1.1. RESEARCH SUBJECT
It is possible to make a broader definition of the concept of health services by considering the factors such as health, services, marketing, management, public relations and technology. According to this definition, health services are the sum of universal quality services that are accepted in a harmony and psychiatry coordination within the scope of some standards specified in the medical literature for individual's physical and mental condition and are provided to regulate social life quality of individuals (Öztürk 2000:142).
Health services create economic value for its producers and sellers with the functionality of differentiating brands, products and services from competitors with similar features (Knox, Maklan 1998:17). Businesses develop brands and present them to consumers by using marketing mixture elements. In contrast, consumers benefit from brands by adding emotional and symbolic values to these products or services by evaluating the features such as the quality, performance and distinctness of the brand with their perceptions (Akın ve Avcılar, 2007: 41).
1.2. RESEARCH PURPOSE AND IMPORTANCE
As a result of the increase in the general education level of the society, regulations for consumer protection, and changes in needs, expectations of the patients receiving health services change in parallel. Also, the physical conditions of the service provided, the attitudes and behaviours of the health personnel, the recognition of the health institution are taken into consideration. Therefore, healthcare providers are trying to maintain their existence and improve themselves in ongoing competition in order to spread the quality, human-oriented service understanding that directly affects corporate brand images.
From this point of view, the present study aimed to determine the factors affecting the brand image, perceived service quality, patient satisfaction and the reasons for patients' preference (loyalty) in healthcare enterprises.
1.3. CONTRIBUTION of the ARTICLE to the LITERATURE
Business image, which is a subjective concept, is difficult to measure. The opinions of two patients, who benefit from the same healthcare service, about the healthcare provider or physician may differ. An image can be created at the organization stage, or it can also be created by the services provided by the organization or the people who provide these services. For example, while the patient has a positive opinion for the healthcare provider, he/she may have quite negative thoughts about a physician working there. In this case, the first thing to be done is to determine what the current image is, if it is positive, to take the necessary measures to protect this image, if not, to develop it positively. Public relations alone are not enough to create a positive image. Having a positive or negative image is a general result of all the efforts and features of the business (Karafakıoğlu 45: 81). This study will shed light on institutions at these points.
2. DESIGN AND METHOD
2.1. RESEARCH TYPE
This research is conducted using quantitative research methods and techniques. The cross-sectional pattern is used in this study which was prepared and conducted.
2.2. RESEARCH PROBLEMS
The research problem is as follows: In the hospital preferences of the patients; Is there a relationship between brand image, perceived service quality, patient satisfaction and intention to visit again (loyalty)? This study attempted to determine the brand image effects in the preferences of the patients (consumers) who came to Sivas Numune Hospital to receive health services.
2.3. DATA COLLECTION METHOD
In the research, survey data of 430 patients were evaluated by a random sampling method. The research application included patients who received healthcare services only for a certain period. First of all, the preliminary survey study was carried out for 30 people with general questions prepared in line with the related literature.
2.4. QUANTITATIVE / QUALITATIVE ANALYSIS
Using the descriptive statistical methods related to the variables used to measure the satisfaction levels of the data, together with Reliability Analysis, Factor Analysis, Correlation Analysis, Independent Sample T-Test, Tamhane's Test, Scheffe Test and One-Way ANOVA were analyzed.
2.5. RESEARCH MODEL and RESEARCH HYPOTHESES
The data were analyzed based on four factors as brand image on the hospital preference, service quality, patient satisfaction perceptions, and intention to re-visit (loyalty) together with the demographic information of the participants.
Accordingly, the following hypotheses were tested in the research.
H1: Participants' opinions on the scales differ according to gender.
H2: The opinions of the participants on the scales differ according to the appointment status.
H3: Participants' opinions on the scales differ according to age.
H4: Participants' views of the scales differ according to marital status.
H5: Participants' opinions on the scales differ according to their educational status.
H6: Participants' opinions on the scales differ according to their professional status.
H7: The opinions of the participants on the scales are statistically significant according to their income status.
H8: Participants' opinions on the scales differ according to social security status.
H9: Participants' opinions of the scales differ according to the number of visits to the same health institution.
H10: Participants' opinions of the scales differ according to the waiting time.
3. FINDINGS AND DISCUSSION
3.1. FINDINGS as a RESULT of ANALYSIS
In calculating the internal consistency of the factors, Cronbach Alpha value was used, and it was determined that the overall reliability of the scale was at a high level (Cronbach's Alpha = 0.938). It is possible to say that the brand image is useful on the perceived service quality and the re-preference (adherence) intentions of the patients.
3.2. HYPOTHESIS TEST RESULTS
According to the results of the research, the opinions of the participants; It varies according to gender, marital status, education, profession, income and hospital stay. However, it does not differ by age.
3.3. DISCUSSING the FINDINGS with the LITERATURE
Health services are now patient-centred, and customer-oriented marketing is also essential in these businesses. Therefore, the perceptions of the customer towards the brand image are critical in healthcare services (Kolade, 2014; 37). The results of this research also support the literature and show that the demographic characteristics of people affect their perceptions.
4. CONCLUSION, RECOMMENDATION AND LIMITATIONS
4.1. RESULTS of the ARTICLE
The results of the analysis showed that the brand image perception of the patients significantly differ concerning the marital status and the brand image perception of married patients was significantly lower compared to the single ones. Because married patients have a more social responsibility in social life compared to the single patients, the married patients were considered not to have expectations about the brand image as much as single patients, but they evaluate the quality of the service.
According to the survey data, the perception of service quality and brand image is higher as the education level of the participants' increases. Effect of the educational level on the loyalty levels of the participants was also analyzed, and the results indicate that the increase in the level of education affected the loyalty levels in the same direction. General scale perceptions were also considered to be parallel to the increase in education level. Societies having an advanced educational level enables individuals to have more selective and questioning perspectives. This situation contributes to the functionality of competition in the health sector. In this way, it will be possible for health institutions to provide better services.
Finally, when the relationship between scale dimensions is examined, it is found that there is a moderately strong positive relationship between service quality and brand image; there is a definite positive relationship between service quality and loyalty; there is a moderately strong positive correlation between service quality and patient satisfaction; there is a strong positive relationship between brand image and loyalty; there is a positive but weak relationship between brand image and patient satisfaction; between loyalty and patient satisfaction It was found that there is a moderately strong positive relationship.
4.2. SUGGESTIONS BASED on RESULTS
At this point, healthcare enterprises need to develop strategies to create a brand image in order to create the most desired customer loyalty in today's conditions. Also, hospitals need to take permanent measures to improve the quality of the service provided. According to the literature, consumers who benefit the services more than their expectations become satisfied. Accordingly, a satisfied customer will be more likely to re-visit. Also, the study showed that the reliability of the enterprises increases loyalty to the brand. For this reason, in the applications, attention should be paid to the reliability factor affecting patient preferences.
The results of the research pointed out that the increase in education level was useful in evaluating the quality perceptions, image perceptions, satisfaction and loyalty levels of the patients, as a result of the increasing number of educated individuals, day by day and the developments in communication and telecommunication technologies, a patient profile with higher awareness requests healthcare service from hospitals. In this context, hospitals have to organize their current efforts more strategically and patient-oriented for all dimensions evaluated in this research.
4.3. LIMITATIONS of the ARTICLE
Patients who receive health care only for a certain period are included in the application. Besides, the psychological status of patients and their reluctance to participate in the questionnaire while receiving health care is another limiting factor.
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