Understanding the mediating effect of switching costs on service value, quality, satisfaction, and loyalty

Vietnam’s healthcare sector is rapidly growing but faces challenges such as overcrowding, infrastructure gaps, and variable service quality, leading many patients to seek care abroad. As competition among providers intensifies, building and maintaining customer loyalty is critical. Prior research shows strong links among service quality, value, satisfaction, and loyalty; however, the roles of switching costs (procedural, financial, relational) in shaping these relationships remain underexplored in healthcare, particularly in private settings. This study addresses this gap by investigating: (1) the roles of SQ, SV, CS, and PSC/FSC/RSC in producing CL; (2) whether PSC, FSC, and RSC mediate the SV–CL relationship; (3) whether PSC, FSC, and RSC mediate the CS–CL relationship. The context is Vietnam’s mixed public–private system with rapidly expanding private provision and documented differences in patient experiences favoring private providers.

Customer loyalty (CL) results from cumulative experiences and is vital for firm performance and retention, including in healthcare. Customer satisfaction (CS) is a cognitive evaluation of performance relative to expectations and is linked to loyalty and retention. Service value (SV), or perceived value, reflects the trade-off between perceived benefits and sacrifices and consistently predicts purchase/repurchase intentions across sectors, including healthcare. The relationships among SQ, SV, CS, and CL are debated, but substantial evidence supports SQ and SV as antecedents of CS, and CS as a predictor of CL. Switching costs (SC) comprise procedural (time/effort/learning), financial (monetary/non-monetary losses, foregone benefits), and relational (interpersonal/identity ties) dimensions. SCs can directly influence loyalty and switching behavior, and may play moderating or mediating roles in the CS–CL and SV–CL links. Prior findings on the mediating role of SCs are mixed; few studies treat PSC, FSC, and RSC separately or examine them in healthcare. This study proposes a theoretical model with hypotheses H1–H10 testing direct effects among SQ, SV, CS, CL, and SCs, as well as mediations of SV (between SQ and CS), CS (between SV and CL), and SCs (between SV/CS and CL).

Design and data collection: A questionnaire-based survey (paper-based and online) was administered in Vietnamese between January and May 2021 following pre-testing. A total of 380 questionnaires (230 paper, 150 online) were distributed; 300 usable responses were obtained (78.95% response rate). Target population: individuals using private healthcare services in Ho Chi Minh City, Vietnam. Sampling: convenience sampling. Measures: All items used 5-point Likert scales (1 = strongly disagree to 5 = strongly agree). Construct item counts: SQ (6 items), SV (4), CS (6 initially; CS1 later dropped), CL (6 initially; CL3 later dropped), PSC (2), FSC (2), RSC (2). Switching cost items were adapted from Burnham et al. (2003) with reduced item sets (following prior practice) to limit respondent burden. Common method bias check: A marker variable technique was used; maximum VIF = 2.493 (<3.3), suggesting CMB was not problematic. Analysis: PLS-SEM using SmartPLS 3.3.3. Reliability and validity assessment followed Hair et al. guidelines: Cronbach’s alpha and rho_A > 0.60; composite reliability (CR) > 0.70; AVE > 0.50; HTMT < 1.0 for discriminant validity. Structural paths were evaluated via bootstrapping (5000 resamples). Predictive relevance was assessed via blindfolding (Q²).

Sample profile (n=300): 51% female; age: 17% (18–22), 36% (23–40), 47% (>40). Descriptives (means; SDs): SQ 3.75 (0.91), SV 3.70 (0.93), CS 3.74 (0.90), PSC 3.80 (0.89), FSC 3.86 (0.91), RSC 3.76 (0.88), CL 3.81 (0.86). Measurement model: All retained items had satisfactory loadings; CR ranged 0.881–0.896; AVE 0.596–0.811; HTMT < 1.0, supporting reliability and validity. Structural model: R² ranged from 0.032 (RSC) to 0.761 (CL), indicating weak to strong explanatory power across constructs. Direct effects (Table 6; standardized β, p):

• H1a SQ → SV: β=0.189, p=0.001 (supported); H1b SQ → CS: β=0.068, p=0.206 (not supported).
• H2a SV → CS: β=0.533, p<0.001 (supported). H2b SV → CL: β=0.134, p=0.001 (supported). H2c SV → RSC: β=−0.029, p=0.664 (not supported). H2d SV → FSC: β=0.183, p=0.002 (supported). H2e SV → PSC: β=0.209, p=0.001 (supported).
• H3a CS → CL: β=0.331, p<0.001 (supported). H3b CS → RSC: β=0.194, p=0.007 (supported). H3c CS → FSC: β=0.390, p<0.001 (supported). H3d CS → PSC: β=0.391, p<0.001 (supported).
• H4 PSC → CL: β=0.445, p<0.001 (supported). H5 FSC → CL: β=0.158, p<0.001 (supported). H6 RSC → CL: β=0.090, p=0.002 (supported). Mediations:
• SV → CL via SCs (Table 7/9): Partial mediation via FSC (indirect β=0.029, p=0.018) and PSC (indirect β=0.093, p=0.004); no mediation via RSC (indirect β=−0.003, p=0.681).
• CS → CL via SCs (Table 8/9): Partial mediation via FSC (indirect β=0.061, p=0.007), PSC (indirect β=0.174, p<0.001), and RSC (indirect β=0.017, p=0.050).
• Additional implied mediations consistent with hypotheses: SV mediates SQ → CS; CS mediates SV → CL. Predictive relevance (Q²): Q² > 0 for CL, CS, FSC, PSC, RSC, SV, indicating predictive relevance (except SQ, which is not reported as having Q² > 0).

The findings address the research questions by showing that SQ influences SV (but not CS directly), SV and CS both contribute to CL, and all three switching costs directly increase CL. Crucially, switching costs function as mediators strengthening the translation of value and satisfaction into loyalty: PSC and FSC partially mediate the SV–CL link, and PSC, FSC, and RSC partially mediate the CS–CL link. This clarifies mixed prior evidence by disaggregating SC into procedural, financial, and relational dimensions. In private healthcare, procedural barriers exhibit the strongest effect on CL, suggesting that time/effort and process complexity meaningfully deter switching. Conceptually, the results support a pathway in which SQ enhances SV, which increases CS, and, together with switching barriers, fosters CL. This underscores the role of co-created value and relationship investments: positive service encounters and added benefits deepen relational ties and, combined with switching barriers, help convert satisfaction into enduring loyalty.

In Vietnam’s private healthcare context, customer loyalty is driven by perceived service value, satisfaction, and switching costs. SQ enhances SV, which in turn increases CS; both SV and CS positively affect CL. PSC, FSC, and RSC directly increase CL. Mediation analyses show that: (a) CS partially mediates the effect of SV on CL; (b) PSC and FSC partially mediate the effect of SV on CL; (c) PSC, FSC, and RSC partially mediate the effect of CS on CL; and (d) SV mediates the effect of SQ on downstream outcomes. The study contributes by jointly modeling three-dimensional SCs as mediators in healthcare, evidencing especially strong roles for procedural and financial barriers. Future research should extend to other regions/sectors, employ longitudinal designs to capture dynamics among SV, SQ, CS, SC, and CL, and use probability sampling to enhance generalizability.

The study is limited to private healthcare users in Ho Chi Minh City, constraining geographic and sectoral generalizability. The cross-sectional survey design precludes causal and temporal inferences. Convenience sampling limits external validity. Future studies should include broader regions and public sector providers, employ longitudinal data, and adopt probability sampling (e.g., stratified or cluster sampling).