality and ultimately patient-hospital relationship (Owusu-Frimpong et al., 2010).

 

Greater treatment efficacy may lead to better treatment-based interactions between the hospital and the patient, potentially leading to greater satisfaction (Ismail et al., 2017). Notwithstanding, for survival of the fittest and to keep a breast with the changing market needs, effective training of the hospital staffs and practitioners are the real time phenomenon that helps in ensuring the empathy and assurance for actualizing the patients revisiting behavior (Saad Ahmed Javed, 2016). Major goal of patients visiting healthcare facilities is to be treated and get treatment of an ailment. The likelihood of revisiting a hospital or recommending the facility to others is based on the effectiveness of treatment (Giovanis et al., 2018; Woodside et al., 1989). Behavioral intentions in terms of fidelity is often measured based on the inclination towards utilizing a product again (Saha & Theingi, 2009).

 

Between service quality and behavioral intentions, patient satisfaction operates as an intermediary (Hasan et al., 2020). The statistically substantial multiple mediation effect of perceived service quality and behavioral intentions on patients shows that in government healthcare, patient satisfaction influences  their behavioral responses to utilise and refer services in the future (Singh & Dixit, 2022). Increased treatment efficacy may result in closer treatment-based interactions between the hospital and the patient, which could lead to increased satisfaction (Ismail et al., 2017).

 

The proposed research model in figure 2 is theoretically found and is based on the perceptions of SERQUAL model instrument, which is used to assess patient perceptions of service quality in five different hospitals. PSQ, PS, TE, and BI were the four components of the research paradigm used in this study. The dependent construct, BI, is proposed, and its direct link with PSQ is investigated. While mediating factors, PS and TE are also included in the model. Research hypotheses were also developed on the basis of the proposed model.

H1

H2

H4

H5

Perceived Service Quality

Behavioral Intentions

Patient’s Satisfaction

Treatment Effectiveness

H3

H6

Figure 2: Conceptual Framework

Source: Researchers on Processing. Mediation hypothesis imbedded in the model

 

Research Hypothesis

 

Theory Alignment

Several theories have been proposed by academic scholars in an attempt to explain the service quality and patient satisfaction (Agyapong et al., 2018). In the 1980s, the majority of these theories were proposed. Emerging theories have mostly rephrased those notions in recent years. Previous work has merely focused to support the concept that GT only support the qualitative researches (Barney G. Glaser, 2010; O’Reilly et al., 2012; Wilde et al., 1993). Although this phenomena is quite factual, yet some recent developments also give a groundbreaking concept by using it in quantitative researches using content analysis and survey method (Belfrage & Hauf, 2016; Raftopoulos, 2005). In addition to, the grounded theory (GT) model was published by Wilde et al., (1993). It explains how people evaluate quality of care is vital for strategy planning and health service evaluation because they are the primary users of health care services (Wilde et al., 1993).

 

The first aspect of human conduct, aids in the development of long-term relationships between customers and businesses, as well as a better understanding of the nature of customer-business interactions (Heath & Cowley, 2004). The second component of the theory refers to individual’s experience towards a service. Moreover, those who deliver the services have to equip with a high level of medico-technical competence (Wilde et al., 1993). The third component of construction of social behavior is based on symbolic interactionism, which holds that experiences, ideas, and assumptions can all contribute to a better understanding of observed social processes (Heath & Cowley, 2004; Wilde et al., 1993). The social behavior of an individual toward a service or product is defined by their feelings of pleasure and satisfaction.

 

The GT implication in this study is it highlights patients' opinions of treatment quality and might be used as a starting point for quality improvement efforts. So all the three components with two major classification as resource structure and patient’s preferences are combined and results in behavioral intentions.

The core data used in this paper were gathered as part of a comprehensive study aimed at determining the association between service quality aspects and BIs of OPD patients. Self-administered close-ended questionnaires were used in this study to collect data using a quantitative approach. The population of the study constituted patients who have visited OPD of five public hospitals; DHQ Hospital, Holy Family Hospital, Benazir Bhutto Hospital, Federal government  services hospital and Pakistan Institute of Medical Sciences (PIMS) in Rawalpindi and Islamabad, respectively. Hospitals of general nature are included in the study because scope is wide as every kind of patients came here for treatment. A sample of 348 OPDs patients is generated from a population of 2700 patient visited during January 2022 to March 2022 using convenience sampling method and Slovin's Formula (n = N/(1 + Ne2) with a confidence level of 95% and a margin of error (e) at 0.05. Whereas due to small sample size evaluation of measurement and structural model is  done using Smartpls3 (Hair et al., 2017; Sarstedt et al., 2021).

 

Measurement Variables

The survey instrument consists of 38 measurement items related to 4 dimensions. The constructs used in the study are as follows: Perceived service quality (PSQ) being a predictor is measured using five dimensions of SERVQUAL model i.e. assurance, empathy, tangibility, reliability, and responsiveness. All the 24 items were obtained from the scale adapted by Agyapong et al., in 2018.  Patient’s satisfaction is taken as an intermediary variable in this study. Scale of Kondasani & Panda, (2015) and Kim et al., (2017) is used to assess the patient satisfaction. This scale is comprised on the 5 items. Treatment effectiveness also an intermediary variable is evaluated using the scale of Kim et al., (2017) which consists of 5 items. Behavioral intentions is also examined using scale of the Agyapong et al., (2018) and Boadi et al., (2019) which is based on the 4 items.

 

Respondents were guaranteed total anonymity of their participation in the survey in order to overcome the common method variance. The 5-point Likert scale is used to record the responses of the targeted population sample ranging from 1 (strongly disagree) to 5 (strongly agree). Moreover, six control variables (gender, age, marital status, educational level, occupation, and name of the visited hospital) were used in the study that were thought to have an impact on mediating as well as dependent variable. These included the respondent's.

 

Data Analysis

Measurement Model

The measurement model construct is necessary to evaluate before the evaluation of the structural model. The measuring model's evaluation is based on analysis of both reflective and formative measurement model. It indicates how well item indicators load on their respective constructs. The same was done for all constructs, such as PSQ, PS, TE, and BI. In analyzing reflective measurement model, factor loadings, Cronbach's alpha, and composite reliability were used to assess construct reliability. The average variance extracted was used to assess the convergent validity of constructs. The reliability and validity values are shown in Table 1. The model meets the threshold criteria for Cronbach’s alpha >0.7, composite reliability >0.7 and average variance extracted (AVE) >0.5 for all the constructs, indicating that the reliability and validity of the constructs are justified. 

 

The discriminant validity of the model is tested using the Fornell–Larcker criterion which is shown in Table 2. According to this criterion, if the estimated intercorrelations among all constructs are smaller than the square root of the average variance extracted (AVE) value of each construct, the model possesses discriminant validity. All of the constructs' values were over the threshold, indicating achievement of discriminating validity.

 

Table 1: Internal Consistency, Reliability and Convergent Validity

Source(s): The authors

 

Table 2: Discriminant Validity

Source(s): The authors

 

In reflective measurement model evaluation, two things are required to analyze in order to validate the conceptual model, potential collinearity difficulties and significance of the constructs. For investigating multicollinearity the variance inflation factor (VIF) was used for this purpose. Multicollinearity occurs when there are more than two indicators involved. It is a check to assure that indicators with same information are not entered twice. VIF is the quotient of the variance in a multi-term model divided by the variance in a single-term model. A VIF rating of less than five indicates that there are no significant multicollinearity issues (Sarstedt et al., 2022). VIF value for this model was tested and for outer model 3.292 recorded as the highest values whereas 1.325 recorded as the lowest value. While for outer model the higher value which is observed is 3.010 and lowest one was 1 which is below the threshold, indicating that there is no collinearity. In addition to, bootstrapping is also ran for assessment of the significance and relevance of the relationship of constructs as hypothesized earlier. The construct’s weights are indicating the relationships in Table 3 which appear as path coefficients in the PLS path model. All the path coefficients are significant (p < 0.05) except the direct link of TE and BI, and intermediation relationship. These results offer clear support for the validity of the reflective-formative measurement model.

 

Table 3: Significance of Constructs

Source(s): The authors

 

Structural Model

Subsequently evaluating the measurement model, the next stage was the assessment of the structural model (Figure 3). Assessment of structural model starts with investigating the relationships between the constructs. The direct effect between PSQ and BI is tested firstly in the model.  It is done to assess the significance of path coefficients without incorporating a mediating variable. H1 states that PSQ is positively and significantly associated with BI and it is statistically accepted (P = 0.000, Coefficient = 0.272, and t = 4.562). The R-Square value was 0.717, which means that the model variable accounts for 71% of the variance in the dependent variable (BI), which is a significant impact.

 

Proceeding further the direct relation of PSQ with PS and TE (the intervening variable) is analyzed. H2 and H3 states that PSQ is positively and significantly associated with PS and TE and both of them are statistically accepted ((P = 0.000 (PS) 0.000 (TE), Coefficient = 0.773 (PS) 0.336 (TE), and t = 33.161 (PS) 5.385 (TE)), respectively.  H4 and H5 are stated PS is positively and significantly associated with TE and BI respectively. The results of the model has statistically accepted both the H4 and H5 ((P = 0.000 (TE) 0.000 (BI), Coefficient = 0.471 (TE) 0.581 (BI), and t = 6.954 (TE) 9.672 (BI)). The direct relation of TE and BI is also analyzed. H6 states the TE is positively and significantly associated with BI. However, the statistical measurements has rejected the H6 (P = 0.279, Coefficient = 0.047, and t = 1.082). The R-Square values of PS and TE was 0.597 and 0.579, which means that the model variable accounts for 59.7% and 57.9 % of the variance in the mediator variables (PS and TE) respectively, which is a moderate range of variability impact.

 

Figure 3: Structural Model

 

Source(s): The authors

 

Lastly the mediation effect of PS and TE is analyzed in the relationship of PSQ and BI. When a variable intervenes between two related conceptions, it is referred to as mediation. The mediation effect is reflected in the PLS-SEM path model when a change in the exogenous construct leads to a change in the mediator variable, which then leads to changes in the endogenous variable. H6a states that PS and TE both mediates the positive and significant relationship between PSQ and BI. The results indicates that collectively both PS and TE does not mediates the relationship of PSQ and BI, hence H6a is statistically rejected (P = 0.292, Coefficient = 0.017, and t = 1.054).  Hence, in this study, the mediating effect of PS and TE collectively were found insignificant.

The study's main goal was to investigate the underlying mechanism and impact of perceived service quality on patients' behavioral intentions using Grounded Theory (Raftopoulos, 2005; Wilde et al., 1993). The research model proposed in this study also explores the role of patient satisfaction and treatment effectiveness as a mediator. According to the findings of the study, PSQ has a substantial positive relationship with BI. Which statistically accepted the H1. As the findings of the hypothesis claimed that perceived service quality is positively and significantly associated with behavioral intention. Quality and patient loyalty have been found to have a strong and favorable relationship in studies conducted on public and private hospitals (Kondasani & Panda, 2015; Liu et al., 2021; McMullan & Gilmore, 2008). This implies that when a hospital's service quality is good, patients' BIs are positive.  PSQ analyzed using SERVQUAL constructs such as empathy, assurance, and responsiveness have a considerable impact on BIs, according to research conducted at tertiary care Indian hospitals (Singh & Dixit, 2022). Service quality was proven to be a substantial predictor of patient loyalty by Fatima et al. (2018). It is critical for hospitals to work on enhancing their service quality in order to build long-term connections with patients. Therefore, the deliverance of best quality services that surpasses the patient’s perception influences and assures the positive behavioral response.

 

In addition to, the direct relation of PSQ with PS and TE were also studied and the above reported results indicated a statistical acceptance of H2 and H3. Which states that PSQ is positively and significantly associated with PS and TE respectively. The findings of this study complement the outcomes of Aliman & Mohamad (2013) who revealed that service quality had a substantial impact on patient satisfaction in Malaysian hospitals. In healthcare, the importance of service quality was also emphasized as a main predictor of PS (Agyapong et al., 2018). Comfortable treatment atmosphere and equipping the hospital with service-friendly facilities is the core responsibility of healthcare practitioners (Shabbir et al., 2017).  Therefore, PS is influenced by the hospital's quality of health care services. As a result, when hospitals please their patients, the patients will trust the hospital's services to cure their condition, which will, of course, have a favorable impact on patient satisfaction and, as a result, on the hospital's image. Patients must also believe that they can trust their doctors and that the treatment they receive is based on appropriate expertise.

 

Furthermore, H4 and H5 of this study analyzed the direct relation of PS with TE and BI and both gains the statistical acceptance. Which endorses that PS has a positive and significant relation with both TE and BI respectively. The outcomes of this study also validates that when providers of healthcare services and administrators of healthcare facilities recognize that offering high quality healthcare services opens the door to patient satisfaction and patients' compliance with treatment regimens improves (T. L. H. Nguyen & Nagase, 2021). Treatment efficacy proved to be most influenced by medical service quality characteristics, while treatment effectiveness appeared to have the highest impact on patient satisfaction (Kim et al., 2017).  As a result, it is claimed that public sector healthcare is expected to be effective and efficient. As in Pakistan majority of population cannot afford the private hospitals. So being a constitutional right, under one roof services’ availability public hospitals always prioritize, as a first choice leaving no other option, by the general public.  In other words, when they visit public sector healthcare institutions, they want to be treated quickly and without unnecessary delays. However, it was observed during the surveying that patients in public sector hospitals were significantly more and that there were huge queues not only outside ticket offices, but also outside physicians' rooms, the findings are aligned with general presumptions in the given context.

 

Moreover, there is no direct relation found between TE and BI that rejected the H6. The results shows that TE has an insignificant relation with BI. This insignificant relation of TE and BI also rejected the mediation hypothesis of PS and TE i.e.H6a. The collective mediation of PS and TE have no impact on the relation of PSQ and BI. In congruousness with our study findings, according to the research findings of Malaysian private hospitals, there is no substantial link between treatment effectiveness and loyalty, and patient response towards treatment efficacy has a no mediation influence on medical quality and revisit intentions (Isa et al., 2019) . It's likely that treatment effectiveness isn't a factor in BIs. Patients may believe and presume the hospital is trustworthy based on their experiences. As a result, people examine the hospital's other attributes while deciding whether or not to return or recommend others. Similarly, if a patient get an effective treatment but many other factors influences the stress and negative impact of hospital facility, then how the BIs can be positive.

The results of this study endorses the previous as well as recent researches (Agyapong et al., 2018; Giovanis et al., 2018; Q. N. Nguyen et al., 2021; Singh & Dixit, 2022) and concluded that perceived service quality has a positive and significant relationship with behavioral intentions of patients. Moreover, the goal of this research is to provide numerous insights to healthcare authorities and other associated authorities in order to improve service quality paradigms in public and government owned healthcare entities. As they are non-profit entities and work only for well-being of the general public. However, it is worth noting that public hospitals are neglecting the relationship marketing and word-of-mouth being important variables in determining patients' willingness to return. Even though treatment effectiveness does not play a role in mediating the relationship between PSQ and BI due to its insignificant association with BI, still it does have a direct and significant association with PSQ and PS. Pakistani hospitals should focus on large-scale service quality measurement so that patients can give positive feedback on their satisfaction and loyalty in terms of revisit behavior. As being a development country majority of people unable to afford private hospital’s services and public hospitals are their last resort.

 

Moreover, this research has also contributed as an explanatory model for health care organizations that measures patients' perceptions of healthcare service quality, behavioral intentions with mediation of satisfaction and treatment effectiveness. As a result, health care providers will benefit from this research, and business associations related to healthcare organizations will benefit as well. The findings also suggest a number of management and social implications that need to be addressed. Firstly, the study’s findings are valuable for the healthcare organization’s studies as they can use these results to devise strategic policies and also assist in managerial decision making in public healthcare sector. Secondly, the findings can help governments and relevant entities including the Ministry of Health, Medical Healthcare Council, and Pakistan Medical and Dental Council (PMDC). In addition to hospital appearance and perceived medical excellence, they can emphasize emotional or social bonding in their marketing element. This will help to boost national income and job prospects in a variety of industries by improving general quality of life.

 

Conclusively, future researches should focus the model in relationship with more personality traits with a large population size and may present a comparative analysis of both public and private hospitals in the country. Keeping in view the limitation of this study, the authors recommend that longitudinal studies can be used to provide a clear embellishment and differences in the patient's expectations and perceptions of treatments. Only perceived service quality is included as primary independent factor in this study to predict patient’s behavior intentions. As a result, the researcher suggests that future research incorporate personal worth, perception, and attitudes. These will contribute from a broader perspective of the various influences on the mediation factors; emotional satisfaction and experience economy, particularly in developing nations like Pakistan.

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