Effect of Service Stigmatization to Patients Loyalty Moderated by

Service Quality

Nurbaiti

, Supriyantoro

, Rokiah Kusumapradja

and Suryanti T. Arief

Departement of Hospital Administration, Esa Unggul University

Departement of Law, Esa Unggul University

Keywords: Healthservice Stigmatization, Quality of Service, Patient Loyalty

Abstract: Leprosy is considered a terrible disease and discriminated by society. Dr Sitanala Leprosy Hospital

Tangerang also suffered the impact of stigmatization. The purpose of this research was to obtain empirical

evidence of the effect of service stigmatization on patient loyalty moderated by the quality of service in

inpatient service ofDr Sitanala Leprosy HospitalTangerang. The study was conducted in the inpatient wards.

The researchwas using casualty design with survey methods. Itwas conducted in January 2018. Samples

were 92 respondents by random. Variables werehealthservicestigmatization, service quality as a moderation

variable and patient loyalty. Instruments used questionnaires with Likert Scale. The analysis used a

moderate regression analysis.The result of the research shown: that health service stigmatization had a

significant negative effect on patient loyalty,thatservice quality influenced to patient loyalty, that service

quality was moderatinginfluence of health service stigmatization to patient loyalty. Quality of service was

moderating health service stigmatization hence increased patient loyalty. The dominant dimension of

stigmatizationwas fear of disclosure, quality dimension was empathy and loyalty was recommend a friend.

Health promotion improvement strategies can be done related to individual and institutional stigmatization,

thus lowering the stigmatization rate. A strategy is required on the dimension of tangibility by completing

high-tech facilities according to public health needs and strengthening the empathy dimension by improving

competence. Efforts to reduce stigmatization by paying attention to perceived service quality as a strategy

mechanism to increase patient loyalty.

1 INTRODUCTION

The ability of hospitals to meet service standards

will provide satisfaction for patients as users of the

service, thereby generating a feeling of reusing

services and patients will be loyal to the services

provided by the hospital. Customer loyalty is a

condition in which the customer has a positive

attitude towards a product, is committed to the

product and intends to repurchase in the future. The

creation of customer loyalty allows companies to

develop long-term relationships with customers.

Also, the cost required to attract new customers is

also greater than the cost of maintaining a loyal

customer in the company (Kotleret al., 2016)

The hallmark of patient loyalty and attitudes in

the hospital is based on the patient's attachment to the

services provided by the hospital that is cross-linked

with the pattern of repeated use of services. As for

the presence of patients with loyal attitudes and

attitudes, they are not only willing to use services

when the patient is sick, but also willing to suggest

the product or service to others, friends, or relatives,

and their family members and colleagues. Long-term

and cumulative loyalty profits, which increased

patient loyalty can lead to increased sources of

income or profits, higher employee retention, and a

more stable financial base. Besides other advantages

of loyalty are to lower marketing costs, shorten the

time and transaction costs, lower turn over costs, and

positive word of mouth (Tjiptono, 2011). By

providing quality services and meet customer

expectations it will create a positive brand image in

the minds of consumers, so the brand can be more

trusted and able to increase customer loyalty. Quality

of service is a benchmark in determining the quality

or quality of the service provided in accordance with

customer expectations (Lewisand Boom, 2005).

Consumers assess quality based on five factors:

reliability (reliable and accurate); responsiveness

Nurbaiti, ., Supriyantoro, ., Kusumapradja, R. and T. Arief, S.

Effect of Service Stigmatization to Patients Loyalty Moderated by Service Quality.

DOI: 10.5220/0009949704710478

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 471-478

ISBN: 978-989-758-458-9

471

(helpful, timely); assurance/trust/confidence

(competence, trust); empathy (caring, individual);

and tangible (presentation, appearance) (Lupiyoadi

and Hamdani, 2009).

Dr. Sitanala Leprosy HospitalTangerang has

developed services and qualities in public services in

various fields of specialization. Dr. Sitanala Leprosy

HospitalTangerang has an integrated service

building which also serves general non-leprosy

patients with general inpatient care facilities, ER,

ICU, surgical services, rehabilitation services and

other support services. Improving the quality of

servicesare expected to provide customer

satisfaction, in this case, is the patient of leprosy or

general health service.

Research on Patient Service Quality and Loyalty

(Study at Private General Hospital in Singaraja City-

Bali) which aims to find out the influence of patient

loyalty service quality dimension at private hospital

in Singaraja-Bali, shows that service quality consists

of tangible, reliability, responsiveness, assurance,

and empathy have a significant influence on patient

loyalty not only partially but also simultaneously;

and the dimensions of reliability have a dominant

influence on patient loyalty (Gunawan, 2011)

Research on Factors Underlying Perception of

Patients to Stigma of Leprosy with respondents

(leprosy patients) amounted to 8 people of 14 - 51

years. The results have shown leprosy patients

perceived, the community around the residence and

his friends do not know that the patient is

experiencing leprosy, the patient assumes that

neighbors and friends suspect other diseased

patients. Patients with leprosy perceived, self-

limiting attitude, covering the deficiency/

disabilityare actions to reduce/overcomebad stamp.

Leprosy patients perceived that leprosy is a

dangerous and seriousdisease can cause death or

disability for life. Lepers perceived, behave

negatively such as not wanting to seek treatment

because it is disgraceful, isolating themselves, and

feeling despair (Soedarjatmi et al., 2009)

Leprosyspeciality hospitals are impacted by the

stigmatization of individuals and communities on

the health services provided. The inherent stigma

that Dr. Sitanala Leprosy HospitalTangerangonly

provides services to leprosy patients. People also

tend to seek general health services outside the

hospital can be caused because they do not want to

be stigmatized as a leper. It can also be said that Dr.

Sitanala Leprosy HospitalTangerangalready has a

branding as a special service provider for leprosy

patients.

When

consumers feel satisfied with the services

provided, it will create loyalty and can make

consumers use the product again. Furthermore,

consumers recommend this to others with pleasure.

The results of research in the communications

industry in Australia that by providing a consistent

service and focus on consumer needs and provide

added value to consumers, it will create loyalty to

the company (Dean, et al., 2007) It is expected that

the improvement of services conducted by Dr.

Sitanala Leprosy Hospital can replace negative

stigma with positive stigma formed from experience

in its ministry.

The contribution of research to analyze the

influence of stigmatization of service to patient

loyalty moderated service quality at inpatient service

Dr. Sitanala Leprosy HospitalTangerang.

2 METHOD

This research is a type of hypothesis testing on the

effect of service stigmatization on patient loyalty

Dr. Sitanala Leprosy HospitalTangerang. THE Type

of research conducted in this research is causality

research with survey method.

The study population were all patients treated in

general health service at Bougenville, Mawar,

Anyelir, Asoka, Melati, Wijaya Kusuma and Tulip

Dr. Sitanala Leprosy HospitalTangerang with 120

patients. Sampling by Proportionated Stratified

random sampling.

Independent variable is service stigmatization,

thedependent variable is patient loyalty and

moderation variable is service quality. The data

analysis use moderate regression analysis.

Researchers prepared instruments by developing the

theory of Brourad & Willis (2006), Parasuraman,

(2009), and Zeithmnal, (1986).

3 RESULT AND DISCUSSION

3.1 Descriptive Analysis

The sample is adjusted to the situation and the

inclusion of respondents in the specified inclusion

criteria so that the disseminated is obtained from 92

respondents who meet the criteria specified with the

characteristics of the sample in table 1.

Descriptive distribution of respondents' answers

is used to evaluate the responses of respondents to

the variables studied, by looking at the minimum

value, maximum value, average value, and standard

deviation.

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Table 1: Characteristic of Respondents at Dr. Sitanala Leprosy Hospital Tangerang in 2018

Respondent Criteria Frequency Percentage (%)

Age (years)

15-20 3 3,3

21-40 45 48,9

41-59 32 34,8

60-74 8 8,7

≥75 4 4,3

Sex

Female 54 58,7

Male 38 41,3

Educational Level

SD 32 34,8

SMP 12 13,0

SLTA 28 30,4

University 19 20,7

Uneducated 1 1,1

Job

Private employees 16 17,4

Civil servant 7 7,6

Entrepreneur 16 17,4

Student 6 6,5

Unemployed 38 41,3

Others 9 9,8

Table 2. Range at Dr. Sitanala Leprosy Hospital Tangerang in 2018

Variables Range Mean Actual Range Actual Mean

Deviation

Stamdard

Stigmatization of Services 5-25 15 11-25 17,29 3,022

Service quality 18-90 54 61-90 76,07 6,771

Patient loyalty 10-50 30 27-50 40,59 4,227

Source: Results of Data

Based on these descriptive statistics then

determined the proportion of values for research

variables stigmatization services, service quality and

patient loyalty.

Table 3: Stigmatization Categoric Descriptive at Dr. Sitanala Leprosy Hospital Tangerang in 2018

Dimension Intervals Frequency Percentage (%)

Perception of self

1,00-3,00

80 86,9

3,01-5,00

12 13.1

Self-Exclusion

1,00-3,00

82 89,1

3,01-5,00

10 10,9

Subterfuge

1,00-3,00

73 79,3

3,01-5,00

19 20,7

Over compensation

1,00-3,00

42 45,6

3,01-5,00

50 54,4

Fear of disclosure

1,00-3,00

87 94,5

3,01-5,00

5 5,4

Source: Results of Data

Effect of Service Stigmatization to Patients Loyalty Moderated by Service Quality

473

In the stigmatization of service variables (table

3), the majority showed high stigma in service with

the fear of disclosure dimension having the highest

score, as many as 87 respondents (94.5%).

Thisindicates the respondent conceals that he or she

is treated in a leprosy hospital by telling others that

the respondent is being treated in another hospital

and does not need to visit the respondent.

Table 4: Service Quality Categoric Descriptive at Dr. Sitanala Leprosy Hospital Tangerang in 2018

Dimension Intervals Frequency Percentage (%)

Reliability

0,00-4,00 0 0,0

4,01-8,00

1 1,1

8,01-12,00

2 2,2

12,01-16,00 58 63,0

16,01-20,00

31 33,7

Responsiveness

0,00-4,00 0 0,0

4,01-8,00

0 0,0

8,01-12,00

1 1,1

12,01-16,00 43 46,7

16,01-20,00

48 52,2

Assurance

0,00-3,00 0 0,0

3,01-6,00

0 0,0

6,01-9,00

1 1,1

9,01-12,00 56 60,9

12,01-15,00

35 38,0

Emphaty

0,00-4,00 0 0,0

4,01-8,00

0 0,0

8,01-12,00

0 0,0

12,01-16,00 47 51,1

16,01-20,00

45 48,9

Tangible

0,00-3,00 0 0,0

3,01-6,00

0 0,0

6,01-9,00

3 3,3

9,01-12,00 47 51,1

12,01-15,00

42 45,7

In the variable of service quality (table 4), the

majority shown high respondent's recognition of

service quality with empathy dimension with the

biggest value between 12,01-16,00 of 47

respondents (51,1%). This shows that Dr. Sitanala

Leprosy Hospital Tangerang provides individual

services, trying to understand the wishes of

respondents. The dimension of empathy is the

dominant dimension in this study, evidenced by no

respondents showing a negative response to this

dimension (all values above 12.01).

Table 5: Patient Loyalty Categoric Descriptive at Dr. Sitanala Leprosy Hospital Tangerang in 2018

Dimension Intervals Frequency Percentage (%)

Say Positive Thing

0,00-3,00 0 0,0

3,01-6,00

0 0,0

6,01-9,00

5 5,4

9,01-12,00 56 60,9

12,01-15,00

31 33,7

Recommend friend

0,00-4,00 0 0,0

4,01-8,00

0 0,0

8,01-12,00

1 1,1

12,01-16,00 55 59,8

16,01-20,00

36 39,1

Continue purchasing

0,00-3,00 0 0,0

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Dimension Intervals Frequency Percentage (%)

3,01-6,00

0 0,0

6,01-9,00

6 6,5

9,01-12,00 53 57,6

12,01-15,00

33 35,9

In the variable of patient loyalty (table 5), the

majority indicate high respondent's loyalty with the

highest score on indicator recommend friends, the

majority of respondents be in the range of values

between 12.01-16,00 of 55 respondents (59,8%).

This shown that respondents do not hesitate and

recommend the service of Dr. Sitanala Leprosy

Hospital Tangerang.

3.2 Hypothesis Test

Table 6: Results of Multiple Linear Regression Stigmatization Interaction Services and Service Quality

Variable Regression Coefficient t

count

Sig t

Konstanta 91,205

Sti

matisasi Pela

anan (X

) -4,442 -3,712 0,000

Kualitas Pelayanan (X

) -0,651 -2,217 0,029

Moderasi (X

) 0,057 3,623 0,000

0,474

hitun

28,291

F 0,000

Source: Results of Data

Table 6 stated that the formula of the interaction

regression equation as follows:

Y = 91,205 – 4,442X

-0,651X

+ 0,057X

4 DISCUSSION

4.1 Effect Health Service of

Stigmatization on Patient Loyalty

Research shown Service Stigmatization had an

average value of 17.29, means that the average

patient treated in Public Inpatient Service

stigmatization of public services or can be

saidstigmatization of services inpatient is high. The

dominant dimension determines whether the patient

gives negativestigmatization of the service appears

to the dimension of fear of disclosure states that the

respondent informs others that the respondent is

treated in another hospital and no need to visit the

respondent. Respondents tend to be afraid to tell

other people that the respondents are hospitalized for

leprosy patients while the respondents are people

with other diseases.

Stigmatization had a significant effect on patient

loyalty, indicated by a significant level (p-value) of

0.00 which was smaller than 0.05. This indicated

that Service Stigmatization had a significant effect

on Patient Loyalty of Dr. Sitanala Leprosy Hospital

Tangerang.

Dr. Sitanala Leprosy Hospital Tangerangdoes not

regard Leprosy Hospital as a hospital that is

marginalized because of the stigma of this disease.

This may be due to increased knowledge of the

patient both about leprosy disease and also other

services provided by Leprosy Hospital. Judging

from the number of visits in 2016,76% of general

service patients compared with 24% of leprosy

patients. For inpatient services, 84% of general

service patients and 16% of leprosy patients. This

number indicates that leprosy patients have

decreased more than in previous years. Number of

general service patients who seek treatment at

Dr.Sitanala Leprosy Hospital Tangerang can

gradually eliminate the stigma against leprosy

patients.

Thisis supported by research on Community

attitudes towards leprosy affected persons in

Pokhara municipality of western Nepal. A sample of

281 people in the community, the median stigma

score perceived was 12 ranging from 0-30. People

who lack information about leprosy have higher

stigma scores than those who have information

about leprosy (p = 0.002). Well informed people had

lower stigma compared to people with leprosy, so do

not hesitate to use the service in Dr. Sitanala

Leprosy Hospital, for understanding the

transmission of leprosy and the separation of

services in hospitalization.

Effect of Service Stigmatization to Patients Loyalty Moderated by Service Quality

475

Leprosy-related stigma, including those in health

care systems and among health care providers,

creates serious barriers to quality access and care. It

is also a major concern of health practitioners

themselves, both as a cultural issue, a workplace and

a barrier to seeking health assistance.

4.2 Effect of Service Quality on Patient

Loyalty

Based on the hypothesis that good or low

stigmatization increased the loyalty of patients to use

general inpatient services moderated by service

quality. In this study, the moderation between

Service Stigmatization and Service Quality had a

positive effect on Patient Loyalty, with a regression

coefficient of 0,024. Based on the test with simple

linear regression and moderation regression that the

coefficient of determination (R2) in simple linear

regression had a value of 0.016 which its value

smaller than the coefficient of determination of

0.474. Its meant that the quality of servicewas a

moderation variable that strengthens the influence of

service stigmatization on patient loyalty. Based on

theR2value that was equal to 0,474 or 47,4% shown

the effect ofstigmatizationservice, service quality,

and interaction between stigmatization of service

and quality of service to patient loyalty was 0,474 or

47,4% and the rest equal to 52,6% influenced by

other variables outside the research model. Based on

a significance value of 0.000 (p< 0.05) indicates that

the effect was significant. Its meant that the

hypothesis stated that quality of service was able to

moderate stigmatization of services to patient loyalty

on inpatient general in Dr. Sitanala Leprosy Hospital

Tangerang was proved.

Research on the stigma of addiction and mental

illness in healthcare: the case of patients' experiences

in dental settings explored how stigma experienced

in health care and dental care by patients with a

history of addiction and mental illness. The method

used audio-taped and semi-structured interviews

with samples from two community-care centers in

Vancouver, Canada. The interview guide contained

questions about the experience while seeking health

care and dental care and was based on the existing

labeling, stereotyping, exclusion, discrimination, and

imbalance patterns of strength. Interviews were

verbatim for coding and thematic analysis. 25

respondents aged 23- 67 years were interviewed; 17

is male. Most had a history of depression with

alcohol and cocaine use; Most only seek dental

treatment for emergency purposes. A textual

analysis of over 300 pages of written interviews

revealed that respondents felt stigmatized when they

were stereotypically 'inappropriate', labeled

'different', excluded from the decision-making

process, discriminated against, 'treated unfairly' and

felt helpless when interacting in health care systems.

When associated with stigma, mental illness and

addiction had negative implications for accessing

health care and dental care. Likewise, leprosy

patients hadnegative access to health care.

Dr. Sitanala Leprosy Hospital already had

integratinga general healthservice into theirprovided

servicesby not distinguishing the quality

improvement between the two services. Integration

of leprosy health services into general health

services had considered as core strategies. Leprosy

services should be provided with the same quality

(no more and no less) as general health problems, to

ensure the similarity of quality of care for leprosy

patients.

This integration reduced the level of

stigmatization of leprosy patients and health

services. Hoped that improved service quality for

leprosy patients and other health problems will

decrease stigmatization and increase patient loyalty

to reuse services provided by Dr. Sitanala Leprosy

Hospital Tangerang.

4.3 Findings

Stigmatization of health service hada negative effect

on patient loyalty, meant that the higher

stigmatization of service would decrease loyalty

patients. Health service Stigmatization had a

significant effect on patient loyalty at Dr.

Sitanala Leprosy Hospital of Tangerang. Service

quality hada negative effect on patient loyalty,

meant that if the quality of service decreased,

patientloyalty tends to decline. Service Quality had a

significant effect on patient loyalty at Dr.

Sitanala Leprosy Hospital Tangerang. Moderation

between service stigmatization and service quality

had a positive effect on patient loyalty. Service

quality was able to moderate the influence of

healthservicestigmatization to patient loyalty.

Stigmatization of health service, quality of

service, and moderation of service stigmatization

with the quality of service jointly affectedpatient

loyalty ofDr. Sitanala Leprosy Hospital Tangerang.

The influence of stigmatization service, service

quality, and moderation of service stigmatization-

service quality to patient loyalty was 0.474 or 47,4%

and the rest 52,6% influenced by other variables

outside the research model. Based on the coefficient

of determination (R

) value, quality of service was a

moderation variable that will strengthen the

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influence of stigmatization of service to patient

loyalty.

5 CONCLUSIONS

Based on the research, service stigmatization had a

significant effect on patient loyalty at Dr.Sitanala

Leprosy Hospital Tangerang. Stigmatization service

hada negative effect on patient loyalty, meant that

themore stigmatization of service, the more

decreasing patient loyalty.

Service quality had a significant effect on the

patient loyalty ofDr. Sitanala Leprosy Hospital

Tangerang. Service quality hada negative effect on

patient loyalty, meant that The less quality of

service, the more decreasing patient loyalty.

Service qualitywas able to moderate the

influence of stigmatization of service to patient

loyalty. Moderation between service stigmatization

and service quality had a positive effect on patient

loyalty. Based on the coefficient of determination

) value, quality of service was a moderation

variable that strengthens the influence of

stigmatization of service to patient loyalty.

Results confirm that the stigmatization of

services had a significant negative effect on patient

loyalty. This means that stigmatization can lead to

the increased loyalty of patients in using services in

hospitals. Patients who are leprosy stigmatizedcan

affect their perspective on a health institution that

specializes in treating the disease. Efforts that can be

done by the hospital was to promote hospital

services either locally or nationally. A

promotionsuch as community-centered real

activities, enhancing the promotion of superior

services and reducing stigma by directly educating

and advertising community service related to leprosy

negative stigma and services.

Quality of service had a significant effect on

patient loyalty. This means improving the quality of

service can increase patient loyalty. The implication

is that patient loyalty can be improved by improving

service quality. Efforts are to improve the services of

the five aspects of quality, tangible, reliability,

responsiveness, assurance, and empathy, either by

equipping facilities and equipment with high

technology and in accordance with the public health

needs, make improvements and increase the

competence of employees, especially the profession

carers through education and training.

Quality of hospital services moderates the effect

of service stigmatization on patient loyalty. Overall

service quality weakens service stigmatization.

Patients pay more attention to the overall service

dimension than the stigmatization that occurs in their

service. Service quality dimensions play an

important role in moderating stigmatization of

services in general inpatients. The patient will

change his stigmatization view on the services and

bring a feeling of loyalty to hospital services. Patient

loyalty is based on the willingness to recommend

hospitals to others, willingness to inform about

hospital benefits and to consider the same hospital as

the first choice in future medical care. In this study,

empathy is the most dominant factor in service

quality. The hospital should maintain good

relationships between patients and staff, improve

communication skills and provide motivation to

provide good service to patients so they can work

efficiently, especially in the treatment of patients.

Furthermore, another important aspect is tangible

regarding facilities, such as equipment and facilities.

A better understanding of patient loyalty building

will improve the manager's knowledge of how to

improve patient loyalty. The strategy of reducing

stigmatization by paying attention to perceived

service quality as a mechanism that will increase

patient loyalty.

The hospital needs to re-develop information

programs on leprosy to further reduce the level of

stigmatization of individuals and hospital

services.The high stigmatization of services can be

reduced by providing quality service quality.

Patients will return to use services that show

improvement of patient loyalty to the service of Dr.

Sitanala Leprosy Hospital Tangerang. So Hospitals

need to continuously improve and maintain the

quality of service so that the Hospital Bed

Occupation Rate will increase, along with

lesserstigmatization to service.

This study only examines the concept of

stigmatization of hospital services, service quality

and patient loyalty from a patient perspective.

However, this study does not explore from a service

provider's perspective. Results are limited to

considering the patient's point of view, which may

differ from the view of the service provider. It is,

therefore, necessary to develop research that

measures both from the perspective of patients and

service providers so that the implications of the

research are more described and become inputs for

service providers developing strategies for

improving patient loyalty.

Effect of Service Stigmatization to Patients Loyalty Moderated by Service Quality

477

ACKNOWLEDGEMENTS

The research was supported by Departement of

Hospital Administration, Esa Unggul University.

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