Health promoting hospital: A practical strategy to improve patient loyalty in public sector.

Background: The Health-Promoting Hospital (HPH) aims to improve the overall quality of health services for patient, families, and the community as a whole, with assessment and intervention as the essential components. In hospitals, this activity needs to be vigorously developed through interdisciplinary teamwork, shared decision-making process, and by involving patients and families during treatment and through the delivery of an evidence-based health promotion process. Previous studies analyzed some steps to improve patient loyalty through the HPH. However, limited studies were carried out on its use in the public sector. This study, therefore, aims to analyze the impact of HPHs to improve patient loyalty in the public sector. Design and
Methods: The simple random sampling method was used to obtain data from 101 respondents in a public hospital, with the cross-sectional design used to gain a better understanding of patient loyalty.
Results: The result showed that HPHs influenced patient expectations (P=0.030), which in turn affected perceived value (P=0.014) and satisfaction (P=0.002). In addition, perceived value and satisfaction have effects on patients' loyalty (P=0.001).
Conclusion: In conclusion, HPHs have a positive impact on patient loyalty. Therefore, the public sector needs to enhance its services in accordance with the standards and guidelines. ©Copyright: the Author(s).

Introduction

Health-promoting hospital (HPH) aims to improve the quality of health services for patients, families, visitors, stakeholders, and the community as a whole. The hospital plays an active role in delivering comprehensive services, and this is implemented through health promotion, prevention, medical treatment, and rehabilitation. There are lots of difficulties associated with the development of awareness for health and related diseases, therefore, HPH encourage patients and families to be involved in the planning procedure as an integral program in hospitals.[1-3]

In Indonesia, the current implementation of HPH is not yet optimal. Therefore, hospitals need to build a change in management policy, health professionals’ competences, and financial budget to foster a successful program. HPH needs to be provided according to the Regulation of the Minister of Health No. 44 of 2018 concerning its implementation. There are 5 dimensions of HPH, which includes promoting good health, preventing illness, educating the patient to improve recovery, enhancing the rehabilitation process, and clinically promoting recovery program.[4] HPH standards were developed based on the needs of the hospital, to improve its quality of services in an optimal, effective, efficient, integrated, and sustainable manner.[5]

However, there are lots of difficulties associated with its implementation in Indonesia, particularly in public hospitals. According to previous studies, only half of the respondents were satisfied with the program, while just 25.3% of the employees felt satisfied, and 13.5% lacked the training. The fundamental importance of the HPH program is associated with the knowledge, attitude, and skills of patients, families, and communities to actively participate in the program. Other factors include health culture, supportive environment, and participation from stakeholders create better achievement in hospital service quality.[3]

The four strategies used to build a strong HPH program were as follows: (1) fulfilling patient needs, (2) facilitating the rights of healthcare staff, (3) encouraging hospital management to develop health promotion, and (4) planning to meet community needs and resources.[6] Other study demonstrated that more than half of the respondents were satisfied with two components of HPH: 53.12% patient assessment and 62.5% intervention. This means that the hospital has difficulties in managing health promotion as they were more focused on medical treatment.[7] HPH program create many health benefits, which includes patient expectation, perceived value, satisfaction, and loyalty.

Patients expected and believed that the hospital team members need to understand their problems, respect them, and treat them with dignity, as well as provide them with adequate support and care. They need to be involved in decision makings during treatment. Furthermore, patients and families need compassionate health care professionals to help them manage their health problems. However, their expectation was considered a determinant factor in influencing satisfaction.[8,9]

Health promotion in hospitals was associated with patient satisfaction (P=0.001), therefore, its addition in medical treatment tends to enhance patient behaviors, loyalty, and effective hospital management.[10,11] However, the HPH program provides better results assuming the management policy has financial regulation and resources for its proper implementation.[12,13]

The patient experienced that the health care staff provided two essential components in HPH, that is, patient assessment and intervention.[7] Health promotion in the hospital need to be vigorously developed through interdisciplinary teamwork, shared decision-making processes involving patients and families, and deliver evidence-based health promotion. Previous studies analyzed the steps needed to improve patient loyalty through the HPH, however, limited studies were carried out on its use in the public sector. This study aimed to analyze the impact of HPH to improve patient loyalty in the public sector through expectations, perceived value, and satisfaction.

Designs and Methods

The simple random sampling method was used to obtain data from 101 respondents in a public hospital, with the cross-sectional design used to gain a better understanding of patient loyalty. Respondents were selected based on the inclusion criteria as follows: (1) aged more than 18 years old, (2) willing to participate in the study, (3) hospital visitors. Data analysis was conducted to determine the assessment and intervention effect on patient expectation, on perceived value and satisfaction, as well as on the influence of perceived value and expectation on patient loyalty. A multiple linear regression statistical test was used to determine the relationships between variables, with data analyzed by using SPSS 22.0. The research ethic approval was obtained from the ethics committee of Universitas Ciputra, Surabaya, East Java, Indonesia.

Results and Discussion

Table 1 describes the characteristics of the respondents based on age, sex, education level, employment status, and income. Approximately 59.4% of the respondents were female, 71.3% were diploma/bachelor degree holders, 79.2% worked in the private sector, and 81.2% earned more than the minimum wages (>3,500,000IDR).

Table 1.

Characteristics of respondents.

Characteristics	Frequency (n=101)	Percentage
Sex
Male	41	40.6
Female	60	59.4
Age (years)
18 – 34	40	39.6
35 – 50	39	38.6
>50	22	21.8
Education
High School	29	28.7
Diploma/Bachelor	72	71.3
Employment status
Public sector	8	7.9
Private sector	80	79.2
Jobless	13	12.9
Income
<3,500,000 IDR	19	18.8
≥3,500,000 IDR	82	81.2

Table 2 and Figure 1 show that HPH influenced patient expectation (P=0.030), which in turn affected perceived value (P=0.014) and satisfaction (P=0.002). In addition, perceived value and satisfaction have effects on patients’ loyalty (P=0.001). Based on the results of the study, assessment, and intervention affected patient expectations. They had a significant effect with a P-value of 0.008 and 0.042, respectively. These expectations are also a reflection of the services/products perceived from previous consumption experiences and predictions regarding the hospital’s ability to convey quality in the future.[14]

Table 2.

Impact of health promoting hospital on patient loyalty

Independent variable	Dependent variable	P value (partial)	B	P value (simultant)
Assesment	Patient expectation	0.008*	0.264	0.030**
Intervention	Patient expectation	0.042*	0.160
Patient expectation	Perceived value	0.014	0.404
Patient expectation	Patient satisfaction	0.002	0.606
Perceived value	Patient loyalty	0.009*	0.039	0.001**
Patient satisfaction	Patient loyalty	0.000*	0.705

*p value based on coefficient table (partial effect)

**p value based on ANOVA table (simultant effect).

Figure 1.

Impact of health promoting hospital to patient loyalty.

The patient expectation is similar to a customer’s confidence before trying or buying a product that is used as a standard or reference in assessing its performance. This comparison led to consumer reactions to products/services in the form of satisfaction or perceived quality.[15] In hospitals, products are in the form of health promotion, and prospective patients tend to compare the conducted assessments with the interventions. The comparison process makes prospective patients show their expectations with reactions in the form of satisfaction or dissatisfaction.

Perceived value is defined as the overall assessment of the patient with regards to the treatment they received.[16] It plays an important role in making patients loyal to a public hospital. This theory, in accordance with this study, led to influence between patient expectation on perceived value (P=0.014). The results of this study are in line with previous studies, which revealed that perceived quality and customer exposition influenced value.[17,18] Similarly, perceived value also directly affects patient loyalty (P=0.009).

This study found that patient expectation influenced their satisfaction (P=0.002). The result is consistent with the previous studies, which perceived that the quality of patients, expectations, and perceived value had significant effects on their satisfaction.[19,20] In addition, patient satisfaction is the level of one’s feelings after comparing perceived performance.[21] It is determined by service performance in meeting patient expectations.[22] This study shows that if the hospital has made efforts to improve HPH, and meet the expectations of patients, it creates more satisfaction. Satisfied patients are more likely to recommend the hospital to the closest person (P=0.000).

Meanwhile, the interaction between perceived value and satisfaction, which influences patient loyalty (P=0.001), shows that the hospital needs to pay attention to their needs and value in relation to visitors and the community around the hospital against HPH program. Therefore, health care providers need to be able to understand patient needs in order to achieve the highest level of satisfaction as it is the main goal of quality health services.

Conclusions

In conclusion, HPHs have positive impacts on patient loyalty. Therefore, it is recommended that public hospitals enhance health promotion in their services in accordance with the standards and guidelines.