Factors Affecting the Decision of Patients to Utilize Health Services for Recycling

Patients in health services have different behaviors in deciding to take advantage of health services. Patients used various considerations to make decisions based on the health products or services for re-treatment. The study aimed to analyze the factors that influence the patient's decision in using health services for re-treatment. This research was quantitative with cross-sectional design and conducted at Tanjung Pura Regional Hospital. The population was 3.946 people, and the sample were 247 respondents taken by using purposive sampling. Data analysis was univariate and bivariate using chi-square and multivariate using multiple logistic regression at the 95% confidence level (a= .05). The results showed that the factors that influenced the patient's decision to use health services for re-treatment at the Tanjung Pura Regional Hospital were the service quality of doctors / nurses (p= .000), distance (p=.049), facilities (p=0.000), and service speed (p = .000). The factors that did not influence we age (p=.461). gender (p=.895), education (p=.371), occupation (p=.593). The most dominant factor influencing is facilities with Exp (B)/OR =14.477, meaning that respondents who stated that the hospital facilities were good, had the opportunity to use health services for re-treatment by 14.4 times higher the respondents who stated that the hospital facilities were not good. It is suggested to Tanjung Pura Regional Hospital to propose and allocate a budget for improving hospital facilities that are still lacking and adding new service facilities so that it can increase public confidence for repeat treatment


Introduction
Hospital is a health service institution that provides complete health services that provide inpatient, outpatient and emergency services (Sonia, 2018). The hospital continues to strive to gain public trust by providing quality services. Regional public hospitals (RSUD) are one part of the existing service industry, unfortunately the image of regional hospitals in the eyes of the community is not good compared to private hospital services (Praptiningsih, 2017).
Pakistan that private hospitals provide a better quality response in serving their patients compared to government hospitals (Mohsin, 2018). Research in Thailand also found that there are differences in the quality of services between private hospitals and government hospitals.
Likewise, the condition in Indonesia is that in terms of service, most private hospitals in Indonesia are better and friendlier than government hospitals. This is because government hospitals are not very enthusiastic about innovation and creations in the field of customer satisfaction so that government hospitals do not improve the quality of their services (Audina, 2017).
Quality becomes important to customers when deciding on a service or product and has been considered a strategic advantage for organizations to gain and maintain success in the business world (Irfan & Ijaz, 2011). Quality health services, namely health services that can satisfy every service user in accordance with the average level of satisfaction of the population and the administration in accordance with the code of ethics and service standards that have been implemented (Chasanah, 2014). Patients will tend to choose to return or decide to get treatment at the same hospital if the patient is satisfied with the services they receive (Azwar, 2014).
Decision making for patients to choose health service facilities in hospitals is influenced by several factors / components. The factors that influence the decision to choose service facilities are social factors, cultural factors, individual factors and psychological factors (Kotler & Armstrong, 2014). According to Andersen's theory, the decision to choose a place of treatment means the patient's decision to take advantage of health services. The utilization of health services is influenced by the predisposing components, enabling components, and a person's need for health services. Andersen describes the predisposing components in three factors, namely: a) Demographic factors (consisting of age, gender and marital status), social structure (consisting of education level, occupation and race), beliefs (consisting of beliefs, attitudes or views towards health services, and knowledge). b) Enabling factors consist of family resources (income, insurance coverage), quality of service and distance. c) The need factors consist of rates, facilities, personnel services, location, speed of service, and information (Notoatmodjo, 2014).
Tanjung Pura Hospital is a type C hospital owned by the local government of Langkat Regency. Based on the profile of Tanjung Pura Hospital, the number of patient visits has decreased in the last 3 years. Data in 2017, the total number of patient visits was 45,992 visits (inpatient 3,946 and outpatient 37,056), in 2018 the total number of patient visits was 42,949 visits (inpatient 4,493 and outpatient 38,456) and in 2019 the total number of patient visits was 41,002 visits (inpatient inpatients 4,437 and outpatients 41,555). Based on data from the visit of the Tanjung Pura Hospital patient, it can be seen that the number of health services utilization at the Tanjung Pura Hospital has decreased (RSUD Tanjung Pura, 2019).
The decrease in the number of visits occurred possibly due to increasingly competitive competition between public and private hospitals in attracting patients, and the existence of several alternative treatments that the people of Tanjung Pura have long believed because alternative medicine offers low cost and short treatment without side effects. Alternative medicine is a shortcut to community or patient dissatisfaction with existing medical treatments. Many people are interested in alternative medicine because of the testimonies of recovered patients who tell them that they have previously undergone medical treatment but were not satisfied. In addition, some of them choose to seek treatment in big cities such as Medan and Jakarta, or for those who have money, they prefer to seek treatment abroad, such as in Malaysia and Singapore.
The initial survey was conducted in early February 2020 by interviewing 15 inpatients asking them why they decided to seek treatment and whether they would seek treatment again at the Tanjung Pura Hospital. The reasons put forward by the patient varied and each patient gave more than 1 answer: as many as 10 people answered because they used a BPJS card, 8 people answered that the distance between the Tanjung Pura Hospital was close to the house, 7 people answered that the health service (doctor / nurse) was good , 7 people answered that the facilities at the hospital were adequate to overcome the disease compared to the facilities at the Community Health Center (puskesmas) that referred the patients, 6 people answered that the services at the Tanjung Pura Hospital were fast. This also means that there are 5 patients who seek treatment who do not use a BPJS card, 7 people say the distance is far from the house, 8 people say that the service of health workers (doctors / nurses) is not good, 8 people said hospital facilities were inadequate, 9 people said service at the hospital is slow.

Methods
This research is an analytic survey research with a cross-sectional design. This research was conducted at the Tanjung Pura General Hospital. The population in this study were all patients who visited and were hospitalized who were registered in the medical record as many as 3,946 visits. The sample using the Lemeshow formula obtained 247 people. The research instrument used a questionnaire that has been tested for validity and reliability. The data used are primary, secondary, and tertiary data. Data analysis was performed univariate, bivariate with Chi-Square test, and multivariate using multiple logistic regression tests with a confidence level of 95% ( = 0.05).
Most of the respondents did not work (54.7%), the respondents worked (45.3%). Most of the respondents stated that the doctor / nurse service quality was good (52.6%), a small proportion stated that the doctor / nurse service quality was not good (47.4%). Most of the respondents stated that the distance from the respondent's house to the hospital was easy to reach (56.7%), a small proportion stated that the distance between their house and the hospital was difficult to reach (43.3%).
Respondents who stated that the hospital facilities were in the good category (58.7%), stated that it was not good (41.3%). Respondents who stated that the speed of hospital services was in the good category (59.9%), a small proportion stated the speed of hospital services in the poor category (40.1%).
The decision to return to utilizing health services at Tanjung Pura Hospital, most respondents decided to use health services to go back to Tanjung Pura Hospital (64.8%), a small proportion decided not to take advantage of health services to go back to Tanjung Pura Hospital (35.2%). This shows that most of the respondents who were hospitalized at the Tanjung Pura Regional Hospital decided that if they were sick they would return to using the health services at the Tanjung Pura Hospital because the services they received while being treated were good and in accordance with their expectations. The health facilities at the Tanjung Pura Regional Hospital are a consideration for patients to decide to return to Tanjung Pura Hospital after receiving previous treatment.

Bivariate Analysis
Based on the research, it showed that the results of statistical tests using the chi-square test obtained p-value for age (p = 0.183), gender (p = 0.895), education (p = 0.041), occupation (p = 0.593), quality of doctor / nurse services. (p = 0.000), distance (p = 0.001), facilities (p = 0.000) and speed of service (p = 0.000). This shows that the significant variables are the quality of doctor / nurse services, distance, facilities, and speed of service. Meanwhile, the insignificant variables were age, gender, education and occupation. Details can be seen in the following table.

Multivariate Analysis
The results of multiple logistic regression test showed that as many as 4 variables that influence the patient's decision to use health services for re-treatment at Tanjung Pura Hospital, namely the quality of doctor / nurse services (p = 0,000, OR = 7,000), distance (p = 0.049, OR = 2.051), facilities (p = 0,000, OR = 14,477), speed of service (p = 0,000, OR = 4,152).
The variable with the greatest influence in this study was the facility variable which had a value of Exp (B) / OR = 14.477, meaning that respondents who stated that the Tanjung Pura Hospital facilities were good, had the opportunity to return to using health services for retreatment by 14.4 times higher than respondents who stated Tanjung Pura Hospital facilities are not good. The quality of doctor / nurse services influences the patient's decision to use health services for re-treatment The quality of doctor / nurse services affects the patient's decision to use health services for retreatment at the Tanjung Pura Hospital. Respondents who stated that the quality of doctor / nurse services was good, the opportunity to take advantage of health services for re-treatment at Tanjung Pura Hospital was 7 times higher than respondents who stated that the quality of doctor / nurse services was poor.
There is a relationship between perceived service quality and the decision to choose to stay at Putri Hijau Hospital (Sonia, 2018). Examines people who come for treatment at PKU Muhammadiyah Simo Hospital, Boyolali Regency, both outpatient and inpatient, that based on data analysis it concludes that there is an effect of service quality on the selection of health services at PKU Muhammadiyah Simo Boyolali Hospital (Anggraheni, 2012). Hospital Semarang that patient satisfaction is supported by an increase in treatment decisions again influenced by the quality of doctor services ( Sari, 2013). Health workers have a good attitude so that most respondents have a good perception of the services provided by officers (Irawan & Ainy, 2018). The results of Sugiono's research at Stella Maris Hospital Makassar showed that there was an effect of service quality on the utilization of inpatient services at Stella Maris Hospital Makassar (Sugiono, 2013).
In line with the increasing public demands for medical services, it causes people to be more selective in choosing services from a hospital (Pohan, 2015). The use of health facilities can be influenced by many factors, one of which is the quality of services for health workers (doctors / nurses, etc.) and the community's concept of illness. The use of health services is the result of the behavior or process of seeking health services by a person or because of that person's experience after receiving previous services (Notoatmodjo, 2014).
Based on this research, it proves that the tendency can be seen from respondents who said that the quality of doctor / nurse services was good choosing to return, while respondents who said the quality of doctor / nurse services were not good chose not to reuse, which means that it is likely that they will choose to seek treatment on the spot other.
The respondent's answer to the statement that doctors and nurses are reliable was justified by 88.3%. This indicates that health workers (doctors / nurses) try to provide excellent service to patients who are hospitalized at Tanjung Pura Hospital. This is reinforced by the statement of most respondents that doctors carry out careful examinations.
But there are things that make some respondents feel uncomfortable with the services provided by doctors / nurses, namely some doctors and nurses are less friendly and less communicative (look bitchy), and the statement that doctors do not explain the things that patients complain about in detail (41 , 3%). This study also found that most respondents felt that doctors and nurses explained the actions given to patients, but still found 40.5% of respondents who said that doctors and nurses did not explain the actions and benefits of the actions to be performed on patients. This makes the patient feel that the doctor and nurse's actions are less satisfying to them. This study also found that the majority of respondents stated that doctors and nurses always explain treatment and medication procedures using language that is easy to understand. However, 38.1% of respondents still found that doctors and nurses did not do this. This indicates that the patient gets an explanation from the doctor / nurse but the language used by the doctor / nurse is difficult to understand because they usually use scientific / medical language which is still common to some patients.
The service quality of doctors / nurses at the Tanjung Pura Regional Hospital is an indicator of a patient's decision to choose treatment and come back to the Tanjung Pura Hospital. The friendliness of doctors / nurses to patients, their ability to provide services to hospitalized patients makes patients feel close to the doctor / nurse. This is also because patients who feel that they are getting good service will feel more comfortable, safe, calm and appreciated so that when they are sick, what comes to their mind is the service of doctors / nurses at Tanjung Pura Hospital. The quality of doctor / nurse services plays an important role in attracting patients to visit again when they are sick or their closest family members, so the first decision taken is to go to Tanjung Pura Hospital.
Some doctors who work at the Tanjung Pura Regional Hospital also work part time (part time), especially doctors from Medan. The impact of a part-time job with a place where you live far from the Tanjung Pura Regional Hospital can disrupt services. For this reason, the services provided by doctors must be provided as well as possible considering the services provided by doctors are related to the patient's life. Not maximum services provided by doctors can have an impact on patient health.

Distance Affects the Patient's Decision to Use Health Services for Re-Treatment
Distance to the patient's decision to use health services for re-treatment at Tanjung Pura Hospital. Respondents who stated that the distance to the hospital was easy to reach, the opportunity to use health services for re-treatment was 2 times higher than respondents who stated that the distance to the hospital was difficult to reach. Near or far the location of the house to the hospital influences people to decide on repeat treatment.

This research is in line with the research of Asriani (2016) in RSUD Labuang Baji Makassar
showing that one of the factors that influence reuse is the distance / location factor. Patients who reuse for various reasons including, such as the location of the hospital which is a major factor, the location of the hospital which is in a strategic place, easy to reach, as well as a comfortable environmental condition (Asriani, 2016). There is an influence between place on patient loyalty in choosing health services at Faisal Makassar Hospital (Nurlia, 2012). The strategic location of the hospital, which is located on the side of the main road, makes it easier for people to access transportation to come for treatment there compared to other service places such as Community Health Center (puskesmas) and other hospitals (Anggraheni, 2012). In contrast to Sugiono's research results, which found that there was no influence of location / distance on the interest in reusing inpatient services at Stella Maris Hospital Makassar (Sugiono, 2013).
Distance or service location is often the dominant factor because it affects the form of the marketing mix. Meanwhile, the choice of location or distance is an important reservation because one of the patient's market segments is the proximity to medical services. A study conducted by Boscarino and Steiber in 1985 found that an important reason for choosing a hospital was its proximity to the location (Asriani, 2016). The low use of health facilities is often caused by the distance between the facility and the community (both physically and socially), high tariffs, unsatisfactory services and so on (Anggraheni, 2012). The relationship between location and interest in reusing inpatient services. According to Engel, Roger and Paul in Sugiono, someone makes a purchase to meet their needs determined by considerations of the place or location where the goods or services are obtained (Sugiono, 2013). Likewise, Gilson's opinion said that the farther a health care center or hospital is from where the community lives, the lower the demand for health services (Asriani, 2016).
Based on the results of this study, it is evident that the distance between the respondent's house and the hospital affects the patient's decision to use health services for re-treatment at the Tanjung Pura Hospital. Respondents who said that the Tanjung Pura Regional Hospital was easy to reach tended to decide to go back for treatment again if they experienced illness or other families who experienced illness, while respondents who said that the distance from the house to the Tanjung Pura Hospital was far or difficult to reach tended to not seek repeat treatment. They tend to choose treatment at a place closer to it, for example a clinic or doctor's office.
Most of the respondents said that the distance between their house and the Tanjung Pura Regional Hospital was> 500 meters, but even though the house was more than 500 meters, they still chose to seek treatment at the Tanjung Pura Regional Hospital even though it was difficult to reach. As many as 57.9% of respondents said that the road was slippery and muddy when it rained so that the hospital felt further away. Likewise with the use of transportation, because 57.5% of respondents said that the distance from the house to the Tanjung Pura Regional Hospital requires transportation costs. 61.5% of respondents admitted that the poor infrastructure (roads) (for example, roads with potholes, not yet paved) from the respondent's house to the Tanjung Pura Regional Hospital. Usually the road with holes is the road that is passed by respondents from villages around the Tanjung Pura area. In general, it is damaged because trucks carrying oil palm fruit are often used. Usually the potholes will get worse if it occurs during the rainy season, causing slippery, muddy roads, and this has an impact on road conditions that are felt to be far away. This result is reinforced which shows that respondents who assessed strategic locations mostly revisited for various reasons such as easy access, very strategic location of the hospital, and a very comfortable environment, and good service, while a small proportion did not re-visit on the grounds the location is very far, the environment is not comfortable and the hospital is not easy to reach (Jumriati et al., 2020).
The long distance to the Tanjung Pura Regional Hospital is a consideration for patients and their families to return to re-treatment or not. Because usually when sick, family and neighbors also visit the hospital. If the conditions are far away, the family must go back and forth to bring patient equipment while being treated at the Tanjung Pura Regional Hospital. The house distance which is close to the Tanjung Pura Hospital will make it easier for patients and their families to come and visit the hospital. The closer the house to the hospital, people tend to choose to decide to get services to the closest health service, such as at the Tanjung Pura Hospital.
Some of the hospitals that are competing with the Tanjung Pura Hospital are Pertamina Pangkalan Beranda Hospital, Surya General Hospital, Putri Bidadari General Hospital, Morita General Hospital, Tanjung Selamat General Hospital, and Delia General Hospital. The existence of these hospitals has their respective markets and has almost the same competitiveness as the Tanjung Pura Regional Hospital such as the Pertamina hospital which is owned by the Pertamina Company, which always provides excellent service. Putri Bidadari General Hospital has received Type B accreditation so that Tanjung Pura Hospital as a hospital owned by the Langkat Regency Government must really improve the quality and quantity of its services.
RSUD Tanjung Pura is a referral hospital from the existing Community Health Center (puskesmas) and is spread across Langkat Regency, namely Stabat Puskesmas, Wampu Puskesmas, Hinai Kiri Puskesmas, Secanggang Puskesmas, Tanjung Beringin Puskesmas, Pantai Cermin Puskesmas, Tanjung Selamat Puskesmas, Gebang Puskesmas, Securai Puskesmas, Pangkalan Puskesmas Brandan, Puskesmas Tangkahan Durian, Puskesmas Batang Serangan, Puskesmas Sawit Sebrang, Puskesmas Besitang, Puskesmas Beras Basah, Pangkalan Susu, Pematang Jaya. The health center closest to the Tanjung Pura Regional Hospital is the Pantai Cermin Puskesmas with a distance of 3.4 km or a distance of 7-10 minutes, while the puskesmas farthest that refers patients to the Tanjung Pura Hospital is the Pematang Jaya Puskesmas with a distance of 89.2 km or 2 hours 13 minutes. After the patient is referred to Tanjung Pura Hospital and recovered, the patient must be in control of his health, with a long distance the patient often thinks again about whether to come back to Tanjung Pura Hospital or not.
Some areas around the sea waters around Tanjung Pura Subdistrict, such as KualaSerapuh, with poor road conditions make people reluctant to seek treatment at Tanjung Pura Hospital, especially for diseases that require serious treatment. However, if they experience a minor illness that can still be handled by the puskesmas, they decide to seek treatment at the puskesmas or the auxiliary puskesmas closest to them. The road conditions are not good (with holes, dusty, narrow) so that the distance is not far from the Tanjung Pura Hospital which is difficult to pass.

Facilities Influence Patients' Decisions to Use Health Services for Re-Treatment
Facilities for the patient's decision to use health services for re-treatment at Tanjung Pura Hospital. Respondents who stated that the hospital facilities were good, the opportunity to use health services for re-treatment was 14.4 times higher than those who stated that the hospital facilities were not good. Facilities are the most dominant factor influencing the patient's decision to use health services for re-treatment at Tanjung Pura Hospital.
The results of this study are in line with the research conducted by Sugiono, who found that there is a relationship between service facilities and the utilization of inpatient services at Stella Maris Hospital Makassar. The availability of facilities is one of the factors that can encourage and motivate people to take advantage of health services or treatment efforts. However, if a health service has incomplete facilities, the community will choose another place or hospital that is more complete (Sugiono, 2013). Asriani (2016) research states that there is an effect of facilities on the reuse of outpatient services at RSUD LabuangBaji Makassar. Respondents are interested in reusing outpatient services at the Labuang Baji Makassar Hospital because the facilities provided are complete (Asriani, 2016). Patients who reuse inpatient services at Syekh Yusuf Hospital because the facilities provided have been fulfilled and complete are due to the wants and needs of existing facilities and have been supported by good equipment (Jumriati et al., 2020).
Most of the community using services at the PKU Muhammadiyah SimoBoyolali Hospital perceived that facilities in the form of facilities and infrastructure in the hospital were complete, meaning that they were able to meet the needs of patients in health services at the hospital (Anggraheni, 2012). In contrast in the disease polyclinic in the GMIM Pancaran Kasih Manado Hospital, which found that there was no influence between the hospital facilities on the reuse of services (Pusungunaung et al., 2018).
Consumers or patients with various needs and desires will have more and more demands for fulfillment. One of the demands of these wants and needs is the facilities they will receive when they pay for using a product or service. The number of hospitals competing in providing various kinds of facilities that can be enjoyed by patients is also a consideration for patients to use these hospital services. The facilities provided will build comfort in the patient so that the patient feels satisfied with the services of the hospital and will return to the hospital (Pohan, 2015).
Based on the results of this study, it shows that the patient's decision to use health services for re-treatment at Tanjung Pura Hospital is influenced by existing health facilities. Facilities that are more complete than the clinic are the choice of patients to seek treatment at the Tanjung Pura Hospital. For people in the city of Tanjung Puraf, the facilities at the Tanjung Pura Hospital are complete (adequate) according to the treatment of diseases experienced by respondents. The thing that makes patients feel happy is that the equipment at the Tanjung Pura Hospital is well maintained, and its condition is always clean. The complete facilities of the Tanjung Pura Regional Hospital make respondents interested or interested in deciding to use health services for repeat treatment and always go to Tanjung Pura Hospital.
Although the facilities at the Tanjung Pura Regional Hospital are deemed sufficient, patients who seek treatment still want the hospital to always add new equipment to the Tanjung Pura Hospital to increase patient confidence. Complete or incomplete facilities at the Tanjung Pura Regional Hospital are a consideration for patients to seek treatment at the Tanjung Pura Regional Hospital. The Tanjung Pura Regional Hospital continues to improve and add hospital facilities or infrastructure such as Scanning, Cardiologists, and Physiotherapy. The facilities and infrastructure are expected to increase the interest of the community around the Tanjung Pura Regional Hospital to decide to seek treatment at the Tanjung Pura Hospital.
This study also found that some respondents said the equipment in the Tanjung Pura Regional Hospital was still incomplete when compared to private hospitals such as Pertamina Pangkalan Berandan Hospital or hospitals in Medan City. This is because some respondents have had medical treatment in Medan City which has better and more complete equipment, so when asked about the equipment at Tanjung Pura Hospital they answered that they were still incomplete. Equipment that is considered incomplete can be a consideration for patients to choose to go to Tanjung Pura Hospital again.
Facilities are the most influencing factors for hospitalized patients to choose repeat treatment. The Tanjung Pura Regional Hospital must prepare standardized facilities according to the type of hospital, namely type C. Facility management and patient safety at the Tanjung Pura Hospital are partly incomplete, such as in the IGD, there is a section of the goods officer who proposes to the Langkap Regency Government according to the budget, but many that has not been fulfilled by the Langkat Regency Government because the government budget is insufficient. Tanjung Pura Hospital still needs to have the ability to manage existing facilities so that it can increase patient visits. Facility management by complying with laws and regulations, all permits already exist such as building permits, proper function permits, and others which lead to safety and security. The Tanjung Pura Regional Hospital has carried out waste management such as medical waste and B3 waste according to standards. Likewise in disaster management by managing it as well as possible. Management of medical equipment by performing calibration annually based on the number and type.

Service Speed Affects Patient Decisions to Use Health Services for Re-Treatment
The speed of service to the patient's decision to use health services for re-treatment at Tanjung Pura Hospital. Respondents who stated that the speed of service was good, the opportunity to use health services for re-treatment was 4.1 times higher than those who stated that the speed of service was not good.
There is an effect of speed and ease of service on outpatient reuse (Sahuleka, 2017). There was an effect of ease and speed of service on service reuse (Pusungunaung et al., 2018).
The effect of the speed of service on the interest in reusing inpatient services, basically the patient wants convenience, the speed of service is fast starting from the admission procedure, the speed of examinations, treatment to the time of discharge (Sugiono, 2013). Reuse is a behavior that appears as a response to an object that shows a customer's desire to reuse it (I. D. Sari, 2016). The intention to reuse is part of the consumer loyalty stage, where loyalty is a deep enduring customer commitment to re-subscribe to selected service providers consistently in the future, even though the influence of the situation and marketing efforts have the potential to cause behavior change. Customer loyalty can be caused by the ease and speed of service it receives (Tjiptono, 2014). The ease and speed of service is all the time it takes to wait before receiving service and the ease with which patients can access services at the hospital (Pusungunaung et al., 2018).
Based on the results of this study, it is evident that the patient's decision to use health services for re-treatment at Tanjung Pura Hospital is influenced by the speed of services provided by health personnel. The speed of service can be seen from the fact that the doctor came on time as scheduled in examining the patient's condition, which was recognized by 76.5% of the respondents studied. Likewise with nurse services, as many as 67.5% of respondents said that the nurse immediately came when called (within <5 minutes). As many as 62.8% of respondents said that doctors and nurses at the Tanjung Pura Regional Hospital carry out physical examinations regularly (regularly). Likewise regarding the nurse's response, as much as 61.5% of respondents said nurses were always responsive when asked for help by patients. The nurse also always helps the patient in taking the medicine given and explains how to take the medicine that has been given / prescribed by the doctor. The nurses at the Tanjung Pura Hospital do not immediately leave the patient after giving the medicine to be taken. Some respondents said that health workers were slow in providing services to respondents. The complaint relates to the arrival of doctors who are not on time, nurses who are difficult to call when needed by patients. There are also those who say that the nurse did not perform the examination on time, because they had to wait for the doctor to visit who did not come on schedule. In addition, there are those who say that the nurse does not accompany the patient when taking medication, only provides the type of medicine and how to drink it, after which the nurse leaves the patient and family.

Conclusion
Factors that influence the patient's decision to use health services for re-treatment at the Tanjung Pura Hospital are the quality of doctor / nurse services, distance, facilities and speed of service (p <0.05). While the factors that did not influence were age, gender, education, and occupation (p> 0.05). The variable that most dominantly influences the patient's decision to use health services for re-treatment is the facility variable which has a value of Exp (B) / OR = 14.477, which means that the respondents who stated that the hospital facilities were good had the opportunity to use health services for re-treatment by 14.4 times higher than that respondents who stated that the hospital facilities were not good.