Social media marketing and hospital brand equity: An empirical investigation

Abstract

Despite the continuous upsurge in the use of social media, the empirical research investigating their economic value in the healthcare industry still lags. This study explores the impact of hospitals’ social media marketing efforts on their brand equity and, ultimately, hospital's financial performance. Using social media data from Instagram, online/offline survey methodology, and financial data obtained from hospitals, data is analyzed using a structural equation model. The study uses a random sample of (728) residents of the Kuwaiti population. Social media marketing efforts regarding use and engagement lead to higher hospital brand equity and financial performance. Particularly, the study finds that posts that are based on educational posts, patient stories, and sharing the latest news and research led to the highest form of brand awareness, perceived brand quality, brand association, and brand loyalty, thereby leading to higher perceived brand equity. The study also finds that brand equity leads to a positive and significant impact on hospitals’ financial performance. The study highlights the importance of creating engaging content, content that is personal and particularly educational. Healthcare organizations should guide their marketing efforts to manage this new marketing method better and communicate with patients to enhance consumer loyalty and financial performance.

Keywords

social media marketing brand equity healthcare marketing financial performance social media patient behavior

Introduction

Social media platforms are being used worldwide at exponentially growing numbers. Facebook grew from 100 million monthly active users in 2008 to 2498 million active users in 2019 (Statista, 2019). Social media is the most innovative and destructive market force that has appeared. A new era for organizations is now created, forcing companies to find novel collaborative ways of reaching and interacting with their consumers (Gallaugher and Ransbotham, 2010; Godey et al., 2016; Kim and Ko, 2012; Liu et al., 2019). This exponentially growing marketing channel provides unmatched prospects for brand enhancement (Correa et al., 2010; Scholz and Smith, 2019; Swani et al., 2019). This disruption has fiercely hit the healthcare industry, enhancing competition (Kemp et al., 2014; Vinodhini and Kumar, 2010). Numerous healthcare institutions use social media platforms to communicate with patients. Mayo Clinic, for example, has a social media center aiming to lead the social media revolution in healthcare. This drastic shift in marketing communication has changed how consumers are influenced, and an organization's brand equity is impacted (Swaminathan, 2016). Social media marketing will now play an integral role as healthcare organizations compete. Thus, effective marketing strategies will require healthcare organizations to develop substantial brand equity (Chahal and Rani, 2017; Godey et al., 2016; Kim and Ko, 2012).

With healthcare organizations’ heightened use of social media as an essential part of their marketing plan, it has become vital to evaluate social media's impact on brand equity quantitatively. Alalwan et al. (2017) evaluated studies investigating social media marketing and found that research in this field could be categorized into the role of social media on (1) advertising, (2) customer relationship management, (3) consumer behavior, (4) adoption in social groups, and (5) firm's performance. In the realm of branding research, the investigation of social media marketing's impact is still in its early stages (Ebrahim, 2019; Harrigan et al., 2018; Jayasuriya et al., 2018). Brand equity and social media marketing have received little academic attention (Godey et al., 2016; Kavisekera and Abeysekera, 2016; Kim and Ko, 2012). Only a few studies have explored the relevance of social media marketing in improving brand experience (Khan, 2022; Zollo et al., 2020). Studies have examined consumer behavior behind social media marketing regarding gratification, affect, and intellect experiences (Tafesse, 2016; Zollo et al., 2020). Such brand experiences impact how consumers behave towards the brand; thus, recognizing the significance of social media marketing's influence on brand equity is essential (Gao and Feng, 2016; Khan, 2022; Kim and Ko, 2012). Current research has shown that social media marketing can improve customer intimacy and trust,(Han and Kim, 2020) brand and value equity (Khan, 2022; Kim and Ko, 2012), brand preference, awareness, and loyalty(Kim and Lee, 2019). There is a limited number of studies delving into the connection between social media marketing and brand equity, with even fewer focusing on the healthcare sector.

Social media marketing in the healthcare industry differs significantly from conventional business social media marketing, considering consumer and industry attributes (Farsi, 2021). This is due to the involvement of individuals’ well-being and the delivery of care within the content. Consequently, healthcare social media marketing demands a unique approach for marketing and engaging with consumers. Generic marketing techniques cannot be applied directly in the healthcare sector, and the healthcare sector needs its own marketing strategy (Purcarea, 2019). As recommended by Kim and Ko (2012), there is a need to study the impact of social media marketing in different industries and develop more effective scales for different sectors. Thus, this study contributes to this stream of literature by addressing the gap and exploring the impact of social media marketing in a unique and understudied sector, the healthcare industry. Understanding the impact of social media marketing on brand equity in the healthcare industry is crucial for crafting effective and ethically responsible marketing strategies that can navigate the complexities of healthcare communication and meet the evolving needs of patients and healthcare consumers.

Moreover, the COVID-19 pandemic has accelerated the adoption of telehealth services and digital communication in healthcare. With more patients seeking medical information and services online, healthcare organizations are increasingly relying on social media platforms to connect with patients, provide educational content, and promote their services (Chou et al., 2021). As a result, studying the effectiveness of social media marketing in building brand equity becomes even more relevant in the current digital health landscape.

Furthermore, healthcare consumers are becoming more discerning and proactive in managing their health. They seek trusted sources of information and engage with healthcare organizations that demonstrate credibility, transparency, and empathy (Gesser-Edelsburg, 2021). Social media platforms offer healthcare organizations an opportunity to establish meaningful connections with patients, build trust, and enhance brand reputation. However, the impact of social media marketing efforts on brand equity in healthcare remains understudied, resulting in healthcare marketers lacking evidence-based strategies to maneuver this evolving landscape.

While previous literature on social media marketing has focused on western populations, this study extends the previous literature by examining social media influence on brand equity in the Middle Eastern population, particularly the Kuwaiti population, an understudied population. Consumers in various cultures have been shown to behave differently (Guftométros and Guerreiro, 2021; Melnyk et al., 2022). Such differences are known to pose a challenge when devising marketing strategies (Izogo and Mpinganjira, 2020). Accordingly, examining the outcomes of social media marketing in different markets and cultures is crucial and can provide valuable insights for healthcare organizations operating in diverse cultural contexts.

Moreover, while the majority of existing studies in social media marketing have relied on survey data for analysis (Li et al., 2021), this study distinguishes itself by adopting a novel approach. Unlike conventional methods, our study utilizes secondary data to quantitatively analyze consumer response, providing a unique perspective on the impact of social media marketing in the healthcare industry. Furthermore, this study goes beyond surface-level analysis by delving deeper into the specific types of posts utilized by hospitals. Through comprehensive evaluation, the study identifies the posts that have the most significant impact on enhancing brand equity. By shedding light on these critical factors, this study contributes valuable insights to the existing literature, offering practical implications for healthcare organizations seeking to optimize their social media marketing strategies.

Drawing on the prevailing gaps in the social media marketing and brand equity literature, this paper responds to the apparent need for an enhanced understanding of healthcare social media marketing by setting out with the following research questions: (1) What is the effect of social media marketing efforts on a hospital's brand equity? (2) and ultimately, consumer response in terms of the number of patient visits? Answers to these questions are essential to the success of this new marketing scheme. They will provide valuable insights into the role of social media marketing on hospital brand equity and resulting patient response in the healthcare industry.

In general, this study makes three main contributions. First, the study fills a gap in the social media marketing literature by providing a more fine-grained conceptual examination of the relationship between different forms of social media activity and brand equity, in particular the type of posts that have impacted consumer response and brand equity in the healthcare industry. The findings of this research will help scholars better understand the relationship between types of digital content and customer response. Second, the conclusions of this study will provide empirical proof of consumer behavior in the healthcare industry. An industry that is unique in terms of its marketing strategy and content delivery due to its unique nature and approach that is not found in other industries (Purcarea, 2019). This study will also provide empirical evidence to an unexplored country and thus will extend the geographic reach of empirical research on the Middle East. Lastly, the study has many contributions to practice. Understanding the evolving patterns in social media usage is instrumental in crafting effective health promotion messages for healthcare providers, health knowledge websites, and physicians. This study's findings will empower healthcare firms to assess and capitalize on diverse social media marketing channels, thereby positively influencing their brand equity and sales outcomes. Additionally, the insights derived from this research will aid marketers in optimizing and amplifying their marketing endeavors, leading to more impactful and resonant engagement with their target audience.

This study uses secondary data extracted from the hospital's social media platform (Instagram) to assess social media use. The study uses a survey to examine brand equity empirically. Lastly, the study uses secondary hospital data to analyze consumer responses. Figure 1 depicts the conceptual framework for social media marketing, brand equity, and consumer response. The paper then elaborates on the methodology and presents the results. The discussion follows along with limitations, implications, and a conclusion.

Figure 1.

Conceptual model.

Literature review

This study draws upon three broad streams of literature. The first relates to research on social media marketing. The second relates to brand equity, and the third is to consumer response.

Social media marketing and hospitals

Marketers use social media platforms to connect and engage with consumers in many ways (Cheung et al., 2019; Kelly et al., 2010). Social media has altered how brand content is produced, controlled, delivered, and consumed (Hollebeek and Macky, 2019; Khan, 2022). Tuten and Solomon (2017) (p.53) defined social media marketing as “the utilization of social media technologies, channels, and software to create, communicate, deliver and exchange offerings that have value for an organization's stakeholders.” According to Dwivedi et al. (2021) (p.291), the main goal of social media marketing is to create value through “a revealing communication on some promotional information.” Other scholars have also highlighted the importance of utilizing social media not only to disseminate brand information to consumers but also to build and manage consumer relationships through two-way interaction (Berthon et al., 2012; Cheung et al., 2020).

Hospital and health care professionals’ usage of social media has skyrocketed in the last years (Huang et al., 2019). Healthcare contributes significantly to the public welfare by building and cultivating customer relationships (Hackworth and Kunz, 2011). Hospitals are increasingly using social media to engage with patients and create relationships with them, as well as to educate the public about key health-related issues and publish research findings (Barnes et al., 2019). The primary goal of any company using social media is to raise brand awareness, engage customers, change attitudes, and stay current on customer concerns and opinions, all of which contribute to brand equity (Smith et al., 2015). Consequently, social media marketing is critical in establishing the hospital's brand equity with patients (Vinodhini and Kumar, 2010).

However, hospitals do not always have complete control over social media dialogues (Brivot et al., 2017; Griffis et al., 2014). Patients and their relatives, employees, and sometimes even competitors contribute a lot of social media content for hospitals (Miller and Tucker, 2013). Some social media sites have allowed members to publicly rate their health experiences. While such ratings may not be accurate, they can provide meaningful signals related to healthcare companies (Bardach et al., 2013; Gao et al., 2012). Furthermore, due to the nature of the healthcare industry, healthcare marketing content and strategy differs from generic social media marketing strategies. As a result, it is critical to understand how social media affects hospital brand equity and, ultimately, patient response.

Only a few studies look at how people utilize social media in hospitals. These studies focused on the motivations for hospital adoption of social media (Garven, 2010; Griffis et al., 2014), how hospitals use social media (Richter et al., 2014), and if different social media platforms appeal to diverse audiences (Glover et al., 2015; Smith, 2017). Other studies have gone into greater detail about effectively communicating a particular health-related message to a specific demographic (Purdy, 2011; Stroever et al., 2011).

Social media use and engagement

According to studies, the primary social media platform for hospitals are Facebook and Twitter as social media platforms. (Huang and Dunbar, 2013; Smith, 2017). These platforms allow the hospital and the patient to communicate and engage with each other.

The current literature has not agreed on the definition of social media marketing (Yadav and Rahman, 2017). While some academics define it as a way to communicate with consumers and build relationships (Chan and Guillet, 2011; Chang et al., 2015; Choi et al., 2016), others describe it as a process of enhancing business value through marketing activities (Felix et al., 2017; Pham and Gammoh, 2015; Tuten and Solomon, 2017). The similar main components of social media marketing among those definitions as highlighted in literature (Chen et al., 2018; Rutter et al., 2016; Yadav and Rahman, 2017) are (1) social media use – or the use of social media platforms, and (2) social media engagement – encouraging users to spread social media content through interaction and engagement. Thus in this study, social media marketing is defined as “a process by which companies create, communicate, and deliver online marketing offerings via social media platforms to build and maintain stakeholder relationships that enhance stakeholders’ value by facilitating interaction” (Yadav and Rahman, 2017).

In particular, social media use is measured through the frequency of posts on social media platforms(Tuten and Solomon, 2017). Social media engagement is a measure of network engagement where users can respond to an organization through followership or by “Like” -ing a post, “Comment” -ing on a post, or just “View” -ing a post (Ashley and Tuten, 2015; De Vries and Carlson, 2014; IMH, 2021). The main goal of this study is to understand how social media marketing, particularly social media use and engagement, impacts brand equity and, ultimately, consumer response in the healthcare industry.

Social media marketing and brand equity

Marketers can acquire competitive advantages and resilience against competitors’ promotional pressures by building a strong brand (Kim and Ko, 2012; Rangaswamy et al., 1993). Brand equity is generally described as the marketing effects and value contributed to the product due to the brand (Keller, 1993; Rangaswamy et al., 1993). Because brand equity is a multidimensional construct, it can have various impacts on customers’ perceptions and attitudes. Brand equity is created by brand awareness, perceptions of the brand's leadership and innovative image, perceptions of the brand's quality, and preference for brand loyalty (Keller, 1993).

While the brand remains the primary means of connecting with customers (Godey et al., 2016), social media marketing efforts help to build consumer brand equity (Coulter et al., 2012; Godey et al., 2016; Kim and Ko, 2012; Yazdanparast et al., 2016). User-generated material on social networking platforms may impact brand equity valuation, making communication more effective for businesses. Social media usage by companies improves brand awareness, perceived quality, association, and loyalty (Aaker, 2009; Callarisa et al., 2012; Zhou et al., 2018). Consumer brand equity is significantly influenced by traditional or social media communication (Ashley and Tuten, 2015; Coulter et al., 2012).

Recent research has examined the use of social media by hospitals and the types of posts and content they share (AlQarni et al., 2016; Kordzadeh and Young, 2018). Generally, these studies have identified several types of content shared by hospitals on social media, such as educational posts, patient stories, behind-the-scenes content, event posts, staff profiles, health tips, and news and research updates.

This study aims to investigate the impact of hospital social media marketing efforts on consumer brand equity creation, with a particular focus on examining the effects of different types of posts. Specifically, the study will focus the different types of marketing efforts on four key brand equity creation strategies: awareness, quality, association, and loyalty.

Brand awareness

Brand awareness is the capacity of a consumer to recognize or recall that a specific brand belongs to a particular product category (Aaker, 2009). Brand recognition and recall are two aspects of brand awareness, which are essential criteria to gain knowledge on a brand (Keller, 1993). Notably, brand awareness serves as a critical precursor to repeat purchases (Cheung et al., 2019), emphasizing its significance in fostering consumer loyalty and market share.

Moreover, brand awareness is influenced by various marketing activities, including advertising and publicity (Hutter et al., 2013). In the digital era, social media platforms have emerged as powerful tools for creating brand awareness, allowing organizations to showcase their brands to a wide audience effectively. Increased social media usage by organizations is associated with higher levels of brand recall among consumers (Dwivedi et al., 2021). Additionally, active engagement and validation of organizations’ social media activities by consumers contribute to reinforcing brand awareness (Hollebeek and Macky, 2019). Following through, the more active consumers engage and validate organizations’ social media activity, the higher the brand's awareness.

H1a: The higher the level of social media use by the healthcare organization, the greater the level of consumer brand awareness.

H1b: The higher the level of social media engagement of the healthcare organization, the greater the level of consumer brand awareness.

Brand quality

Consumers’ perceptions of a product's or service's reliability and dependability, known as perceived brand quality, are directly linked to their preferences and decisions (Nikhashemi et al., 2017). Firms try to engage customers with the brand to improve the brand's quality perception and stimulate sales (Nikhashemi et al., 2017; Shanahan et al., 2019). Social media platforms, with their collaborative and interactive environment, offer unique opportunities for consumers to connect with brands and share their experiences.

Engaging customers through social media facilitates direct communication and interaction, fostering a sense of connection and trust between consumers and the brand (Nurhadi et al., 2023; Shanahan et al., 2019). This heightened connectivity enables consumers to develop more positive perceptions of brand quality, as they perceive the brand to be more responsive and reliable (Bazi et al., 2023) Moreover, social media platforms serve as forums where consumers can freely express their opinions and experiences with the brand through comments, likes, and reviews. These interactions not only increase consumer engagement but also provide valuable feedback for the brand, further enhancing perceived brand quality (Hollebeek and Macky, 2019). Therefore, the study hypothesizes:

H2a: The higher the level of social media use by the healthcare organization, the higher the consumer perceived brand quality.

H2b: The higher the level of social media engagement of the healthcare organization, the higher the consumer perceived brand quality.

Brand association

Brand association encompasses a company's reputation, encapsulating all aspects of a product or service that consumers associate with the brand (Aaker, 2009). Brand association is created through attitudes, traits, and benefits (Keller, 1993), and it serves as a tool for gathering information to attain brand differentiation and expansion (Van Osselaer and Janiszewski, 2001). Notably, consumers’ emotional attachments to brands often lead them to be willing to pay a premium for branded goods (Hamann et al., 2007).

In the digital age, social media platforms serve as powerful tools for reinforcing and amplifying brand associations. By consistently promoting the brand's unique benefits and advantages on social media, organizations can create instant associations in consumers’ minds (Malik et al., 2023). Moreover, the interactive nature of social media facilitates immediate feedback and response, enabling consumers to have heightened experiences with the brand's associations (Aljuhmani et al., 2023). Thus:

H3a: The higher the level of social media use by the healthcare organization, the higher the consumer brand association.

H3b: The higher the level of social media engagement of the healthcare organization, the higher the consumer brand association.

Brand loyalty

Brand loyalty, defined as the consistent purchasing or re-patronizing of a favorite product or service over time (Aaker, 2009), plays a pivotal role in shaping consumer behavior and influencing brand success. Loyal customers exhibit stronger emotional connections with the brand, leading to favorable reactions and increased likelihood of repeat purchases (Callarisa et al., 2012). Additionally, loyal consumers are more inclined to share positive reviews and recommendations, contributing to the brand's reputation and attracting new customers (Kim et al., 2004; Wang et al., 2011).

Moreover, brand loyalty is recognized as a core dimension that enhances brand equity, driving long-term profitability and sustainable growth (Aaker, 2009). In the digital era, social media emerges as a powerful tool for cultivating and reinforcing brand loyalty. Social media platforms offer unique opportunities for customization, allowing organizations to tailor their content and offerings to cater specifically to loyal consumers (Ebrahim, 2020; Hollebeek and Macky, 2019). Furthermore, direct communication channels provided by social media enable organizations to engage with loyal consumers in real-time, fostering deeper connections and strengthening brand loyalty (Samarah et al., 2022; Shanahan et al., 2019). Additionally, loyal consumers often serve as brand advocates, leveraging their social networks to share their positive experiences and endorse trustworthy brands (Wilk et al., 2021).Thus:

H4a: The higher the level of social media use by the healthcare organization, the greater the level of consumer brand loyalty.

H4b: The higher the level of social media engagement of the healthcare organization, the greater the level of consumer brand loyalty.

Healthcare social media marketing and consumer response

Healthcare organizations harness the power of social media for direct marketing purposes and brand enhancement by disseminating information on healthy lifestyles and health-related topics (Smith, 2017). For example, healthcare organizations utilize platforms like Facebook to provide well-being tips and updates on medical research discoveries, while platforms like Twitter are utilized for crucial post-vaccination reminders during flu season (Sharma et al., 2014). Additionally, social media platforms serve as essential platforms for patient engagement, fostering forums, reviews, and social support, which in turn, drive patient interest and participation in healthcare organizations’ social media pages (Farsi, 2021; Sendra et al., 2020).

Furthermore, collaborative communication facilitated by social media platforms allows consumers to benefit from feedback and evaluations, thereby strengthening their relationships with the organization, the brand, and fellow consumers (Zhang and Mao, 2016). These robust relationships not only enhance consumer trust and loyalty but also influence consumer response (Merchant et al., 2021) in terms of patient visits to healthcare organizations.

H5a: The higher the level of social media use by the healthcare organization, the greater the consumer response in average patient visits per day to the hospital.

H5b: The higher the level of social media engagement of the healthcare organization, the higher the consumer response in average patient visits per day to the hospital.

Brand equity and consumer response

Substantial brand equity is known to significantly influence consumer response, leading to increased consumer engagement and loyalty (Aaker, 2009; Keller, 1993). This relationship holds true even in the context of social media marketing. According to studies, social media marketing creates a positive brand experience (Khan, 2022) and consumer response (Callarisa et al., 2012; Godey et al., 2016; Kim and Ko, 2012).

In the healthcare industry, consumer response is often manifested in the form of patient visits to hospitals, which serves as a key performance indicator for healthcare organizations (Liu et al., 2020; Razzouk et al., 2004; Welch et al., 2017). Therefore, this study focuses on assessing the impact of brand equity on the average number of patient visits per day to hospitals.

H6a: The higher the hospital's brand awareness, the higher the average number of patient visits per day to the hospital.

H6b: The higher the perceived brand quality of a hospital, the higher the average number of patient visits per day to the hospital.

H6c: The higher the brand association of a hospital, the higher the average number of patient visits per day to the hospital.

H6d: The higher the brand loyalty of a hospital, the higher the average number of patient visits per day to the hospital.

Methodology

This study aims to investigate within the healthcare industry the inﬂuence of social media marketing efforts of a hospital on creating hospital brand equity and patient response. The study focused on the most prominent private hospitals in Kuwait, a total of 10 hospitals.¹ Public hospitals are excluded because healthcare is free in public hospitals in Kuwait; in addition, public hospitals do not use social media. Private hospitals in Kuwait have much competition, especially from public hospitals, given the free healthcare nature of the country. Therefore, private hospitals strongly utilize social media to enhance their brand and consumer response, making Kuwait an excellent context for the study.

From May 2022 to July 2022, data was collected in three formats as displayed in Table 1. For the social media marketing efforts, an API was designed to collect the number of posts, followers, likes per post, and comments per post on Instagram (the most used social media platform in Kuwait) for the ten hospitals. Social media use was defined as the total number of hospital posts on Instagram. Social media engagement was defined as the total average interaction per hospital post on Instagram by the hospital. Measured by the sum of the average “Like/Heart” per post, the average number of “Comments” per post done by the hospital. The types of social media content used by hospitals as defined in previous research (AlQarni et al., 2016; Kordzadeh and Young, 2018; Lapointe et al., 2014) was also analyzed and manually categorized as displayed in Table 1. The categories are : patient stories, behind the scenes, event posts, staff profiles, health tips, and news research. For example, the total the number of posts that were educational in the hospitals Instagram during the time period were collected.

Table 1.

Construct and data source.

	Variable	Data Source
Social Media Marketing
	Use: Total number of hospital posts on Instagram during period collection.	Instagram
	Engagement: Total average interaction per hospital post on Instagram during period collection.Measured by the sum of the average “Like/Heart” per post and the average number of “Comments” per post done by the hospital.	Instagram
	Post Type – Number of posts that are:Educational posts: Hospitals may share educational posts that focus on healthcare topics, such as how to manage chronic diseases or how to prevent the spread of infections.Patient stories: Hospitals may share patient stories to showcase their success in treating patients and to highlight the compassionate care they provide.Behind-the-scenes posts: Hospitals may share behind-the-scenes posts that provide a glimpse into their operations and highlight their staff's hard work and dedication.Event posts: Hospitals may share posts about upcoming events, such as health fairs or community outreach programs.Staff profiles: Hospitals may share posts that feature their staff, introducing them to the community and highlighting their expertise.Health tips: Hospitals may share health tips and advice to help their followers maintain good health and wellbeing.News and research: Hospitals may share posts about the latest healthcare news and research to keep their followers informed and engaged.	Instagram
Consumer Based Brand Equity
	Brand Awareness	Survey
	Perceived Brand Quality	Survey
	Brand Association	Survey
	Brand Loyalty	Survey
Patient Response
	Number of visits	Hospital Data

Next, a quantitative survey was designed to assess the consumer-based brand equity targeting consumers and followers of these ten private hospitals. The questionnaire came in two formats, Arabic and English. The survey's brand equity measures were adapted from previous studies and scales, as shown in Table 2. Respondents were asked to express their opinion and evaluate the hospitals on a classic five-point Likert scale of strongly disagree to strongly agree.

Table 2.

Brand equity survey questions.

Construct	Variable	Questions	Adopted from
Brand Awareness	BA1	BA 1: I am aware of this hospital that appeared on social media.	(Aaker, 1996; Atilgan et al., 2005; Yoo and Donthu, 2001)
	BA2	BA 2: I can recognize this hospital in comparison with the other competing hospitals.
	BA3	BA 3: I know how this hospital looks like.
	BA4	BA 4: Some characteristics of the hospital that appeared in the social media come to my mind quickly.
	BA5	BA 5: I can quickly recall the symbol or logo of the hospital that appeared on social media.

Perceived Brand Quality	PQ1	PQ 1: The hospital provides prompt services at the promised time.	(Kim and Kim, 2005)
	PQ2	PQ 2: The hospital handles customer complaints effectively.
	PQ3	PQ 3: The hospital can tell patients exactly when the services would be performed.
	PQ4	PQ 4: The hospital gives individual patients attention.

Brand Association	BAC1	BAss 1: This hospital that appeared on social media has its own personality.	(Kim and Kim, 2005; Yoo and Donthu, 2001)
	BAC2	BAss 2: This hospital is different in comparison with the other competing hospitals that appeared on social media.
	BAC3	BAss 3: I trust the company that owns the hospital that appeared on social media.
	BAC4	BAss 4: This hospital that appeared on social media is familiar to me.
	BAC5	BAss 5: There are reasons to go to this hospital over the competing hospitals that appeared on social media.

Brand Loyalty	BL1	BL 1: I regularly refer to this hospital through social media.	(Kim and Kim, 2005; Yoo and Donthu, 2001)
	BL2	BL 2: I usually use this hospital as my first choice in comparison with the other hospitals.
	BL3	BL 3: I would recommend this hospital to others through social media.
	BL4	BL 4: I will not switch to another hospital that appeared on social media next time.
	BL5	BL 5: I am satisfied with the hospital that appeared on social media.

The survey instrument was pilot-tested using a sample of 48 patients who had been patients in one of the ten hospitals in the two months preceding the survey, leading to minor refinements to a few items. The survey was distributed to the followers and patients of these hospitals for three months, from May 2022 to July 2022. All followers of the hospital's Instagram accounts were contacted directly through Instagram and sent a link to the online survey. A reminder follow-up was also sent two weeks later for those that did not respond. In addition, a QR code link to the survey was distributed to patients in the hospitals’ waiting rooms from May to July 2022. A total of 749 participants took the survey. Due to missing responses to items, 21 observations were excluded, resulting in a sample size of 728. Lastly, the private hospitals provided the study with consumer response data regarding average patient visits per day. Responses were coded, validated, and analyzed using SPSS version 27.0 and AMOS version 26.

Table 3 presents the distribution of hospital Instagram posts by content type. Out of all the hospital posts, staff profiles account for 27%, followed by news and research (21%), patient stories (17%), health tips (16%), behind-the-scenes posts (10%), and events (7%). Additional statistics on hospital posts are provided in Table 4. During the data collection period, a total of 355 posts were published, and hospitals had an average of 29.5K followers on Instagram. On average, each post received 54 likes and 2 comments.

Table 3.

Hospital Instagram posts types.

Theme	Total number of posts N = 355
PatientStories_posts	60 (17%)
BehindtheScenes_posts	36 (10%)
EventPosts_posts	25 (7%)
StaffProfiles_posts	99 (27%)
HealthTips_posts	57 (16%)
NewsResearch_posts	78 (21%)

Table 4.

Hospital social media mean scores.

	Hospitals
Total Number of Posts	355
Average Number of Followers	29.5K
Average Likes per Post	54
Average Comment per post	2

The survey sample represents private hospitals’ target consumers, with around 39.4% of the sample having an average annual income between 60,000–79,999 USD. The sample comprised 57.7% females and 42.3% males, with an average age of 37. The average expenditure on private hospitals is around 3000 USD per year. Around 48% of the sample spent more than 7 h per week on social media. Table 5 shows further sample characteristics.

Table 5.

Survey sample demographics (n = 728).

Variable		Percent	N
Age	19 or younger	1.79	13
	20–30	8.65	63
	31–40	44.23	322
	41–50	18.13	132
	More than 50	27.20	198
Gender	Male	42.31	308
	Female	57.69	420
Average time spent on social media per week	Less than 1 h	0.27	2
	1–3 h	3.02	22
	3–5 h	7.55	55
	5–7 h	41.07	299
	More than 7 h	48.08	350
Annual Income	Less than $20,000	1.51	11
	$20,000–$39,999	6.46	47
	$40,000–$59,999	13.46	98
	$60,000–$79,999	39.42	287
	$80,000–$99,000	21.15	154
	More than $100,000	17.99	131

Results

The conceptual model was tested in two stages: the measurement model and the structural model (Anderson and Gerbing, 1988). First, the measurement scale structures for the deﬁnitive sample were validated. Next, exploratory and conﬁrmatory factor analyses of brand equity were conducted. Last, the causal relationship model tested social media marketing, brand equity, and consumer response. Covariance based structural equation model (CB-SEM) is used to analyze the data as per previous studies, using similar theoretical frameworks (Callarisa et al., 2012; Ebrahim, 2019; Godey et al., 2016; Harrigan et al., 2018; Kim and Kim, 2005). CB-SEM is more appropriate for larger samples than PLS-SEM(Hair et al., 2017). Also, while PLS-SEM is for exploratory analysis, CB-SEM is better off for testing theoretical-based models (Hair et al., 2011, 2012).

Analysis of measurement scales of the model

The measurement model and all the constructs were tested for reliability, convergent validity, and discriminate validity (Chin and Newsted, 1999). Internal component reliability, composite reliability, and factor loadings were used to assess reliability. As shown in Table 6, findings indicate that all three indices exceeded the required cut-off values. All survey constructs of brand equity were tested for reliability using Cronbach's alpha and normality using Kolmogorov-Smirnov. As shown in Table 6, all constructs had composite reliability of greater than 0.7; thus, all measurement scales for the constructs are reliable and consistently acceptable (Cavana et al., 2001), the data also displayed a normal distribution.

Table 6.

Construct reliability and validity analysis.

Variable	Factor Loading	Eigen-Value	Percentage of Variance Explained	Cronbach Reliability Coefficient	α	CR	AVE	AVE >Corr2	Loadings	Mean	SD	t-value
BA1	0.872								0.805	0.804	0.026	30.928
BA2	0.851								0.782	0.781	0.03	25.831
BA3	0.871	7.971	14.8	0.914	0.863	0.9	0.644	0.644>0.494	0.808	0.808	0.028	29.093
BA4	0.872								0.81	0.81	0.023	35.942
BA5	0.771								0.806	0.804	0.033	24.739

PQ1	0.782								0.925	0.925	0.009	97.733
PQ2	0.745	1.697	10.054	0.838	0.908	0.942	0.844	0.844>0.494	0.936	0.936	0.009	102.66
PQ3	0.783								0.895	0.894	0.013	67.715
PQ4	0.805								0.869	0.868	0.028	30.627

BAC1	0.873								0.953	0.953	0.008	119.276
BAC2	0.852								0.964	0.964	0.007	146.331
BAC3	0.871	1.928	11.035	0.795	0.96	0.974	0.926	0.926>0.370	0.97	0.97	0.004	242.404
BAC4	0.874								0.918	0.918	0.013	70.259
BAC5	0.755								0.88	0.88	0.018	50.166

BL1	0.646								0.921	0.921	0.01	95.039
BL2	0.736								0.886	0.887	0.017	53.471
BL3	0.563	2.598	11.365	0.821	0.821	0.893	0.737	0.737 > 0.400	0.761	0.759	0.049	15.559
BL4	0.801								0.883	0.882	0.022	40.756
BL5	0.823								0.896	0.897	0.015	60.505

Note: KMO Measure of Sampling Adequacy =0.855; p = 0.0001 (p < .05); df = 351; Cumulative Percentage Rotation Sums of Squared Loadings = 69.638.

Note: Satorra-Bentler scaled chi-square = 2.5568; GL = 6; p = 0.88614; GFI = 0.997; AGFI = 0.978; RMSEA = 0.059.

Next, exploratory and confirmatory factor analyses were conducted to measure construct validity, as shown in Table 6. The model ﬁt is adequate because the probability associated with chi-square is 0.886 (Bentler and Wu, 1995). Convergent validity was evaluated using average variance explained (AVE). Results in Table 6 show that AVEs of all latent variables are satisfactory and have an expected value of greater than 0.5, fulfilling the requirements for convergent validity (Fornell and Larcker, 1981). Discriminant validity was tested and established since the AVEs of the constructs were greater than the squared correlation of the same construct (as measured by Pearson's correlation coefficient) (Fornell and Larcker, 1981). As shown in Table 6, the results confirmed that discriminant validity was established.

Structural model analysis

The theoretical model was tested according to Anderson and Gerbing (1988). Figure 2 displays the findings. Overall, the model fit was satisfactory. The chi-squared statistic (χ²= 193.5, df = 351) was at a significant level (p = .000). The fit indices were within accepted standards (RMR = .03, NFI = .95, IFI = .95, CFI = .96, GFI = .96, RMSEA = .05). After the overall model fit approval, hypotheses were tested via structural equation modeling.

Figure 2.

Results of structural equation model.

Regarding SMM and brand awareness (H1a and H1b), the estimation results showed that all paths were significant at the p = .000 level. Hospital use of social media use had a significant and positive effect on patient brand awareness (β = .36, t = 5.70), and hospital social media engagement also had a significant and positive effect on consumer brand awareness (β = .47, t = 6.10), supporting H1a and H1b.

Similarly, for the relationship between SMM and brand quality (H2a and H2b), the estimation results showed that every path was significant at the p = .000 level. Hospital use of social media had a significant and positive effect on consumer brand quality (β = .37, t = 5.13), and hospital social media engagement also had a significant and positive effect on consumer brand quality (β = .24, t = 4.12), supporting H2a and H2b.

The relationship between SMM and brand association (H3a and H3b) was positive and significant. Hospital social media use significantly and positively affected consumer brand association (β = .19, t = 3.17). Hospital social media engagement also significantly affected consumer brand association (β = .33, t = 6.12), supporting H3a and H3b.

In addition, the relationship between SMM and brand loyalty (H4a and H4b) was also positive and significant. Hospital social media use significantly and positively affected consumer brand loyalty (β = .17, t = 3.88). Hospital social media engagement also significantly and positively affected consumer brand loyalty (β = .54, t = 8.33), supporting H4a and H4b.

SMM also had a positive and significant direct impact on patient response regarding average patient visits per day to the hospital. Hospital social media use significantly and positively affected patient response (β = .11, t = 3.66). Hospital social media engagement also significantly and positively affected patient response (β = .73, t = 9.76), supporting H5a and H5b.

Lastly, all brand equity constructs positively and significantly impact patient response. Brand awareness (β = .26, t = 4.16), perceived brand quality (β = .43, t = 7.11), brand association (β = .36, t = 5.66), and brand loyalty (β = .59, t = 8.32) all positively and significantly impact average patient visits per day to the hospital (p = .000) supporting H6a-H6d. Since all the brand equity constructs were significant, SMM activities of hospitals could consequently influence patient response through the effects of brand equity.

Hospital content post analysis

The impact of social media use on brand equity was further investigated by examining how the different types of posts impact brand equity, and untimately consumer response. Formal specification of the general model is as follows:

B r a n d A w a r e n e s s_{i} = β_{0} + β_{1} \times P o s t T y p e_{i} +_{ε} i

(1)

P e r c e i v e d B r a n d Q u a l i t y_{i} = β_{0} + β_{1} \times P o s t T y p e_{i} +_{ε} i

(2)

B r a n d A s s o c i a t i o n_{i} = β_{0} + β_{1} \times P o s t T y p e_{i} +_{ε} i

(3)

B r a n d L o y a l t y_{i} = β_{0} + β_{1} \times P o s t T y p e_{i} +_{ε} i

(4)

P a t i e n t R e s p o n s e_{i} = β_{0} + β_{1} \times B r a n d A w a r e n e s s_H A T_{i} + β_{2} \times P e r c e i v e d B r a n d Q u a l i t y_H A T_{i} + + β_{3} \times B r a n d A s s o c i a t i o n_H A T_{i} + β_{4} \times B r a n d L o y a l t y_H A T_{i} + +_{ε} i

(5)

Seemingly unrelated regression (SUR) is used to estimate the β coefficients of the key parameters and employ robust standard errors to test the models. Last, ε are disturbances associated with each observation. SUR is used to estimate to what extent our set of key variables influence patient response. The patient response model (Eqn 5) uses the predicted values of brand awareness (BrandAwareness_HAT), perceived brand quality (Perceived Brand Quality_HAT_), brand association (BrandAssociation_HAT), and brand loyalty (BrandLoyalty_HAT) from the first stage models (Eqn 1–4).

Table 7 displays the results of the Seemingly Unrelated Regression Models (SUR) on post types. Overall, the results display that Educational posts positively and significalty impact brand awareness (β = 0.132, SD = 0.03), perceived brand quality (β = 0.328, SD = 0.01), brand association (β = 0.211, SD = 0.08), and brand loyalty (β = 0.501, SD = 0.06). Patient stories also positively and significantly impact brand awareness (β = 0.328, SD = 0.06), perceived brand quality (β = 0.260, SD = 0.03), brand association (β = 0.371, SD = 0.07), and brand loyalty (β = 0.172, SD = 0.05). Behind the scenes posts had no significant impact. Event posts had a significant impact (p < .01) on perceived brand quality (β = 0.101, SD = 0.04) only. Staff profile posts had a significant impact (p < .01) on brand awareness (β = 0.232, SD = 0.07) only . Health tips posts only had a significant impact (p < .05) on brand awareness (β = 0.046, SD = 0.02) only. News and research had a positive and significant (p < .001) association with all brand equity measures : brand awareness (β = 0.249, SD = 0.05), perceived brand quality (β = 0.201, SD = 0.02), brand association (β = 0.246, SD = 0.06), and brand loyalty (β = 0.286, SD = 0.06). Lastly, it is also clear that all brand equity measures have a positive and significant impact on consumer response.

Table 7.

Seemingly unrelated regression models (SUR) on post types.

	Consumer Based Brand Equity on Hospital X				Patient Response on Hospital X
VARIABLES	(1)	(2)	(3)	(4)	(5)
VARIABLES	Brand Awareness	Perceived Brand Quality	Brand Association	Brand Loyalty	Patient Response
Educational_posts	0.132***(0.03)	0.328***(0.01)	0.211**(0.08)	0.501***(0.06)
PatientStories_posts	0.328***(0.06)	0.260***(0.03)	0.371***(0.07)	0.172***(0.05)
BehindtheScenes_posts	0.021(0.04)	0.071(0.06)	0.007(0.11)	0.009(0.05)
EventPosts_posts	0.001(0.03)	0.101**(0.04)	0.015(0.08)	0.047(0.03)
StaffProfiles_posts	0.232**(0.07)	0.007(0.11)	0.055(0.18)	0.085(0.08)
HealthTips_posts	0.046*(0.02)	0.032(0.03)	0.014(0.07)	0.029(0.02)
NewsResearch_posts	0.249***(0.05)	0.201***(0.02)	0.246***(0.06)	0.286***(0.06)
Brand Awareness					0.533***(0.11)
Perceived Brand Quality					0.240***(0.06)
Brand Association					0.185***(0.04)
Brand Loyaty					0.240***(0.06)
constant	2.260***(0.13)	2.676***(0.18)	1.798***(0.29)	3.033***(0.15)	2.895***(0.15)
R-sq.	0.1586	0.1979	0.1480	0.1498	0.1771

Standard errors in parentheses. *p < .05, **p < .01, ***p < .001.

Discussion

Social media's theoretical and practical implications for brand enhancement have been charted in many studies (Cheung et al., 2019; Cheung et al., 2021; Ho and Wang, 2020; Huerta-Álvarez et al., 2020), along with their challenges (Dwivedi et al., 2021; Kaplan and Haenlein, 2020; Kizgin et al., 2020). Studies have argued that although social media is extensively used in many industries, it is in its infancy in the healthcare industry (Nayal and Pandey, 2021; Pentescu et al., 2015). Thus far, literature has sought to find empirical evidence of how SMM in hospitals successfully influences brand equity and how this influence successively further impacts vital organization goals such as patient response in hospitals.

This study significantly contributes to the existing body of social media and branding literature (Budiman, 2021; Fernandes and Castro, 2020; Huerta-Álvarez et al., 2020) by offering a comprehensive framework elucidating the intricate relationship between social media marketing (SMM) in hospitals, brand equity, and patient response. Drawing upon empirical findings, the study underscores the pivotal role of various dimensions of brand equity—namely brand awareness, perceived brand quality, brand association, and brand loyalty—in shaping patient perceptions and behaviors in the context of healthcare.

The findings of our study underscore the importance of cultivating a strong brand presence across social media platforms for hospitals. Previous research has consistently demonstrated the significance of brand awareness in driving consumer perceptions and behaviors (Supiyandi et al., 2022; Susilowati and Sari, 2020). By strategically leveraging social media activities to enhance brand awareness, hospitals can effectively increase their visibility and reach among target audiences, thereby fostering a deeper connection and familiarity with the brand. Research has shown that consumers are more likely to engage with brands that they are familiar with and trust, highlighting the strategic importance of enhancing brand awareness through social media marketing efforts (Scholz and Smith, 2019; Smith, 2017).

Moreover, this study highlights the significance of promoting perceived brand quality through SMM initiatives, as patients are more likely to trust and engage with hospitals that are perceived to offer high-quality services and care. Research in brand management underscores the pivotal role of perceived brand quality in shaping consumer perceptions and behaviors (Dabbous and Barakat, 2020; McClure and Seock, 2020). Therefore, hospitals should strategically leverage social media platforms to communicate their commitment to delivering exceptional quality services and care to patients.By consistently delivering positive brand experiences and exceeding patients’ expectations, hospitals can enhance their perceived brand quality and differentiate themselves from competitors in the healthcare industry. In addition, our study suggests that hospitals can utilize social media platforms to showcase their expertise, accomplishments, and patient-centric approach, thereby enhancing their perceived brand quality among target audiences. By sharing testimonials, success stories, and patient testimonials on social media, hospitals can reinforce their reputation as trusted healthcare providers and instill confidence in patients seeking medical treatment or services.

The findings of this study emphasize the critical role of brand association in shaping patient perceptions and preferences (Godsey et al., 2020). By actively cultivating positive associations with the hospital brand through engaging and relevant social media content, hospitals can effectively differentiate themselves from competitors and strengthen their brand positioning in the minds of patients. Previous research has shown that consumers form brand associations based on various factors such as product attributes, benefits, and overall brand image (Dada, 2021; Phong et al., 2020; Pranata and Permana, 2021). Therefore, hospitals should strategically tailor their social media content to evoke positive brand associations that resonate with patients and align with their values and preferences.

Moreover, fostering brand loyalty among patients through targeted SMM efforts can significantly enhance patient retention and advocacy, thereby driving long-term business growth and sustainability (Hossain et al., 2020). Research has shown that loyal customers are more likely to repurchase from the same brand and recommend it to others, thereby serving as valuable brand ambassadors (Nadila and Windasari, 2022). Therefore, hospitals should prioritize building strong relationships with patients through personalized engagement, responsive communication, and exceptional service quality, all of which can be facilitated through effective social media marketing strategies.

This study underscores the paramount importance of actively engaging with patients on social media platforms. Simple actions such as ‘liking’ patients’ comments and promptly responding to their inquiries significantly contribute to enhancing the brand equity of hospitals. Moreover, it is imperative to provide various avenues for patient interaction to foster a sense of community and involvement (Aw and Labrecque, 2020). The findings highlight that effective SMM efforts can serve as a significant competitive advantage for hospitals (Denga et al., 2022). Patients are increasingly inclined to choose hospitals that demonstrate higher levels of SMM engagement, as it reflects a commitment to open communication and patient-centric care. Research by Kim and Ko (2012) supports this notion, indicating that SMM activities offer unique value propositions compared to traditional media marketing channels. Hospitals’ social media presence not only provides a platform for patient engagement but also facilitates open communication among patients and the hospital itself. This transparent and inclusive approach positively influences consumer perceptions of brand equity and, ultimately, drives patient response.

The study highlights the significance of leveraging educational posts, patient stories, and news and research updates to enhance brand equity in the healthcare sector. Educational content not only demonstrates the hospital's expertise and commitment to patient education but also fosters trust and credibility among patients seeking reliable healthcare information. Patient stories humanize the brand, allowing patients to connect emotionally with the hospital and fostering a sense of empathy and understanding. Additionally, sharing news and research updates showcases the hospital's dedication to innovation and continuous improvement, further enhancing its reputation as a trusted healthcare provider.

This study found significant positive impacts in comparing brand equity to patient response. With hospital brand building barely mature, patients seem strongly influenced by the hospital's brand, suggesting that investments in brand image building and brand equity are essential. This result is consistent with the previous studies that displayed that a favorable brand image can enhance consumers’ confidence towards its brand and products (Cham et al., 2021; Song et al., 2019). The perceived brand equity developed from the brand may reduce patients perceived risks associated with the medical services and enhance the quality of medical services leading to higher patient response. Hospital advertisements and social media usage influence patients’ brand equity perception towards the hospital; a positive perception would result in a favorable decision. Thus, this finding highlights the importance of marketing communication and investment in the brand equity of the hospital.

An in-depth insight into the impact of social media marketing on patient response and brand equity would assist healthcare marketers in implementing the relevant changes on their social media platforms. The results of this study provide insights into the need to enhance social media usage by healthcare organizations and improve hospital and patient interactions. Such improvement can be made by incorporating social media to offer maximum interaction with patients and by delivering patients more pertinent and tailored information on social media to enhance the relationship and brand equity. Patients brand equity is enhanced through brand awareness, perceived brand quality, brand association, and brand loyalty. Therefore, appropriate social media marketing content should be created to enhance these measures.

Healthcare marketers also need to examine the social media marketing of their competitors; such insight will facilitate deriving innovative and customer-centric social media strategies to achieve anticipated objectives. Currently, social media marketing helps build positive brand equity. By applying innovative health marketing strategies, organizations can position their brand equity better serve their patients. Therefore, the benefits of implementing social media marketing strategies are to improve competitive advantage, increase brand visibility, create a solid reputation among patients, understand consumers’ needs and expectations, and understand patients’ perceptions of the quality of the healthcare organization and the brand.

Limitations and future research

It is essential to consider the study's limitations before interpreting the findings. One limitation of this study is that it does not measure traditional marketing efforts influencing brand equity. Future research may compare the impact of social media marketing efforts versus traditional marketing efforts and their impact on perceived brand equity and patient response. Furthermore, only Instagram was used as a social media platform. Future research could examine more social media platforms, such as Twitter and Facebook, and disintegrate any differences in the types of social media platforms and their impact on brand equity and patient response. Lastly, the study collected social media use and engagement at a single point in time, which may raise concerns about the predictive value of the study. Since social media use and engagement will keep changing, future research should explore social media use and engagement in a longer timeframe. Furthermore, the current study is based on hospital and social media data from Kuwait, implying that the results are limited to cultures similar to Kuwait. Therefore, future research is warranted to investigate the relationship between social media marketing, brand equity, and patient response in diverse cultural contexts. Understanding how these factors interact with social media strategies can provide valuable insights for healthcare organizations aiming to optimize their marketing efforts.

Conclusion

Given the increasing reliance of healthcare organizations on social media, it is imperative to comprehensively examine the impacts of social media on brand equity and, ultimately, patient response. The present study addresses this need by developing a robust research model grounded in social media marketing and brand equity literature. The study findings underscore the pivotal role of social media use and engagement in shaping not only brand equity perception but also patient response. Patients actively form their perceptions of hospitals based on their interactions and experiences on social media platforms. Notably, certain types of posts, such as educational content, patient stories, and news and research updates, have been identified to have a particularly pronounced impact on enhancing brand equity. Furthermore, our study highlights the critical link between brand equity and patient response, indicating that a strong brand can significantly influence patients’ decision-making processes and behaviors. Therefore, healthcare organizations should prioritize efforts to build and reinforce brand equity, as it serves as a potent catalyst for driving patient engagement and loyalty. By investing resources in cultivating a strong brand identity, hospitals can effectively differentiate themselves in the competitive healthcare landscape and foster enduring relationships with patients. By strategically curating content and fostering meaningful engagements with patients, hospitals can maximize the impact of their social media marketing efforts and cultivate a loyal patient base. Ultimately, the study findings underscore the transformative potential of social media in reshaping healthcare marketing practices and empowering organizations to thrive in an increasingly digital-centric era.

Footnotes

ORCID iD

Abrar Al-Hasan

Notes

About the author

Abrar Al-Hasan received a B.Sc. degree in computer engineering from Kuwait University, Kuwait, and an M.B.A. and PhD degree in management of information systems from the University of Maryland at College Park, MD, USA. She is an Associate Professor of information systems at the College of Business Administration, Kuwait University. She has more than ten years of consulting experience in IT, specializing in digital transformations, data mining, and market analysis. Her research interests include social media and social networks, health IT, digital strategy, online markets, digital innovations, and the economics of information systems. She is currently involved in research on the impact of digital markets on consumer behavior within the financial, educational, and healthcare industries.

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