Evidence Synthesis/Review

Health Services Management Research

0(0) 1–8
Brand image to loyalty through perceived ! The Author(s) 2020
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DOI: 10.1177/0951484820962303
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1
Vimla and Udita Taneja1

Abstract
Brand image (BI) is a relatively new concept in the healthcare sector and its value is important for healthcare organizations to
survive in this competitive era. Extant research in academics shows the diversity in determinants of patient satisfaction (PS),
perceived service quality (PSQ), loyalty and brand image (BI) in the healthcare sector. The large numbers of existing studies
mainly emphasize constructs such as PS, PSQ or the relationship between these two, taking into consideration other factors
like cost and loyalty. The purpose of this study is to systematically review and summarize current research as well as propose
a conceptual model of hospital brand image and its impact on patient loyalty through PSQ and PS. We provide a research
framework for future theoretical and empirical studies on the impact of BI on patient loyalty.

Keywords
brand image, loyalty, patient satisfaction, perceived service quality

Introduction
In service marketing literature Brand Image (BI) was
identified as an important factor in the overall percep-
tion of a company.1,2 In the healthcare sector a favour-
able brand image impacts the perception of service
quality (PSQ), patient satisfaction (PS), loyalty and
repurchase intention of patients.3–5 In terms of determin-
ing its strategy a hospital’s brand image plays an impor-
tant role. Hospitals can improve their competitive
position in the industry by using strategic marketing
activities as suggested by Javalgi et al.6
In Aaker’s7 path breaking book, Managing Brand
Equity, managers discovered the value of a brand as a
strategic asset and a company’s primary source of com-
petitive advantage. A positive hospital brand image can
be leveraged strategically and can attain competitive
advantage over other players in the healthcare sector.
Companies with loyal customers can increase their
market share by reducing their operating costs.8 Loyal
customers are not only willing to purchase more often
but they also try the company’s other services or prod-
ucts and introduce new customers.9
Studies related to ‘brand image and loyalty’ have been
around for decades10 and are still continuing.11–13 In
studying the relationship, however, among brand
image, loyalty, perceived service quality, and patient sat-
isfaction, studies are fragmented. In our study, we see
that: a number of studies focus on indicators of PS,14 PS
as a multi-dimensional construct;15,16 PS as a strategic
tool with operational relevance;17 and PS for bench-
marking purposes.18 Similarly, studies propose that ser-
vice quality is a multi-dimensional construct;19–22 service
quality can be used for evaluation;2 and service quality
may be used for benchmarking.23 When we talk about
PSQ and the relationship between PS and PSQ, we see
that there is a causative relationship between PSQ and
PS.24 On examining the relationship between more than
two constructs we find differences among studies. The
better the service quality, the higher will be the PS25 and
BI will be positive.26 PSQ has also been shown to have a
positive significant effect on loyalty directly and indirect-
ly through PS.12 Some studies show that PS positively
1
University School of Management Studies, Guru Gobind Singh
Indraprastha University, New Delhi, India
Corresponding author:
Udita Taneja, Guru Gobind Singh Indraprastha University, Sector 16-C,
Dwarka, New Delhi 110078, India.
Email: udita.taneja@gmail.com
2 Health Services Management Research 0(0)
affects BI,13 and factors of service quality (satisfaction,
trust) lead to loyalty.27
To study the relationship ‘brand image to loyalty
through perceived service quality and patient satisfac-
tion’, we start with prior research related to ‘patient sat-
isfaction’, ‘perceived service quality’, ‘loyalty’, ‘hospital
brand image’ and the respective relationships among
them. There are many studies with regard to the
impact of PSQ on PS, or the impact of satisfaction on
loyalty. There is, however, a lack of studies that examine
the impact of brand image on loyalty along with their
relationship with PSQ and PS. This is a gap in the liter-
ature. This paper, therefore, attempts to answer the fol-
lowing research questions as they pertain to the
healthcare sector:
• How does hospital BI influence Loyalty? How do
PSQ and PS influence Loyalty?
• Do PSQ and PS mediate or moderate the relationship
between BI and Loyalty in the healthcare sector?
To answer these questions a literature review was
done. In the following sections the scope of the review
is explained and the evolution of the literature is exam-
ined over the years. Next, we examined the factors that
moderate or mediate the relationship between BI and
Loyalty. Finally, we synthesize the findings of this
review into a conceptual framework and suggest avenues
for future research.
Methodology
We used a systematic approach for our literature review
and considered all kinds of studies: theoretical,
Records collected Records collected
from Google Scholar from Emerald
n = 49 n = 90
Total number of
collected records
n = 168
Records screened on their titles, abstracts
and keywords
n = 107
Records included in the analysis
n = 61
Figure 1. Process of selection of papers.
empirical, cross-disciplinary, multidisciplinary and
meta-analytic.28 We looked for articles in different data-
bases with words such as Brand Image or patient
Loyalty showing in either the ‘title’, ‘abstract’ or ‘key-
words’. We chose two criteria for inclusion. Initially, we
selected articles that discussed PSQ and/or PS. Next, we
studied articles where the relationship between PSQ, PS,
with at least one other construct like Loyalty, was
explored and selected those as well. We have referred
to journal articles over the recent 21-year period
(1998–2018) from the healthcare management literature.
A total of 168 research papers were collected: 49 out of
these were obtained from Google Scholar, 90 from
Emerald and 29 from others like Sage. These 168
papers were then screened with respect to the criteria
set for our research as mentioned above and we were
finally left with 61 articles. Figure 1 illustrates this
graphically.
The remaining 61 articles discuss the effects of BI,
PSQ and PS on patient loyalty, as shown in Figure 2.
The details of a select few are given in Table 1.
The geographical distribution of these selected
61studies is as follows: Australia (1), Bahrain (1),
Bangladesh (2), China (1), Egypt (2), France (2), India
(9), Indonesia (20), Iran (1), Kuwait (1), Malaysia (3),
Netherlands (1), Norway (2), Oman (10), Portugal (3),
Qatar (10), Saudi Arab (1), Taiwan (2), UAE (1), UK (1)
and USA (10).
We included 61 papers from the years 1998 to 2018
and considered some landmark papers published earlier
that current researchers have referenced. Donabedian29
proposed that “patient satisfaction may be considered to
be one of the desired outcomes of care . . . information
Records collected from
others
n = 29
Records excluded due to poor
relevance to the objective of
the research
n = 46
Vimla and Taneja 3

about patient satisfaction should be as indispensable to
assessments of quality as to the design and management
of health care systems”. Considering performance alone,
service quality can be predicted in healthcare services.30
Constructs Included in the Study
25
20
No of Papers
Our analysis of the literature includes these papers
whose findings are relevant to our research objectives
and are discussed in the following sections.
Findings
Patient satisfaction (PS)
As a construct, satisfaction is a consequence of how

15 customers evaluate their experiences as well as their

10 outcomes.31
5 In our study, we see that past research focussed on
0
SQ, PS & dimensions, predictors and utilization of PS. Andaleeb16
PL/BI or
PS SQ SQ & PS PS & PL RM, PS &
established that PS is a five-factor model (quality of
PL or SQ, facilities, communication with patients, perceived costs,
Price & PS
Series1 14 8 20 9 10
competence of staff and patients’ demeanour) that
explains considerable variations in patient satisfaction
Figure 2. Final selection of papers used in the study (PS-Patient with hospitals. Crow et al.14 in their meta-analytic
Satisfaction; SQ-Service Quality; BI-Brand Image; PL-Patient study of 37 research articles found that in the healthcare
Loyalty and RM-Relationship Marketing). environment there was no definitive conceptualisation of

Table 1. Depicting the construct-wise study individually and with the relationships among other constructs (PS-Patient Satisfaction;
SQ-Service Quality; BI-Brand Image; PL-Patient Loyalty and RM-Relationship Marketing).

S. No. Author (date) Region Constructs Sample size Data analysis technique
34
1 Naik et al. India PS 436 Descriptive statistics,
Confirmatory Factor
Analysis (CFA)
2 Ferreira et al.17 Portugal PS Simulation Model Case study
3 Hekkert et al.18 Netherlands PS In Patients-16,904 Multi-level Analyses using
(academic hospitals) & MLwiN 2.02 software
11,015 (general package
hospitals); Out
Patients-23,344 &
15,348
4 Shafei et al.22 Egypt Evaluation of SQ 384 Females Factor Analysis & Ordinal
Logistic Regression
5 Al-Abri et al.39 Oman PS & SQ Databases utilized: Google Review Article
Scholar, Medline,
Emerald, Pub-Med &
Science Direct
6 Padma et al.19 India PS & SQ 408 Bivariate Correlation &
Multiple Regression
7 Naidu37 India PS & SQ Conceptual model built Literature Review
8 Byram26 India PS, SQ & BI 500 CFA
9 Moreira and Silva27 Portugal SQ, Time, Commitment & 175 Structural Equation
Loyalty Modelling (SEM)
10 Kian et al.44 Malaysia Medical Error, Cost of 131 Descriptive Analysis,
Treatment, Quality Pearson Correlation
Service, Expertise,
Availability, PS & Loyalty
11 Astuti et al.45 Indonesia RM, PS & Loyalty 307 SEM with smart PLS
software
12 Wu56 Taiwan PS, SQ, PL & BI 437 SEM-CFA
4 Health Services Management Research 0(0)
satisfaction. Administrators need to develop some pro-
cesses to gauge PS. This finding is consistent with the
meta-analytic study conducted by Gill and White32 that
similarly concluded that PS is being used interchange-
ably with PSQ and as a construct has little standardisa-
tion, whereas, PSQ is a conceptually different and
superior construct.
On the other hand, PS is also found to be a major
indicator while evaluating and improving quality in
healthcare.3,33 It was shown that patient characteristics
such as age, health status and education are significant
determinants of PS and can be used for benchmarking.18
To improve PS without an increase in operational costs,
Ferreira et al.17 established that PS has operational and
strategic relevance for hospital administrators. Along
similar lines, and based on an extensive literature
review, Naik et al.34 identified six different dimensions
of patient satisfaction for the healthcare sector. These
dimensions of patient satisfaction were first impression
of hospital services; food and housekeeping services;
nursing care; clinical care; communication (keeping
the patient informed); and overall conditions of
hospital care.
Patient satisfaction (PS) and perceived service
quality (PSQ)
Service quality can be defined as a customer’s post-
consumption evaluation of service which compares
expectations with perceptions of performance.30,35
Gr€onroos2 defined perceived service quality as an evalu-
ation in which the consumer compares their expectations
with their service perceptions. Excellent service is a not
just a profitable strategy but increases business with
existing customers and results in lower customer losses.35
Shemwell & Yavas36 proposed three sets of attributes
of service quality, i.e., search attributes (consumer
knows about the product or service before its actual
purchase or consumption), experience attributes (after
product purchase or service consumption the consumer
can make rational evaluations) and credence attributes
(making an evaluation about a product or service
though the customer does not have enough knowledge)
dominate consumers’ service choice decisions. Other
researchers assessed SQ as one-dimensional,21 while
Shafei22 assessed PSQ as comprising of eight constructs
and 17 sub-constructs. These constructs are hospital
premises and employees; nursing medical service;
doctor’s medical service; diagnostic medical service; dis-
charge; admission; rooms and housekeeping; and meals.
The sub-constructs are physician reliability; physician
assurance; physician interaction; physician’s compe-
tence; nursing tangibles; nursing reliability; nursing
assurance; nursing interaction; nursing responsiveness;
diagnostic service competence; diagnostic service
reliability; hospital premises and employees tangibles;
admission responsiveness; admission knowledge and
courtesy; meal tangibles; room tangibles and housekeep-
ing courtesy; and discharge knowledge and courtesy.
Hospital service quality can be used as a benchmark
by hospitals so that they can improve their services as
compared to other hospitals.19 Naidu37 developed a
comprehensive model to better understand healthcare
services after reviewing 24 international articles on
patient satisfaction and healthcare quality. Health care
output, access, caring, communication and tangibles
were found to be the dimensions that determined patient
satisfaction. The antecedents to patient satisfaction were
determined to be healthcare service quality perceptions
(‘access’, ‘care quality’, ‘cost’, ‘physician role and behav-
iour’ and ‘tangibles and others’). Moderators such as
demographic factors also play a significant role in affect-
ing the relationship between PS and PSQ. Swain & Kar38
proposed another set of dimensions of quality (technical,
procedural, infrastructural, interactional, personnel and
social support).
Despite extensive research having been conducted
since the 1980’s, scholars still feel that patient satisfac-
tion is not a well-defined construct although it is a strong
and important indicator of quality in a health care deliv-
ery system.39
Brand image (BI)
In the health care context, Kotler and Clarke40 suggested
that “a hospital’s brand image can be seen as the sum of
beliefs, ideas, and impressions that a patient holds
toward a particular hospital. A brand image of a hospi-
tal is not absolute; it is relative to brand images of com-
peting hospitals”. Patients usually form a brand image of
a hospital from their own past medical examination and
treatment experiences.41 Bloemer et al.3 also studied the
role of image and its impact on perceived service quality
in banks. They found that a positive brand image of a
bank significantly improved perceived service quality.
Therefore, we can say that Brand Image is an important
determinant of Service Quality. In the healthcare envi-
ronment a positive hospital Brand Image may increase a
patient’s Perceived Service Quality.
Patient satisfaction (PS), perceived service quality
(PSQ), brand image (BI) and loyalty
When we discuss patient satisfaction in terms of loyalty,
many researchers have found that patient satisfaction is
significant in forming loyalty intentions as suggested by
Gaur et al.42 The antecedents to loyalty are service qual-
ity, satisfaction, trust and commitment.27 Researchers
have also proposed that the dimensions which lead to
loyalty are the physical environment, customer friendly
Vimla and Taneja
staff, communication, responsiveness and customer sat-
isfaction.43 Kian & Heng44 explored the factors (medical
errors, cost of treatment, quality service, expertise and
availability) that impact patient satisfaction positively
and that had a further effect on patient loyalty.
Astuti & Nagase45 investigated relationship market-
ing (RM), PS and loyalty in two different settings of the
healthcare sector: one in clinics and the other in hospi-
tals. They demonstrated that the cause of diminishing
patient loyalty is not the patient’s dissatisfaction but
the quality of relationship marketing. Lonial & Raju12
suggested that Perceived Service Quality (PSQ) has a
strong impact on overall customer satisfaction and that
in turn has a strong impact on customer loyalty. The
results also showed a significant direct link between
PSQ and customer loyalty. In continuing the research
related to complex relationships among the constructs,
Byram26 established that there is a significant relation-
ship between patient satisfaction and behavioural inten-
tion. This implies that positive word of mouth, revisiting
the provider and recommending the provider to others,
are based on a patient’s willingness to recommend the
hospital to others and use it as their own preferred
healthcare provider in the future. It was also suggested
that the strongest predictor of a patient’s intention to
return to the same hospital and recommend the hospi-
tal’s services to others is empathy followed by respon-
siveness, assurance, reliability and tangibility. This
implies that hospitals must solve a patient’s problems
expeditiously.
The relationship among brand image (BI),
perceived service quality (PSQ), patient satisfaction
(PS) and loyalty
It has been found in some studies that Brand Image may
have both a direct and/or indirect positive effect on
Loyalty or behavioural intention. Merrilees and Fry46
concluded that Loyalty is directly affected by Brand
Image. Davies and Chun47 found, in contrast, that
Loyalty is indirectly affected by Brand Image through
customer satisfaction. Furthermore, Loyalty can be both
directly and indirectly affected by Brand Image.10 We
can conclude that Brand Image is a strong antecedent
of customer Loyalty. In the hospital environment we
can, therefore, hypothesize that a positive hospital
Brand Image may enhance patient Loyalty:
Hypothesis 1: Hospital BI directly influences loyalty. While
evaluating services, Brand Image is viewed as a vital
factor.1 Studies have proved that image has a significant
impact on customers’ evaluative judgments such as on
perceptions of quality.10 Bloemer et al.,3 in their research
in the banking sector, proposed that BI significantly
improves PSQ. This leads us to our second hypothesis:
5
Hypothesis 2: Hospital BI has a positive effect on PSQ.
Research has showed that there is a relationship between
Service Quality and customer Satisfaction and further-
more with purchaser intention.48 Researchers have sug-
gested that for any healthcare organisation’s success,
customer Service Quality is a determinant that in turn
drives Patient Satisfaction and hospital profitability.29
Several studies have examined the links between
Service Quality and customer Satisfaction. They found
that Service Quality has a positive relationship with cus-
tomer Satisfaction in a general service context. In the
healthcare sector, the relationship between Service
Quality and Patient Satisfaction has always been a
matter of discussion. Ware et al.49 observed that the
characteristics of service providers and medical services
affect Patient Satisfaction. Subsequently, Woodside
et al.50 verified that the linkage of Service Quality to
behavioural intention exists through Patient
Satisfaction. Kim et al.51 suggested that some factors
have a positive influence on Patient Satisfaction. These
factors pertain to healthcare Service Quality such as the
quality of medical doctors, care procedures, and reliabil-
ity. Lee et al.52 found that there exists a positive corre-
lation between healthcare Service Quality and Patient
Satisfaction. In addition to these studies, Yeşilada and
Direkt€or53 conducted their study in public and private
hospitals and established that Patient Satisfaction is pos-
itively and significantly affected by Service Quality.
Therefore, a patient’s perception of Service Quality will
positively influence Patient Satisfaction and we
hypothesize:
Hypothesis 3: Perceived service quality has a positive effect on
patient satisfaction. Earlier studies showed that there can
be loyalty as a result of customer Satisfaction.31
Szymanski and Henard54 did a meta-analytic study, in
which they found that there exists a positive significant
correlation between Satisfaction and repurchase. In the
health care context, a positive relationship has been
found between Patient Satisfaction and Loyalty.50
Furthermore, Kim et al.51 performed their study in a
large hospital and examined the correlation between
Patient Satisfaction and re-visit intention. They found
the influence of Patient Satisfaction on their re-visit
intention to be significant. Therefore, it can be hypoth-
esized that satisfied patients will be more loyal towards
their hospital:
Hypothesis 4: Patient satisfaction has a positive effect on
loyalty. Pollack55 presents strong support for a sequential
Perceived Service Quality – Patient Satisfaction –
Customer Linkage. Wu56 recognized that in the relation-
ship between hospital Brand Image and re-visit intention
of patients, Service Quality and Patient Satisfaction
serve as important mediators. They also established
6 Health Services Management Research 0(0)
that in forming a favourable Brand Image, BI not only
acts as the main antecedent but also significantly, and
directly, affects patient Loyalty. It also enhances Patient
Satisfaction by improving Perceived Service Quality,
that in turn increases re-visit intention of patients.
A conceptual framework from BI to loyalty through
PSQ and PS
The literature review shows that there are comparatively
few papers that make an attempt to measure hospital
Brand Image. In fact, the concept of hospital Brand
Image is explicitly mentioned in only five of the 61
papers. To fill this gap in the research we look at the
relationship from BI to Loyalty in two ways: one directly
and the other one through PSQ and PS. Our model is
shown in Figure 3.
Discussion
Theoretical implications
We propose a novel integration to understand the rela-
tionship among BI, PSQ, PS and Loyalty in the health-
care sector. The findings of our study suggest that
though extensive theoretical and empirical research has
been carried out, yet the study of the relationship from
BI to Loyalty in the healthcare sector is in a nascent
stage. We extend our study beyond the established
frame of PSQ and PS, in which BI can be explored.
Brand image has become an important concept in
academic research and business practice since its incep-
tion in the early 1950s. Healthcare organizations need to
build their Brand Image if they want to succeed in this
Perceived Service Quality (PSQ)
• Multi-dimensional
• Evaluation process
• Can be used as benchmark
• Factors, sub-factors
• Total Quality Service
• Credence, experience and search
attributes
• Causative relationship between
PSQ and PS
• Antecedents of PSQ lead to PS
• Overall PS is a strong indicator
of PSQ
Brand Image (BI)
• PS positively influences BI
• PSQ influences PS which in turn
influences BI
Figure 3. A conceptual model of brand image (BI) to loyalty through perceived service quality (PSQ) and patient satisfaction (PS).
competitive era because Satisfaction and Brand Image
are two important routes that can take them to customer
Loyalty (in order to retain customers or attract new
ones).10 Furthermore, when services are difficult to eval-
uate, BI is believed to be an important factor in influenc-
ing customers’ evaluation of Satisfaction with the
service, their perception of Quality, and customer
Loyalty.
Practical implications
From a managerial perspective, by using this frame-
work, hospital managers can not only understand the
complex relationships among hospital BI, PSQ, PS and
Loyalty but they can also use it in several ways. Since BI
is the main antecedent of our conceptual model, it not
only impacts patient Loyalty directly but also indirectly
through PSQ and PS. Hospital managers can integrate
several marketing strategies such as patient communica-
tion, service training to their employees, advertising,
public relations and internet marketing to establish BI
so as to attain competitive advantage over their rivals. In
this way, they can differentiate themselves in terms of
increased brand awareness, improved trust among
patients, and achieving high returns and organisational
growth.
Moreover, our conceptual model has strong implica-
tions for managers in terms of brand building. When the
BI of one hospital is significantly higher than that of
others, we say that the hospital has a strong and positive
BI. The key to profitability of healthcare organisations is
to retain and attract patients, that is Loyalty and BI are
the dominant routes to profitability. Therefore, from
Patient Satisfaction (PS)
• Can be used as five and six-factor model
• Dimensions (four, five, multi-
dimensional)
• Predictors
• Utilization of PS
• For benchmarking
• Used as an indicator of quality
• Little standardization, low reliability and
uncertain validity
• Has operational and strategic relevance
Loyalty
• Patient satisfaction leads to loyalty
• Antecedents of loyalty
• Trust positively influences loyalty
• Factors which lead to loyalty
• PSQ positively influences loyalty
Vimla and Taneja
a managerial perspective, understanding drivers of BI,
Loyalty, PSQ and PS are crucial.
Brand Image plays a significant role in the healthcare
sector and is mainly dependent on Patient Satisfaction.
The frequency of patient visits can be increased if a
healthcare organisation establishes a strong Brand
Image in this sector. In today’s competitive era, consum-
ers have multiple options from where they can avail
healthcare services. This should push hospital adminis-
trators and managers to improve their hospital’s image.
Future directions
Our literature review, on Brand Image to Loyalty, has
identified a number of research gaps, that provide
opportunities for future research. More research is
required that integrates all these constructs, that is, BI,
PSQ, PS and Loyalty, and studies the mediating roles of
PSQ and PS in the BI to Loyalty relationship. While
constructs like PSQ and PS are often determined in prac-
tice and studied as individual constructs or as the rela-
tionship among two or more constructs taken together,
our literature review shows that they can have a different
impact on patient Loyalty if studied together. Other con-
structs related to this concept such as ‘Perceived Value’
and ‘Trust’ can be explored in the future. Research on
the constructs PSQ and PS can be used in a more elab-
orate unified framework consisting of inclusion of other
related constructs as well. Hence, future research can
explore the relationship of BI to Loyalty directly and
indirectly through mediating roles by PSQ and PS.
Conclusion
Today hospital users are more sophisticated and aware.
Understanding how to attract new patients and retain
old ones has become necessary to survive in this com-
petitive era. It begins with Brand Image. As researchers
and healthcare managers we need to understand that
healthcare brands must stand out in terms of doing
things differently within a crowded market. A hospital’s
BI is an important concern for practitioners and schol-
ars. The literature, however, lacks a unified conceptual
framework. This study proposes such a framework in
which more constructs can be included in the future.
Studies mostly consist of cross-sectional research designs
that should be followed by longitudinal studies to gain
additional insight. Future conceptual and empirical
work can be performed to fill this gap in the literature.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
7
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Vimla Vimla https://orcid.org/0000-0002-8873-867X
Udita Taneja https://orcid.org/0000-0002-4494-4244
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