DETERMINANTS OF SANITATION AND MENSTRUAL HYGIENE ADHERENCE AMONG FEMALE STUDENTS IN COASTAL NORTH SUMATERA INDONESIA

Abstract

Service quality is a key determinant of patient satisfaction and loyalty. While extensive evidence exists in 
hospital settings, findings in primary care remain fragmented, particularly in contexts undergoing health 
financing reforms. This review aims to synthesize empirical evidence on the relationships between SERVQUAL 
dimensions, patient satisfaction, and patient loyalty in primary care settings. 
Methods: A narrative review was conducted on 34 primary empirical studies published between 2020 and 
2025. Studies examining SERVQUAL dimensions—tangibles, reliability, responsiveness, assurance, and 
empathy—in relation to satisfaction and loyalty were included. Data were extracted and synthesized 
narratively, supported by an evidence frequency mapping. Responsiveness, empathy, and tangibles 
consistently demonstrated strong associations with patient satisfaction. Satisfaction frequently mediated the 
relationship between service quality and loyalty, whereas direct effects of service quality on loyalty were 
inconsistent. Reliability and assurance showed variable effects across contexts. Most studies employed cross
sectional designs and SEM-PLS analytical approaches. Evidence supports a service quality–satisfaction
loyalty pathway in primary care. Contextual and financial factors, such as institutional financing models, may 
moderate these relationships and warrant further investigation using longitudinal and context-sensitive 
designs.