Strategic management in healthcare: Influence of service quality and brand image on patient loyalty: A cross-sectional study

Abstract

BACKGROUND:

Hospital service quality and brand image are essential factors influencing patient satisfaction and loyalty in competitive healthcare environments. This study aimed to assess their effects on patient loyalty, mediated by patient satisfaction.

MATERIALS AND METHODS:

This cross-sectional quantitative study was conducted in public and private hospitals of Rawalpindi, Pakistan, from January to April 2025, where 200 hospitalized patients were tested. A validated structured questionnaire was used to collect data about four domains: service quality, brand image, patient satisfaction, and patient loyalty. The analysis was made using SPSS version 25; the statistical techniques used were descriptive statistics, Pearson correlation, and multiple regression, followed by Preacher and Hayes bootstrapped mediation analysis (n = 5000 repetitions). The significance level was set at P < 0.05.

RESULTS:

Hospital service quality significantly predicted both patient satisfaction (β = 0.410, P < 0.001) and patient loyalty (β = 0.570, P < 0.001). Brand image also significantly predicted patient satisfaction (β = 0.100, P < 0.002) and loyalty (β = 0.120, P < 0.032). Patient satisfaction was positively associated with loyalty (β = 0.560, P < 0.001). Mediation analysis confirmed that patient satisfaction significantly mediated the relationships between service quality and loyalty (β = 0, P < 0.0013) and between brand image and loyalty (β = 0.0591, P < 0.002).

CONCLUSION:

This study showed that patient satisfaction mediates the effects of service quality and brand image on loyalty. It contributes novel evidence from Pakistan’s healthcare sector and calls for future research in diverse hospital settings.

Introduction

Health care systems exist to promote population well-being through preventive, diagnostic, and therapeutic interventions. The performance of these systems is frequently evaluated in terms of service quality and patient-centered outcomes rather than medical treatment alone.[1,2,3] The Institute of Medicine defines healthcare quality as “the extent to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.[4] That definition emphasizes that quality extends beyond clinical proficiency to include characteristics such as responsiveness, safety, access, and meeting patient expectations. Consequently, the perception of quality of service by patients is being considered within the key elements of institutional performance.

Among the most common indices of such perceptions is patient satisfaction, which has come to dominate the assessment of health care.[5] The latter is related to better compliance with medical recommendations, higher mental well-being, lower numbers of complaints, and positive word-of-mouth.[6] On the other hand, dissatisfaction can erode confidence, lead to noncompliance with treatment regimens, and harm the prestige of the hospital. Patient satisfaction surveys have now routinely become a means for health care managers to identify service gaps, support quality improvement programs, and develop stronger long-term relationships with patients.[7]

While quality and satisfaction lay the groundwork around the delivery of care, branding in health care has become a force to be reckoned with in the decision-making process of patients. Branding, unlike traditional health outcomes, speaks to the intangible and psychological aspects of consumption of a service. The complexity, invisibility, and pre-consumption productivity of health services mean that patients often select providers without certain knowledge or even a good idea of which option is best. In these scenarios, a positive brand image serves as a beacon of trustworthiness and capability, framing expectations prior to treatment and supplementing perceptions during and post service experiences.[8,9,10]

The shift from building clinical quality to branding also highlights an essential truth: quality is not is not enough to win the hearts and minds of patients in modern health care. Institutions must also communicate that excellence through credible and recognizable brand identities. Branding, therefore, serves as a bridge between objective service delivery and subjective patient experience, ensuring that perceptions align with actual quality.

In marketing and management research, brand image is widely recognized as a determinant of consumer behavior, influencing preference, purchase intentions, and loyalty.[11,12,13] Applied to health care, these dynamics translate into trust, preference for specific hospitals, and a greater likelihood of recommending services to others.[14] In global sectors such as medical tourism, where patients choose across borders, brand identity is particularly influential in differentiating providers.[15] Despite this, empirical studies examining brand image in health care remain scarce, especially compared with retail or corporate sectors. The literature that does exist is fragmented, often focusing narrowly on service quality or satisfaction while overlooking how brand image interacts with these elements to shape loyalty.[16,17]

The research gap is even more evident in developing countries, where the health care sector faces resource constraints, uneven quality standards, and varying levels of patient awareness. In such contexts, patients may rely more heavily on brand cues to reduce uncertainty and guide decision-making. Yet, little empirical work has investigated how brand image contributes to patient satisfaction and loyalty in these settings. This absence of evidence limits the ability of managers and policymakers to design effective branding strategies that complement service improvements.

Recent studies suggest that service quality, brand image, satisfaction, and loyalty are not independent variables but interdependent drivers of patient behavior.[9,18] Service quality directly affects satisfaction, while a favorable brand image amplifies this effect by fostering confidence and reducing perceived risk. Satisfaction then serves as a mediating mechanism that converts quality perceptions into behavioral outcomes such as loyalty. Loyalty, in turn, ensures patient retention, repeat visits, compliance with medical advice, and advocacy through positive word-of-mouth.[19] In this sequence, brand image operates both as a reinforcing factor that enhances the impact of service quality and as a psychological lens through which satisfaction translates into loyalty.

Despite these theoretical linkages, the integrated relationships among service quality, brand image, satisfaction, and loyalty have not been systematically studied in hospital settings, particularly in developing economies. Most existing work examines dyadic connections (e.g., quality–satisfaction or satisfaction–loyalty) rather than testing a comprehensive model that includes brand image as a key determinant. Addressing this gap is essential to understanding how hospitals can strengthen competitiveness not only through clinical excellence but also through strategic brand positioning.

Therefore, this study aims to investigate the impact of hospital service quality and hospital brand image on patient loyalty, with patient satisfaction tested as a mediating variable. By examining these interrelationships, the study contributes to a more holistic understanding of how health care institutions can achieve competitive advantage through patient-centered branding and service excellence. The findings are expected to guide managers and policymakers in developing integrated strategies that improve service delivery, build strong brand reputations, and foster enduring patient loyalty in resource-constrained health systems.

Materials and Methods

Study design and setting

The present study employed a quantitative, cross-sectional survey design to examine the influence of hospital service quality and hospital brand image on patient satisfaction and loyalty, using a field-based data collection approach that enabled patients to provide real-time feedback during their admission. The study was conducted in public and private hospitals across Rawalpindi, Pakistan, between January and April 2025.

Study participant and sampling

The target population consisted of adult patients admitted to general medicine, surgery, and gynecology departments. Inclusion criteria required participants to be at least 18 years of age, hospitalized for a minimum of 24 hours, and mentally capable of completing the survey independently. Due to time and access limitations, a non-probability convenience sampling technique was used, and 200 participants were recruited; although this approach facilitated recruitment, it reduces the generalizability of findings to the wider hospitalized population. The sample size was determined using Cochran’s formula , where Z = 1.96 for a 95% confidence level, P = 0.5 (estimated proportion), q = 1 – P = 0.5, e = 0.07 (margin of error). The minimum calculated sample size was 196. To ensure adequacy, 200 questionnaires were distributed and all were returned complete, resulting in a 100% response rate.[18]

Data collection tool and technique

Data were collected through a demographic questionnaire and four structured measurement scales. The demographic tool collected information on gender, age, education, and type of hospital. Hospital service quality was measured with a validated scale that assessed admission services, medical services, total services, discharge process, and social obligations[20]; each item was scored on a five-point Likert scale from one (strongly disagree) to five (strongly agree), with higher scores indicating better perceived service quality, and the internal consistency of the tool was excellent with a Cronbach’s alpha of 0.851. Hospital brand image was assessed with a scale measuring perceptions of trustworthiness, emotional connection, visual identity, and reputation[21]; items were rated on a five-point Likert scale, higher scores indicated stronger brand image, and reliability was acceptable with a Cronbach’s alpha of 0.758.[22] Patient satisfaction was measured with a scale including items on cleanliness, responsiveness, staff attitude, and service coordination[23]; items were scored on a five-point Likert scale, higher scores represented greater satisfaction, and the scale showed acceptable reliability with a Cronbach’s alpha of 0.720. Patient loyalty was evaluated using a scale that assessed revisit intentions, recommendation behavior, and trust in hospital services[24]; responses were given on a five-point Likert scale, higher scores indicated stronger loyalty, and the internal consistency of this scale was good with a Cronbach’s alpha of 0.759.

Ethical consideration

The study was conducted in accordance with the principles of the Declaration of Helsinki, and ethical approval was obtained. All participants provided written informed consent, and confidentiality, anonymity, and voluntary participation were ensured.

Statistical analysis method

Data analysis was conducted using IBM SPSS Statistics version 25.[25] Descriptive statistics were applied to summarize demographic characteristics, Cronbach’s alpha coefficients were used to confirm reliability of the scales, Pearson correlation analysis was performed to explore associations among the study variables, multiple regression analysis was applied to examine the direct effects of hospital service quality and brand image on patient satisfaction and loyalty, and mediation analysis was conducted using the Preacher and Hayes bootstrapping method with 5000 resamples to test indirect effects of service quality and brand image on loyalty through satisfaction. Statistical significance was determined at P < 0.001.

Results

Demographic characteristics of respondents

A total of 200 hospitalized patients participated in the study. Of these, 70% (n = 140) were male and 30% (n = 60) were female. The majority (30.5%) were aged 31-40 years, followed by 27% (20-30 years), 19% (41-50 years), 13.5% (51-60 years), and 10% (above 60 years). Regarding education, 59% had a bachelor’s degree, 18% were postgraduates, 12% had secondary education, and 11% had other certifications. In terms of hospital affiliation, 72.5% (n = 145) were from private hospitals, while 27.5% (n = 55) were from public hospitals [Table 1].

Table 1.

Demographic characteristics of study participants

		Frequency		Percent
Gender
Male		140		70
Female		60		30
Age distribution of respondents
20–30		54		27
31–40		61		30.5
41–50		38		19.0
51–60		27		13.5
60 above		20		10
Academic education
Secondary		24		12
Bachelor		118		59
Post-graduate		36		18
Other		22		11
Nature of hospital/organization
Public		55		27.5
Private		145		72.5

Descriptive statistics (frequencies and percentages) used to summarize demographic characteristics

Correlation analysis

As shown in Table 2, Hospital Service Quality was positively correlated with Hospital Brand Image (r = 0.365, P < 0.001), Patient Satisfaction (r = 0.323, P < 0.001), and Patient Loyalty (r = 0.313, P < 0.01). Similarly, Hospital Brand Image showed a significant correlation with Patient Satisfaction (r = 0.210, P < 0.001) and Patient Loyalty (r = 0.170, P < 0.01). Furthermore, Patient Satisfaction was significantly correlated with Patient Loyalty (r = 0.421, P < 0.05

Table 2.

Pearson correlation matrix among main variables

Variables		Hospital service quality		Hospital brand image		Patient satisfaction		Patient loyalty
Hospital service quality		1
Hospital brand image		0.365***		1
Patient satisfaction		0.323***		0.21 **		1
Patient loyalty		0.313**		0.17**		0.421*		1

Statistical test: Pearson correlation; *P<0.05, **P<0.01, **P<0.001

Regression analysis

Multiple regression was conducted to assess direct effects. Hospital Service Quality significantly predicted both Patient Satisfaction (β = 0.410, P < 0.001) and Patient Loyalty (β = 0.570, P < 0.001). Hospital Brand Image was also a significant predictor of Patient Satisfaction (β = 0.100, P < 0.002) and Patient Loyalty (β = 0.120, P < 0.032). Patient Satisfaction had a strong influence on Patient Loyalty (β = 0.560, P < 0.001) [Table 3].

Table 3.

Regression analysis of hospital service quality and brand image predicting satisfaction and loyalty

Predictor		β		<P
Hospital Service Quality → Satisfaction		0.410		0.001
Hospital Service Quality → Loyalty		0.570		0.001
Hospital Brand Image → Satisfaction		0.100		0.002
Hospital Brand Image → Loyalty		0.120		0.032
Patient Satisfaction → Loyalty		0.560		0.001

Statistical test: Multiple linear regression

Mediation analysis

The Preacher and Hayes bootstrapping method (5000 resamples) was used to evaluate the mediating role of Patient Satisfaction.

As displayed in Table 4, Hospital service quality significantly predicted both patient satisfaction (β = 0.423, P < 0.001) and patient loyalty (β = 0.568, P < 0.001). Patient satisfaction also significantly predicted patient loyalty (β = 0.500, P < 0.001). Mediation analysis using bootstrapping confirmed that patient satisfaction partially mediated the effect of service quality on loyalty (indirect effect β = 0.213, 90% CI [0.061,0.483], P < 0.001).

Table 4.

Mediation analysis: Hospital Service Quality → Satisfaction → Loyalty

Relationship		β		SE		t		P
Service Quality → Loyalty		0.5688		0.1204		4.8872		<0.001
Service Quality → Satisfaction		0.4234		0.0793		4.8790		<0.001
Satisfaction → Loyalty		0.5001		0.0799		5.8908		<0.001
Indirect effect (Bootstrapped)		0.2128		-		-		<0.0013
90% CI (Lower-Upper)		0.0611-0.4832

Statistical test: Mediation analysis using Preacher & Hayes bootstrapping method (5000 resamples)

From the analysis of Table 5 utilizing the Preacher and Hayes macro, it has been revealed that hospital brand image predicts patient loyalty and patient satisfaction. Patient Satisfaction stands as a predictor for Patient Loyalty at the patient level. The partial mediation relationship exists between hospital brand image and patient loyalty since beta (β) values decrease in the same direction beyond lower limit and upper limit.

Table 5.

Mediation analysis of Hospital brand image on patient loyalty and patient satisfaction

Relationship		β		SE		t		P
Brand Image → Loyalty		0.1197		0.0453		2.6434		0.0031
Brand Image → Satisfaction		0.1084		0.0326		3.3263		0.0000
Satisfaction → Loyalty		0.5456		0.0813		6.7110		0.0010
Indirect effect (Bootstrapped)		0.0591		-		-		0.0021
90% CI (Lower-Upper)		0.0145 – 0.1267

Statistical test: Mediation analysis using Preacher and Hayes (bootstrapping with 5000 resamples)

Discussion

This study examined the relationships among hospital service quality, hospital brand image, patient satisfaction, and patient loyalty in the context of Rawalpindi, Pakistan. The findings confirm that high hospital service quality significantly enhances patient loyalty, supporting the idea that when patients perceive providers as attentive, responsive, and capable, they are more likely to return and recommend services to others.[26] These results reinforce the centrality of service quality in driving behavioral outcomes in health care settings.

Importantly, the analysis demonstrated that patient satisfaction plays a mediating role in the relationship between service quality and loyalty. This suggests that satisfaction is not only a direct consequence of service delivery but also a mechanism that translates perceived quality into loyalty behavior.[27] This finding is consistent with Shie et al.,[28] who reported that service quality—through timely service, responsiveness, and personalized attention—predicts loyalty. Similarly, Wali and Nwokah[29] emphasized that satisfaction emerges when service delivery meets or surpasses patient expectations. Our study extends these observations by confirming that in Pakistan’s hospital context, satisfaction channels the effects of quality into sustained loyalty. Moreover, as Daramilas and Jaspal[30] argued, satisfaction may also arise from psychological and emotional responses shaped by prior experiences. Our findings resonate with this perspective, as many respondents emphasized feelings of trust, reassurance, and respect during care—suggesting that loyalty stems not only from functional aspects but also from emotional engagement with providers.

The results also revealed that hospital brand image exerts a positive influence on both satisfaction and loyalty. Patients who viewed their hospitals as trustworthy, professional, and reputable reported higher satisfaction levels and stronger loyalty intentions. This aligns with Vimla and Taneja.[9] who argued that positive brand perceptions shape how patients evaluate hospital performance and outcomes. Our findings are further supported by Gavurova and Kubak, who highlighted the confidence-building effect of a favorable brand image. However, the data also indicated that satisfaction is influenced by operational factors such as waiting times and service accessibility. This nuance echoes prior studies[31,32] suggesting that while brand image creates initial trust, consistent operational performance sustains satisfaction and revisits.

The mediation analysis provided additional insights, showing that patient satisfaction significantly mediates the effects of both service quality and brand image on loyalty. This supports the conclusions of Asnawi et al.,[33] who emphasized satisfaction as a bridge linking brand perception to loyalty. Moreover, our findings align with the view of scholars who argue that perceived value reflected in reliability, responsiveness, and consistent service delivery forms the basis of long-term loyalty.[34] This highlights that patients expect not only a reputable brand but also tangible value in their service experiences.

Taken together, these results contribute to existing literature by integrating service quality, brand image, satisfaction, and loyalty into a unified framework. While prior studies have examined these variables in isolation or in dyads, our research demonstrates how they interact to produce patient loyalty within the hospital setting of a developing country. The psychological and emotional dimensions of satisfaction observed in our data provide additional depth, showing that beyond technical care, elements such as respect, empathy, and reassurance are crucial in fostering patient trust and long-term loyalty.

Despite its contributions, this study has limitations. The research was conducted in a single urban setting using convenience sampling, which may limit generalizability. Furthermore, reliance on self-reported data introduces the possibility of response bias. Nevertheless, the use of validated measurement tools and mediation analysis strengthens the reliability of the findings and uncovers complex mechanisms linking quality, branding, satisfaction, and loyalty.

Overall, the study makes a unique contribution by providing empirical evidence from a developing country context, where health care branding remains underexplored. It demonstrates that both service quality and brand image significantly shape satisfaction and loyalty, with satisfaction serving as a key mediating mechanism. These insights not only validate prior research but also extend it by highlighting the interplay of operational, psychological, and branding factors in driving patient loyalty. For hospital managers and policymakers, the findings suggest that efforts to improve service quality must be complemented by strategies to strengthen brand image and foster emotional connections with patients in order to secure sustainable competitive advantage.

Limitation and recommendation

This study demonstrates that hospital service quality and brand image significantly influence patient satisfaction and loyalty, with satisfaction serving as a partial mediator. Scientifically, the research contributes by integrating these variables into a single framework within the Pakistani healthcare context, where empirical evidence on the role of brand image in shaping patient loyalty remains scarce. This contextual novelty adds depth to the global literature, showing that both operational quality and perceived reputation are critical drivers of loyalty in resource-constrained systems.

The findings also carry practical implications: managers should strengthen both service delivery and branding to build trust, enhance patient experiences, and secure long-term loyalty. However, the study’s use of convenience sampling and focus on a single urban setting limit generalizability. Future research should employ multi-site, longitudinal, and comparative designs to validate and extend these results across diverse hospital contexts, including public versus private facilities.

AI policy statement

The authors confirm that artificial intelligence (AI) tools were not used during the preparation of this manuscript for language editing, grammar correction, and improvement of clarity and readability. AI tools were not used to generate the study results, analyses, interpretations, or scientific conclusions.

Ethical approval

Ethical approval was obtained from the Shifa Tameer-e-Millat University (Reference No. PH/RP-25/112). All participants were provided with informed consent prior to participation. Confidentiality and anonymity were maintained throughout the study, and participants were informed of their right to withdraw at any time without consequence.

Authors’ contributions

Conceptualization: RA, MO, OA and AK. Methodology: RA and MO. Software: RA, OA and SI. Validation: RA, MO, AK, OA and SI. Formal analysis: RA and AK. Investigation: RA and AK. Resources: RA and AK. Data curation: RA, AK and MD. Writing—original draft preparation: RA, MO and MD. Writing—review and editing: RA, SI and MD. Visualization: RA and OA. Supervision: RA and OA. Project administration: RA and AK.

Data availability statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to ethical and/or confidentiality considerations.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.