1. INTRODUCTION:

The healthcare sector is undergoing rapid global expansion, emerging as the fastest-growing service industry worldwide¹. This growth is driven by lifestyle changes, the demand for improved medical care, and the convergence of financial and economic crises².

The transformations occurring in today's healthcare landscape have given rise to evolving patient expectations and heightened competition among healthcare service providers³. This escalating competition in the healthcare industry, coupled with shifts in societal living standards, has underscored the imperative of delivering high-quality healthcare services⁴.

The significance of service quality within hospital settings has emerged as a pivotal determinant affecting patient satisfaction and subsequent intentions significantly⁵. Acknowledged as an indispensable component in the healthcare sector^6,7, service quality plays a central role in shaping patient experiences. Moreover, patients are increasingly attuned to competitive advancements and are gaining familiarity with the array of healthcare offerings available to them. These challenges make service quality insufficient for enduring patient-centred care⁸.

Considering increased patient expectations and heightened competition, understanding the complex dynamics among hospital service quality, patient satisfaction, and intentions emerges as crucial for ensuring long-term success^9,10.Amidst the healthcare industries, a growing emphasis is placed on patient-centered care towards delivering quality services through customer satisfaction. Patient satisfaction plays a pivotal role in the creation and sustenance of relationships within healthcare organizations^11,12. Furthermore, patient care outcomes serve as pivotal indicators for evaluating the effectiveness and quality of care provided¹³. Consequently, the interplay between service quality, patient satisfaction, and overall healthcare has become more intricate, necessitating a closer examination of these dimensions.

Enhancing the quality of hospital care stands as a paramount priority worldwide, particularly in developing nations where hospitals serve as the primary healthcare providers¹⁴. In India, the healthcare industry has witnessed remarkable growth, fuelled by domestic demand, corporate culture, and medical tourism¹⁵. These challenges in Indian healthcare systems are underscored by factors such as resource constraints, government social benefit schemes, and dependency on referral procedures; the importance of service quality cannot be ignored¹⁶. Our study aims to explore the impact of widely accepted HEATHQUAL model dimensions¹⁷, uncovering critical factors that guide service organizations in enhancing their offerings. By bridging existing gaps in the literature and examining the impact of HEATHQUAL variables on patient satisfaction and intention, we contribute significantly to understanding hospital service quality and its effects within health institutions.

2. REVIEW OF LITERATURE:

HEALTHQUAL Frameworks and Models:

The foundation of understanding healthcare service quality lies in conceptual frameworks and models developed to assess and enhance service delivery. The SERVQUAL model, introduced by Parasuraman et al. ^18,19, stands as a pivotal framework in this domain. Lee et al.¹⁷ adapted these principles to healthcare dynamics, creating the HEATHQUAL framework. This multidimensional measurement system encompasses Empathy (EM), Tangible (TA), Safety (SA), Efficiency (EF), and Improvements of care service (DI) tailoring service quality assessment within the context of healthcare settings.

Patient Loyalty and its Relationship with Service Quality:

Customer loyalty emerges as a keystone with a substantial positive impact on firm performance, widely acknowledged by several companies as the paramount source of competitive advantage^20,21,22. Recent years have witnessed remarkable progress in the study of patient loyalty, yielding tangible benefits such as increased revenue, lowered customer acquisition costs, reduced expenses associated with repeat buyers, and a consistent trend towards heightened profitability^22-25. Patient loyalty serves as a critical determinant of healthcare, intricately linked with ensuring the delivery of high-quality services is paramount for enhancing patient value and satisfaction.

Assessment of Healthcare Service Quality:

Amidst the constantly shifting terrain of healthcare, the pursuit of quality stands as a foundational principle. Taner and Antony²⁶ emphasize that the journey toward enhancing and managing quality within healthcare systems begins with the rigorous measurement of service quality. This critical step has sparked a growing interest in evaluating the quality of hospital care^26,27. At its core, this endeavour revolves around not merely meeting but surpassing the needs of patients but also necessitates assessment of hospital services²⁸.

Patient Satisfaction and its Role in Healthcare:

Variable to assess healthcare services, providing insights for further improvement in services, has been highlighted by Alhusban et. al.,²⁹ and Gadalean and Cheptea³⁰, emphasizing the significance of patient-centered care and its impact on satisfaction levels. Additionally, patient satisfaction signifies patient active involvement in decision-making and collaborative efforts to enhance service quality, as highlighted by Sarah LC et al.³¹ and Iftikhar, et al.³². Patient satisfaction stands as one of the foremost considerations in hospital selection, representing a multifaceted construct that includes cognitive and affective dimensions^33,34. Top of Form

Patient Expectations and Service Quality Gap:

In the dynamic landscape of healthcare, the convergence of patient expectations and service quality is paramount, serving as the linchpin for narrowing the service quality gap and ensuring unparalleled patient satisfaction. Lee et al.³⁵ asserted that aligning patient expectations stands as a crucial barometer for monitoring healthcare service quality within healthcare organizations. By meticulously gauging patients' expectations and satisfaction levels, healthcare organizations can identify operational strengths and weaknesses, laying the groundwork for targeted interventions to elevate service quality⁶.

Financial Implications and Service Quality:

Delivering quality service in healthcare organizations is paramount for organizational success, as highlighted by Dawkins et. al.³⁶, Parasuraman et al.¹⁸, and Zeithaml et al.³⁷, who underscored its direct impact on customer retention and loyalty. Jones et al.³⁸ emphasized the cost-effectiveness of retaining existing customers through service improvement, stressing the importance of prioritizing service quality to maintain competitiveness³⁹.

The reviewed literature underscores the intricate interplay between healthcare service quality, patient satisfaction, and loyalty. Conceptual frameworks such as SERVQUAL and HEATHQUAL provide a foundation for assessing service quality in healthcare settings. Patient loyalty hinges on the delivery of quality services, while patient satisfaction serves as a crucial criterion for evaluating service delivery.

2.1 Theoretical Framework:

The various dimensions of Healthcare Service Quality are as follows:

· Foundation: The SERVQUAL model, adapted to healthcare dynamics by Lee et al.¹⁷, serves as the basis for understanding HEATHQUAL.

· Dimensions: Empathy (EM), Tangible (TA,) Safety (SA), Efficiency (EF), Improvements of care service (DI) constitute the core dimensions of HEATHQUAL.

· Justification: These dimensions form the pillars of service quality assessment in healthcare settings, aligning with patient expectations and perceptions.

Patient Satisfaction and Loyalty:

· Relationship: Patient satisfaction acts as a mediator between HEATHQUAL and patient loyalty.

· Importance: Satisfaction with healthcare services directly influences patient loyalty, contributing to the continuity of care and sustained engagement with healthcare providers.

· Justification: Numerous studies^40,41 emphasize the pivotal role of patient satisfaction in fostering loyalty and long-term relationships within healthcare organizations.

Determinants of Patient Satisfaction:

· Service Quality: The perceived excellence of healthcare services, including reliability, responsiveness, and empathy, plays a crucial role in determining patient satisfaction.

· Expectations and Perceptions: The degree to which patient expectations align (or misalign) with their perceptions of service quality significantly influences their satisfaction levels.

· Justification: Past research, such as studies by Cruz & Mendes^13,42, emphasizes the impact of service quality and patient perceptions on overall satisfaction levels.

Factors Influencing Patient Behavioural Intentions:

· Service Quality Gap: Discrepancies between patient expectations and actual experiences contribute to the formation of behavioural intentions.

· Patient-Centric Culture: Hospitals fostering patient-centred approaches are likely to elicit positive behavioural intentions from patients.

· Justification: Understanding the factors driving patient behavioural intentions is crucial for addressing gaps in service quality and enhancing patient loyalty.

Implications for Healthcare Organizations:

· Strategic Decision-Making: From the understanding of HEATHQUAL, patient satisfaction, and loyalty inform strategic initiatives are aimed at improving service delivery.

· Service Quality Management: Identification of determinants of service quality guides hospitals in designing and implementing effective quality improvement strategies.

· Justification: Studies⁴³ underscore the significance of service quality in shaping organizational strategies and fostering customer loyalty.

2.3 Conceptual Framework:

The various dimensions of HEATHQUAL are as follows:

· Definition: HEATHQUAL encompasses Empathy (EM), Tangible (TA), Safety (SA), Efficiency (EF), and Improvements of care service (DI) adapted from SERVQUAL model¹⁷.

· Operationalization:Measurement of each dimension using established scales or surveys validated in previous research¹⁸.

Patient Satisfaction and Loyalty:

· Definition: Patient satisfaction refers to the degree of fulfilment of patient expectations and perceptions regarding healthcare service quality.

· Operationalization: Quantitative assessment through patient surveys, interviews, or standardized scales (e.g., SERVQUAL) to measure satisfaction levels. Loyalty is operationalized as repeat visits, recommendations, or intention to continue using healthcare services⁴⁰.

Determinants of Patient Satisfaction:

· Definition: Determinants include service quality, patient expectations, and perceived service quality gap.

· Operationalization: Quantitative analysis of the impact of each determinant on patient satisfaction through regression analysis or structural equation modeling¹³.

2.4 Factors Influencing Patient Behavioural Intentions and Implications:

Behavioural intentions encompass patient decisions regarding future healthcare utilization, referrals, or adherence to treatment plans. Examination of the service quality gap, patient-centred culture, and perceived value on behavioural intentions using qualitative or quantitative surveys⁴⁴. Implications include strategies for enhancing service quality, improving patient satisfaction, and fostering patient loyalty. Development and implementation of quality improvement initiatives based on research findings, such as training programs for staff, technology integration, or process optimization⁴³.

2.5 Research Gap:

The existing literature highlights a critical gap in the comprehensive analysis of subjective aspects in patient evaluations of HEALTHQUAL leading to an incomplete understanding of the nuanced dimensions of patient satisfaction and loyalty. Additionally, there is a notable deficiency in exploring the underlying factors influencing patient behavioral future intentions.

3.0 METHODOLOGY:

3.1 Sampling procedure.

A mixed methods sampling approach was utilized, integrating both qualitative and quantitative methods to ensure a comprehensive understanding of the research phenomenon. The population frame included patients or their caretakers who received medical treatment in various healthcare service providers in Rajasthan, India. 1420 questionnaires were disseminated to patients or their caregivers in Rajasthan, either in person or via email, to collect quantitative data. A purposive sampling method was employed to guarantee diversity within the sample. Of the distributed surveys, 1232 complete responses were received, yielding a response rate of 87%. Data were gathered through surveys and interviews, tailored to resource availability and respondent accessibility. Surveys covered personal, demographic, social, and economic details, along with participant perceptions. Semi-structured interviews utilized pre-tested questionnaires to explore patient experiences and perspectives in depth. Quantitative methods were employed for data analysis and data was analyzed using statistical tools such as Paired Sample T-Test, Multivariate Analysis of Variance (MANOVA), and Correlation Analysis. IBM SPSS package was utilized for statistical analysis.

3.2 Statement of Problem:

To address the problem statement, several key research questions emerge:

1. What are the significant disparities between patient expectations and perceptions across various dimensions of HEATHQUAL, as measured by the HEATHQUAL framework?

2. How do these disparities affect patient satisfaction, loyalty, and purchase intention within healthcare sector?

3. What is the nature of the relationship between patient satisfaction, loyalty, and purchase intention, and how are these variables interconnected?

4. What are the potential implications of addressing these disparities for healthcare practitioners, policymakers, and researchers?

3.3 Objectives/Hypothesis Development:

Following hypothesis can be developed:

1. Hypothesis H1: There will be no significant disparities between patient expectations and perceptions across multiple dimensions of healthcare service quality, with variation of these disparities.

2. Hypothesis H2: The patient expectations and perceptions will have no significant impact on patient satisfaction, loyalty, and purchase intention within the healthcare sector.

3. Hypothesis H3: There will be no significant correlations between patient satisfaction, loyalty, and purchase intention, indicating no interdependence among these variables.

3.5 Significance, Scope and Limitations:

Addressing disparities between patient expectations and perceptions is crucial for enhancing satisfaction, fostering greater loyalty, and ultimately improving the overall quality of healthcare delivery. The scope of the study encompasses a comprehensive analysis of service quality disparities, patient evaluations, and their impact on patient satisfaction, loyalty, and purchase intention within the framework of the HEATHQUAL. This study was conducted in Rajasthan, India the findings may not be directly applicable to populations in other geographic regions. This study does not cover critical care illness.

4.0 RESULTS AND DISCUSSIONS:

4.1 Testing of Hypothesis H1:

Paired Samples t-test (Table 1) was conducted to assess disparities between patient expectations and perceptions across various dimensions of healthcare service quality.

Table 1: Paired Sample T-Test

Dimensions		Measurement variables (Likert type 5-point Scale, 1 = Very Dissatisfied/ Strongly Disagree, 5 =Very Satisfied/ Strongly Agree	Paired Differences			t	Sig. (2-tailed)
Dimensions			Mean	Std. Deviation	Std. Error Mean	t	Sig. (2-tailed)
Empathy (EM)	Pair 1	Welcoming demeanour of staff	0.623	0.884	0.025	24.761	0.000
	Pair 2	Elaborating on information	0.367	0.990	0.028	13.009	0.000
	Pair 3	Patient empathy and understanding	0.532	1.144	0.033	16.339	0.000
	Pair 4	User-friendly website with accessible information	1.010	1.095	0.031	32.368	0.000
Tangible (TA)	Pair 5	Acquisition of advanced medical equipment	0.451	0.937	0.027	16.903	0.000
	Pair 6	Recruitment of highly skilled medical personnel	0.506	0.956	0.027	18.605	0.000
	Pair 7	Availability of convenient amenities.	0.620	0.934	0.027	23.301	0.000
	Pair 8	General hospital cleanliness	0.607	1.145	0.033	18.612	0.000
Safety (SA)	Pair 9	Comfort and safety during treatment	0.373	1.137	0.032	11.523	0.000
	Pair 10	Hospital's poor understanding of patient problems	0.380	1.088	0.031	12.251	0.000
	Pair 11	Confidence in doctors’ diagnostic accuracy	0.357	0.779	0.022	16.094	0.000
	Pair 12	Patient comfort and safety during their stay	0.406	1.030	0.029	13.835	0.000
Efficiency (EF)	Pair 13	Disposition towards avoiding useless medication	0.156	1.079	0.031	5.068	0.000
	Pair 14	Fair and affordable medical costs	0.136	1.157	0.033	4.135	0.000
	Pair 15	Appropriateness of medical service pricing	0.006	1.120	0.032	0.204	0.839
	Pair 16	Efforts to minimize unnecessary medical procedures	0.705	0.951	0.027	26.014	0.000
Improvements of care service (DI)	Pair 17	Quality and suitability of care services	0.471	1.138	0.032	14.517	0.000
	Pair 18	Improvement in health due to treatment efforts	0.721	1.332	0.038	18.994	0.000
	Pair 19	Clarity of information to prevent related ailments	0.464	1.144	0.033	14.248	0.000
	Pair 20	Dedication and actions to prevent diseases	0.039	1.022	0.029	1.338	0.011
	df = 1231

Table 2: Multivariate Tests^a

Effect		Value	F	Hypothesis df	Error df	Sig.
Intercept	Pillai's Trace	0.990	15447.341^b	3.000	490.000	0.000
	Wilks' Lambda	0.010	15447.341^b	3.000	490.000	0.000
	Hotelling's Trace	94.576	15447.341^b	3.000	490.000	0.000
	Roy's Largest Root	94.576	15447.341^b	3.000	490.000	0.000
Expectation Mean	Pillai's Trace	0.774	4.074	126.000	1476.000	0.000
	Wilks' Lambda	0.394	4.249	126.000	1469.072	0.000
	Hotelling's Trace	1.142	4.428	126.000	1466.000	0.000
	Roy's Largest Root	0.666	7.802^c	42.000	492.000	0.000
Perception Mean	Pillai's Trace	0.822	4.759	117.000	1476.000	0.000
	Wilks' Lambda	0.378	4.818	117.000	1468.771	0.000
	Hotelling's Trace	1.167	4.874	117.000	1466.000	0.000
	Roy's Largest Root	0.551	6.950^c	39.000	492.000	0.000
Expectation Mean * Perception Mean	Pillai's Trace	0.658	5.116	81.000	1476.000	0.000
	Wilks' Lambda	0.473	5.149	81.000	1466.414	0.000
	Hotelling's Trace	0.858	5.178	81.000	1466.000	0.000
	Roy's Largest Root	0.395	7.195^c	27.000	492.000	0.000

a. Design: Intercept + Expectation Mean + Perception Mean + Expectation Mean * Perception Mean

b. Exact statistic; c. The statistic is an upper bound on F that yields a lower bound on the significance level.

Table 3: Tests of Between-Subjects Effects

Source	Dependent Variable	Type III Sum of Squares	df	Mean Square	F	Sig.
Corrected Model	Patient Satisfaction	130.743^a	123	1.063	10.125	0.000
	Patient Loyalty	130.886^b	123	1.064	10.158	0.000
	Patient Intention	115.125^c	123	0.936	9.766	0.000
Intercept	Patient Satisfaction	4074.814	1	4074.814	38812.748	0.000
	Patient Loyalty	4075.186	1	4075.186	38900.001	0.000
	Patient Intention	4281.369	1	4281.369	44673.146	0.000
Expectation Mean	Patient Satisfaction	29.011	42	0.691	6.579	0.000
	Patient Loyalty	29.078	42	0.692	6.609	0.000
	Patient Intention	24.859	42	0.592	6.176	0.000
Perception Mean	Patient Satisfaction	24.718	39	0.634	6.037	0.000
	Patient Loyalty	24.701	39	0.633	6.046	0.000
	Patient Intention	19.071	39	0.489	5.102	0.000
Expectation Mean* Perception Mean	Patient Satisfaction	13.513	27	0.500	4.767	0.000
	Patient Loyalty	13.491	27	0.500	4.769	0.000
	Patient Intention	14.594	27	0.541	5.640	0.000
Error	Patient Satisfaction	51.653	492	0.105
	Patient Loyalty	51.542	492	0.105
	Patient Intention	47.152	492	0.096
Total	Patient Satisfaction	7079.587	616
	Patient Loyalty	7079.194	616
	Patient Intention	7550.444	616
Corrected Total	Patient Satisfaction	182.397	615
	Patient Loyalty	182.428	615
	Patient Intention	162.277	615

a. R² = 0.717 (Adjusted R² = 0.646); b. R² = 0.717 (Adjusted R² = 0.647); c. R² = 0.709 (Adjusted R² = 0.637)

Subsequent univariate tests (Table 3) validate these findings, revealing significant main effects for both patient expectations (expectation mean) and perceptions (perception mean) on patient satisfaction (F(2, 492) = 6.579, p<0.001) and loyalty (F(2, 492) = 6.037, p< 0.001). Similar significant effects were observed for patient intention. The significant effects across all dependent variables underscore the importance of addressing discrepancies between patient expectations and perceptions to enhance healthcare outcomes. The interaction effect highlights the nuanced relationship between these factors and their combined impact on patient satisfaction, loyalty, and intention.

4.3 Testing of Hypothesis H3:

The correlation analysis (Table 4) revealed strong and significant positive correlations between patient satisfaction, loyalty, and purchase intention (all p < 0.01). Specifically, patient satisfaction exhibited a high correlation with both patient loyalty (r = 0.798) and purchase intention (r = 0.734), highlighting a robust relationship. Similarly, patient loyalty showed a strong positive correlation with both patient satisfaction (r = .798) and purchase intention (r = 0.745). Furthermore, purchase intention exhibited a strong positive correlation with both patient satisfaction (r = 0.734) and loyalty (r = 0.745).

Table 4: Correlations

		Patient Satisfaction	Patient Loyalty	Purchase intention
Patient Satisfaction	Pearson Correlation	1	0.798^**	0.734^**
	Sig. (2-tailed)		0.000	0.000
	N	1232	1232	1232
Patient Loyalty	Pearson Correlation	0.798^**	1	0.745^**
	Sig. (2-tailed)	0.000		0.000
	N	1232	1232	1232
Purchase intention	Pearson Correlation	0.734^**	0.745^**	1
	Sig. (2-tailed)	0.000	0.000
	N	1232	1232	1232

**. Correlation is significant at the 0.01 level (2-tailed).

These findings provide compelling empirical evidence to reject Hypothesis 3, suggesting a significant interdependence among patient satisfaction, loyalty, and purchase intention within the healthcare sector. The strong positive correlations underscore the interconnectedness of these variables, indicating that improvements in one aspect may positively influence the others.

4.4 DISCUSSION:

Hypothesis H1 examined the disparities between patient expectations and perceptions across multiple dimensions of healthcare service quality. The paired samples t-test revealed statistically significant differences across all 20 dimensions examined, highlighting the pervasive nature of these gaps. These findings underscore the tangible manifestation of the discrepancy between patient expectations and their actual experiences, emphasizing its profound implications for patient satisfaction, loyalty, and overall healthcare outcomes.

Hypothesis H2 investigated the impact of these disparities on key healthcare outcomes. Significant effects were observed across all dependent variables – patient satisfaction, loyalty, and intention. The interaction effect between patient expectations and perceptions further emphasized the nuanced relationship between these factors and their combined influence on patient outcomes.

Finally, Hypothesis H3 explored the interdependence among patient satisfaction, loyalty, and purchase intention. Strong positive correlations between these variables were observed, highlighting the need for a holistic approach to address disparities and enhance overall patient experiences and outcomes. The consistent significance of the p-values further strengthens the reliability and applicability of our findings in real-world healthcare settings. Hospitals, being medical service businesses founded on principles of trust, seats utmost importance on service quality, patient satisfaction, and patient loyalty, as these factors collectively delineate the success of hospitals and other healthcare organizations⁴⁵.

6. CONCLUSION:

The study sheds light on the intricate interplay between healthcare service quality, patient satisfaction, and future intentions within the dynamic landscape of healthcare provision. We have gained valuable insights into the factors shaping patient experiences and outcomes in healthcare settings. Our research emphasizes the critical imperative of prioritizing service quality to meet the evolving needs and expectations of patients. In an increasingly competitive healthcare landscape, heightened patient awareness underscores the necessity for hospitals to deliver exceptional services to ensure patient satisfaction and loyalty. Quality service not only fosters patient retention but also directly impacts revenue generation and organizational profitability. A strong relationship between patients and hospitals will lead to increased customer satisfaction and enhanced patient loyalty. The concept of value-satisfaction-loyalty serves as a guiding principle for hospital management in formulating effective marketing strategies aimed at creating superior customer value. Embracing patient-centered approaches, investing in staff training, leveraging technology, and fostering a culture of continuous improvement are crucial steps toward achieving patient-centered excellence in healthcare delivery.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 01.05.2024 Revised on 26.10.2024

Accepted on 28.01.2025 Published on 02.05.2025

Available online from May 07, 2025

Research J. Pharmacy and Technology. 2025;18(5):1989-1996.

DOI: 10.52711/0974-360X.2025.00284

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