| Patient loyalty refers to the emotional preference and a psychological tendency to repeatedly purchase medical services from the same organization.Identifying and maintaining loyal patients in health care facilities not only has emerged as an important strategy for health institutions to establish a harmonious doctor-patient relationship,improve the economic efficiency,service quality and market competitiveness,but also is correlated with patients' health service utilization and good health outcomes.It has been demonstrated that effective primary care is of great significance for providing more effective and equitable care,optimizing the allocation of medical and health service resources and promoting the construction of hierarchical medical system.Therefore,attracting and retaining more patients,establishing a sustained strong relationship with patients that shapes their loyalty as to guide residents to make reasonable use of medical and health services is imperative for healthcare providers to facilitate the improvement of primary care.Objectives:The purposes of this study are to understand the current status of patient loyalty to primary health care facilities;explore the influence of individual factors(demographic sociological characteristics,health literacy,perceived value,patient satisfaction and patient trust),organizational factors(the type of health care facility,the area of operational housing per 10,000 serving population,types of pharmaceuticals,human resources allocation,training,patient involvement in the service delivery and service quality)and policy environment[social support and family doctor(FD)contract service]on patient loyalty based on the social ecology theory.According to the stimulus-organism-response theoretical framework,investigate the mechanism of internal stimuli(patient health literacy),organizational stimuli(patient perceived involvement,patient perceived service quality),policy-environment stimuli(FD contract service,social support)and organism(patient perceived value,patient satisfaction,and patient trust)on patient loyalty.Furthermore,examine the correlation between patient loyalty and health service utilization in primary care.This study would provide implications for health managers and policymakers in terms of building patient loyalty,improving patients' primary health service utilization.Methods:This study adopted a hybrid research method combining quantitative investigation and qualitative interview.A multi-stage sampling method was used in in the quantitative research.First,four regions were chosen according to their economic level and geographic distribution in Jilin province.Second,two districts or counties were selected in each region,randomly.Third,we stratified between rural and urban areas within each district or county,so one community health service center and one township hospital were selected in each district or county.We used purposive sampling method which based on the research of our local research partner from the Health Commission of Jilin Province and faculty from the School of Public Health at Jilin University,to select study sites.Altogether,16 primary health care facilities were investigated in this study.Forth,in the investigation,we adopted the convenience sampling method to select patients that had received medical or public health service in the institution surveyed.All surveys were conducted at primary health care facilities by postgraduate students from the Public Health School at Jilin University.Altogether,16 primary health care facilities and 1225 patients were investigated through face-to-face electronic questionnaire survey between August 2019 and September 2019.The questionnaire includes two parts:?the institution questionnaire:the type of health care facility,the area of operational housing,the number of serving population,types of pharmaceuticals,the number of physicians,the number of nurses,the age of medical staffs,the education of medical staffs,the number of physicians receiving standardized general practitioner training,the number of nurses receiving community nurse post training,the total number of patients that signed the FD contract service and the number of FD contract service teams;?the patient questionnaire:demographic sociological characteristics,health literacy,patient perceived involvement,patient perceived service quality,perceived value,patient satisfaction,patient trust,patient loyalty,whether signed the FD contract service,social support,and primary health service utilization.Confirmatory factor analysis,single variance analysis,multivariate analysis,mediation model,moderation model and path analysis were performed using the IBM SPSS 24.0 version program and Amos 21.0 software.The convenience sampling method was used in the qualitative research.22 patients that had received medical or public health service in the institution surveyed and 27 primary medical staffs were selected for the in-depth interviews on August 2019.The recordings and transcripts of interviews were manually converted into text and saved as word documents.Then,we analyzed the qualitative data by the thematic framework analysis method.Results:(1)The scores obtained from patient loyalty to primary health care facilities in Jilin Province ranged from 1 to 5,and the average score was 3.30±0.96.The average score of the item of positive word of mouth was rated the highest at 3.45(SD=1.08),followed by willingness to recommend(3.38,SD=1.08),intention to repurchase(3.33,SD=1.12),willingness for first treatment(3.06,SD=1.14).(2)The influences of individual factors on patient loyalty indicated that married patients(3.33±0.97)had significantly higher levels of loyalty than unmarried/divorced/widowed patients(3.19±0.89)(P<0.05).Patients that self-perceived poor health status(3.49±0.93)reported higher degrees of loyalty than patients that self-perceived good(3.24±0.98)or fair(3.18±0.94)health status(P<0.05).Patient loyalty was significantly positive associated with patient health literacy(B=0.681),patient perceived value(B=0.695),patient satisfaction(B=0.840)and patient trust(B=0.499)(P<0.001).(3)The influences of organizational factors on patient loyalty indicated that patients in government-managed institutions(3.42±0.92)reported higher scores in loyalty than patients in hospital-managed institutions(3.25±0.98)(P<0.05).Patients in institutions with 240 or more types of pharmaceuticals had higher levels of loyalty(3.42±0.95)than patients in institutions with less than 240 types of pharmaceuticals(3.25±0.96)(P<0.05).Patients in institutions with a ratio of doctors to nurses of less than one(3.38±0.97)had higher levels of loyalty than patients in institutions with a ratio of doctors to nurses of one or more(3.22±0.94)(P<0.05).Patients in institutions with 50%or more physicians receiving standardized general practitioner training(3.50±0.95)had higher levels of loyalty than patients in institutions with less than 50%physicians receiving standardized general practitioner training(3.25±0.95)(P<0.05).Patient loyalty was significantly associated with patient perceived involvement(B=0.086)and patient perceived service quality(B=0.734)(P<0.001).(4)The influences of policy and environment factors on patient loyalty indicated that patients who contracted with FDs(3.47±0.99)had higher levels of loyalty compared with those did not contract with FDs(3.04±0.86)(P<0.001).Patients in institutions with 2000 or less average service population of each contracted service team(3.38±0.97)had higher levels of loyalty than patients in institutions with more than 2000 average service population of each contracted service team(3.23±0.94)(P<0.05).There was a higher level of patient loyalty when patient perceived more social support(B=0.027,P<0.001).(5)Patient health literacy had an indirect effect on patient loyalty via patient perceived value(effect=0.2409,95%CI=[0.1776,0.3071]),patient satisfaction(effect=0.2990,95%CI=[0.2315,0.3702])and patient trust(effect=0.1798,95%CI=[0.1187,0.2430]).Furthermore,patient perceived value,patient satisfaction and patient trust sequentially mediated the relationship between patient health literacy and patient loyalty.The FD contract service moderated the effect of patient health literacy on patient loyalty.Besides,the FD contract service also played a moderating role in the indirect effect of patient health literacy on patient loyalty through patient perceived value/patient satisfaction/patient trust.The multi-group path analysis indicated that the FD contract service played a moderating role in the path of "patient health literacy?patient trust?patient loyalty"(effect difference=0.042,P<0.05)and the path of "patient health literacy?perceived value?patient satisfaction?patient loyalty"(effect difference=0.178,P<0.05).(6)Patient perceived involvement had an indirect effect on patient loyalty via patient perceived value(effect=0.0323,95%CI=[0.0226,0.0430]),patient satisfaction(0.0369,95%CI=[0.0270,0.0479])and patient trust(effect=0.0301,95%CI=[0.0202,0.0407]).Furthermore,patient perceived value,patient satisfaction and patient trust sequentially mediated the relationship between patient perceived involvement and patient loyalty.The FD contract service moderated the effect of patient perceived involvement on patient loyalty.Besides,the FD contract service also played a moderating role in the indirect effect of patient perceived involvement on patient loyalty through patient perceived value/patient satisfaction/patient trust.The multi-group path analysis indicated that the FD contract service played a moderating role in the path of "patient perceived involvement?perceived value?patient satisfaction?patient loyalty"(effect difference=0.030,P<0.001).(7)Patient perceived service quality had an indirect effect on patient loyalty via patient perceived value(effect=0.5066,95%CI=[0.3331,0.6838]),patient satisfaction(0.6352,95%CI=[0.4778,0.8062])and patient trust(0.2557,95%CI=[0.1548,0.3688]).Furthermore,patient perceived value,patient satisfaction and patient trust sequentially mediated the relationship between patient perceived service quality and patient loyalty.The FD contract service also played a moderating role in the indirect effect of patient perceived service quality on patient loyalty through patient perceived value/patient satisfaction/patient trust.The multi-group path analysis indicated that the FD contract service played a moderating role in the path of "patient perceived service quality?perceived value?patient satisfaction?patient loyalty"(effect difference=0.245,P<0.001).(8)Patient social support had an indirect effect on patient loyalty via patient perceived value(effect=0.0061,95%CI=[0.0040,0.0085]),patient satisfaction(0.0074,95%CI=[0.0051,0.0099])and patient trust(0.0037,95%CI=[0.0021,0.0055]).Furthermore,patient perceived value,patient satisfaction and patient trust sequentially mediated the relationship between patient social support and patient loyalty.The FD contract service moderated the effect of patient social support on patient loyalty.Besides,the FD contract service also played a moderating role in the indirect effect of patient social support on patient loyalty through patient perceived value/patient satisfaction/patient trust.The multi-group path analysis indicated that the FD contract service played a moderating role in the paths of "patient social support?patient loyalty"(effect difference=0.015,P<0.05)and "patient social support?perceived value?patient satisfaction?patient loyalty"(effect difference=0.003,P<0.05).(9)A greater proportion of patients with higher levels of loyalty reported to have a usual source of primary health care facility(OR=10.693),have at least 13 visits to the facility in previous 12 months(OR=5.725),have more than one year duration in the facility(OR=1.818),receive appointment service(OR=2.997),receive follow-up service(OR=2.900),receive referral service(OR=6.209),receive doctor-to-doctor service(OR=5.207),receive health education(OR=1.762),receive rehabilitation guidance service(OR=10.114),receive priority treatment service(OR=17.372),receive long-term prescriptions service(OR=13.987)and receive free blood pressure and blood glucose measurement service(OR=3.133)compared with patients with lower levels of loyalty(P<0.05).(10)The qualitative interview indicated that individual factors(patient's inherent recognization of medical treatment),organizational factors(physician age,the number of physicians,the communication between doctor and patient,health expenses,pharmaceutical provision,medical technology,the weakness of medical service)and policy environment(peer support,reimbursement rate and FD contract service).Patients and medical staffs wished to improve patients' behavior intentions to primary health care facilities through increasing the government financial support and publicity,perfecting physical examination items,constructing specialist departments,expanding pharmaceutical provision,enhancing reimbursement rate,strengthening the construction of medical teams and facilities,combining medical care and health service reasonably,and strengthening the vertical cooperation between primary health care facilities and large hospitals.Conclusions:(1)The results of this study showed that patients with higher levels of loyalty were more likely to utilize primary health services and regard the primary health care facility as a usual source of care.However,improvements in patient loyalty to primary health care facilities are needed,which would hopefully be used to provide implications for health managers in terms of strengthening the awareness of cultivating loyal patients,especially,focusing on the loyalty of patients with poor health,and gradually cultivating the loyalty of other patients.(2)Patient health literacy,perceived value,patient satisfaction,and patient trust could predict patient loyalty.Therefore,health managers should pay attention to the positive effects of them on patient loyalty,and improve patient health literacy and trust,enhance patient perceive value and satisfaction through carrying out health education,improving the level of medical technology,providing personalized services,and so on.(3)The types of pharmaceuticals,the ratio of doctors to nurses,the number of physicians receiving standardized general practitioner training,and the number of physicians affected patient loyalty,which provided evidences that primary health care facilities need to perfect the pharmaceuticals allocation,strengthen the team construction of physicians and nurses to increase patient loyalty to primary halth care facilities.In addition,patient perceived involvement and perceived service quality were positively associated with patient loyalty,which provided implications that health managers should encourage patients to participate in the medical visits and enhance patient perception of service quality through promoting and popularizing the shared medical decision,paying attention to patients' health service needs.(4)This study confirms the value of the FD contract service in improving patient loyalty.Therefore,the government should continue its ongoing efforts on perfecting the FD contract service through publicity,incentive and guidance policies to establish a long strong relationship with patients.(5)Patient social support was positively related to patient loyalty.Enhance family support and primary health care provider support,and peer emotional support could increase patient loyalty to primary health care facilities.(6)This study explored the pathway of influencing factors on patient loyalty and examined the relationship between patient loyalty and health service utilization in primary care through mediation effect,moderation effect,moderated mediation effect and path analysis,which contributes theoretical and empirical basis for the small but growing body of research on patient loyalty,as well as provides certain implications for health managers in terms of understanding the cognitive psychology in the process of patient visit and the intrinsic driving factors in service purchasing,cultivating loyal patient strategy and enhancing patient primary health service utilization. |
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