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Report Title

Healthcare Branding : Developing emotionally based consumer brand relationship

Chapter 1 : Introduction

1.1 Background of the study

Health care is one of the most important services a consumer experiences, but it is personal. Health care
is not only very complex and expensive, but it is also a commonly used service that affects the quality of
daily life and significantly affects economies (Berry and Bandabudi, 2007). Most countries have become
service-dominated economies (Klaus & Maklan, 2007) due to the huge contribution that the service
sector has made to their economic growth compared to other sectors (Bateson, 1995; Skaalvik and
Oslen, 2014). Research (Andaleeb, 1998; Corbin, Kelley, & Schwartz, 2001; Berry and Bendapudi, 2007)
points to health care as the largest service industry and one of the world's fastest growing, conceivably
the purest form of the service industry. For example, in India, healthcare has emerged as one of the
largest service sectors in terms of revenue and employment (Deloitte, 2014; IBEF, 2015). The healthcare
industry largely represents an important sector due to its global trend of strong economic performance,
and also because of its significant role in increasing the quality of life by providing services to citizens
and improving public welfare (Andaleeb, 1998; Atinga, AbekahNkrumah & Domfe, 2011). Moreover, as
more healthcare options become available to consumers, there will be more competition within the
industry. Marketing will play a key role as hospitals compete for care outcomes and quality. An effective
marketing strategy requires organizations to develop a strong brand identity.

The brand is a promise to consumers that the hospital will provide the type of care required. It can drive
business and growth for an organization, especially when there are high levels of satisfaction and
emotional commitment. Healthcare branding requires a strong and structured commitment to deliver
unique standards of consistency through an organization's products and services. As mentioned earlier,
health care is a very personal service. Just as product brands include psychosocial attributes, service and
healthcare brands can bestow unique meaning to consumers. This meaning and personal experience
with the brand can create a connection or relationship between the consumer and the brand. Fournier
(1994, 1998) was one of the first to conceptualize consumer brand relationships. In this metaphor, the
consumer and the brand are seen as being in a binary relationship similar to that of two people.
Developing business relationships with the consumer can be a difficult and complex process. Business
relationships can take many different forms. For example, a brand-to-consumer relationship may be
cognitive based and simply habitual, or it can be emotionally based (Park et al., 2009; Thompson et al.,
2005; Brakus et al., 2009; Grisavi and Nguyen, 2011).

When an emotional connection exists between the consumer and the brand, it can give the organization
a competitive advantage, making the brand resistant to competitive attacks due to strong attitudes
towards the brand by the consumer. Consequently, health care providers are looking for alternative
means of attracting and retaining patients (Corbin et al., 2001; Kemp et al., 2014) due to a desire to
reach consumers in an increasingly crowded market (Basu and Wang, 2009). To this end, Mangini (2002)
proposes influencing consumer choice and differentiating a healthcare organization from competition as
critical to success in a changing and highly competitive healthcare field; It states that branding can be a
way to achieve this. Not only does this proposal give credence to Kapferer's (2002) view of branding as
an integrated process of serving consumers to create identity for products/services and differentiate
them from competitors, but also finds support in Kotler and Keller's (2006) position that branding can be
applied anywhere a consumer is the choice. In addition, the tangible unavailability of services that
emphasize the critical importance of service branding and image creation (Berry, 2000; Murthy, 2002;
Davis 2007), is further amplified for healthcare services due to their highly credible nature with complex
and unique features ( Hariharan et al., 2004); Their performance depends on a combination of
qualitative factors such as quality of services by highly skilled staff, patient satisfaction, awareness,
patient trust, nature of loyalty, brand image etc.

The purpose of this research is to study how to develop emotional or impact-based business
relationships for a service-based product - specifically healthcare. Contributes to the current literature
by identifying important variables that enhance emotional commitment in consumers' brand
relationships with healthcare providers. Furthermore, it suggests that emotion-based relationships are
so strongly associated with the healthcare brand that the brand can align with the consumer's self-
concept. When such phenomena occur, the consumer may start to act as an “advocate” for the brand by
actively promoting it via word of mouth. For healthcare organizations, achieving such status with
consumers will be invaluable in the increasingly competitive environment.

1.2 Problem Statement

Health care for consumers is one of the most intimate and personal services and can be said one of the
most important services they buy (Kemp et al., 2014; Berry Bendapudi, 2007). Research refers to that
health care consumers become increasingly active decisions in their health care options (NKETIAH-
AMPONSAH and HIEMENZ, 2009; Abuusi and Attaza, 2012). Therefore, health care organizations are
struggling to create a form of consumer value, the market share and targeted the desired consumer
segments (Brakus et al., 2009) and improve profitability by creating consistency and personalization of
service (Corbin et., 2001); It has also begun competition on the basis of care and quality (Atinga et al.,
2011). The success of these initiatives requires( Corbin et al .,2001) branding, a major component of
public consumer demand, trust, and patient satisfaction. On this note, determining factors that affect
favorable healthcare branding is necessary. In this study, major factors that affect healthcare branding
are service quality, Brand awarness, Patient trust, patient loyalty, hospital brand image etc. Without the
above mentioned factors successful branding in healthcare industry is not possible. By introducing an
efficient patient service quality, healthcare industry will not only have positive feedback but will also
earn its patient's trust and loyalty (kemp et al., 2014 ; corbin 2001). The impact of poor service quality
may lead to bad consequences such as dissatisfied patient, few loyal patients and lack of trust in health
care system( corbin et al., 2001; Kemp et al., 2014). Poor quality service can disrupt funding, damage the
reputation of organisations and individuals and lead to inappropriate planning decisions (Hariharan et
al., 2004) . Improving quality means improve patient care and value for money. It is important to
improve quality because it will lead to preventing ill health and provide patient-centred care. Patient
satisfaction is an important and commonly used indicator for measuring the quality in health care.
Patient satisfaction affects clinical outcomes, patient retention, and medical malpractice claims. It
affects the timely, efficient, and patient-centered delivery of quality health care. In addition, dissatisfied
pateints have more vocal than satisfied patients and their message is far reaching. Dissatisfied patients
may have less trust on the particular hospitals and the may have less commitment toward the hospital
(Rose et al., 2004 Tuan , 2012) .

A large number of business in the brand of the service did not apply in health care very well. There
seems to be a scarcity in this field compared to other brands. Research on health care in public literature
for services has been a number of mostly subjects, including the marketing of health care / health
services (Corbin et al. 2001; Rooney, 2008; QQ 2007), Quality of service and customer satisfaction in
health care (Rose et al, 2004; 2006; 2012; Tuan, 2012). The central concern was for these brand studies
to ensure that building stocks and relationship between these structures. Many research refers to,
although value, suggesting that the brand of health care is a fairly new idea in the services of literature
and health care organizations are struggling with how the process is mainly implemented in order to
obtain a competitive advantage.

In addition, the organizational restriction in health care organizations from running commercials
advertisements leaves health care providers more anti-actors with that advertising works as a means of
publishing the desired brand letter (Perry and Seltman, 2007); and plays a role in informing consumers
directly and indirectly (Grossman and Shapiro, 1984; Milgrom and Roberts, 1986) about brand features;
It is also the key to developing and continuing attractive brands (O'Malley, 1991). However, very little or
no work has been done on healthcare brands in cumilla. In addition, most hospitals still struggle with the
practice and implementation of the branding process to differentiate their services from those of other
hospitals in order to elicit positive feedback from current and potential patients.

Therefore, this study examines the factors in the context of Gomati hospital for hospital branding that
drive patients to resettle and shape their perception of hospitals in healthcare, a service industry that
has received little scientific attention, despite its increasing global importance. It is hoped that
identifying the right factors will help all hospitals especially those that are self-financed private hospitals
whose sources of operating costs are mainly from personal payments and NHIS reimbursement as well
as public hospitals that aim to provide services to the well- being citizens through effective identity and
image creation.

1.3 Objectives of the study

This study seeks specifically:
 1. To determine the factors that influence branding in healthcare industry.

2. To empirically examine the factors ( service quality, trust, customer satisfaction, brand awarness,
patient's lotalty, brand image) in relation to branding in healthcare industry.

1.4 Significance of the Study

The current study is expected to make both theoretical and practical contributions to the understanding
of branding in healthcare specifically for hospitals. Regarding research, this study will add to the body of
knowledge on healthcare branding by examining factors of healthcare branding and their influence on
developing emotionally based consumer brand relationship .This could also facilitate the development
of strategies that could help build strong hospital brands in the wake of intensifying competition among
healthcare organizations and help attract customers in spite of the promotional regulatory restriction.
Additionally, the study has the potential of helping hospital management appeal to “one-time” patients
and turn them into customers who would keep coming back.

Chapter 2

LITERATURE Review

2.1 INTRODUCTION
In the competitive market, branding is a valuable intangible asset of a company. Branding plays an
important role because positive brands will enable customers to better visualize and understand
products, reduce customers’ perceived risks in buying services (Kim et al., 2008a), and help companies
achieve sustained superior performance. In particular, brand image is a critical issue in the field of brand
management. Research interest is growing among academics and practitioners in the topics of brand
image’s antecedents and outcomes. The proposition that a strongly positive brand image allows a
corporation to gain reputational value and competitive advantage (Porter and Claycomb, 1997) nurtures
this growth. A favourable brand image increases various outcomes such as customer satisfaction, service
quality, loyalty, and repurchasing intention (Bloemer et al., 1998; Da Silva and Alwi, 2008; Lai et al.,
2009).Health care institutions face unique challenges around the world. An increasing number of
hospitals face extremely competitive environments owing to open-door policies in the medical service
market (Kim et al., 2008b). The growth of senior citizens population and growing focus on health are
dynamically increases particular health wants and needs within the general populace. The current
medical service market favours the buyer, rather than the seller (Lee et al., 2010). Hence, the field of
medical service is now emphasizing the importance of customer-oriented marketing. Hospitals
endeavour to establish marketing strategies which promote brand image among patients for enhancing
the satisfaction and loyalty of patients as well as further promoting performance.In general, the
research of brand image mostly focuses on corporate context such as goods producing firms, service
firms, and retail stores (Bloemer and de Ruyter, 1998; Nguyen and LeBlanc, 1998; Lai et al., 2009).
Although hospital brand image is becoming an increasingly important issue in the competitive health
care industry (Javalgi et al., 1992), few studies are available in this field.

This chapter is dedicated to the review of relevant and contemporary literature in relation to the
concepts and theory underpinning the study. This chapter presents a discussion on branding, brand
equity, branding in the service sector and healthcare branding.

2.2. The Concept of a Brand

Brand can be a name, term, sign, symbol, design or a combination of these that identifies the makers or
seller of the product or services (Kotler et al. 2006) . Similar to and extending this definition is that of the
American Marketing Association (AMA), which defines a brand as a “name, term, sign, symbol or design
or a combination of them, intended to identify the goods and services of one seller or group of sellers
and to differentiate them from those of competitors” (Keller, 2008, p.2). These definitions however,
have been scrutinized by scholars like Keller et al. (2008), and de Chernatony (1999) who believe the
definitions do not cover all aspects but just some elements of a brand; and limit the function of a brand
to the mere identification and differentiation of products and services from others of their sort.
As a result, many academics have also attempted to provide definitions that transcend these limitations.
Southgate (1994) states that a brand is not only a name, logo or graphic device, but also a set of
intangible values in the mind of consumers. Prasad and Dev (2000) align with this view and note that a
brand is all tangible and intangible attributes that the business stands for which also includes how
people think about the company. Kotler and Armstrong (2009) likewise opine that a brand goes beyond
an identifier to represent consumers’ sensitivity and emotional product, a service or a solution including
goods, services, information and other elements, based on all kinds of brand contacts that the customer
is exposed to”

According to de Chernatony and Dall’Olmo Riley (1998), though a brand might initially come into
existence with nothing more than a distinctive name, over time it becomes recognized by consumers for
its functional capabilities and ultimately develops into a representation that is associated with several
unique values. From a customer’s point of view, brands are seen as purveyors of advantages in terms of
both economic and symbolic values (O’Cass and Grace, 2003). In this respect, brands not only serve as a
rich source of information which might signal the quality of a product and reduce consumers’ search
costs and risks of transaction (Biswas, 1992; Janiszewski and Van Osselaer, 2000) but further act as a
symbol that directs meaning to the consumer and thus represent a form of promise regarding future
purchases (Keller, 1998); and serve as a signal of consistency and in a way, control the customer
experience from start to finish (Davis, 2007). A brand is therefore argued to be one of the most essential
concepts in marketing due to its ability to create a perception of superiority in consumers’ minds
(Levine, 2003) and is one of the most important intangible assets of a firm (Leone et al., 2006 ).
Consequently, brands have become an integral part in most companies’ marketing strategies since they
are increasingly understood as valuable assets and a major source of competitive advantage (O’Cass and
Grace, 2003; Skinner in Grace and O’Cass, 2002); through offering recognition, security and exclusivity,
contributing to brand image and identity, mutual development and strengthening of trading
relationships, and legal protection (Jones, Shears, Hillier and ClarkeHill, 2002). it is based on these
understanding that branding has been highlighted as a mechanism to engage both buyer and seller in
long-term trusting relationships (Fournier, 1998; Keller, 1993) and as a process of creating value which,
in turn, will satisfy customers and ultimately keep them coming back (Gad, 2001; Aaker, 1991).

According to branding theory, branding is a competitive strategy that differentiates and positions
products, services and companies in order to build economic value for customers’ and the brand owner
(Tsiotsou and Ratten in Skaalsvik and Olsen, 2014). Though there still remains little unanimity on an
overarching umbrella definition of the scope and the dimensional confines of branding as a managerial
term (Mitchell, Hutchinson and Bishop, 2012), branding however, transcends the logo, differentiation
and perceptions. The relevant points of branding theory is captured in Greenawalt’s work (as cited in
Dominiak, 2004) that branding is not limited to creating a logo or trademark, but is a full process that
includes research, identity development, and continuing evaluation of the success of the brand.

2.3 The Brand Equity Concept

Because of the growing appreciation of the brand as one of the most important issues for the success of
the company especially in a highly competitive business environment(Leone et al., 2006),combined with
the rising need for marketers to justify the effect of their marketing activities and programs (O’Sullivan
and Abela, 2007); brand equity as a central business concept has received much attention in research
and seen rapid developments since its emergence in the 1980’s (Leone et al., 2006). As a result,
accountability and return on investment which has been the central tenet of brand equity research led
to two prevailing perspectives on the brand equity measurement discussion (Asamoah, 2014; Kapferer,
2002).

The financial perspective supports the measurement, where interest lies in exactly how much a brand
contributes to the firm’s total asset (Christodoulides and de Chernatony, 2010). Brand equity is
understood in the financial context to be the monetary outcome a firm can elicit as a result of its brand
exposure to consumers (Christodoulides and de Chernatony, 2010). According to these authors a firm‘s
brand equity is estimated by deriving financial market estimates from brand-related profits. Taking the
financial market value of a firm as a base, they extract the firm‘s brand equity from the value of the
firm‘s other tangible and intangible assets, which results in an estimate based on the firm‘s future cash
flows. In marketing literature, brand equity has been defined diversely by academics in certain
dimensions; first in terms of the relationship between customer and brand (consumer-oriented
definitions), where Keller (1998) defines brand equity as the differential effect of brand knowledge on
consumer response to the marketing of that brand. Second, as something that accrues to the brand
owner (company-oriented definitions) and in this regard, Aaker (1991, p.15) defined brand equity as “a
set of brand assets and liabilities linked to a brand, its name and symbol, that add to or subtract from
the value provided by a product or service to a firm and/or to that firm’s customers”.

Third, other researchers like Farqhar (1989), and Winters (1991) also relate brand equity to added value
by suggesting that brand equity involves the value added to a product by consumers’ associations and
perceptions of a particular brand name .In marketing, though the consumer aspect of brand equity,
which focuses on the cognitive aspect of consumer, is frequently followed; it is conceptualized
differently by different authors (Chahal and Bala, 2012). Brand equity is defined by Aaker (1991) in terms
of a set of assets associated with the brand and these assets include brand loyalty, brand awareness,
brand association, and perceived quality. Other scholars such as Atilgan et al. (2005) and Pappu et al.
(2005) tested and verified these assets. However Keller (1993) considers brand equity in terms of brand
knowledge that is, brand awareness and brand image. On the other hand, Lassar et al. (1995), associate
brand equity with five dimensions such as performance, social image, value, attachment, and
trustworthiness. According to Srivastava and Shocker (1991), any way that brand equity is considered, it
can be understood as the incremental value a brand name grants a product.

2.4 The influences of factors on healthcare branding

In this study, there exist six factors that influence branding activites in healthcare industry. It involves
two variables . These are Independent variable ( patient satisfaction, Brand loyalty, Service quality,
Trust, Brand awarness, Brand image) and Dependent variable ( Healthcare branding).

2.4.1 Healthcare Branding

Health care is a unique form of service and has been variously qualified in the literature: as a highly
complex and expensive service (Berry and Bandabudi, 2007), arguably the purest form of service (Corbin
et al., 2001) and one of the most personalized and intimate (Kemp et al., 2014); It is a globally used
service that affects the quality of daily life and significantly affects economies (Berry and Bandabudi,
2007). For more than a decade, Corbin et al. (2001) alluded to the fact that the healthcare sector
appears to be the largest sector of the service industry with tremendous progress over the past five
decades in the technical areas of procedures and delivery in order to meet patients' needs. However,
less than 3 decades ago, the concept of marketing health care services was alien and also viewed as a
questionable activity (Thomaselli, 2010); Hence healthcare institutions, as well as individual clinicians,
began to widely recognize the need to market their services in the past two decades (Kemp et al., 2014).
Although more healthcare companies today are realizing the importance of branding and have begun to
incorporate these initiatives into their corporate marketing strategy (Thomas, 2010), healthcare
organizations are still lagging behind other service industries in brand practice almost as well as on the
other side of the business. Service marketing (Corbin et al., 2001; Mangini, 2002; Kennet and Henson,
2005). Given that healthcare branding is not an entirely new idea, few studies are available in this area.
Existing research on healthcare brands in the services literature has mainly focused on brand ownership
in healthcare (Kim et al. 2008; Tuan, 2012; Chahal and Bala, 2012; Karbalaei et. al., 2013). These studies
have documented the importance of brands in healthcare. For example, a study by Kim et al. (2008)
identified trust, customer satisfaction, relationship commitment, brand loyalty, and brand awareness as
the main factors influencing healthcare brand ownership, and empirical testing of the relationships
between these factors indicates that hospitals can succeed in creating a positive image and brand value.
business if they can manage customer relationships well.

Similarly, a study by Chahal and Bala (2012) examined three important components of a service brand
and found that perceived quality and brand loyalty have a positive effect on brand ownership in
healthcare. The results indicate that clients with high and positive perceptions of loyalty prefer to use
hospital services in the future as well as share their experiences and recommend the hospital to others,
which subsequently helps in building a positive image of the hospital in the minds of users and potential
users. and tangible to contribute to the perceived quality of service. Specifically, items of tangible
factors that have been found to contribute to perceived quality include adequate stock of medication,
availability of the latest technological equipment, and availability of parking facility. More so, a recent
study by Kemp et al. (2014) also found that trust, benchmarking influence, and CSR are positively
correlated with consumer emotional commitment to a healthcare provider's brand. Therefore, the
authors suggest that developing strong, emotional bonds with consumers would be of great value to
healthcare providers in an increasingly competitive market. These provide an indication that branding
and building a strong brand in healthcare is essential and holds a lot of potential for healthcare
organizations given the transformations facing the industry in most countries. Healthcare providers and
marketers face unique challenges all over the world due in part to the role that the healthcare field plays
in contributing to general well-being; and the highly competitive environments faced by an increasing
number of hospitals due to open policies in medical services markets (Kim et al., 2008). Consequently,
healthcare organizations and practitioners have become aware of the importance of enhancing their
services to increase public awareness, market share and reimbursement (Corbin et al., 2001; Chahal and
Bala, 2012); In response to the current and imminent challenges mentioned above, leading healthcare
organizations are finding it appropriate to promote their brands (Thomaselli, 2010).

Healthcare branding can help organizations achieve the goal of differentiating their products and
services from those of competitors given today's savvy healthcare consumers (Mangini 2002; Devries
and McKeever, 2008) who have more choices than ever (Mangini, 2002; Sparer, 2011) by using their
name, products, services, , and facilities (Thomas, 2010). Mangini (2002, p. 22) reinforces this viewpoint
by succinctly stating “When consumers are faced with a variety of choices, a strong brand tends to
produce confidence in the products and services they choose”.Drawing from services branding
literature, Berry (2000) points to the special role of branding in increasing customers trust in service
firms. In the words of Morgan and Hunt (1994, p.23) “…trust exists when one party has confidence in an
exchange partner’s reliability and integrity”.From the patient's perspective, trust has a significant impact
on the experience of being a receiver of healthcare (Thom et al., 2004). Accordingly, trust is one of the
major factors Kim et al. (2008) found as influencing brand equity in healthcare. Kim et al. stress the
importance of building high levels of trust and patience confidence in order to have a successful
healthcare organization. Brands offer some measure of assurance that the provider of the good or
service will deliver consistently on its promises, and is therefore worthy of trust (Kemp et al., 2014).
Moreover, Kim et al. (2008) notes the role of branding in enabling consumers to better visualise and
understand service offerings. This helps to overcome barriers of uncertainty that might otherwise
prevent people from becoming customers; and also reduces customers perceived monetary, social, or
safety risks in buying health services (Ritchie et al., 1998; Mangini, 2002).

Likewise, Kemp et al. (2014) argues that branding is a promise to consumers that the hospital will
provide the type of care required; It can drive business and growth for an organization, particularly
when levels of satisfaction and emotional commitment are high. Corbin et al. (2001) in their study
additionally note that branded healthcare services can provide a platform for patients to reduce the
impact of the credibility characteristics associated with such interactions (that is, the characteristic that
a healthcare service cannot be evaluated even after consumption or purchase, for example surgery was
performed on the patient). Branding efforts may provide healthcare professionals with a controlled
means of creating awareness rather than relying on current or former patients to get the marketing
message across (Corbin et al., 2001); And branding efforts related to consumer convenience, practice
environment, and professional behavior may help consumers focus on their salient health needs and
desires (Chalal and Bala, 2012; Corbin et al, 2001). It should address how to maintain fairness, build
trust, as well as how to manage consumer perceptions and emotions in relation to a healthcare
organization (Speak, 1996; Mangini, 2002). Magini's (2002) also suggests as a condition of healthcare
branding a strong and structured commitment to delivering unique standards of consistency through an
organization's products and services. They also add that when delivering unique and distinct brand
experiences, healthcare providers must effectively position the organization and its brand as an
important contributor to health (Kemp et al., 2014).

2.4.2 Patient Satisfaction

Understanding the consumer’s needs and opinions may greatly influence their experiences and
outcomes (Bolster & Manias, 2010), as well as helping hospitals to achieve market differentiation. In the
service environment, customer satisfaction is considered as a special form of customer attitude.
Woodeside et al. (1989) described it as a phenomenon of post-purchase reflection on how much the
customer likes or dislikes the service after experiencing it. The strategic importance of customer
satisfaction for organizations is more highlighted (Wang and Pho, 2009; Khattak and Rehman, 2010) for
services. Patient satisfaction is deemed one of the important factors which determines the success of
healthcare organizations (Musunuru, 2011). In the field of healthcare, Kim et al. (2008b) adopted the
concept of customer satisfaction and defined that patient satisfaction is the judgment of perceived value
and sustained response toward service related stimulus before, during or after the consumption of
medical services by a patient. Patient satisfaction is concerned with the degree to which the
expectations of a patient are fulfilled by the medical services. Furthermore, patient satisfaction is a
critical indicator for medical service industry (Wu, 2011) and providers of medical services need to
understand patients' expectations and try to meet those (Lee et al., 2010). Studies (Sharma and Chahal,
1999; Mryyan, 2006; Mpinga and Chastonay; 2011) found that patient satisfaction depends on the
performance of doctors, atmospheric distinguishers like comfort, cleanliness and the facilities. These
studies therefore concluded that customer satisfaction is the degree to which healthcare meets
patients’ expectations in terms of technical quality which includes competent health personnel, physical
environment and facilities, and availability and accessibility of health services. Satisfied patients prefer
the same hospital for same or different treatments and may recommend it to their friends and relatives
unlike dissatisfied patients who may discontinue their treatment from the same hospital (Corbin et al.,
2001) which can be detrimental to the hospital's competitive position (Atinga et al., 2011). Similarly,
according to Hekkert et al. (2009), for hospitals, satisfied patients are important because they are more
likely to keep using medical services, follow the prescribed treatment plan, and maintain the
relationship with a specific health care provider. Patient satisfaction is therefore seen as a gateway to
profitability in the hospital setting (Atinga et al., 2011). Factors like the physician-patient
communication, appropriate expectations and waiting time are examples of factors conditioning the
patient’s satisfaction (Shirley & Sanders, 2013).Nowadays work routines and traditions are not leveling
with consumer’s needs ( (Bolster & Manias, 2010). It is proven that healthcare professionals (physicians
and nurses) can improve the patient’s satisfaction by understanding the implications of their practices.
Focusing on a person-centered approach while practicing medical activities has the potential to improve
the overall patient experience. Listening, explaining and giving patients the chance to participate can
significantly influence their understanding, satisfaction and outcomes.

2.4.3 Brand loyalty

Brand loyalty is defined as the consumer's attachment to a brand even when the organization makes
changes in price or other product features (Aaker, 1991); It is considered the most powerful path to
trademark ownership (Atilgan et al., 2005). Scholars (including Aaker, 1991; Mellens et al., 1996; Chahal
and Bala, 2010) have conceptualized it as an essential function of behavior (ie, brand purchase
frequency) and attitude. In the healthcare sector, service brand loyalty means the loyalty of consumers
who continue to prefer services from the same healthcare service provider, which has a positive effect
on them (Chahal and Bala, 2012). Several studies have used the intention to re-visit as a proxy for
patient loyalty in the health care setting (Boshoff and Gray, 2004; Kim et al., 2008). Chahal and Bala
(2010) also balance service brand loyalty with positive attitude (behavioral loyalty) and repeat buying
behavior (behavioral loyalty) of consumers towards the hospital. In other words, patient loyalty is brand
loyalty to healthcare organizations. Thus, according to Chahal and Bala (2012), loyal patients generate a
strong financial foundation for future activities because even after discharge from hospital they may
continue to support the healthcare organization through affirmative speech, donation or other form of
cooperation. However, the authors point out the disposition of public healthcare institutions in not
paying much attention to the value that loyal patients can add to their success. Basically, patient loyalty
is critical for healthcare units to retain patients and survive in the competitive market. Hence, patient
loyalty is a competitive asset of hospitals (Wu, 2011).

2.4.4 Service Quality

Service quality that can be considered as one of the important factors in business management has been
widely discussed and emphasized in both academic and business fields (Chen and Chen, 2010; Liu and
Tsai, 2010). The definition of service quality is the customer's overall impression or rating regarding the
relative inferiority or superiority of an organization and its services (Zeithaml, 1988; Bitner and Hubbert,
1994). It can be measured by comparing customers' expectations with customers' perceptions of actual
service performance (Parasuraman et al., 1985). Customers form their expectations before confronting
them with services. They develop perceptions during the service delivery process, and then compare
their perceptions with their expectations in evaluating the outcome of the service encounter.
Specifically, service quality means that service delivery must meet customer requirements and
expectations (Tan et al., 2010). According to the above-mentioned viewpoints, service quality can be
viewed as a measure of how well the level of service provided matches the expectations of customers.
With regard to health care, service quality can be defined as a gap between patients' expectations and
perceptions (Woodside et al., 1989). Expectations are treated as what patients believe ought to be
provided in medical services, and perceptions may be taken as an assessment of patients regarding
specific features of the medical service in relation to their expectations. Operationally, the quality of
service in a hospital depends on the balance of patients' perceptions and expectations. Further, Lytle
and Mokva (1992) suggested that service quality meets patients' needs, and patients evaluate hospital
service quality from service output, service process, and physical environment.With patient satisfaction
in mind, hospitals should attempt to adopt a value-creating framework for patients (Porter, Pabo, & Lee,
2013) with the goal of improving primary care practice. This framework should group patients according
to needs and give them appropriate care not only during the full cycle of care but also after it has ended
so that the patient's needs are responded to at all times.

Aside from adopting a patient-centered system, hospitals should try to address existing issues such as
combating medical fraud, introducing more appropriate primary care business models, investing in
reducing medical errors, improving care coordination and increasing electronic medical records. Quality
should be a concern for hospitals. By adopting a Clinical Governance Approach (Bogada, 2006), whose
pillars focus on continuous quality improvement, team development, leadership and innovation
diffusion, hospitals must be able to increase health consumption while reaching higher levels of well-
being, better skills and productivity and providing a better quality of life for patients.

2.4.5 Patient Trust

Most definitions of trust describe it as a firm's belief that a partner will perform actions that lead to
positive outcomes for the former (Schur and Ozan, 1985; Dwyer, Schur and Oh, 1987; Anderson and
Narus, 1990; Moorman, Deshpande and Zaltman, 1993; Morgan and Hunt, 1994; Sanzo). et al., 2003). As
stated by Serdeshmukh et al (2002), trust is the expectation a consumer holds that a service provider is
“reliable to deliver on its promises”. Hall (2005) shows that those who trust have an expectation that the
trusted person will act in good faith toward them and competently in the domain in which they trust (or
in the care of what is entrusted). Mishra et al. (2008) hypothesized that there are four dimensions of
trust (i.e., reliability, openness, competence, and anxiety) and find that communication is critical for
demonstrating all aspects of trust (Al-Rubaie and Looking, 2010). Scholars (including Berry, 2000;
Gomeros et al., 2004) point to the role that brands play in enhancing consumer confidence for intangible
performance in service organizations. According to Berry (2000) and Beckham (2000), branding in
healthcare is highly dependent on trust. Berry and Bendapudi (2007) illustrate this by saying that the
buyer completely surrenders to the seller and in many cases lives temporarily in the health care facility.
In the context of healthcare, trust can create an environment of exchange in which a hospital can
provide better care to its patients or clients, while becoming profitable or remaining profitable. Trust is
built on managerial ability, a standard that hospitals and their staff provide to patients. When patients
complain about the service, the hospital and its staff should do their best to respond to complaints and
thus maintain or rebuild trust (Kim et al., 2008). Kemp et al. (2014), found in their study that trust in a
healthcare brand would be driven by displaying competency and customer-oriented behavior by the
staff and physicians present in the healthcare facility among others. Relationships characterized by trust
often result in the desire for a long-term commitment between two parties (Morgan and Hunt, 1994).
Patient safety concerns may cause clients to stop using certain hospital services due to negative
feedback. According to Entwistle and Quick's (2006), confidence in patients is awakening, that is,
confidence is not just vague hope or optimistic thinking; Health providers must keep patients alert to
errors during their care. Some examinations by the patient are appropriate even in the presence of
confidence especially when honest errors are possible, which can be easily discovered and corrected,
and patients may continue to trust even when they are harmed.

2.4.6 Brand Awareness

Brand awareness is one of the components of a brand that can add to its value. The value depends on
how easily the brand gets into the mind of the customer (Riezebos, 2003). According to the author,
there are four different levels that show how aware a customer is of a particular brand: unconscious,
passive awareness, active awareness, and general awareness. The higher the level of brand awareness,
the more likely the consumer will make a purchase decision in favor of that particular brand (Keller,
1993). Riezebos' passive awareness (2003) is similar to Keller's (1993) brand recognition and active
brand recall awareness. Brand awareness is an important component of service brand ownership (Berry,
2000) and as illustrated by the service brand model (see Figure 1), it is influenced by a company's
intentional presentation of its brand through name, advertising, and various symbolic associations. In
healthcare, scholars such as Mangini (2002) stress the importance of outreach to hospitals. A strong
brand identity for a healthcare organization according to Mangini (2002), is created by defining the
brand (eg, full health service or outpatient services); defining the message to communicate about the
service to be differentiated (eg good care, comfort); Finally, communicate this brand internally (to
ensure employee acceptance and enthusiasm necessary for the brand's success) and externally. Keeler
(2008) notes the ability of branding elements (particularly the name) to build awareness. Creating and
building brand awareness helps to get into the minds of consumers and encourage them to develop a
brand preference that ensures a successful brand (Keller, 2003; Ross and Harradin, 2004).

2.4.7 Hospital Brand Image

Brand image has been an important concept in consumer behavior research since the early 1950s and
plays an important role in brand building (Mao, 2010). According to Shanti (2006), image plays an
important role in differentiating the service of a health care provider from that of its competitors. Brand
image is a combination of the perceived dimensions of quality and respect (Kumar et al., 2014). Kotler
and Armstrong (1996) define brand image as a set of beliefs relating to a particular brand. This set of
beliefs plays an important role in the buyer's decision-making process, when customers evaluate
alternative brands (Al-Haddad, 2015). Brand image describes consumers' thoughts and feelings about
the brand (Lee et al., 2011) and also consists of symbolic and functional beliefs about the brand (Low
and Lamb, 2000). Alternately, the brand image is a perception of the brand that is preserved in the
memory of the customer and that reflects the general impression of the consumers (Wu, 2011). A
positive brand image can be considered as an essential ability of an organization to maintain its position
in the market (Wu, 2011; Kumar et al., 2014). Descriptively, a company with a favorable corporate image
of its offering can bring individuality and differentiation that leads to greater awareness, loyalty and
reputation (Heerden and Puth, 1995) and will certainly be in a position to attract consumers (Chahal and
Bala, 2012). In the health care setting, Kotler and Clarke (1987) advanced that a hospital's brand image is
the sum of the beliefs, ideas and impressions that a patient has toward the hospital. The authors further
point out that patients' perception of a hospital's image is not absolute but is related to the brand
images of competing hospitals. According to Kim et al. (2008) Patients can quickly form a specific idea of
a hospital. Patients often shape a hospital's brand image from their experiences in medical examination
and treatment (Kim et al., 2008). Colad et al. (2014) presented that a hospital's brand image is based on
the impression patients perceive through interactions with services and activities; What they read about
the hospital and the visual symbols they learn from from the time they arrive through treatment
experiences until they leave. Thus, the preferred hospital brand image is built through patients' trust in
treatment, services and knowledge of the hospital (Kim et al., 2008), which helps in attracting and
retaining patients (Kolade et al., 2014); Strengthening patients' intentions and improving their tendency
to choose that hospital in the future (Kim et al., 2008; Wu, 2011).

2.5 Chapter Summary

This chapter reviewed literature related to healthcare branding . The concept of branding was
extensively discussed highlighting the concept of a brand, branding activities, brand equity and service
branding. Healthcare branding and equity was as well discussed drawing out the factors of healthcare
branding.

Chapter 3

Research Methodology
3.1 Introduction

In the previous chapter, the literature review has demonstrated various studies related to healthcare
branding . The variables that have been identified for investigation are patient satisfaction, Brand
loyalty, service quality, Trust, Brand awarness, Brand image, and relationship commitment. This chapter
outlines the methodology used for the research. The research framework and hypothesis development
from literature review have been discussed to show the relationship between the independent variables
and dependent variables. The research design , data collection method and procedures and techniques
of data analysis have been described in the following sections.

3.2 Research Framework

Drawing from the literature, a framework which leads to the complete developments of this study has
been created emphasizing on the objective of the research . The framework provides a graphic view of
the study highlighting and integrating the factors found to influence healthcare branding activities . It
involves two variables :- Independent variables( patient satisfaction, Brand loyalty, Service quality, Trust,
Brand awarness, Brand image, Relationship commitment), and Dependent variable ( Healthcare
branding).

Patient Satisfaction

Brand Loyalty

Service Quality Healthcare

Branding
Trust
 Brand Awareness

Brand Image

3.3 Hypotheses Formulation

In this section, the relationship among healthcare branding , service quality, patient satisfaction, brand
loyalty, trust, awarness, brand image are discussed.To examine this relationship between dependent
and independent variables some research hypotheses are developed as follows:

H1: Patient satisfaction has a positive effect on healthcare branding.

H2: Loyalty is positively releated to healthcare branding.

H3: Service quality has a positive effect on healthcare branding.

H4: Trust has a positive and significant impact on healthcare branding.

H5: Brand awarness positively influences healthcare branding.

H6: Hospital brand image has a positive effect on healthcare branding.

Patient Satisfaction H1

H2
Brand Loyalty

H3
Service Quality Healthcare

H4 Branding
Trust

H5

Brand Awareness
H6
 Brand Image

3.4 Research design

Research design refers to the blueprint, plan or framework for conducting research (Malhotra and Birks,
2007). Creswell (2003) points to the ability of such framework to put together claims made about what
constitutes knowledge, a strategy of inquiry and specific methods. According to McGivern (2006), a
research design essentially aims to structure the research to answer research problems as accurately
and explicitly as possible. This is buttressed by Kumar (2005) who states it as a plan that is adopted by
the researcher to answer questions validly, objectively, accurately and economically. Guy et al. (1987)
earlier submitted that the use of research design is to ensure that the objectivity of the research is
assured. Moreover, Churchill and Iacobucci (2009) contend that besides facilitating the collection and
analysis of data, a research design also helps to specify the details of the procedures necessary for
obtaining the information needed to structure or solve marketing research problems. A research design
is a blueprint & system of analyzing to attain answers to the research question (Kothari, 2009).

In view of the above and earlier discussions, it is evident that this research is conducted from a
quantitative/positivist perspective because grounded on Gill and Johnson’s (1997) argument, the study
was based on structured methodology and quantifiable responses which led to statistical analysis.
Quantitative research aims to “control, predict, explain, and interpret the scientific phenomenon”
through attention and investigation (Arghode, 2012). According to Knipe and Mackezie (2006),positivism
is closely aligned to “quantitative methods of data collection and analysis”. Besides, research
hypotheses were formulated from existing literature and were empirically tested. This study is purposed
on an explanatory basis as it aims at understanding what customers consider the best and most
important factors (hospital branding activities) in availing hospitals’ services and the interrelationship
among these variables.

3.5 Research Approach

A quantitative approach was employed to enable the study test the relationship among some latent
variables. The study adopted the survey method via the use of structured questionnaires designed to
elicit information from respondents in order to help the study identify and explain statistically, the role
of certain factors in healthcare branding and also on the basis that the study is cross-sectional in nature
and previous cross-sectional studies (Chahal and Bala, 2012; Wu, 2011) have mostly employed the
survey strategy.
3.6 Population , Sample and Sampling Technique

Population of the study

Target population of a study is the collection of elements or objects that possess the information sought
by the researcher and about which inferences are made (Malhotra, 2007). According to Salant and
Dillman (1994), a requirement to sample selection is to define the target population as narrowly as
possible. Defining the sample population helps focus the research and puts the findings and
recommendations of the study into comely perspective for the intended audience. Hence the target
populations for this study encompassed clients of cumilla Gomati Hospital.

Sample Size of the study

According to Malhotra and Birks (2007), several qualitative and quantitative considerations are involved
in sample size determination. Research scholars including (Burns, 2000; Gray, 2009; Hair et al., 2009)
recommend from a quantitative perspective that researchers use large sample sizes as much as possible.
Hair et al. (2006) consider sample sizes of 100 and above appropriate for quantitative studies. According
to these scholars, large sample sizes increase the chances that the mean, percentages and other
statistics will reflect the actual estimates of the population. Malhotra and Birks (2007) also submit that
large sample sizes allow for the effect of randomness and reduced chances of errors as the sample size
increases.The present study has been undertaken with a sample size of 100.

Sampling Technique

There are two general categories of sampling techniques; probability and non-probability sampling. The
former is often associated with survey and experimental research strategies; and the latter though more
generally used in case study research, is employed by some scholars in quantitative studies especially
when the sample to choose from seems larger (Saunders et al, 2009). In probability sampling, each
element in the sample frame has an equally known possibility of being included in the sample, which
allows researchers to answer research questions and to achieve purposes that require them to estimate
statistically the characteristics of the population inferred from the sample (Saunders et al., 2009). In
direct contrast, is non-probability sampling, in which the possibility to make valid inferences about the
population is limited. All non-probability samples rely on personal judgments somewhere in the process,
which implies that samples gotten using non-probability sampling techniques are not necessarily
representative of the entire population but generalizations may still be made about the population
(Malhotra, 2010). Non-probability sampling can be classified under techniques such as quota, purposive,
snowball and convenience sampling. Quota sampling involves selection of cases within strata that are
entirely non-random (Saunders et al., 2009). Purposive sampling involves selecting cases based on the
researcher’s judgment. Snowball sampling involves randomly selecting initial respondents who provide
referrals for subsequent respondents (Malhotra and Birks, 2007), and convenience sampling involves
selecting indiscriminately those cases that are easiest to obtain for a sample (Saunders et al., 2009).

The current study intends to gather responses from Gomati hospital clients and since the population is
large, using non-probability sampling was deemed suitable. The sampling technique for this study was
convenient sampling, this method is based on a group or subgroup which is readily available. Convenient
sampling is a type of non–probability sampling based on individuals known by the researcher or readily
available.

3.7 Data Collection Technique

This study has used quantitative methods to investigate the factors that may have a strong influence on
branding in healthcare industry . For preparing this study, a combination of primary and secondary
sources of data has been used.

Primary Data : Primary data have been collected through a questionnaire survey. Questionnaires were
distributed to a convenience sample. Convenience sampling is beneficial where it is otherwise difficult to
stimulate a sufficient level of response. To gather the data from the respondents, print questionnaires
were distributed among respondents of cumilla gomati hospital. Data were collected for more than two
weeks, to survey a chosen sample of patients.
Secondary Data: Secondary data are the data that have already been collected by someone else for
several purposes than the problem at hand. These secondary data have been collected through several
journals, different articles, books as well as the internet such as International journal of healthcare
quality assurance, special focus series : health promotion and fitness, International journal of service
industry management, An international journal vol.15 No.5 2008, American journal of Health science -
spring 2012, Journal of service management 2009, European journal of Business and Management
research vol.5 , No.6 November 2020, International journal of Marketing studies, International journal of
Healthcare Management, November 2019, African journal of Business Management vol.5(12) 18 june,
2011. This study also identified a connection with articles by evaluating the reference list of collected
articles.
3.8 Questionnaire development and instrument
Based on the objectives of the study, questions were developed following the procedures outlined by
Malhotra and Birks (2007) for designing survey questionnaires. The pre - test sample was guided by the
suggestion by Fink (saunders et al., 2007) that the minimum of ten (10) members for pre - testing is
adequate.The pre test was carried out with focus on the content, wording, sequence and question
difficulty in order to determine the practically, suitability and reliability of the questions, and to
eliminate ambiguity after which final revisions and discussion with the supervisor were made with
respect to phrasing and clarity of measurement items.

The questionnaire was designed in two sections.The first section was confined to general demographic
questions, such as gender , age, level of education, occupation and monthly income. The second section
examined issues pertaining to respondent's perceptions of branding activites of the hospital which
focused on six major factors : Patient's satisfaction, Brand loyalty, Service quality, Trust, Brand
awarness , Brand image etc. There are 24 items for measuring the variables : Patient's satisfaction was
measured with four items adapted from fornell ( 1992) , Brand loyalty was measured with four items
adapted from Hardeep chahal and Madhu Bala (2010) , Service quality was measured with six items
adapted from Hardeep chahal and Madhu Bala (2010), Trust was measured with four items adapted
from Chaudhuri and holbrook (2001), Brand awarness was measured by two items adapted from
priscilla Mensah (2015) , Brand image was measured by four items adapted from Hardeep chahal and
Maadhu Bala ( 2010).

I visited the premises of gomati hospital and after seeking the approval of the appropriate hospital
authorities ( administrators, managing directors and public relations officers) . Within the premises, I
approached persons who had experienced the hospital services and sought their consent to help fill a
questionnaire by explaining to them the purpose of the study, which is to ascertain their perception
about hospital, and factors that drive branding activites of gomati hospital. This lasted between the
periods of (1.1.2022 -10.2.2022).
3.9. Techniques Of Data Analysis
The data gathered from respondents was analyzed and interpreted by IBM SPSS 25 which is the latest
and available for use. The relationship of the dependent variable and independent variable is tested
through regression, correlation and other descriptive analysis. All the data collecting tools such as
reliability and validity is also checked with the help of SPSS 25 software.

3.10 Measurement Scale of Variables

This study aims to examine which factors are influencing branding activites in healthcare industry. For
collecting data from primary sources, a structured questionnaire with close-ended questions containing
a five point Likert scale (developed by Likert in 1932) has been used.“Likert scale” having five stages was
used to analyze responses of individuals and measure the independent and dependent variable. Each
statement in the questionnaire was measured by 1= Strongly disagree, 2= Disagree, 3=Neutral, 4= Agree,
and 5= Strongly agree. By using this measurement, respondents can scale from one to five on how much
they agree and disagree with each of the statements based on branding activites in healthcare industry .

Chapter : 4
 Data findings and Analysis

Data Analysis and Interpretation

Cooper and Schindler (2008) define; data analysis and interpretation are a system of observing
directions and structure, correlating statistical techniques, and submitting a summary of the
data.

This system enables one to interpret the findings in response to research objectives. Reliability
analysis was the aim to determine the stage of reliability of the data attained from the
questionnaire. Regression analysis was evaluated for this purpose. Descriptive statistics and
factor analysis were obtained to evaluate the collected data. Data are collected from indoor
and outdoor patients of gomati hospital and encoded in SPSS (Statistical Package for Social
Studies) version 25.0 was used. It is analyzed by adopting descriptive statistics analysis, and
Linear regression analysis.

4.1 Descriptive Statistics

The empirical analysis was based on frequency tables, descriptive statistics, linear regression
analysis. The frequency table prepared data on the demographics of the sample and the
findings of each question.

The descriptive analysis was obtained to test and to describe the sample. Descriptive statistics
contribute to information such as frequency, percentage, essentials to normality. This data was
presented on the dependent and independent variables measured.

Table-1: Descriptive Statistics Analysis

Gender

Variable Frequency Percentage

Male 44 56

Female 56 44

Total 100 100

The total number of the participants as presented in Table 2 shows a total of 44 males in the
distribution representing 44% and 56 females accounted for 56%. The difference between the
number of male and female respondents is narrow. This close representation of respondents
indicates that the data collected from these two categories will be highly representative of
people.
Age

Variable Frequency Percentage

Below 18 years 5 5

18-28 years 5 5

29-39 years 15 15

40-50 years 35 35

Above 50 40 40

Total 100 100

It occurs that most of the respondents are in the age above 50 years old (4o%). The second
highest of the respondents are in the age of 40-50 years (35%). The third highest of the
respondents are in the age of 29-39 years (15%), and the minority of the respondents are in the
age of 18-28 years (5%) and below 18 years (5%). From the table it is apparent that adults
dominated the participants of this research study and which without a doubt contributed to the
quality of opinions collected.
Educational Qualification

Variable Frequency Percentage

Secondary 5 5

Graduate 15 15

Postgraduate 15 15

Professional 65 65

Total 100 100

In the case of educational qualification, (65%) of the respondents are professional, (15%) of the
respondents are postgraduate. (15%) of the respondents are graduates and only (5%) of the
respondents are secondary level.

Occupation

Variable Frequency Percentage

 Student 10 10

Business 20 20

Service holder 40 40

Pensioner 30 30

Total 100 100

With attention to implicate what types of occupation , the majority of the respondents are
service holder (40%), the second-highest of the respondents are pensioner (27.7%), the third
highest of the respondents are doing business (20%), the fourth highest of the respondents are
students (10%).

Monthly Income
 Variable Frequency Percentage
Below 1000 0 0

1000 - 5000 10 10

5000 - 10,000 15 15

10,000 - 15,000 17 17

15,000 - 20,000 13 13

Above 20,000 45 45

Total 100 100

It presents that the majority of the respondents are in the income level above 20,000 tk (45%),
the second-highest of the respondents are income level 10,000-15,000 tk (17%), the third-
highest of the respondents are income level 5000-10,000 tk (15%). The fourth highest of the
respondents are income level 15,000-20,00 tk (13%).The fifth highest of the respondents are
1000-5000 tk (10%).We can see that there is no respondent of income level below 1000 in my
research.

For how long have you patronized gomati hospital?

Variable Frequency Percentage

Less than 1 year 15 15

1 - 2 years 35 35

3 - 5 years 33 33

6 - 10 years 17 17

Above 10 years 0 0

Total 100 100

It occurs that majority of the respondents (35%) patronize gomati hospital for 1-2 years. 33%
respondents patronize this hospital for 3-5 years. We can see that about 17% respondents
patronize gomati hospital for 6-10 years and 15% respondent patronize for less than 1 year.
There is no respondent who patronize gomati hospital more than 10 years in my research.

How did you find out about gomati hospital?

Variable Frequency Percentage

From family members 35 35

Friends or relatives 33 33

Doctors suggestion 32 32

Total 100 100

It presents that majority of the respondents have learned about gomati hospital from their
family members. The second highest of the respondents have informed about this hospital
from their friends or relatives. Rest of the respondents have learned about gomati hospital
from doctors.
4.2 Regression Analysis
A regression was statistical processes for performed to predict the relationship between a
dependent variable (Healthcare Branding) and independent variables ( Patients Satisfaction,
Brand Loyalty, Service Quality, Trust, Brand Image, Brand Awarness). The dependent variable
determines for this study remains unchanged as used through this analysis.

Table 2 : Model Summary

Model R R Square Adjusted Std.Error of the

Estimate
R Square

1 .931 .868 .861 .41532

Source : SPSS output based on Primary Data

4.2.1 Predict the Relationship between Factors and Healthcare

Branding
Table-2 demonstrates that the value of the correlation coefficient, R= 0.931 indicates that there
is an accepted positive correlation between a dependent variable (Healthcare Branding) and
independent variables ( Patients Satisfaction, Brand Loyalty, Service Quality, Trust, Brand
Image, Brand Awarness). Though, 86.8% (R-square values of 0.868) variation dependent
variable (Healthcare Branding) accounted for due to independent variables (Patients
Satisfaction, Brand Loyalty, Service Quality, Trust, Brand Image, Brand Awarness . The adjusted
R-square is .861 indicated that the six factors can pointedly report for 82% variance in
increasing the healthcare branding.

Table 3: ANOVA

Model Sum of df Mean F Sig.

Squares Square
Regression 107.348 5 21.470 124.465 .000

Residual 16.387 95 .172

Total 123.735 100

Source :SPSS output based on primary Data

Table-3 reveals that the ANOVA is clarified that the overall model was significant & regression
analysis is conducted to evaluate the relationship between dependent variable (Healthcare
Branding) and independent variables ( Patients Satisfaction, Brand Loyalty, Service Quality,
Trust, Brand Image, Brand Awarness). Six factors are instructed, and outcomes are computed in
Table 4 and revealed in F-statistics created (f = 124.465) is significant at 1 percent level (sig. f <
0.01) with 5 and 95 degrees of freedom, therefore accepting the fitness for the model.
Model Unstandardized Standardized t Sig. Decision
coefficients
Coefficients

B Std.Error Beta
(Constant) .172 .150 1.145 .255

Patients .183 .079 .169 2.310 .023 Accepted

satisfaction

Brand Loyalty -.212 .084 -.195 -2.524 .013 Rejected

Service Quality .410 .097 .408 4.228 .000 Accepted

Trust .260 .071 .258 3.662 .000 Accepted

Brand Image .336 .108 .336 3.110 .002 Accepted

Brand .302 .070 .345 4.310 .000 Accepted

Awareness

Table : Coefficients
4.2.2 Factors that influence the effectiveness of branding in healthcare industry.
The findings of regression analysis for H1 as presents in Table 5 that patients satisfaction as an
essential factor, which positively and significantly influence healthcare branding ( t value =
2.310; p < 0.05). H1 is accepted. The findings of the study indicated that healthcare branding is
considerably affected by patients satisfclielhly

The next one is Loyalty as the vital factor, which is weakly or not affect branding in healthcare
industry (β2= -.195; t-value = -2.524; p < 0.05). For that reason, in this factor, the t value is
negative and the t value is below than accepted value 1.9. So, H2 is not accepted which means
H2 is rejected.

The next one is service quality as the key factor, which positively and extensively affects
healthcare branding (β3= .408; t-value = 4.228; p < 0.05). H3 is accepted. Therefore, healthcare
branding is influenced by service quality.
The next one is Trust as the critical factor, which positively and considerably affect healthcare
branding (β4= .258; t-value = 3.662; p < 0.05). H4 is accepted. Thus, healthcare branding is
affected by patients trust.
The next one is Brand image as the major factor, which positively and significantly affect
clients' purchase intention (β5=.336; t-value = 3.110; p < 0.05). H5 is also accepted.
Consequently, healthcare branding is considerably dominated by hospital's brand image.

The last one is Brand awareness as the major factor, which positively and significantly affect
clients' purchase intention (β6=.345; t-value =4.310; p < 0.05). H6 is also accepted.
Consequently, healthcare branding is considerably dominated by brand awarness.

Healthcare Branding

Patient Satisfaction

(β1=.169; t-value = 2.310 P< 0.05) Accepted

Brand Loyalty (β2= -.195; t-value = -2.524 P< 0.05) Rejected

Service Quality (β3=.408; t-value = 4.228 P< 0.05) Accepted

 Trust (β4=.258; t-value = 3.602 P< 0.05) Accepted

Brand Awareness (β5=.336; t-value = 3.110 P< 0.05) Accepted

Brand Image (β6=.345; t-value = 4.310 P< 0.05) Accepted

4.3 Decision On Hypothesis

Hypothesis Decision
Patients satisfaction has a positive effect on healthcare branding. Accepted

Brand loyalty is positively releated to healthcare branding. Rejected

Service quality has a positive effect on healthcare branding. Accepted

Trust has a positive and significant impact on healthcare branding. Accepted

Brand awarness positively influences healthcare branding. Accepted

Hospitals brand image has a positive effect on healthcare branding. Accepted

4.4 Discussion of Findings

The focus of this study was to investigate the extent of relationship among healthcare branding,
patients satisfaction, loyalty, service quality, brand image,Trust,and brand awarness. Result
demonstrates both direct and indirect influences of this independent factors on healthcare
branding. Evident from the analysis, all the healthcare branding factors patients satisfaction,
service quality, brand image,Trust,and brand awarness except brand loyalty have a positive and
significant relationship with branding in healthcare Industry.These are subsequently discussed
in relation to existent literature surrounding the areas of branding, service branding and
healthcare branding.Findings from the sampled clients in the study brought to light the fact that
brand loyalty do not to a significant extent influence consumer of gomati hospital in cumilla.
This on the one hand is to affirm that healthcare consumers in cumilla may not avail gomati
hospital services just because of loyalty.so, it can be said that brand loyalty may not necessarily
pull clients toward gomati hospital since most of these clients visit for peculiar health needs.
The name of the hospital often comes to mind during the consumer initial consideration of
medical solution which constitutes awareness (Kim et al., 2008) but does not typically engender
repeat patronage. Such views are posited by scholars such as (Kashinath et al., 2010; Kim et al.,
2008) who opined that customers usually revisit hospital which are able to provide solutions to
their health needs. This current finding is in contrast to previous studies (Lau et al., 2006; Reber
et al., 1998) ) who pointed to the ability of established brand name to preserve some form of
loyalty; and Keller's (1993) view that brand names that are recognized more quickly and easily
are liked more and ultimately chosen frequently. Likewise, the results in the current study are
indicative of the fact that loyalty have no significant influence on clients revisit decisions in
gomati hospital . This finding seem conflictive with that of Bidhan et al. (2004) who postulated
that healthcare facilities that leave their visitors confounded and worn-out could keep clients
from revisiting. On the other hand, the significant positive relationship found among
healthcare branding and patients satisfaction, service quality, trust, brand awarness, brand
image etc.patients satisfaction and clients' brand image perception of hospital in the Cumillaian
context confirms (Yorkston and Menon,2004; Klink, 2001; Aaker, 1991) who point out that the
name is a critical core sign of the brand which serves as the basis for awareness and an
instrument that affects consumers' perceptions of a company's attributes. Kim et al. (2008)
argue that patients are able to form a specific impression about any hospital within a rapid time
and according to Keller (2003) the brand name can be noticed and its meaning registered or
activated in memory within seconds leading to the formation of judgments . Similarly service
quality which connotes issues regarding ease of way-finding both without and within hospital
premises and availability of information about hospital services influence clients' hospital brand
image perceptions.

Furthermore, Trust was found to significantly influence branding in gomati hospital. This relates
to competence of medical staff, availability of specialists for services provided and the ability of
medical personnel to educate and provide answers to clients' questions (knowledgeableness).
This confirms the views of (Kemp et al., 2014; Leonard et al., 2007; Andaleeb, 1998) who posit
that competent care providers form an essential basis on which patients make healthcare
decision. This finding is likewise in line with literature that patients trust toward the hospital is
of vital importance in shaping a favourable image and some level of trust for healthcare
organizations and patients will generally form an impression of the level of competence of the
staff as they experience various services during their hospital visit (Rao et al., 2006; Andaleeb,
1998). Essentially, any information encountered in association with a brand, can become linked
to the brand name in memory and thus become part of the brand image (Keller, 2003).

Also we can notice that service quality of the hospital has a positive effect on healthcare
branding. This comprises visually appealing nature of the physical facilities, doctors politeness
to patients,availability of modern medical equipment and knowledgeable staffs , presence of
effective and rapid responses, comfort level of waiting rooms and general cleanliness of
hospital premises/environment. Generally, patients derive their first impression of the hospital
through the physical evidences and for healthcare consumers who are already depressed,
traumatized and mostly on edge, ambient conditions, effective and well functioning amenities
could make a great deal of difference. The finding in this regard is concordant with previous
studies that physical evidence (relating to clean, safe and pleasing environment and effective
facilities) communicate to customers that the hospital will provide satisfactory services. This
assertion, according to previous researchers, may significantly improve patients' healthcare
experience; and impact perceptions and revisit decisions (Atinga et al., 2011; Hair, 1998;
Andaleeb, 1998). Convenience is an expectation every rational customer holds and this is likely
to be amplified in healthcare where clients' are inconvenienced by sickness and injuries and
their autonomy is temporarily reduced. For this reason, within the healthcare domain, such
services as basic medical services, specialist services and support services like pharmaceuticals,
ambulatory etc. hold relevance to patients' decisions. Previous studies (Abodurin et al., 2010;
Dubey and Sharma, 2013; Singh and Shah, 2011) have posited that availability of a wide range
of services (pharmaceuticals, laboratory) influenced patients' choice of hospitals and the
impressions they form about the facility. This assertion in the literature has been confirmed
within the context as the study's result indicated a significant positive relationship between
critical service lines and healthcare branding. The implication is that for healthcare consumers
in cumilla, the array of essential services provided by hospitals is a necessary factor in their
decision to revisit a health facility and in shaping their perceptions about the hospital.

The results of the study also established a significant positive relationship between brand image
and branding; demonstrating that perceived brand image strongly predicts positive branding of
gomati hospital in cumilla . In the health care environment, hospital brand image is the sum of
beliefs, ideas, and impressions that a patient holds toward a hospital and it’s not absolute but
relative to the brand image of competing hospitals (Kim et al., 2008; Kotler and Clarke, 1987). A
favourable hospital image is therefore built by patients' knowledge of the hospital and trust in
treatment and services which help in attracting and retaining patients (Kolade et al., 2014; Kim
et al., 2008). According to some researchers (Burmann et al., 2008; Wu, 2011) brand image is
an important determinant of a buyer’s behaviour and a favourable hospital brand image helps
strengthen the intentions patients have for selecting a hospital. In a similar Vain, Chahal and
Bala (2012) in their study reported that high and positive consumers’ perception towards a
brand reflected the preference of patients to avail the same or different medical treatments
from the same hospital in future as well. Brand image is therefore, extremely relevant to
healthcare providers more so in enhancing branding activites of the hospital . Consistent with
previous studies on brand image and hospital brand image (Andreassen and Lindestad, 1998;
Esch et al., 2006; Wu, 2011), it is reasonable to posit that for clients to revisit a hospital, they
must have knowledge of, encounter and interact with the hospital and develop a favourable
image about the hospital. This finding conforms to previous empirical outcomes and therefore
provides a concrete basis for generalization that brand image is a strong predictor of developing
branding activites in healthcare.

4.5 Chapter Summary

This chapter presented the results of the research findings in line with the objectivess discussed
in chapter one of the study. Results of the quantitative analysis support the applicability of the
conceptual framework presented in chapter three of the study.Tables and suitable wordings
have been used to interpret the findings of the survey branding graphical clarification.

Chapter : 5

Recommendations and conclusion

Introduction
The previous chapter presents the results of the quantitative analysis and a discussion of the
results of the study. This chapter summarizes the major findings and implications of the study,
draws conclusions based on the objectives of the study, and preffers recommendations for
further research.

5.1 Summary of the Study

The study inquired into healthcare branding in gomati hospital. Specifically, the study
investigated the healthcare branding factors that develope emotional relationship with patients
of gomati hospital. An essential rationale for the study is the increased competitive pressures
healthcare facilities are experiencing and the active role consumers have taken in their
healthcare choices given the abundant options and alternatives among hospitals that are
available to them.
Pursuant to these objectives delineated in chapter one, the study reviewed extant literature on
healthcare branding, patient satisfaction, brand loyalty,servuce quality, trust,brand
image,brand awarness (Davis, 2007; Keller, 2008; Atinga et al., 2011; Abousi and Atinga, 2012;
Kemp et al., 2014). Six factors were identified to have influence in healthcare branding. These
factors were thus integrated into a conceptual framework for predicting hospital branding
activities resulting into the formulation of applicable hypotheses.
A survey strategy was adopted and questionnaires were used as the instrument for data
collection. The questionnaire was developed based on the theoretical framework and the
objectives of the study. One hundred patients were purposively and conveniently selected as
the study's sample.
Furthermore, data was analyzed using descriptive statistics, and multiple regression analysis on
the bases that quantitative data analysis techniques allow for numerical representation and
manipulation of data for the purpose of explaining the phenomenon mirrored by the data; and
also for the testing of hypotheses and generalization of results.

5.2 Implications for Management and Practice

The findings of the study suggest that hospitals stand a better chance of being revisited by
clients if their branding factors result in a favourable brand image perception relative to other
hospitals.

The inference therefore is that in order to develop gomati as a branded hospital and gain a
competitive advantage, managers must focus on building and maintaining a strong and positive
hospital brand image. Following from the significant influence of critical service lines on clients'
brand image perception of hospitals, it is imperative for hospital managers to enhance service
lines that provide convenience for patients in their search for medical solutions. Patients tend
to form favourable perceptions about hospitals when essential services they require on visit are
provided within the same facility. For instance such support services as pharmaceuticals,
laboratories, diagnostics etc. send signals of a wholesome and comprehensive healthcare
provider.
Similarly, with brand elements playing a major role in clients' perceived brand image, hospital
managers could leverage this by making information on the hospital and its services well
available to clients and easing way-finding both without and within hospital premises via sign &
written direction etc. Digital Signage is presently one of the huge trends in healthcare which can
immensely boost clients' hospital experiences. Given that all through the day in hospitals and
healthcare facilities, patients sit in the waiting rooms and visitors loiter in hallways and lobbies,
hospital managers can seize these moments as opportunities to deliver informative materials
and relevant content with educate patients and visitors through digital signage that benefits
each specific audience. This can be used to enhance direction/ wayfinding, check-in
appointments and education on hospital procedures etc.

Also of significance, is the need for hospital managers to focus on improving the status and
performance of the peripheral health facilities. Hospitals must strive to maintain a clean and
neat environment, waiting rooms and wards should be pleasing and fashioned to provide
patients a sense of comfort and relaxation. Likewise, hospital managers must make available
state-of-the-artand effective medical equipment and a good parking area since this were found
to be important to patients’ impressions. Furthermore, raising and keeping the standards of
medical staff competence and practices in the hospitals is also a commitment hospital
managers should make.
In order to gain and keep patients’ confidence in the hospital, medical staff have to consistently
demonstrate technical skills, excellent professionalism and efficacy.

5.3 Limitations of the study and Future Research Directions

As with any study, the present study was conducted amid certain limitations.This study
identifies the first limitation is the sample size. This investigation is limited only during the
coronavirus disease (COVID-19) pandemic, and the result may be not correlated to other
hospitals in Bangladesh. The analysis is limited to only few clients of gomati hospital for using a
questionnaire survey. The findings may vary over time and situational constraints. Another
constraint is some respondents were unwilling to convey their opinion and they were not
willing to expend a few minutes to respond accurately. This study using some independent
variables. As a result, there may be some other variable that may affect branding in healthcare
industry. This study using some factors is left for future research & they can use numerous
factors that may have effects on healthcare branding.

Future research can use numerous methodologies, as like longitudinal surveys, focus groups,
and interviews who are connected with the different types of patients . Future research could
increase the more sample size, using probabilistic samplings this method could increase the
reliability, validity & accuracy of their research.

Furthermore, the model can be replicated with a variety of hospital types or other settings in
order to verify its applicability. Likewise, extra constructs such as patient engagement and
response time can be included in the model to determine their relationship with healthcare
branding. In spite of all these, the result of the study is deemed reliable and representative of
other clients of gomati hospital.
5.4 Conclusions
The study established that healthcare branding influences clients’re-patronage of hospitals.
From the foregoing discussion and analysis so far, it is rational to conclude that, hospitals can
differentiate their facilities in today’s competitive and volatile business environment when they
focus on the factors ( patients satisfaction, service quality, brand awarness, trust,brand
image,brand awarness) to ensure consumer re-patronage and general profitability. The study
also established that the brand image resulting from the healthcare branding activities has a
stronger influence on clients’ re-patronage decisions. With the shifting competitive landscape
where healthcare consumers are increasingly focusing on strong reputation as a selection
criterion for hospitals and physician practices, creating a distinct brand image becomes crucial
for healthcare providers. In order to be recognized, differentiated and reliable in the view of
patients to maintain client patient base and to attract new ones, hospitals must build strong
positive brand image.

Questionnaire

Dear Sir/Madam,
I am Nishat Tasnim , marketing student of comilla University . This survey seeks to elicit responses on
the topic of “Healthcare branding .” Information provided for the purposes of this research will be
treated confidentially and used for academic purposes only. Please take a few minutes to fill out this
questionnaire by ticking (√) where appropriate. For any questions, kindly contact me via my details
provided below:

Email: nishattasnim9498@gmail.com

Section A: Background Information

1. Gender

□ Male □ Female

2. Age

□ Below 18 years □ 18-28 years □ 29-39 years □ 40-50 years □ Above 50

3. Educational Qualification

□ Secondary □ Graduate □ Postgraduate □ Professional

4. Occupation

□ Unemployed □ Salaried employed □ Self-employed □ Pensioner

5. Monthly Income

□ Below 500 □ 500-1,000 □ 1,100-1,500 □ 1,600-2,000 □ Above 2,000

6. For how long have you patronized gomati hospital

□ Less than 1 year □ 1-2 years □ 3-5 years □ 6-10 years □ Above 10 years

Section B : On a scale of 1-5, please indicate by ticking (√), the extent to which you agree or
disagree with the following statements regarding gomati hospital.

1=Strongly Disagree, 2=Disagree, 3=Neutral, 4=Agree, 5=Strongly Agree

Serial Statements 1 2 3 4 5
No

Patient satisfaction

1 I am satisfied with the services of gomati hospital. 20 5 65 10

2 I would feel that the hospital's way of dealing with the situation 25 5 60 10
is acceptable

3 The hospital is getting close to the ideal service provider in 10 15 67 8

service industry.

4 Gomati hospital always meets my needs. 10 75 15

Brand Loyalty

1 I select gomati hospital as first choice 12 15 8 55 15

2 My family member generally visit gomati hospital 10 3 70 17

3 I would like to recommend this hospital to others. 10 10 60 20

4 If there is variation in price, I won't go to another hospital. 7 35 8 50

Service Quality

1 Gomati hospital has an acceptable level of quality if we compare 15 72 13

it to others.

2 Doctor's are courteous while dealing with patients. 4 12 67 17

3 Hospital authority quickly and efficiently respond to my request. 7 15 5 59 14

4 The health problems are always accurately identified. 10 10 8 62 10

5 Hospital staffs are knowledgeable to answer my questions. 15 15 8 52 10

6 Hospital staffs provide services right at the first time. 10 20 12 50 8

Trust

1 I trust the care that i receive from health professionals of gomati 6 12 5 65 12

hospital.

2 If problems arise, one can expect to be treated fairly by gomati 4 15 10 58 13

hospital.
3 I feel safe at gomati hospital 11 72 17

4 Presence of correct , accurate and reliable billing system in 10 10 65 15

gomati hospital.

Brand Image

1 Gomati hospital is sincere to the patients. 3 15 12 57 13

2 The hospital has clean environment. 3 78 19

3 The hospital has positive image in my mind 12 8 63 17

4 The hospital has differentiated image in terms of quality 30 5 55 10

Brand Awarness

1 When I think of healthcare services, gomati hospital's name 15 10 5 57 13

comes to my mind.

2 When we talk about hospitality then gomati hospital comes first. 15 10 65 15

3 Gomati hospital provide better healthcare services at affordable 7 8 75 10

cost that can improve their quality of life.

Healthcare Branding

1 Gomati hospital is known for affordable, dependable and 10 10 72 8

trustworthy healthcare service provider.

2 Gomati hospital has the best neurology specialist in the city. 5 5 75 15

3 Gomati hospital has the best technological tools to generate 15 10 5 65 5

accurate test results.
i