Analysis of Service Quality and Perception to the Loyalty and Interest of General Patients Revisit in Public Health Center Kalianget Sumenep District

A person's interest in services is related to the ability of the service provider to provide care. Public interest in utilizing outpatient services is influenced by several factors, including the patient's perception of the quality of outpatient services at the Puskesmas. The purpose of this study was to analyze the effect of service quality and perceptions on loyalty and interest in repeat visits of general patients at the Kalianget Public Health Center, Sumenep Regency. The design of this research is an observational quantitative study with a cross sectional approach with the focus of the research directed at analyzing the effect of service quality and perceptions on loyalty and interest in repeat visits of general patients at the Kalianget Public Health Center, Sumenep Regency. The total population is 191 respondents and the sample is 132respondents were taken using Simple Random Sampling technique. In the study, it was found that almost half of the respondents had sufficient service quality as many as 59 respondents (45%). Almost half of the respondents have a sufficient category perception as many as 57 respondents (43%). Almost half of the respondents have loyalty in the moderate category as many as 61 respondents (46%). Almost half of the respondents have an interest in the medium category as many as 58 respondents (44%). Based on the results of the Path Analysis analysis, it shows that the p-value <0.05 then H0 is rejected and H1 is accepted so it is concluded that there is a direct effectservice quality and perceptions of loyalty and interest in general patient repeat visitsat the Kalianget Health Center, Sumenep Regency. It is expected that general outpatients can provide constructive input and criticism so that the services provided can be as expected. Patients can also contribute to efforts to improve quality services, which pay attention to and focus on the interests of community members.


INTRODUCTION
Users of health services in hospitals demand quality services not only regarding recovery from physical illness but also regarding satisfaction with the attitudes, knowledge and skills of officers in providing services and the availability of adequate facilities and infrastructure that can provide comfort.
With the increasing quality of service, the function of services in hospitals needs to be improved to be more effective and efficient and provide satisfaction to patients and the community. The function of the hospital which is very heavy in providing services to the community is faced with several challenges in terms of human resources and increasingly sophisticated health equipment, but must continue to provide the best service (Khusnawati, 2010).
Based on the above conditions, the authors are interested in researching the analysis of service quality and perceptions of loyalty and interest in repeat visits of general patients at the Kalianget Health Center, Sumenep Regency.

MATERIALS AND METHODS
In this study, the researcher used an observational quantitative design with a cross sectional approach, which is a study to study the dynamics of the correlation between risk factors and effects, by approaching, observing or collecting data all at once (point time approach), that is, each subject The study was observed only once and measurements were made on the status of the character or variable of the subject at the time of examination. This does not mean that all research subjects are observed at the same time (Soekidjo, 2012). This research will analyzethe effect of service quality and perception on loyalty and interest in repeat visits of general patients at Kalianget Public Health Center, Sumenep Regency. The total population is 191 respondents and a sample of 132 respondents is taken by using Simple Random Sampling technique. Data analysis using Path Analysis test. This research has conducted an ethical test with the number SK: 2361/KEPK/III/2021.

a. The Influence of Service Quality on Loyalty
Based on the results of the Linear Regression analysis of the family support variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly influence service quality on general patient loyalty at Kalianget Public Health Center, Sumenep Regency. b. The Influence of Perception on Loyalty Based on the results of the Linear Regression analysis of the service quality variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly the effect of perception on general patient loyalty at the Kalianget Public Health Center, Sumenep Regency. c. Influence Service Quality Through Loyalty to Interests It is known that the direct effect given by the quality of service on loyalty is 0.533. While the indirect effect of service quality through loyalty to interest is 0.120 x 0.667 = 0.080. Then the total effect of service quality through loyalty on interest is 0.533 + 0.080 = 0.613. The total influence value is 0.613, so it can be concluded that there isthe effect of service quality through loyalty on the interest in repeat visits of general patients at the

A. Service Quality of Health Officers at Kalianget Health Center, Sumenep Regency
The results showed that almost half of the respondents had sufficient service quality category as many as 59 respondents (45%). In addition, 41 respondents (31%) have poor service quality category. Meanwhile, a number of 32 respondents (24%) have good service quality category.
Society as consumers would want quality service. Service quality is defined as the level of excellence expected and control over the level of excellence to meet customer desires (Dimas and Oktafani, 2014). Service quality can be interpreted as an effort to fulfill consumer needs and desires as well as the accuracy of delivery in balancing consumer expectations (Dimas and Oktafani, 2014).
One of the services that is widely used by the community is health services. According to Azwar (2014) the use of health services is the use of service facilities provided either in the form of outpatient care, inpatient care, home visits by health workers or other forms of activity from the use of these services based on the availability and continuity of services, public acceptance and fairness, easy to use. accessible to the public, affordable and of good quality.
Suryono (2013) explains that a health service must have various basic requirements, namely: basic requirements that influence the community in determining their choice of using health services in this case, namely the availability and continuity of services, fairness and acceptance of the community, easy to achieve by the community. , Affordable and Quality From the results of the study, the researcher argues that health services must have various basic requirements, namely the basic requirements that influence the community in determining their choice to use health services. The services needed by the community in general are health services that are available in the community and are sustainable, health services must be reasonable and acceptable to the community, locations are easily accessible by the community, the services provided are affordable and the perfection of health services provided. With good service, it will attract people to use health facilities properly and wisely.
Based on the results of the study, it was found that most respondents said the quality of service provided by health workers was in the fairly good category, but there were some who said that the quality of service was still not good where this was because the puskesmas had not provided home visits for certain patients. Health services do not provide explanations regarding the flow of services and also often discriminate between services that are members of JKN and the general public so that the quality of services must be improved so that the community becomes better at assessing.

B. General Patient Perception at Kalianget Health Center, Sumenep Regency
The results showed that almost half of the respondents had a sufficient category perception as many as 57 respondents (43%). In addition, a number of 42 respondents (32%) have a perception of the category less. While a number of 33 respondents (25%) have a good category perception.
Service is an activity or a series of tools that are invisible (cannot be touched), which occur due to interactions between consumers and employees or other things provided by service providers that are intended to solve consumer problems (Ratminto and Winarsih, 2015) .
Good services are health services that are available to the community (acceptable) and sustainable (sustainable). This means that all types of health services needed by the community are found and their presence in the community is available at any time of need. Health services must be reasonable (appropriate) and acceptable (acceptable) by the community. This means that health services can overcome the health problems faced, do not conflict with customs, culture, beliefs and beliefs of the community, and are unnatural, not a condition of good health services (Suryono, 2013).
The goals of outpatient services include providing consultation to patients who need the opinion of a specialist doctor, with treatment or not and to provide follow-up for inpatients who have been allowed to go home but their health condition still needs to be controlled. Outpatient should have a comfortable and pleasant environment for the patient. This is important to note because it is from outpatient treatment that patients get the first impression about the puskesmas. A good outpatient environment should be spacious enough and have good air circulation, comfortable seating, attractive furniture and no disturbing sounds.
Based on the results of the study, it was found that most of the respondents had a fairly good perception of health workers at the puskesmas but there were some respondents who had a bad perception of the officers and everything in the puskesmas. Where respondents think that there are several things that must be improved, it is related to the patient's confidence in the ability of health workers, where most of the respondents do not believe in the abilities of health workers. This is also due to the fact that officers are not quick to respond to patient complaints. This causes the services provided are less in line with patient expectations.

C. General Patient Loyalty at Kalianget Health Center, Sumenep Regency
The results showed that almost half of the respondents had loyalty in the sufficient category as many as 61 respondents (46%). In addition, a number of 40 respondents (30%) have loyalty in the less category. While a number of 31 respondents (23%) have loyalty in the good category.
Sutisna (2011), said that loyalty is grouped into two groups, namely brand loyalty and store loyalty. Consumer loyalty can be defined as "a favorable attitude towards a brand that is represented in consistent purchases of that brand over time".
Setiawan (2011), revealed that consumer loyalty is defined as a measure of customer loyalty in using a product brand or service brand at a certain time in a situation where there are many choices of products or services that can meet their needs and customers have the ability to get them. The level of consumer loyalty to a particular good or service depends on several factors, such as the cost of switching to another good or service, the similarity in quality, quantity or service of the type of substitute goods or services, the risk of changes in costs due to substitute goods or services. Odabası (2014), explains customer loyalty as a tendency, Existing research states that loyalty as a real behavior that is consistent over time. The approach to loyalty cannot be seen as a comprehensive thing about the factors that cause loyalty, but loyalty can be formed from behaviors. Over the past few decades, loyalty has been studied using an attitude approach, this is reflected in one of them by the desire to recommend service providers to others. However, with the passage of time and many studies, research with behavioral and attitude approaches to loyalty has developed, such as the elements of loyalty developed by Zeithaml, et al (2011), Aspects that affect patient loyalty are: satisfaction (satisfaction) is a comparison between expectations before doing with perceived performance, emotional bonding (emotional bonds), where patients can be affected by a hospital name that has its own charm, so that patients can be identified. in a hospital name. Trust, namely the willingness of someone to entrust a company or a hospital name to perform and carry out a function, choice reduction anhabit (convenience), patients will feel comfortable with a hospital name when making transactions provides convenience, history with the company (experience with the company), namely the patient's experience with the company can shape behavior (Putri, 2010).
Based on the results of the study, it was found that almost half of the respondents had a fairly good loyalty to the services provided by health workers, where this was because patients believed that everything that health workers gave to patients was the best. So that patients follow all instructions given by officers and even patients are willing to queue because all patients must be served well when checking their illness. However, there are some respondents who have loyalty in the less category where this is because they feel objected to having to wait a long time to queue for services and likewise doctors lack detail in examining patient complaints. In loyalty, there are things that are considered weak, namely the patient's commitment to the puskesmas.

D. Public Patient Revisit Interest at Kalianget Health Center, Sumenep Regency
The results showed that most of the respondents had an interest in the medium category as many as 58 respondents (44%). In addition, 39 respondents (30%) had an interest in the low category. While a number of 35 respondents (27%) have an interest in the high category.
According to Crow and Crow in Djaali (2013) said that interest is related to the style of movement that encourages a person to face or deal with people, objects, activities, experiences stimulated by the activity itself. According to Gerungan in Djaali (2013:122), interest is the mobilization of feelings and interpretations for something (there is an element of selection). In addition, interest is part of the realm of affection, starting from awareness to the choice of values. Interest does not arise alone, there is an element of need.
Djaali (2013) concluded that interest has elements of affection, awareness to choice of values, mobilization of feelings, selection, and inclination of the heart. Interest can be expressed through statements that indicate that the patient prefers one thing over another, it can also be manifested through participation in an activity.
Theoretical studies on the reuse of the opinion of Zeithalm et all. (2006) that repurchase intention (future intention) emphasizes the importance of measuring customer repurchase interest to find out the desire of customers who remain loyal or leave a service. From the experience thatIt can be noted, the target of repurchasing goods or services is the quantity and quality of goods or services purchased not to be lacking. Another thing that is still related to repeat purchases is maintaining the quality of goods or services so that they do not decrease (Nitisusastro, 2012: 245).
Continuous reuse of the same service will show patient loyalty to the service. The level of patient satisfaction will affect the degree of service quality, the more satisfied a patient is with a service, the more loyal he will be to the service. However, loyalty is often not caused by patient satisfaction but because of compulsion and lack of choice (Sunyoto, 2013).
Outpatient health services must have various basic requirements, namely the basic requirements that influence the community in determining their choice of using health services. The services needed by the community in general are health services that are available in the community and sustainable, health services must be reasonable and acceptable to the community, locations are easily accessible by the community, the services provided are affordable and the perfection of health services provided. With good service it will attract people to want to use health facilities repeatedly without worrying about things that are not wanted.
based on the results of the study, it was found that most of the respondents had moderate interest but there were still some respondents who had low interest. Where this is because the respondent lives in an area that is not so close to the puskesmas and so is not so close to a clinic or other doctor's practice. So that sometimes when they are sick, respondents sometimes choose to go to a doctor's practice so that interest in repeat visits tends to be in the low category.

E. The Influence of Service Quality Through Loyalty on Revisit Interests of General Patients at Kalianget Public Health Center, Sumenep Regency
Based on the results of the Linear Regression analysis of the family support variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly influence service quality on general patient loyalty at Kalianget Public Health Center, Sumenep Regency.
It is known that the direct effect given by the quality of service on loyalty is 0.533. While the indirect effect of service quality through loyalty to interest is 0.120 x 0.667 = 0.080. Then the total effect of service quality through loyalty on interest is 0.533 + 0.080 = 0.613. The total influence value is 0.613, so it can be concluded that there isthe influence of service quality through loyalty to the interest of general patient re-visit at Kalianget Public Health Center, Sumenep Regency.
Development in the health sector is an important part of national development. The main objective of development in the health sector is to improve the health status of the community, by providing wider, equitable and affordable health services, both for urban communities and rural communities. A high degree of health is expected to improve the quality of human resources itself (Armen and Azwar, 2013).
One of the main ways to differentiate health services, including outpatient services, is to consistently provide quality health services, higher than competitors. The key is to meet or exceed patient expectations about the quality of service they receive. After receiving health services, patients will compare the services experienced with the expected services, patients are no longer interested in using health service providers. If the service experienced meets or exceeds expectations, they will use the health care provider again. Hartanto (2014).
Health care standards are part of the health service itself and play an important role in overcoming the problem of the quality of health services. If a health care organization wants to provide quality health services in an obedient or consistent manner, this desire must be translated into a health service standard or operational procedural standard. Health service standards are an organizational tool to describe the quality of health services into operational terminology so that everyone involved in health services will be bound in a system, whether patients, health service providers, health care support, or the management of health service organizations, and will be responsible for accountability in carrying out their respective duties and roles (Imbalo, 2015).
Consumer behavior interest in buying or using services from service providers is strongly influenced by the experience of satisfaction with the services provided previously. After receiving health services, patients will compare the services received with the expected services. (Rustiyanto, 2011). Therefore, the decrease in the number of long visits indicates that the interest in patient visits to return to puskesmas services has also decreased. The services of medical personnel, paramedics, facilities and infrastructure can also improve the quality of service if users can feel and are interested in reusing these services (Anggraini, 2012). The results of research from Trimurthy (2010), show that there is a relationship between interest in reuse and service quality, namely about reliability, responsiveness, direct evidence, Users of health services in hospitals demand quality services not only regarding recovery from physical illness but also regarding satisfaction with the attitudes, knowledge and skills of officers in providing services and the availability of adequate facilities and infrastructure that can provide comfort. With the increasing quality of service, the function of services in hospitals needs to be improved to be more effective and efficient and provide satisfaction to patients and the community. The function of the hospital which is very heavy in providing services to the community is faced with several challenges in terms of human resources and increasingly sophisticated health equipment, but must continue to provide the best service (Khusnawati, 2010).
According to the researcher, there are several things that can affect the interest in revisiting outpatients to a health facility where health facilities must have health workers who have good services so that patients can feel comfortable with the services provided and will reuse them if one day they get sick again. So the researchers argue that there is an influencequality of service through loyalty to the interest of general patient re-visit at Kalianget Public Health Center, Sumenep Regency.

F. The Influence of Perception Through Loyalty on Interest in Revisiting General Patients at Kalianget Public Health Center, Sumenep Regency
Based on the results of the Linear Regression analysis of the service quality variable on utilization, it shows that the p-value is 0.000 <0.05 then H0 is rejected and H1 is accepted so it can be concluded that there is directly the effect of perception on general patient loyalty at the Kalianget Public Health Center, Sumenep Regency.
It is known that the direct influence given by the perception of loyalty is 0.582. While the indirect effect of perceptionthrough loyalty to interest is 0.881 x 0.667 = 0.588. Then the total effect of perception through loyalty on interest is 0.582 + 0.588 = 1.170. The total effect value was 1.170, so it can be concluded that there is an influence of perception through loyalty on the interest in repeat visits of general patients at the Kalianget Public Health Center, Sumenep Regency.
A person's interest in services is related to the ability of the service provider to provide satisfaction. Consumer satisfaction can be defined as big quality or broad quality (wide satisfaction). This broad satisfaction is related to the overall quality of service quality, financing, distribution channels, guarantee of safe use and aspects of employee morality/performance of a health service organization. Public interest in utilizing outpatient services is influenced by several factors, including the patient's perception of the quality of outpatient services at the Puskesmas (Depkes RI, 2013).
Ambulatory service is one form of existing medical services. In simple terms, outpatient services are medical services provided to patients not in the form of inpatient care. In the sense of outpatient this includes not only those organized by service facilities that are commonly known such as hospitals, health centers or clinics, but also those held at the patient's home (Depkes RI, 2013).
Puskesmas in carrying out its function as a health-minded development center, community empowerment center, primary community health service center, and primary individual health service center, the Puskesmas is obliged to provide mandatory health efforts at the Puskesmas and development health efforts, including: Health Promotion Efforts, Environmental Health Efforts, Maternal and Child Health and Family Planning, Nutrition Improvement Efforts, Infectious Disease Prevention and Eradication Efforts, and Treatment Efforts (Depkes RI, 2017).
Health care standards are part of the health service itself and play an important role in overcoming the problem of the quality of health services. If a health care organization wants to provide quality health services in an obedient or consistent manner, this desire must be translated into a health service standard or operational procedural standard. Health service standards are an organizational tool to describe the quality of health services into operational terminology so that everyone involved in health services will be bound in a system, whether patients, health service providers, health care support, or the management of health service organizations, and will be responsible for accountability in carrying out their respective duties and roles (Imbalo, 2015).
Perception is formed in a communication process where with a cognitive informative communication process there will be a perception that considers all related information that previously existed in accordance with one's abilities and intelligence in terms of analyzing, instinctive accuracy and awareness of the needs that are needed in certain conditions and at this stage. Then someone takes action in accordance with the motivational impulses that are controlled by attitudes and emotions where similar actions are repeated, then this can be said to be behavior in life.
The perspective of the patient regarding the available health services gives rise to their respective perceptions, good service will lead to a good perception or perspective as well. Therefore, health facilities must organize good services by prioritizing patient satisfaction so that patients are satisfied with the services provided by health workers so that patients are interested in making repeat visits to the nearest health facility without having to look for other health facilities.So the researchers argue that there is an influence perception through loyalty to the interest in repeat visits of general patients at the Kalianget Public Health Center, Sumenep Regency.

CONCLUSION
1. Almost half of the respondents have sufficient service quality category as many as 59 respondents (45%). 2. Almost half of the respondents have a perception of sufficient category as many as 57 respondents (43%). 3. Almost half of the respondents have loyalty in the moderate category as many as 61 respondents (46%). 4. Almost half of the respondents have an interest in the medium category as many as 58 respondents (44%). 5. There is the effect of service quality through loyalty on the interest in repeat visits of general patients at the Kalianget Public Health Center, Sumenep Regency 6. There is an influence of perception through loyalty to the interest in repeat visits of general patients at the Kalianget Health Center, Sumenep Regency.

For Respondents
It is expected that general outpatients can provide constructive input and criticism so that the services provided can be as expected. Patients can also contribute to efforts to improve quality services, which pay attention to and focus on the interests of community members.

For Educational Institutions
It is hoped that educational institutions can use the results of this research as learning input in the analysis of service quality and perceptions of loyalty and interest in repeat visits of general patients at the Kalianget Health Center, Sumenep Regency and can be developed again for further research to be more useful for readers and for researchers.

For Further Researchers
It is hoped that further research needs to be deepened and added more specific research on the analysis of reliability, responsiveness, assurance and tanggible to the interest in repeat visits of general patients at the Kalianget Public Health Center, Sumenep Regency.