FACTORS INFLUENCING PATIENTS’ REVISIT INTENTION TO PUBLIC HEALTH CENTER DURING COVID-19 PANDEMIC

Background: COVID-19 was declared a community health emergency, prompting the Indonesian government to implement a large-scale social restriction policy on March 2022. As a result, the number of patients’ visits to the Public Health Center (PHC) was decreased. Aims: This study aimed to analyze the factors affecting the revisit intention of patients at PHC during the COVID-19 pandemic. Methods: This observational study was conducted at PHC XYZ in West Jakarta in September and October 2022 using a cross-sectional approach. Inclusion and exclusion criteria were employed to select 244 samples. The data collected through a questionnaire with 37 questions were analyzed using PLS-SEM. Results: Government trust and trust in healthcare facilities positively affect revisit intention, with t-statistics of 4.816 and 0.003 as well as a p-value of 0.000. Meanwhile, perceived crowding and health risk, reputation, self-confidence, familiarity, and brand image did not significantly influence revisit intention at the PHC during the COVID-19 pandemic. Conclusion: This study showed that trust in government and healthcare facilities affects the revisit intention of patients. Patients' trust that the Government can overcome COVID-19 and that PHC can be trusted during COVID-19 has a positive influence on patient's intention to revisit. It is important to identify the factors influencing revisit intention at PHC during the pandemic, because PHC has a role as a primary healthcare service


Introduction
The World Health Organization (WHO) declared the novel coronavirus disease (COVID-19) a global pandemic on 11 March 2022. In Indonesia, the first confirmed case was reported on 2 March, 2022. The number reached 1790 confirmed cases, with 170 deaths as of April 2 (Djalante et al., 2020). The virus has a high mortality rate and spreads rapidly between people. Therefore, countries have selected lockdowns, self-isolation, social distancing, and curfews as disease control methods (Hakim, Zanetta and da Cunha, 2021;Untaru and Han, 2021). In response to this, the Indonesian government has declared COVID-19 a community health emergency and implemented a large-scale social restriction policy (Djalante et al., 2020).
Previous literature showed that people avoid hospitals during health crises. This behavior was seen during the Human Immunodeficiency Virus (HIV) outbreak, severe acute respiratory syndrome (SARS) in 2003, and the novel influenza virus A (H1N1) pandemic in 2009 (Cho and Kwon, 2021). Similarly, the impact occurred during the COVID-19 pandemic. Studies showed that non-respiratory emergency visits fell by 57% in Chile in mid-March 2022. Outpatient visits in the U.S. decreased by 40% after the first week of March 2022. Furthermore, follow-up clinic visits in Ethiopia were reduced by 40.4% during the first three months of the pandemic (Abebe et al., 2021;Cho and Kwon, 2021).
The same pattern is also shown in Indonesia. A study found that the number of overall patients' visits in a Public Health Center (PHC) or Puskesmas in Central Java dropped by 46.3%. Registered patients' visits decreased by 49% at the start of the pandemic (Rhatomy and Prasetyo, 2020). Also, a decrease in visits was recorded at PHC XYZ in West Jakarta, DKI Jakarta. In Indonesia, DKI Jakarta is the province with the most cumulative COVID-19 cases (Kemenkes RI, 2022 , the intention to visit in a risky situation relates to the perception of the threat intensity. This theory shows that risky situations such as the COVID-19 pandemic increase protective behavior and reduce patients' revisit intention. Therefore, the intention to visit may be influenced by several factors affecting their threat perception (Castaldo, Penco and Profumo, 2021).
Revisit intention is based on the experience of patients. In this case, patients are willing to return to the same healthcare facility when their expectations are met (Su, Swanson and Chen, 2015). Revisit intention is influenced by government trust (Hakim, Zanetta and da Cunha, 2021), perceived crowding, perceived health risk, trust, reputation, selfconfidence, familiarity (Castaldo, Penco and Profumo, 2021), and brand image (Cham et al., 2016). The COVID-19 pandemic and the resulting social restrictions have changed people's attitude regarding their intention to revisit a healthcare facility (Castaldo, Penco and Profumo, 2021;Dedeoğlu and (Agustina et al., 2019;Susanto et al., 2020). Therefore, this study aimed to evaluate the influence of government trust, perceived crowding and health risk, trust, reputation, self-confidence, and familiarity on the intention to revisit PHC during the pandemic. PHC is the primary healthcare facility during the pandemic. However, studies on the intention to revisit the facility are limited.

Method
This observational quantitative study was conducted using a cross-sectional approach on patients who visited PHC XYZ in West Jakarta in September and October 2022. The samples were determined using purposive sampling with two criteria, including individuals aged above 17 who have visited the PHC once within the last one year. This study has 244 respondents. Furthermore, respondents filled out a questionnaire containing 37 closed-ended questions using a five-point Likert scale. The scale ranged from (1) to (5) for strongly disagree and strongly agree, respectively.
The indicators developed and used in this study were taken from several previous literature. Figure 1 shows the study model. In this model, Government Trust was measured using four indicators adopted from Hakim, Zanetta and da Cunha (2021). Perceived Crowding and Perceived Health Risk were measured using three and two indicators, respectively. Furthermore, Trust and Familiarity were measured using five indicators each, while Self-Confidence used four indicators adopted from Castaldo, Penco and Profumo (2021). Reputation was measured with five indicators adopted from Su, Swanson and Chen (2015) and Castaldo, Penco and Profumo (2021). Brand Image was also measured with four indicators adopted by (Cham et al., 2016). The Theory of Planned Behavior (TPB) is an example of predicting individual behavior based on attitudes and beliefs. Attitudes, subjective norms, and perceptions of controlled behavior determine behavioral intentions, which influence behavior based on TPB (Bae and Chang, 2021). In line with this, revisit intention is the willingness to return to the same healthcare facility in the future. This future intention is usually based on patients' experience. Therefore, patients whose expectations are met are more likely to revisit the same healthcare facility (Su, Swanson and Chen, 2015;Isa, Lim and Chin, 2019).
The COVID-19 pandemic makes people anxious due to the resulting uncertainty. In this situation, government authorities are responsible for providing information and guidelines. People with trust in the government are more accepting of risk and uncertainty (Min et al., 2020;de Rooij, van Liempt and van Bendegom, 2022). Therefore, the following hypothesis was proposed.

Original Research
Crowding results from spatial, sociological, and individual interactions (Yin et al., 2020;Castaldo, Penco and Profumo, 2021). A study found that patients do not seek medical help fearing that the healthcare facility is overcrowded (Lidin et al., 2021). This perceived crowding is a negative feeling in a high-density setting (Kim and Kang, 2021). In line with this, the following hypothesis was formulated.

H2: Perceived Crowding negatively affects revisit intention
The perceived health risk is the judgment of a potential danger to health or well-being. Individuals make decisions intuitively based on their perceived risk of a possible adverse event (Hakim, Zanetta and da Cunha, 2021). In this case, the perceived health risk is a negative perception related to anxiety, insecurity, and fear of the COVID-19 pandemic. This perception influences the intention to visit (Castaldo, Penco and Profumo, 2021). Therefore, the following hypothesis was proposed.

H3: Perceived Health Risk negatively affects revisit intention
A previous study showed that trust is a positive indicator of intention to visit. It reduces risk levels in decision-making, specifically during uncertain situations such as the COVID-19 pandemic (Castaldo, Penco and Profumo, 2021;Dedeoğlu and Boğan, 2021). In healthcare industry, trust is defined as a patient's belief that a doctor's words and actions are credible and reliable. Trust plays an important role in maintaining patients' relationships with service providers within the organization and its members (Isa, Lim and Chin, 2019). Therefore, a hypothesis was proposed as follows.

H4: Trust positively affects revisit intention
Reputation is the overall evaluation of the organization, reflecting on its good and bad qualities (Castaldo, Penco and Profumo, 2021). Customers with a positive reputation of a company are recognized through their loyalty (Su, Swanson and Chen, 2015). Therefore, the following hypothesis was formulated.

H5: Reputation positively affects revisit intention
Self-confidence is the capability to research before making a decision. Therefore, it reflects a subjective evaluation of the ability to make positive decisions. A previous study found that higher selfconfidence influences people's visit intention (Castaldo, Penco and Profumo, 2021). Based on this explanation, a hypothesis was proposed as follows.

H6: Self-Confidence positively affects revisit intention
Familiarity is the number of experiences that individuals have accumulated with the product. It influences various aspects of decision-making and is considered a significant factor in explaining consumer choices and behavioral intentions. A previous study showed that familiarity positively influences revisit intention (Kim, Leht and Kandampully, 2019). Therefore, the following hypothesis was formulated.

H7: Familiarity positively affects patients' revisit intention
Brand image is the perception of the organization based on previous experiences (Khoo, 2022). Studies showed that a hospital's brand image significantly impacts future visit decision (Cham et al., 2016). Therefore, the following hypothesis was proposed.  Bootstrapping is used to assess the path coefficient's significance with a minimum tstatistics value of 1.65 in a one-tail test (Hair, Ringle and Sarstedt, 2011).
A preliminary study was conducted to evaluate the validity and reliability of all indicators. The study used 40 respondents and analyzed the data using PLS-SEM. The results showed that the CR value for all indicators exceeded 0.7. The loading and AVE values also exceeded 0.4 and 0.5, respectively, while the HTMT value was less than 0.95. The results indicated that all items' values are valid and reliable.

Results and Discussion
Demographic profiles from this study displayed in Table 1. The data showed that 67.6% of the respondents are female, 51.2% are aged 26-41, 63.5% completed high school, 42.6% were housewives, 47.5% visited the PHC between 2-5 times within the last year, and 94.7% used BPJS as payment method. Table 2 shows the measurement model analyzed using PLS-SEM. All the indicators' CR value exceeds 0.7, meaning the internal consistency reliability is verified. Furthermore, all indicators' loading value exceeds 0.4. The convergent reliability is fulfilled because all indicators' AVE values are more than 0.5. Discriminant validity is also adequate because all HTMT values are less than 0.95. Additionally, there is no multicollinearity because each indicator's Variance Inflation Factor (VIF) is less than 5 (Hair, Ringle and Sarstedt, 2011;Sarstedt et al., 2022).
Hypotheses were tested using the SEM approach. The structural model results in Table 3 showed that hypotheses H1 and H4 are supported because the tvalue is>1.65 and the p-value is <0.05. Meanwhile, H2, H3, H5, H6, H7 and H8 are not supported. The R 2 value for revisit intention is 0.501, meaning that government trust, perceived crowding and health risk, trust, reputation, selfconfidence, familiarity, and brand image moderately affect revisit intention.    (2021), and Hsieh, Chen and Wang (2021). Therefore, it is important for the government to ensure that the availability of intensive care unit beds is sufficient for the community. It is also important for the government to provide information and news regarding the COVID-19 pandemic. The findings showed that trust positively affects patients' revisit intention in PHC during the pandemic, supporting H4. This result is consistent with Castaldo, Penco and Profumo (2021), Dedeoğlu and Boğan (2021), and de Rooij, van Liempt and van Bendegom (2022). These results illustrate that it is important for PHC to gain the trust of patients. Health centers need to maintain patient trust and make the patient's interests the main priority in providing services. It means that patients in PHC trust the healthcare facility and the government. Therefore, their anxiety and risk level toward the COVID-19 pandemic are decreased, positively influencing the revisit intention.
The results showed that Reputation (H5), Self-Confidence (H6), Familiarity (H7), and Brand Image (H8) do not positively affect revisit intention. This finding contradicts Cham et al. (2016), Kim, Leht and Kandampully (2019), and Castaldo, Penco and Profumo (2021). Based on descriptive analysis, respondents agreed that PHC has a good reputation. Therefore, the respondents are confident in making decisions and familiar with PHC, which has a good brand image. The respondents have a positive perception of this PHC, though this does not affect their revisit intention. During the COVID-19 pandemic, people with mild conditions were discouraged to visit healthcare facilities to reduce the risk of infection (Rhatomy and Prasetyo, 2020). As a result, this could lead to patients' hesitation to revisit PHC. It is recommended that the PHC maintain all these factors well so that they do not become a problem in the future.

Conclusion
This study found that government trust and confidence in healthcare facilities positively affect the intention to revisit PHC during the COVID-19 pandemic. Perceived Crowding, Perceived Health Risk, Reputation, Self-Confidence, Familiarity, and Brand Image did not significantly influence the revisit intention. Based on the findings, PHC must re-evaluate its role as a primary healthcare service in Indonesia because it is depended upon by most Indonesians. Patients are not willing to revisit PHC, specifically during a health crisis. This could lead to changes in the health status of the community. However, this study had limitations and should be repeated in different pandemic periods.

Ethics Approval and Consent Participant
The Research Committee Ethics, Faculty of Economics and Business, Universitas Pelita Harapan, granted Ethical Approval for this study. All respondents were informed about the study objectives and Saputri, Berlianto Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) (Jurnal Administrasi Kesehatan Indonesia)