The study set out to capture e-service quality holistically, meaning that the researchers did not treat a hospital’s online presence as a single undifferentiated feature. Instead, they broke the digital purchase experience into five key dimensions: website appearance, information quality, security, personalization, and responsiveness. Website appearance covers the visual design and navigational clarity of the platform. Information quality concerns the accuracy, completeness, and usefulness of the content patients encounter, from service descriptions to pricing details. Security addresses the protection of personal and financial data during online transactions. Personalization reflects the degree to which the platform tailors content and services to individual needs, and responsiveness measures how quickly and effectively the system reacts to patient inquiries and problems.

To measure these constructs, the team built a survey questionnaire grounded in the E-S-QUAL model, a widely used framework in electronic service research designed to assess customer perceptions of online service delivery. The instrument was administered to patients of private hospitals in Dhaka, Bangladesh, a city where private healthcare providers have invested heavily in digital front ends as competition for patients intensifies. After data collection, 391 usable responses were processed for analysis. The researchers employed partial least squares structural equation modeling, or PLS-SEM, a statistical technique well suited to studies that involve multiple latent constructs measured through survey items and hypothesized pathways between them.

PLS-SEM works by estimating measurement models, which link observed survey responses to the underlying latent variables they are meant to represent, and a structural model, which specifies the directional relationships among those latent variables. The technique is particularly popular in information systems and marketing research because it handles complex models with multiple predictors and moderators, performs reasonably well with moderate sample sizes, and places few distributional assumptions on the data. In this study, the structural model tested two broad propositions: first, that the five dimensions of e-service quality jointly determine overall perceived e-service quality, and second, that perceived e-service quality drives patient satisfaction. The moderating hypotheses asked whether online literacy and trust alter the strength of the link between e-service quality and satisfaction.

The results on the first proposition were largely affirmative, though not uniformly so. Four of the five dimensions emerged as significant contributors to e-service quality: information quality, security, personalization, and responsiveness. Notably, website appearance did not follow the same pattern, suggesting that in this healthcare context, a polished visual design alone does not meaningfully elevate patients’ perceptions of digital service quality. What patients appear to care about is substance: whether the information they find is reliable, whether their data is protected, whether the experience feels tailored to them, and whether the hospital responds promptly when something goes wrong or a question arises.

The second core finding confirmed the pathway that much prior research has proposed: e-service quality positively affects patient satisfaction. In other words, when private hospitals deliver strong digital services, patients report being more satisfied with their overall experience. This matters because patient satisfaction is widely treated in the healthcare management literature as a driver of loyalty, word-of-mouth recommendation, and continued engagement with a provider. For private hospitals operating in competitive urban markets, the digital channel is often the first and most frequent point of contact, which makes the quality of that channel a strategic asset rather than a technical afterthought.

The moderation results are where the study becomes genuinely provocative. Online literacy, defined as the patient’s ability to find, evaluate, and use online information and services effectively, significantly moderated the relationship between e-service quality and patient satisfaction. In practical terms, the effect of good digital service on satisfaction is not the same for everyone: patients who are more comfortable and competent online appear to convert high e-service quality into satisfaction differently from those who are less digitally skilled. The authors interpret this as evidence that digital capability shapes how patients experience and judge hospital websites and apps, meaning that a one-size-fits-all digital strategy may leave less literate users behind even when the underlying service is excellent.

Trust, by contrast, did not show any moderating effect. This null result challenges an intuitive assumption that patients who trust their hospital would be more forgiving of digital shortcomings, or that distrust would amplify dissatisfaction with poor online experiences. According to the study, trust simply did not change the strength of the relationship between e-service quality and satisfaction. The finding does not mean trust is irrelevant to healthcare relationships in general; rather, it indicates that within this specific pathway, satisfaction with digital services operates independently of how much patients trust the institution. For theory building, this suggests that trust and e-service quality may influence satisfaction through partly separate channels rather than interacting with each other.

The authors frame their contribution as an extension of the theoretical understanding of e-service quality practices in healthcare contexts, a domain where much of the existing evidence comes from retail banking, e-commerce, and travel rather than clinical settings. By applying the E-S-QUAL model to private hospitals in a developing country context, the study also addresses a geographic gap, since most e-service quality research has been conducted in high-income markets. The Dhaka setting is significant: private hospitals there serve a rapidly urbanizing population with uneven levels of digital access and literacy, making it an ideal environment for testing whether digital skills condition the payoff from investing in online services.

Beyond theory, the research offers what the authors describe as a strategic roadmap for healthcare organizations, especially private hospitals, seeking to enhance patient satisfaction through proper electronic service quality. The practical implications follow directly from the findings. Hospitals should prioritize the accuracy and usefulness of online information, invest in robust security for transactions and personal data, build personalization into their platforms, and ensure rapid, effective responses to patient queries, while treating visual polish as a baseline expectation rather than a differentiator. Because online literacy moderates the satisfaction pathway, providers may also need to consider digital onboarding, simpler interfaces, or assisted channels for less digitally skilled patients, ensuring that investments in e-service quality benefit the full patient population rather than only the most tech-savvy users.

The study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Research Committee of the Department of Business Administration at Shanto-Mariam University of Creative Technology in January 2025, with informed consent obtained from all participants. The authors declare no competing interests, and the research received no external funding. Published as open access under a Creative Commons Attribution license, the work adds to a growing body of evidence that in modern healthcare, the quality of the digital interface is inseparable from the quality of care as patients perceive it, and that understanding who benefits from digital investments is just as important as making them.

Subject of Research: The effect of e-service quality on patient satisfaction in private hospitals and the moderating roles of online literacy and trust

Article Title: The moderating role of online literacy and trust in shaping patient satisfaction through e-service quality in private hospitals

Article References: Karim, M. R., Hassan, M. S., Mai, N. H., Azad, M. A. K., Amin, M. B., Joof, F., & Rahman, M. M. (2026). The moderating role of online literacy and trust in shaping patient satisfaction through e-service quality in private hospitals. Discover Social Science and Health. https://doi.org/10.1007/s44155-026-00429-z

Image Credits: AI Generated

DOI: 10.1007/s44155-026-00429-z

Keywords: e-service quality, patient satisfaction, private hospitals, online literacy, trust, E-S-QUAL model, PLS-SEM, healthcare digital services, Bangladesh, information quality, security, personalization

The study recruited adults aged 18 and older who reported at least one chronic condition and direct experience of follow-up or treatment at a healthcare institution. Data were collected online between January 1 and March 15, 2026, using a self-administered structured questionnaire covering sociodemographic characteristics, healthcare access indicators, and an 18-item Turkish patient satisfaction scale. Rather than treating satisfaction as a single undifferentiated feeling, the analysis separated it into three domains: administrative aspects of care, physician-related care, and the service and environment in which care is delivered. This decomposition proved to be the study’s most revealing analytical move.

The headline numbers tell a story of qualified contentment with clear weak points. The mean overall satisfaction score was 3.43 on a scale with a standard deviation of 0.66. Physician-related satisfaction scored highest, at 3.61 plus or minus 0.75, while service and environment-related satisfaction lagged furthest behind at 3.24 plus or minus 0.72. In other words, patients in İstanbul rated the interpersonal, face-to-face quality of their medical encounters more generously than the organizational shell surrounding those encounters—the scheduling, the waiting, the physical setting, and the flow of services.

Before drawing any conclusions from these scores, the study put its measurement instrument through a demanding statistical vetting. The overall scale showed high internal consistency, with a Cronbach’s alpha of 0.95, indicating that the items hang together as a coherent measure. Exploratory factor analysis supported a three-factor structure corresponding to the administrative, physician-related, and service/environment domains, with a Kaiser-Meyer-Olkin measure of sampling adequacy of 0.946 and a significant Bartlett’s test. These are technical markers, but they matter: they signal that the satisfaction domains the study distinguishes are genuinely distinct dimensions of patient experience rather than statistical artifacts.

The core of the analysis was a robust multivariable regression on complete cases, using HC3 standard errors—a heteroscedasticity-robust estimator that guards against distorted significance when variability differs across respondents. In the primary overall model, which included 445 participants, several access-related variables emerged as significant predictors. Higher appointment waiting category was associated with lower satisfaction, with a coefficient of minus 0.09 and a p-value of 0.014. The direction is intuitive but the quantification is valuable: each step up the waiting-time ladder erodes how patients evaluate their care, independent of the other factors in the model.

Institutional context also mattered. Patients who used private hospitals reported higher satisfaction than those who used state hospitals, with a coefficient of 0.19 and a p-value of 0.013. Meanwhile, relying on public transport rather than a private vehicle was associated with lower satisfaction, at a coefficient of minus 0.21 and a p-value of 0.004. Travel time told a similar story: longer journeys were inversely associated with satisfaction, with a coefficient of minus 0.13 and a p-value of 0.048. Intriguingly, log-transformed distance showed a positive conditional association with satisfaction—a coefficient of 0.16 and a p-value of 0.011—suggesting that once travel time and transport mode are held constant, the raw geographic distance itself does not simply translate into worse experiences, a nuance that complicates any simplistic assumption that closer is always better.

Read together, these coefficients sketch a hierarchy of burden. What corrodes satisfaction most reliably is not the kilometers between home and clinic but the accumulated friction of the journey: the wait for an appointment, the dependence on public transit, and the time spent traveling. For people managing chronic conditions, who typically attend outpatient facilities repeatedly over years, this friction compounds. A patient with diabetes or hypertension who must navigate crowded buses and long appointment queues for every routine check-up is having a fundamentally different service experience from one who drives directly to a private hospital, even if the clinical encounter itself is comparable.

To test whether these patterns were fragile artifacts of missing data, the author conducted a multiple-imputation sensitivity analysis, a technique that fills in plausible values for missing responses across repeated simulated datasets and checks whether conclusions hold. The stability of the findings across this analysis strengthens confidence that the associations are not driven by which respondents happened to answer every question. The study also employed cluster analysis, which identified three distinct satisfaction profiles among the respondents—evidence that outpatient experience in this population is not evenly distributed but clusters into recognizable patterns, likely reflecting different combinations of access conditions and institutional settings.

The study’s conclusions are carefully framed. Patient satisfaction among adults with chronic conditions, the author writes, was associated with both interpersonal care and the organizational experience of accessing services. Appointment waiting, transport conditions, travel burden, and institutional context differentiated the outpatient experience, while physician-related evaluations remained comparatively favorable. This asymmetry is arguably the most policy-relevant finding: the component of care that health systems invest most heavily in training—the clinical encounter—is already the best-rated, while the surrounding infrastructure of access is where dissatisfaction concentrates.

For a megacity like İstanbul, where geography, traffic, and a mixed public-private hospital landscape shape daily life, the implications extend beyond patient surveys. The findings suggest that interventions targeting waiting times, transport accessibility, and the organization of outpatient services could shift satisfaction even without changes in clinical practice. They also highlight a measurement lesson for health services research worldwide: satisfaction scales that collapse everything into a single number risk masking the very dimensions—administrative friction and environmental quality—where improvement is most actionable. As health systems everywhere grapple with aging populations and rising chronic disease, this İstanbul study is a reminder that the road to the clinic, and the wait before it, are part of the medicine.

Subject of Research: Associations between healthcare access conditions and outpatient satisfaction among adults with chronic conditions in İstanbul

Article Title: Access, institutional context, and outpatient satisfaction among adults with chronic conditions in İstanbul: a cross-sectional study

Article References: Sönmez, K. (2026). Access, institutional context, and outpatient satisfaction among adults with chronic conditions in İstanbul: a cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15689-3

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15689-3

Keywords: patient satisfaction, chronic disease, healthcare access, appointment waiting time, transport burden, outpatient care, İstanbul, health services research, private hospitals, public transport, cross-sectional study, Türkiye