Effective Marketing Strategies in Health Services: Systematic Literature Review

Keywordsdirect-to-consumer advertising effective marketing strategies health services internal marketing internet marketing marketing meta-synthetic Word of mouth

JEL Classification I11, M30

Full Article

1. Introduction

The effects and importance of marketing assessment in the health sector are often underestimated. What is important and needed by patients is sometimes different from what is important to the organization that makes up the healthcare system. In this case, marketing tools are very important because marketing can significantly affect the performance of a healthcare organization as a system. Promotional programs also affect the performance of health organizations by influencing public perceptions of health issues and priorities. Therefore, marketing can play an important role in the healthcare system by bridging the relationship between patients and health services and disseminating health information (Kay, 2007).

Marketing strategy is a method that bridges the organization’s desires and the results of implementing marketing programs that will be run or applied to customers (Varadarajan, 2010). Marketing is a company’s core activity that has an important role in promoting the company’s products or services to reach consumers. Generally, marketing is made up of four fundamental components: product, pricing, distribution, and promotion. Each of these components has the potential to influence and persuade customers to use the company’s products or services. In practice, it can take many forms. A company can simultaneously carry out several marketing forms, such as personal selling, advertising, promotion, customer service, or product development programs (Armstrong et al., 2014).

Marketing strategy is not only important for industrial companies but also for healthcare organizations, such as hospitals, health centers, or clinics. These organizations constantly deal with new and different types of marketing becausethe organizations, technology, and health issues change over time. Kay (2007) has provided evidence that healthcare organizations need to use marketing tools better to inform patients and facilitate decision-making in their healthcare. Thus, they must catch up with the demand to improve the quality and accessibility of healthcare.

Although much work has been done on marketing strategies used by healthcare organizations, they do not yet provide the latest critical synthesis and reflection. Therefore, using evidence from previous studies, this paper combines various marketing and medical science elements covering aspects of hospital marketing strategy. It intends to search for an effective marketing strategy in health services using qualitative content analysis.

2. Research Methodology

In order to guide the researchers in selecting articles from digital library databases, a specific checklist tool called PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was used. This tool was developed by Moher, Liberati, Tetzlaff, Altman, and the PRISMA Group (Moher et al., 2009).

2.1. Database

Articles in this research were screened from six databases of research journal publishers: Taylor & Francis Online, Science Direct, Sage Publications Inc., Inderscience Publisher, and Emerald Insight. In addition to searching the publisher database, the author also added sources fromselected journals found in Butt et al. (2019) study. The journals covered the Health Marketing Quarterly and International Journal of Healthcare Management from Taylor & Francis,the Health Services Management Research from Sage Publications Inc,the International Journal of Healthcare Technology and Management published by the Inderscience Publisher; the International Journal of Pharmaceutical and Healthcare Marketing hosted by Emerald Insight; and the Journal of Medical Marketing from SAGE Publications Inc.

2.2. Data Collection

Articles were searched in the database using keywords, such as “healthcare marketing” OR “marketing strategy” OR marketing OR market AND hospital OR healthcare OR “healthcare industry”. In this research, the inclusion and exclusion followed the criteria developed by Hadi et al. (2020). Articles were included in the data analysis if they were:

1. research articles/original research.

2. involving participants from various countries.

3. from the health industry sector.

4. published in 2014 - October 2021.

5. available in full text.

6. using or assessing marketing techniques that influenced patients to use health services.

7. English-written articles.

It is necessary to note that Zotero 5.0. was used to avoid duplicate metadata in RIS (Research Information Systems) format. The data were thenanalyzed to see research trends and variables that had not been much studied in the healthcare marketing fields.

2.3. Critical Appraisal Tools (CAT)

The researchers conducted critical assessments using two different forms. Critical Appraisal Tools (CAT) developed by the Joanna Briggs Institute qualitative assessment, review, and appraisal instruments (JBI-QARI) (Lockwood et al., 2015). were applied to evaluate qualitative-based articles. Meanwhile, the quantitative method articles or case studies were assessed using CAT developed by the Public Health Agency of Canada (PHAC) (Public Health Agency of Canada, 2014).

2.4. Meta-Synthesis Analysis

Each finding had an amount of credibility, and we evaluated them in accordance with the criteria established by the Joanna Briggs Institute. The levels of credibility are described as follows: 1) Unequivocal (U) = undoubted evidence 2) Credible (C) = The finding remained an interpretation, but it is made based on the existing data 3) Unsupported (Un) = findings are not supported by data.

After establishing the level of credibility, each finding was classified or grouped into statements that adequately described the findings based on their meaning (semantic) similarity. The articlesearch yielded twelve publications that were classified into five groups. The categories were then submitted to meta-synthesis to provide synthesized findings that served as a foundation and suggestions for practitioners and researchers. The extracted and synthesized data were analyzed using a meta-synthesis approach with the help of the Nvivo 12 trial version software. It described the data based on the publication trends for the period 2014-October 2021 using VOSviewer software.

3. Analysis and Results

3.1. Search Result

Figure 1. PRISMA Flowchart

Source: The authors’ elaboration

The analysis began by sorting a total of 4797 articles to find duplicate or similar articles. From this process, only one was found similar. It was continued by screening the article’s title and abstract, which resulted in 843 articles. After that,the screening stage continued and generated 22 articles because 821 items were considered unrelated to the research subject. The researchers then read the entire article (n=22) and decided that 12 articles met the inclusion criteria.

3.2. Critical Appraisal Result

Of 12 articles found in the search stage, five of them were qualitatively based. Thus, they were assessed using the Critical Appraisal Tool (CAT) JBI-QARI. As presented in Table 1, all qualitative articles scored 7 out of 10. It shows that the five articles have the same scoring pattern on answering the ten assessment questions, except for the following questions 1,6 and 7.

Table 1. Qualitative CAT JBI-QARI

Source: The authors’ elaboration

Furthermore, one study was found to use a quantitative analytical method. Thus, the study was assessed using the CAT PHAC version, as shown in Table 2. The study had a medium quality with a strong study.

Table 2. Quantitative Analytic CAT PHAC

Source: The authors’ elaboration

Table 3 illustratesfive other studies using descriptive quantitative methods with medium study quality.

Table 3. Quantitative Descriptive CAT PHAC

Source: The authors’ elaboration

Finally, Table 4 indicates that only one study used the case series method, with a high-quality study.

Table 4. Case Series CAT PHAC

Source: The authors’ elaboration

In addition to the above findings, this research found that the 12 articles generated 28 key findings, where 21 were classified as Unequivocal (U), and 7 were Credible (C), as provided in Table 5.There was no Unsupported (Un) credibility level reported in those findings. They then produced one synthesized finding, “Effective marketing strategies for health services,” supported by five categories: Internal marketing, Internet marketing, WOM, DTCA, and Effective marketing tools. The meta-synthesis of study findings, the specific findings, categories, and synthesized findings, are summarized in Table 5.

Table 5. Results of Meta-Synthesis Research Findings

Source: The authors’ elaboration

3.3. Publication Trend for the Period 2014-2021

Based on the search results, 4797 articles on healthcare marketing strategy were found from 2014 to 2021 in the selected database. Thus, the trend of publications for 2014-2021 can be described through the VOSviewer, as shown in Figure 2.

Figure 2. Publication Trends on the Topic of Marketing Strategy in Period 2014 – October 2021

Source: The authors’ elaboration

The Figure shows that the research trend in the marketing strategy fieldfrom 2014 to 2021 was brand equity. This is evidenced by the yellow circles that represent the brand equity theme. It is important to note that the lighter color of the circle indicates the more current research topic. On the other hand, when the circle color gets darker, the research topic is older. Another interesting finding from the picture above is that the novelty of the marketing strategy topic in the healthcare sector is still very narrow. This is indicated by the absence of direct linkages to the issue of marketing strategy or indirect connections through the themes of business marketing, competitiveness, brand equity, and b2b marketplaces.

4. Discussion and Conclusion

Before carrying out marketing program activities, it is advisable to assess the current market situation experienced by the hospital or clinic. Jena (2020) developed a marketing assessment tool called the 4S of the market (size, shape, share, & soar) so that marketers can work more effectively. The 4S model can measure prevalence rates, diagnosis and treatment rates, socio-demographic levels and variables (patient age, income, residence), and other factors influencing health service demand. These data provide a model or guide for hospital or clinic marketers to independently use this marketing assessment tool to determine their potential market. Then, various key categories or areas are identified in this research and discussed in detail in the following sections.

1. Effective marketing strategy by WOM (word of mouth)

In the internet era and the web 2.0 era, consumers or patients can use tools or media that can be accessed easily and quickly to obtain information about a company’sproducts or services. This convenience eliminates space and time limitations as product or service recommendations are currently available on social media or the web. This concept is called online WOM (Barreto, 2014). Previous researchers and practitioners have recognized WOM as one of the most effective in disseminating information (Katz and Lazarsfeld, 2017; Kotler, 2002; Maxham III and Netemeyer, 2002).

While WOM has been much studied in many service industries, observing its effect in the healthcare industry is interesting. Research by Gombeski et al. (2015). Marketing-stimulated WOM is more likely to attract new patients than non-marketing-stimulated WOM. WOM influences new patients in determining the health facilities they will visit. They found several factors that influenced new patients in choosing a health facility. They argued that the patients would decide on the health facility after seeing journalists’ coverage, finding information on websites, watching health events, and reading brochures. Further, they also tendedto listen to other people (coworkers/family/friends talk), look at the actions taken by an organization, ask for referrals from other doctors/professionals, and obtain recommendations from previous patients.

Although WOM ofpatient’s neutral experiences may enhance trust (Hyder et al., 2019), WOM that comes from a family working as internal employees of the organization is even stronger. Research conducted by Mohd Isa et al. (2019) shows that relationship marketing and WOM are significant determinants of patient intention to revisit. Relationship marketing focuses on increasing customer interaction to create an emotional connection (Berry, 2002; Grönroos, 1994). Creating a strong emotional relationship with the patient can bring up the intention to visit again and cause a WOM effect that encourages the patient to give testimony totheir relatives (Berry and Parasuraman, 2004).

To extend the market and boost patient trust, especially worldwide, Han and Hyun (2015) assert that reasonable service charges may effectively affect patients' perceptions of trust and satisfaction. This will make the patients spread the information to the public through WOM and network building. This argument is supported by previous research, which states that customer satisfaction is a match between expectations and the obtained results, or the results are greater than customer expectations (Christopher et al., 1993). This satisfaction will make the patients repurchase the product and service, which leads to positive WOM by customers. Positive WOM can be seen in the form of giving recommendations to others.

Accreditations JCI (Joint Commission International), AC (Accreditation Canada), and ISO (International Organization for Standardization) also contribute to increasing international patient confidence. In the study of Hyder et al. (2019), Alpha Clinic, Beta Hospital, and Gama Hospital can be used as benchmarks. Their specialist clinics and hospitals are among the most advanced in Asia. It is not surprising then if their patients are not only domestic but alsoforeign people.

2. Effective marketing strategy by internet marketing

To compete in today's digital era, health organizations must have different values from their competitors to increase demand for health services. Social media can help the organization expand and reach new patients or customers, thereby increasing the demand for services (Kotsenas et al., 2018). One research that examined the use of social media to expand marketing coverage was conducted by John (2017). He investigated how social media was used to promote medical tourism in Asia. In conclusion, he found that Facebook was still the social media with the most users in four countries (Thailand, Singapore, India, and Malaysia).

From the patient's point of view, there are three main reasons for the importance of social media: to give education on health issues, to connect people with other patients who experience similar health problems, and to provide information about the health conditions experienced by the patients (Cangelosi et al., 2018). This important information can be used as a guide in creating events or marketing activities on social media to influence patients in choosing a clinic or hospital. The marketing activities can be exemplified by making a health education class or creating social groups to connect people with fellow cancer sufferers. Other examples include organizing certain events to deepen knowledge about the current disease or to become a medium for sharing daily life experiences with the disease they have.

Regarding gender, a study in the US revealed that homemakers are more active in sharing health information than working women. At the same time, those aged 19-24 and 26-34 years are more likely to seek and need information about health than other age groups (Cangelosi et al., 2018). This data can help healthcare organizations customize their social media content. However, research on similar topics is still needed because the community's social, cultural, and economic conditions vary.

Social medial content is not the only issue that needs attention; Hospital or clinic marketers should also encourage patients to give helpful testimonials or reviews. A review or testimonial is considered useful when it contains information related to communication (the quality of communication between doctors, nurses, and staff to patients), the environment (room and toilet conditions), and the quality of care (compassion, kindness, and empathy) (Church & Chakraborty, 2018). McCullough and Dodge (2002) add that a good hospital review is content related to services, such as the range of services offered or the technology available in the hospital.

So far, hospitals have not carried out interactive communication and promotions on social media or websites. Hospitals use social media primarily to promote the hospital name, health education, and the expertise they have. It indicates that hospitals use social media primarily for informational purposes rather than participation or interaction with prospective patients. Therefore, prospective patients' comments, reviews, and questions on social media should be monitored and responded to as early as possible (John, 2017). If necessary, the hospital assigns special staff responsible for taking care of the hospital’s social media.

The present research believes that social media can affect hospital income. For example, Apenteng et al. (2020) reveal a positive relationship between hospital Facebook and an increase in the US hospital revenue. Interestingly, this positive relationship occurs only in rural hospitals, not urban hospitals. One of the possible reasons is that the users' interactions on the Facebook content lead to the spread of WOM information among village communities. Social networks are closely interwoven among rural residents, making disseminating information and recommendations about hospitals easier and more impactful. This is different from urban residents. Villagers have closer ties even through social media. However, this evidence also needs to be examined in other countries or regions with social, economic, and cultural differences.

Besides increasing the demand for services and hospital revenues, social media also influences the quality of medical and nursing services. An interesting finding was reported by the Department of Orthopedic Surgery at the Mayo Clinic. They revealed that videos introducing operating rooms and surgery could reduce anxiety about the patient's surgery (Kotsenas et al., 2018). Therefore, hospitals or clinics should pay more attention to internet marketing, especially social media. Besides increasing the demand and income, marketing through social media also affects clinical outcomes, such as reducing patient anxiety before surgery. Future research is still required to enrich the claim’s empirical evidence. This is true, especially in relationship marketing which introduces medical services in videos with nursing care or medical therapy outcomes.

3. Effective marketing strategy by DTCA

DTCA (direct-to-consumer advertising) is often defined as the efforts of pharmaceutical companies to promote drugs directly to patients, usually through media channels (FDA, 2015). In previous studies, there were still pros and cons to using DTCA in the health industry. Only the US and New Zealand allow DTCA to include a claim on a product. It should be noted that most other countries do not allow DTCA (WHO, 2009). In this review, researchers found only DTCA studies in the support group. For example, the support group in this review claim that DTCA can communicate health information to improve health behavior among patients, such as the elderly, consumers requiring health information, and consumers with difficult information understanding (An and Muturi, 2011).

Treating the market as a means of positively elevating the hospital's reputation is legal. However, strict regulations that limit paid advertising in hospitals require public relations to act as trustworthy people in finding sources of information for patients (Tengilimoglu et al., 2007). This is true, especially in health care environments where paid advertising is restricted.Community-related programs and health education are considered appropriate and beneficial pathways for hospital marketing (Kim et al., 2008). However, Fischer (2014) warns that hospitals cannot use advertising and promotion as the main marketing strategy because patients will easily switch. Therefore, the synergy between DTCA and other marketing programs is needed.

In general, advertising aims to build image and reputation, not to direct patients to certain procedures. However, the promotion carried out in Kiani et al. (2016) research is unique because it has a clear goal, to influence patient decisions regarding the therapy offered. They analyze the campaign's effectiveness against the increased demand for the promoted service. The results show that DTCA effectively influences prospective patients, increasing the demand for promoted services. In addition, another study argues that exposure to DTCA can encourage people to choose specialist services based on medical expertise and services claimed by the hospital (Zwier, 2017).

Willis (2017) research can complement this DTCA strategy. Willis investigated the visual elements used in DTCA advertisements that affect the Arthritis patient's understanding of a disease and treatment options. The results showed that the patients liked the examples of health advertisements about physical activity. They also want to see other people's stories with Arthritis, such as experiences of pain, disability, joint deformities, and/or limitations in daily life.

Although DTCA offers some benefits, research is still needed to examine its other benefits and risks, especially for people with low education. So far, the measurement of the benefits and risks of DTCA is still carried out in countries with high and equitable levels of education.

4. Effective marketing strategy by internal marketing

Internal marketing can improve service quality if applied in health facilities. Internal marketing places great emphasis on providing information in an inspiring way through employees. They are encouraged to see actions from the customer's perspective. Employees are taught not to be passive and wait for opportunities to serve yet actively seek opportunities to serve and address patient wants and needs (Fortenberry & McGoldrick, 2016)

Internal marketing is a phrase used to describe all the measures an institution should take to grow, empower, and reward its staff for raising the quality of the services they serve to consumers (Iliopoulos and Priporas, 2011). In essence, internal marketing in hospitals focuses on supporting health personnel to boost job enjoyment, performance, and consequent contributions to providing health care.

Research by Al-Weshah (2019) shows that internal marketing has a strong beneficial impact on job participation. Several studies found that work participation boosts employee job satisfaction (Asiamah et al., 2020; Peltier et al., 2006; Suprihanto et al., 2018). Some of these studies suggest that internal marketing improves the quality of care and employee satisfaction and loyalty to the organization.

Fortenberry and McGoldrick (2016) developed an internal marketing campaign that can minimize or avoid the issues reported by patients. For example, these difficulties include filling non-medical rubbish containers and dispersed garbage at beauty clinics. This fact can lead to an adverse patient experience and reduce the reputation of a beauty clinic focused on beauty.

4.1. Practical Implications

Hospital employees should start marketing programs through WOM, for example, by holding health events, making brochures, conducting interviews with colleagues/family/friends, informing actions taken by an organization, and giving awards to people who have recommended people to come. To create a strong emotional connection between service providers and recipients of health services, service providers should contact patients again about their condition after the treatment. In addition, to expand marketing coverage, health service providers should not only create content about health. They should make more interactive content that encourages two-way communication. Otherway, they can create content about a patient's experience with certain disease conditions as it can form a community for fellow patients. Finally,the hospital employees should actively seek opportunities to serve and address patient wants and needs.

4.2. Future Directions of Research

Further empirical research is directed to investigate countries with culturally diverse societies. Such research will certainly complement existing research but with different points of view or values believed by the community or patients. Future research can also be addressed to examine marketing strategies that influence the medical therapy outcome, a nursing diagnosis, or nursing interventions. This topic is interesting and still not much discussed by health professionals or marketers. In addition, this research will require collaboration between disciplines.

We believe that marketing programs implemented in the non-health service industry can also be applied in the health care industry because, basically, marketing is one's attempt to communicate to prospective customers to make them satisfied and make repeat purchases.Therefore,future studiesresearching marketing programs that have never been implemented in health care organizations are still wide open.

4.3. Limitations

Although this paper has some key findings, they should be interpreted cautiously because the authors did not include unpublished studies in the analysis. The search should have included unpublished studies. Furthermore, the search is limited to English-written articles and does not include non-English literature.

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Author Contributions: Andri Nur Rahman: Conceptualization, Methodology, Data curation, Writing- Original draft preparation. Nuryakin: Software, Supervision, Formal analysis. Firman Pribadi: Visualization, Investigation, Validation.

Acknowledgements: I would like to express my gratitude to my lecturer Dr. Elsye Maria Rosa, SKM., M.Kep. Her guidance helped me in the critical appraisal part of this research.

Funding: This research was funded by Borneo Lestari Foundation for the publication fee.

Conflicts of Interest: The authors state that they have no conflicts of interest.

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