THE IMPACT OF SERVICE QUALITY ON CUSTOMERS’ LOYALTY...

THE IMPACT OF SERVICE QUALITY ON CUSTOMERS’

LOYALTY AND ADVOCACY; MEDIATING ROLE OF

TRUST: A COMPARATIVE STUDY OF PUBLIC AND

PRIVATE SECTOR HOSPITALS

DOCTOR OF PHILOSOPHY

(MANAGEMENT SCIENCES)

SAJJAD AHMAD AFRIDI

Registration No. 1094-113017

Supervisor

DR. TAHIR SAEED

FACULTY OF BUSINESS ADMINISTRATION

PRESTON UNIVERSITY KOHAT

ISLAMABAD CAMPUS

SAJJAD AHMAD AFRIDI

ISLAMABAD CAMPUS

SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS

FOR THE DEGREE OF

DOCTOR OF PHILOSOPHY

(MANAGEMENT SCIENCES)

SAJJAD AHMAD AFRIDI

Supervisor

DR. TAHIR SAEED

ISLAMABAD CAMPUS

Supervisor Certificate

This is to certify that PhD. (Management Sciences) thesis titled “The Impact of Service

Quality on Customers’ Loyalty and Advocacy; Mediating Role of Trust: A Comparative

Study of Public and Private Sector Hospitals”, is submitted by Mr. Sajjad Ahmad Afridi,

Registration No. 1094-113017 in partial fulfillment for the award of PhD. degree is a

record of the candidate’s own work carried out under my supervision and has been

approved for submission.

Prof. Dr. Tahir Saeed

CANDIDATE DECLARATION FORM

I, Sajjad Ahmad Afridi

Son of Khan Afzal Khan

Discipline Management Sciences

Candidate of Doctor of Philosophy at the Preston University Kohat

(Islamabad Campus), do hereby declare that the dissertation The Impact of Service

Quality on Customers’ Loyalty and Advocacy; Mediating Role of Trust: A

Comparative Study of Public and Private Sector Hospitals, submitted by me in partial

fulfillment of PhD degree in discipline of Management Sciences is my original work, and

has not been submitted or published earlier. I also solemnly declare that it shall not, in

future, be submitted by me for obtaining any other degree from this or any other university

or institution.

I also understand that if evidence of plagiarism is found in my dissertation at any stage,

even after the award of a degree, the work may be cancelled and the degree revoked.

August, 2016

Signature

Sajjad Ahmad Afridi

Copyrights

All rights are reserved. Material of this manuscript is protected by copyright laws. Any part

of the document may not be reproduced or utilized in any form or means, electronic or

mechanical, photocopy, recording, information storage and retrieval system, without the

permission of the University authority.

Plagiarism Undertaking

I solemnly declare that research work presented in the thesis titled “The Impact of Service

Quality on Customers’ Loyalty and Advocacy; Mediating Role of Trust: A

Comparative Study of Public and Private Sector Hospitals” is solely my research work

with no significant contribution from any other person. Small contribution/help wherever

taken has been duly acknowledged and that complete thesis has been written by me.

I understand the zero tolerance policy of the HEC and Preston University Kohat, Islamabad

Campus towards plagiarism. Therefore I as an Author of the above titled thesis declare that

no portion of my thesis has been plagiarized and any material used as reference is properly

referred/cited.

I undertake that if I am found guilty of any formal plagiarism in the above titled thesis even

after award of PhD degree, the University reserves the rights to withdraw/revoke my PhD

degree and that HEC and the University has the right to publish my name on the

HEC/University Website on which names of students are placed who submitted plagiarized

thesis.

Student/Author Signature:________________

Name: Sajjad Ahmad Afridi

ABSTRACT

Quality has become a very important element for customers while availing any services

and it is also a strategic advantage for organizations to gain success and remain

competitive in the market. The purpose of the current study is to compare the service

quality of public and private healthcare institutions of Peshawar and to examine its impact

on customers’ loyalty and advocacy with mediating role of trust. For this purpose the

famous servqual scale was adopted to measure the service quality. Confirmatory factor

analysis through Structural equation modeling (SEM) was run to confirm the validity and

reliability of the instruments. In Pakistan, efforts to link service quality with customers’

loyalty and advocacy through trust is equal to naught. The present study is an effort to

address this gap. Independent sample t-test was performed to compare the service quality,

trust, customers’ loyalty and advocacy of public and private hospitals. It was found that

customers’ perception regarding service quality, trust, loyalty and advocacy is significantly

higher in private as compare to public hospitals. Path analysis was used to investigate the

direct and indirect impact of service quality with customers’ loyalty and advocacy and it

was revealed that trust fully mediates the association of service quality, customers’ loyalty

and advocacy. The current study delivers literature concerning customers’ advocacy,

customers’ loyalty, service quality, and trust. Theoretically it contributes in the

verification of the trust as intervening variable regarding service quality, customers’

loyalty and advocacy. It has also some stimulating repercussions for management and

marketing experts, and offers imperative evidences concerning the role of trust, the

meaning of loyal customers and advocates for the endurance and progression of

organizations in a competitive environment.

Keywords; Service Quality, Customer Loyalty, Customer Advocacy, Trust, Hospitals

CONTENTS

ABSTRACT ................................................................................................... viii

LIST OF TABLES .......................................................................................... xii

ACKNOWLEDGEMENT ............................................................................ xvii

CHAPTER 1 INTRODUCTION ....................................................................... 1

Background ......................................................................................................................... 1

Statement of the Problem .................................................................................................... 7

Research Questions ............................................................................................................. 9

Research Objectives ............................................................................................................ 9

CHAPTER 2 LITERATURE REVIEW .......................................................... 10

Service .............................................................................................................................. 10

Quality .............................................................................................................................. 14

Quality Models ................................................................................................................. 14

Performance .............................................................................................................................. 15

Features ..................................................................................................................................... 15

Reliability .................................................................................................................................. 15

Conformance ............................................................................................................................. 15

Durability .................................................................................................................................. 15

Serviceability ............................................................................................................................. 15

Aesthetic .................................................................................................................................... 15

Perceived Quality ...................................................................................................................... 15

Ease of Use ................................................................................................................................ 16

Versatility .................................................................................................................................. 16

Durability .................................................................................................................................. 16

Serviceability ............................................................................................................................. 16

Performance .............................................................................................................................. 17

Prestige ...................................................................................................................................... 17

Service Quality ................................................................................................................. 17

Service Quality Models .................................................................................................... 19

Servqual Model and Healthcare ........................................................................................ 29

Servqual Model and Criticism .......................................................................................... 31

Theoretical Bases ...................................................................................................................... 31

Process Oriented ........................................................................................................................ 31

Dimensions ................................................................................................................................ 31

Expectation ................................................................................................................................ 31

Pakistan Health System .................................................................................................... 35

Customer Loyalty ............................................................................................................. 36

Behavioral Loyalty .................................................................................................................... 39

Affective Loyalty ...................................................................................................................... 40

Service Quality and Customer Loyalty ............................................................................. 40

Customer Advocacy .......................................................................................................... 41

Trust .................................................................................................................................. 43

Trust and Customers’ Loyalty .......................................................................................... 49

Trust and Advocacy .......................................................................................................... 53

Service Quality, Trust, Customer Loyalty and Advocacy ................................................ 54

Rational of the Study ........................................................................................................ 55

Conceptual Framework ..................................................................................................... 59

Conceptual Model ............................................................................................................. 66

CHAPTER 3 RESEARCH METHODOLOGY .............................................. 67

Research Philosophy ......................................................................................................... 67

Research Approach ........................................................................................................... 68

Survey Design ................................................................................................................... 68

Research Strategy ............................................................................................................. 68

Data Collection Procedure ................................................................................................ 69

Sampling Technique and Sample Size .............................................................................. 70

Measures and Instruments ................................................................................................ 70

Operational Definitions of Variables ................................................................................ 72

Statistical Analysis ............................................................................................................ 73

Inferential Statistics .......................................................................................................... 73

Structural Equation Modeling ........................................................................................... 75

Statistical Software ........................................................................................................... 75

Pilot Study of the Survey Instrument ................................................................................ 76

Confirmatory Factor Analysis for Service Quality ........................................................... 77

Confirmatory Factor Analysis for Trust ........................................................................... 79

Confirmatory Factor Analysis for Customer Loyalty ....................................................... 81

Confirmatory Factor Analysis for Customer Advocacy ................................................... 84

Confirmatory Factor Analysis for Overall Measurement Model of Pilot Study .............. 85

Confirmatory Factor Analysis for Overall Structural Model for Pilot Study ................... 87

Pearson Correlation of Pilot Study ................................................................................... 88

Ethical Consideration ........................................................................................................ 89

CHAPTER 4 RESULTS AND ANALYSIS .................................................... 90

Response Rate ................................................................................................................... 90

Descriptive Statistics of the Demographics ...................................................................... 90

Descriptive Statistics of the Variables .............................................................................. 93

Inferential Statistical Analysis .......................................................................................... 94

Confirmatory Factor Analysis for Service Quality ........................................................... 94

Confirmatory Factor Analysis for Customers’ Loyalty .................................................... 98

Confirmatory Factor Analysis for Trust ......................................................................... 100

Confirmatory Factor Analysis for Customer Advocacy ................................................. 103

Confirmatory Factor Analysis for Overall Measurement Model .................................... 104

Pearson Correlation of the constructs ............................................................................. 107

Confirmatory Factor Analysis for Structural Model ....................................................... 108

Overall Model Fit ............................................................................................................ 110

Hypotheses Testing ......................................................................................................... 112

Service Quality, Customers’ Loyalty, Customers’ Advocacy and Trust ........................ 123

CHAPTER 5 DISCUSSIONS AND CONCLUSION ................................... 125

Discussions ..................................................................................................................... 125

Limitations ...................................................................................................................... 129

Delimitation .................................................................................................................... 130

Contribution to Knowledge ............................................................................................ 131

Implications of the Study ................................................................................................ 131

Future Research Recommendations ................................................................................ 134

Research Conclusion ....................................................................................................... 135

REFERENCES ............................................................................................... 136

APPENDIX A ................................................................................................ 161

Survey Questionnaire ..................................................................................... 161

LIST OF TABLES

Number Page

Table 1 Product/Service Dimensions

Table 2 Health Facilities in Pakistan

Table 3 Trust Dimensions

Table 4 Validity/Reliability of the Instrument (N=60)

Table 5 CFA for Service Quality

Table 6 CFA for Trust

Table 7 CFA for Customer Loyalty

Table 8 CFA for Customer Advocacy

Table 9 Model Fit Indices for Pilot Study

Table 10 Correlation Matrix (N=60)

Table 11 Gender Specification

Table 12 Age of the Respondents

Table 13 Public and Private Health Institutions

Table 14 Educational Level

Table 15 Profession of the Respondents

Table 16 Internal Consistency and Reliability

Table 17 CFA for Service Quality Dimensions

Table 18 CFA for Customer Loyalty

Table 19

CFA for Trust 102

Table 20 CFA for Customer Advocacy

Table 21

Mean Standard Deviation

Table 22

Model Fit Indices

Table 23

Comparison of Goodness of Fit Indices

Table 24 Results of Hypothesis 118

Table 25

Table 26

Result of Independent T Test

Summary of Hypothesis

Table 27 Results of Direct and Indirect Effects 124

LIST OF FIGURES

Number Page

Figure 1 Continuum of Tangibility

Figure 2 Characteristic of Services

Figure 3 Product Quality Dimensions

Figure 4 Dimensions of Quality

Figure 5 Two dimensional service quality model

Figure 6 Attribute Service Quality Model

Figure 7 Three dimensional Service Quality Model 23

Figure 8

Service Quality Model

Figure 9 5 Qs Model

Figure 10 Gap Model 27

Figure 11 Servqual Model 29

Figure 12

First Hypothesis of the Study

Figure 13 Second Hypothesis of the Study

Figure 14 Third Hypothesis of the Study

Figure 15 Fourth Hypothesis of the Study

Figure 16 Fifth Hypothesis of the Study

Figure 17 Sixth Hypothesis of the Study

Figure 18

Seventh Hypothesis of the Study

Figure 19

Theoretical Framework 66

Figure 20 CFA for Service Quality (N=60)

Figure 21 CFA for Trust (N=60)

Figure 22 CFA for Customer Loyalty (N=60) 82

Figure 23 CFA for Customer Advocacy 84

Figure 24 CFA for Overall Model 86

Figure 25

CFA for Structural Model 87

Figure 26 CFA for Service Quality (N=492) 96

Figure 27 CFA Customer Loyalty (N=492) 99

Figure 28

CFA of Trust (N=492) 101

Figure 29 CFA for Customer Advocacy 103

Figure 30 CFA for Measurement Model 106

Figure 31

CFA for Structural Model 109

Figure 32 Path Analysis of 1st Hypothesis 112

Figure 33 Path Analysis of 2nd Hypothesis 113

Figure 34

Path Analysis of 3rd Hypothesis 114

Figure 35

Path Analysis of 4th Hypothesis 115

Figure 36 Path Analysis of 5th Hypothesis 116

Figure 39 Overall Mediation 124

LIST OF ABBREVIATIONS

Abbreviation Description

ADV Advocacy

AF Affective Loyalty

AFFLOY Affective Loyalty

AT Attitudinal Loyalty

ATTLOY Attitudinal Loyalty

BEHLOY Behavioral Loyalty

BH Behavioral Loyalty

AMOS Analysis of Moment Structures

CA Customer Advocacy

CFA Confirmatory Factor Analysis

CFI Comparative Fit Index

CL Customer Loyalty

CMIN Chi Square Minimum

DF Degree of Freedom

GFI Goodness of Fit Index

RMR Root Mean Square Residuals

RMSEA Root Mean Square Error of Approximation

SQ Service Quality

SERVQUAL Service Quality Model

TRT Trust

ACKNOWLEDGEMENT

First and foremost I will thank Almighty Allah, the compassionate, the almighty

and merciful, who kindly helped me to complete my thesis.

I would like to express my honest appreciation to my Supervisor, Professor, Dr.

Tahir Saeed for his constant support of my PhD study and associated research, for his

persistence, motivation, and immense knowledge. His supervision facilitated me in my

research and writing of this thesis. I could not have imagined having a better advisor and

mentor for my PhD thesis.

Beside Supervisor, I would like to thank my co-supervisor, Associate Professor Dr.

Muhammad Arif Khattak for his insightful observations and encouragement, and also for

his challenging questions which incited me to widen and view my research from various

perspectives.

I am enormously obliged to all the worthy faculty members of Management

Sciences Department, Preston University, Islamabad for their caring attitude and persistent

sustenance, especially from Associate Professor Dr. Khawaja Arsalan, Associate Professor

Dr. Afzal, Assistant Professor Dr. Haji Rahman and Associate Professor Dr. Mohammad

Iqbal.

My sincere appreciations also goes to Dr. Wali-ur-Rehman, Associate Professor,

Sarhad University of Science and Technology, Peshawar, for his assistance and direction in

learning AMOS and Performing Structural Equation Modeling. It could not be easy without

his support.

I would also like to acknowledge Dr. Umar Farooq, Dean of Faculty of

Management Sciences, Abasyn University Peshawar and Dr. Maqsood Haider for inspiring

me for PhD and for their honorable and academic support.

I would also want to show gratitude to my PhD fellows, Mr. Mohammad Hashim and

Mr. Mehbobullah for their honest provision. I really relished their company and it was

prodigious fun working together.

Last but not the least; I would like to show appreciation to my parents, my wife,

brother and sisters for their unwavering support throughout the writing of this thesis.

CHAPTER 1

INTRODUCTION

Intensive competition and aggression of environmental factors have forced the

companies to improve their service quality. “A service company is defined by its service

quality. If the service company’s service is mediocre, the company is mediocre” (Berry and

Parasuraman, 1992, p.5). Service quality is crucial for the success of any firm. Constantly

provision of extraordinary service can support in intensifying trust, creating loyal

customers and contributing to the profit of the firm. Quality has extended prominence in all

concepts of management and marketing related literature. Quality was initially considered

only for tangible goods, but later on was interconnected to all the elements of the

production process consisting inbound logistics, operations, outbound logistics, marketing,

sales and services. Quality is not only restricted to tangible products, and according to

Feigenbaum (1991) quality is the anticipation of the customer concerning marketing,

designing, manufacturing, repairing and maintenance of product or service.

Background

Quantifying service quality is slightly difficult , since service and goods are of

diverse nature like the intangibility and heterogeneity (Mudie & Pirrie, 2006). According

to Kotler, Armstrong, Ang, Leong, Tan, & Tse, (2005) “Service is a form of product that is

made up of activities, benefits or satisfaction that sellers offer to buyers, which are

intangible and where ownership cannot be claimed by the client”. According to Beer (2003)

service is a set of characteristics which aim to entertain the necessity of customers. Services

comprise of indescribable activities that take place between service receiver and service

provider to elucidate the customer’s problems (Gronroos, 2000).

According to Fogli, (2006) service quality is a worldwide judgment towards a certain

service, the overall good or bad intuition allied to service providers. Further, author argued

that customers can judge the service through learning and knowing. “Companies providing

service can express the eminence of their service via physical evidence and presentation;

such as place, people, equipment, communication material, symbols and price” (Booms,

Bitner, 1981).

Place represents the interior and exterior, waiting lines, the design of desks and the

flow of people for lines should properly be managed. Similarly for service companies

“people” play very important role. Their ability in communication, interaction and

guidance may encourage customers in decision making. The equipment of the company

such as; copier machine, computer, X-ray machine, dialysis machines, etc. should be up to

the mark, visually alluring and in proper working condition. Likewise the communication

material, such as; pamphlets, brochures, text and photos should communicate the

company’s service providing qualities. Moreover, Booms and Bitner, (1981) argued that

companies should advertise a fractional recompense as per policy, if customers don’t get

the desired service.

However, service quality is the assessment of the service by the customer (Eshghe,

Roy, & Gangoli, 2008) or the degree to which the perceived service quality encounters the

anticipated service quality by the customer (Asubontang, McClery, & Swaan, 1996).

According to Parasuraman, Zethaml, & Bery, (1988) service quality is the variation

between the perceived and expected service by the customer, offered by a firm. If the

perceived quality is lower than hopes, it follows that the quality is low and if the perceived

quality is equal or better than the expected one, it means the quality is good. According to

Kasper, Van & De, (1999) service quality is the value that is rendering to the confidence of

the customers whereas Grönroos, (1984) defined quality service as the function of

expectation, image and outcome.

Just like other service related organizations, the health sector has also become a very

competitive and growing industry (Irfan and Ijaz 2011). Quality in a healthcare

organization is complicated to measure because the quality gauged by a patient depends on

his/her life (Eiriz and Figueiredo, 2005). Service quality in the healthcare industry got

auspicious consideration of different authors. According to Andaleeb, (2001) customers

that are pleased with the service quality of a hospital will desire the same hospital when

compulsory. However, Lim, Tang & Jackson, (1999) advocated two aspects of service

quality in the healthcare sector; technical and interpersonal skills. Technical is related to the

routine working procedures, operating hours and expertise of doctors. Interpersonal skills

are related to the service providers and patient’s affairs, their complications,

communication and giving complete information. But for patients, interpersonal skills are

very imperative as they are not aware of the technical skills, because it is very hard to judge

the technicality of the doctors since internal things are not exposed to patients (Vinagre &

Neves, 2008). Diverse models were used by numerous authors to investigate the service

quality of hospitals and proposed Servqual model a valid and dependable model for service

quality measurement in healthcare (Babakus and Mangold 1992; cited by Irfan and Ijaz,

Parasuraman, Zeithaml and Berry, (1985, 1988, 1990, 1991, 1994) offered the

Servqual model to gauge the variation between the perceived and expected service quality.

They identified 5 important aspects of service quality and entitled it the Servqual model.

Tangibility. Tangible amenities, tools, and outlook of the employees. The hospital’s

physical appearance, like condition of rooms, beds, floor, different wards, bathrooms etc.

The employee’s physical appearance, their attire, the apparatus used by them.

Reliability. The skills of the employees to work dependably and accurately. The

supporting staff and doctor’s trustworthiness.

Responsiveness. The enthusiasm to assist patients and offer quick service. The

compassion of the supporting staff and doctors in providing service to patients which

means providing service at the proper time and prompt response.

Assurance. Information and gentility of employees. Assurance is related to the

knowledge and politeness of the employees and their skills to express trust and confidence.

Empathy. The ability to comprehend the frame of mind and worries of the patients.

It is related to the understanding of individual requirements and provide its customers

customized attention.

Service quality and customer satisfaction are considered highly linked with each

other by numerous authors in their literature, and also considered as a key for

organization’s success (Ruyter, Bloemer, & Peters, 1997). However, Caruana (2002)

considered customer loyalty the most important component for service marketing because

of its positive word of mouth and repurchase intentions. Loyal customers are very

imperative for organizations since it is easy and more gainful for companies to retain

existing customers rather than getting new customers (Alexandris, Dimitriadis & Markata.

2002; Czepiel, & Rosenberg, 1983 and Priluck, 2002). Loyalty is not simple and companies

cannot produce loyal customers promptly, it is developed with a passage of time by

providing unfailingly quality service according to the expectancy of the customers (Teich,

1997). Bowen and Shoemaker (2003) defined customer loyalty as the loyal customers

talking upright about the firm and its product/service purchases repeatedly and recommend

the company to others.

Customer loyalty according to Hamid, Ebrahimpour, Roghanian, & Gheysari, (2013)

is an important element of an effective business strategy. Trust, customer satisfaction and

customer loyalty are interconnected, and positively related (Kassim & Asiah, 2010).

Ganesh, Arnold, Reynolds, 2000 proposed two dimensions of customers’ loyalty which are;

active and passive loyalty. According to them, active loyalty is taken deliberately and can

be perceived in both purchase behavior and purchase intentions, whereas passive loyalty is

affected by variation in price and switching cost. Likewise, Lam, Shankar, Erramilli, &

Murthy, (2004) elucidated two other facets of loyalty; repurchase intentions and

recommendations. Fullerton, (2005) pronounced repeat purchase and advocacy as the

dimensions of customer loyalty and Kumar and Shah (2004) portray behavioral and

attitudinal loyalty as facets of loyalty. Bowen and Chen, (2001) enlightened three extents of

customer loyalty; behavioral, attitudinal and composite loyalty.

Just like loyalty, advocates play a very important role for companies in tough

competition. An advocate is “someone who actively recommends you to others, who does

your marketing for you” (Payne, Christopher, Clark, Peck, 1999). Lawer and Knox, (2006)

defines customer advocacy as “an advanced form of market-orientation that respond to the

new drivers of consumer choice, involvement and knowledge”. They further suggested that

advocacy is a strong element for building and maintaining long term relationships.

Advocates voluntarily use positive word of mouth and recommend the company to others

(Harrison-Walker, 2001; Hills, Provost and Volinsky 2006) and even defend organizations

against detractors (Bendapudi and Berry, 1997). Roy, (2015) argued that companies need to

impart trust and confidence by providing better service quality, and in return customers do

advocacy for them.

Marketers are having a tough time in bringing new customers due to the challenging

competition (Kotler et, al, 2005). Companies work hard to build a positive connection by

imparting trust and commitment, in order to make customers loyal who eventually turn into

advocates. For service firms, advocates are very essential because advocates talk

confidently about the company and endorse it to others. White and Schneider (2000)

defined advocates as “happy customers who enthusiastically participate themselves in a

positive word of mouth while doing marketing for an organization”. According to

Mangold, Miller, Brockway, (1999) advocacy is the extreme form of positive word of

mouth; advocates are not only highlighting the valid points about the organization, its

brands/goods/services but also recommend it to others.

However, it is tricky to produce loyal customers and advocates in such a competitive

environment. A satisfied customer is not always loyal to a company. According to Ribbink,

Dina, Allard, Van (2004); Kassim & Asiah (2010) it is not only customer satisfaction that

leads to loyalty as trust and commitment also play a vital role in customer loyalty. Ouyang

(2010) found that customer satisfaction does not significantly affect customer loyalty.

Similarly Ndubisi (2007) argued that trust is imperious for producing loyal customer and

links optimistically with customer loyalty.

Trust is a belief or confidence that one party has on another party that will deliver the

service or product according to anticipations (Anderson and Narus, 1990; Dwyar, Schur

and Oh, 1987; Morgan and Hunt, 1994; Morman, Deshpande and Zaltman, 1993; Sanzo,

Santos, Vezquez, and Alvarez, 2003 and Schurr & Ozanne, 1985). Morgan and Hunt

(1994) found trust and commitment an important factors between two parties in building

and maintaining lifelong association. Customers are generally disinclined to do business

with those they do not trust (Jarvenpaa and Tractinsky, Saarinen, 1999). Trust is the

important factor of business between two parties (Reichheld and Schefter, 2000).

Hence, trust plays an important role in customer loyalty and plays a decisive role

when customers face many alternatives (Harridge, March 2006). Trust enhances

commitment and influenced by service quality (Al Hawari, 2011). Moorman, Deshpande

and Zaltman (1993) found a significant role of trust in creation of loyal customers and

considered it very important. Other authors such as Garbarino and Johnson (1999),

Chaudhari and Hallbrook (2001), Singh and Sirdeshmukh (2000), Sirdeshmukh, Singh and

Sabol (2002) also sustained the prominence of trust in developing customers’ loyalty. Trust

has gained considerable importance in marketing literature and is understood as the

mediating variable of customer loyalty. According to Ribbink, Dina, Allard, Van (2004)

trust mediated between customer loyalty and service quality.

Consequently, it is important to evaluate the service quality of hospitals perceived by

customers and its impact on customers’ loyalty and advocacy. For more than two decades

service quality got promising attention. Several authors worked on service quality and its

impact on customer satisfaction, loyalty, organizational performance, reputation etc.

however, in Pakistan, efforts to connect service quality with customers’ loyalty and

advocacy trough trust as a mediator is equal to naught. This study is an effort to fill this

Statement of the Problem

High service standards for companies became vital for endurance due to increase in

competition, technological advancement and consumer’s preferences. Hospitals are the

institutions that are providing healthcare services to patients. Service quality and

extraordinary standards for hospitals are very decisive. An overview of the health system of

Pakistan will provide confirmation of both tried efforts as well as hindrance. Various

programs developed and financial resources allocated for health sector in recent years.

However, the execution of these programs and policies remained hostage of governance

and management issues. According to Nishter, (2006) service quality is one of the primary

issues in the health sector of Pakistan.

It is therefore indispensable to analyze the service quality in hospitals and determine

its influence on customer loyalty and advocacy. Though hospitals have formal evaluation

systems of service quality, they hardly follow that system (Irfan and Ijaz, 2011). Moreover,

loyal customers and advocates are very important for health institution in such a

competitive environment and it is not easy to produce them instantly that stay with the

company and appraise the company to others. It entails consistent delivery of service

quality that meets or surpasses customer’s anticipations (Teich, 1997). Therefore, trust

plays a significant role in producing loyal customers (Moorman, Deshpande and Zaltman,

1993). Morgan and Hunt (1994) found trust and commitment the key factors between two

parties in building and upholding enduring relationships.

A number of authors analyzed service quality with the famous servqual model

(Alrubaiee & Alkaa'ida, 2011; Figen & Ebru, 2010; Kleynhans & Zhou, 2012; Lim &

Tang, 2000 and Youssef, Nel, & Bovaird, 1995), few worked on the linkage of service

quality with trust and loyalty (Eisingerich, 2007; Foster and Cadogan, 2000; Fullerton,

2003; Gizaw and Pagidimarri, 2013 and Harridge-March, 2006). However, customers’

advocacy and customers’ loyalty on the other hand got very limited literature, particularly

in healthcare in general and specific in Pakistan. Pakistan health system is facing numerous

problems, such as weak regulatory systems, lack of accredited body and poor performance

measurement standards has distracted the perception of customers. Therefore, it is very

important to assess the healthcare quality, customers’ loyalty, advocacy and trust.

Furthermore, keeping in mind the prominence of loyal customers and advocates for

services in general and for healthcare in particular, the researcher has decided to conduct

this research on service quality, customers’ loyalty and advocacy with mediating role of

trust. Conferring to the above discussion, research questions have been presented for the

current study.

Research Questions

How do patients consider the relationship between the perceived service quality and

their level of advocacy?

What is the degree of relationship between service quality and customers’ loyalty?

Whether service quality has any effect on trust in public and private hospitals of

Peshawar?

What is the prevalent level of trust on customers’ loyalty?

How does trust and customers’ advocacy associated?

Does trust intervene between service quality and customers’ loyalty relationship?

How does service quality affect customers’ advocacy when trust mediates?

Is there any difference worth mentioning between the mean scores of service

quality, trust, loyalty and advocacy of private and public hospitals?

Research Objectives

The drive of the research is to scrutinize the connection of service quality, customers'

loyalty and customers’ advocacy in the hospitals of Peshawar, the capital city of KP. The

major objectives are the following:

To assess the perception of service quality, customers’ loyalty, advocacy and trust

in public and private hospitals

To observe the impact of healthcare quality on customers’ loyalty and advocacy and

To investigate the role of trust as a mediator between the association of service

quality, customers’ loyalty and advocacy

CHAPTER 2

LITERATURE REVIEW

In this chapter the researcher will deliberate some of the important variables of the

study. This part of the study will put some light on the concept of service quality and its

dimensions. This section will also elaborate various theories regarding service quality,

trust, loyalty and advocacy. Furthermore, discussion regarding health sector of Pakistan,

the propositions and the conceptual model of the study is presented.

Service

“Services consist of elusive activities that take place between service receiver and

service provider to solve customer’s problems” (Gronroos, 2000). When you purchase a

product, you owned that but when you purchase a service, there is no tangible ownership--

just a right to use what is provided (Kotler 1998), (e.g. a ride on an airplane). At most you

could claim ownership of the right to take a specified ride one time. According to Kotler et

al, (2005) “Service is a form of product that is made up of activities, benefits or satisfaction

that sellers offer to buyers, which are intangible and where ownership cannot be claimed by

the client”. Likewise Zeithaml 1981; cited by Kotler & Keller (2012) proposed a tangibility

spectrum that comprises of five classifications which are the following;

Pure Tangible Goods. Tangible product with no service related association. For

example pen, paper, pencil. The products mentioned in the examples are pure tangible

products with no service association.

Tangible Product with Accompanying Services. Tangible products with

supportive services such as LCDs, laptops, and mobiles are tangible goods associated with

services like warranty, repair and maintenance, installation, delivery etc.

Hybrid. In the hybrid group the tangible and intangible percentages are equal. As

an example for the hybrid group are restaurants, where food and drink are tangible goods

and cooking and serving the intangible part.

Services with Minor Goods Associated. In this part the major portion is service

related with the support of tangible goods. Just like in hotels, where the major service is

accommodation with supported tangible goods like food, drink, laundry etc.

Pure Service. This group consists of pure services with no goods, like doctors,

consultants etc.

Figure No. 1. Continuum of tangibility (Zeithaml, 1980)

Moreover, Kotler and Keller, (2012) classified services into five categories that

discriminate between tangible goods and services. Whereas Mudie and Pirrie, (2006)

suggested three additional P’s; People, Physical Evidence and Process as marketing

strategies for services which are the following;

Intangibility. Unlike goods, services cannot be touched, felt, tasted or tested before

its purchase. Hence purchase of service is a bit risky.

Inseparability. Services cannot be used separately from the production of the

services. Services can be consumed at the same time it produces. Whereas goods can be

produced separately and can be consumed later on.

Variability. Services provided by human beings, hence its homogeneity can be a

problem. A service provided on one day may not be same on the other day. Whereas goods

can be produced uniformly.

Perishability. Unlike tangible goods, services cannot be warehoused. It cannot be

produced a month ago and used later on. It can be produced when asked for by the client.

For example in the airline industry, if there are 15 seats available on a flight then the

possible income for those particular seats is lost. They cannot be stored and used later on.

Ownership. Contrasting tangible products that one can purchase and take possession,

a service can be purchased, but cannot claim ownership of that service. One can use the

airline services but cannot take possession of the airline company.

Figure No. 2. Characteristic of services (Kotler, & Keller, 2012).

Mudie & Pirrie, (2006) documented four characteristics of services; such as

intangibility, inseparability, perishability and variability which are concisely explained in

the following paragraphs.

Intangibility. Services are intangible unlike physical products. Customers can

touch the physical product before purchase, while for service; customers cannot touch and

see the service before making a purchase. Consequently to identify the service quality,

customers must purchase the service. For example, one cannot be sure about the expertise

of a heart surgeon before the heart surgery.

Inseparability. Physical products can be produced, stored and can be used later on,

whereas services entail concurrent production and delivery. Services cannot be detached

from the service receiver so it can be disbursed at the same time it produces.

Perishability

Variability

Intangibility

Inseparability

Ownership

Service

Characteristics

Perishability. Services cannot be stowed, kept, returned or resold once they have

been used. For example an airline ticket cannot be stored, returned or resold to anyone after

the flight.

Variability (Heterogeneity). Service quality is subject to, who is providing, when

and where it is provided. For example, one airline service is different from another one.

Services provided by human beings, varies from one another.

Quality

Quality is defined contrarily by various authors. There is no single clear definition of

quality. According to Gyorgy (2003) quality was allied to tangible products and for Crosby

(1979) quality means no imperfection. Quality is excellence, value, conformance to

specification and meeting or surpassing customer expectation (Reeves and Bednar, 1994).

Later on the impression of quality moved to all the elements of the production chain, which

is also called value chain by Michael Porter, (1985). For Feigenbaum, (1991) quality is the

anticipation of the customer regarding marketing, designing, manufacturing, repairing and

maintenance of product or service. Deming (1986) and Freund, (1985) defined quality as

hopes of customers. According to Tenner and DeToro (1992) quality is a business strategy

through which corporate gratify their employees and customers by providing a product or

service that meets their beliefs.

Quality Models

Quality, rendering to literature has numerous dimensions. In this section, the

researcher describes the quality dimensions proposed by various authors. However, quality

dimensions for product and service are different, as goods and services differ in

characteristics.

Garvin, (1987) proposed eight dimensions of product quality. However his proposed

dimensions have some issues while using for measuring service quality such as;

serviceability and durability. These dimensions are the following;

Performance. The operating characteristics of a product. Such as in a mobile phone,

clear sound is the operating quality. For a LCD, picture clarity and sound is the operating

quality.

Features. According to Garvin, features are the “bell and whistle” of the product.

Examples include automatic transmission of a vehicle, Bluetooth on a mobile device etc.

Reliability. Reliability means dependability; it also refers to how much the customers

trust the product. According to Garvin it refers to the chance of failure of a product.

Conformance. Conformance refers to the uniformity of the product. Is the product

measuring up to the quality standards set by the company?

Durability. Durability is the life of a product under stressful condition. According to

Garvin, durability has both economic and technical dimensions. It is the life of a product

before it stops working.

Serviceability. Serviceability denotes to the after sale service of the product; such as

repair and maintenance of the product. Customers value the product if it is economical and

easy to maintain.

Aesthetic. Refers to the physical look, shape, design, and the feeling of having the

particular product.

Perceived Quality. Customers do not have abundant information concerning the

durability and attributes of the product hence, they measure the quality of the product based

on indirect sources, such as comparison of brands and advertisements.

Figure No. 3. Product quality dimensions (Garvin, 1987).

Brucks, Zeithaml, and Naylor, (2000) proposed six dimensions of quality and like

Garvin's, these apply mainly to product quality. They used reliability in the same dimension

of performance and used prestige instead of aesthetics and perceived quality by Garvin,

(1987). Six dimensions presented by them are the following:

Ease of Use. It relates to the usage of the product. It includes how easily consumers

can function the product and how easily they can understand the instructional manual.

Authors showed significance of “ease of use” dimension in products such as; “camera,

video recorder, lawn mowers” (Brucks, Zeithaml, and Naylor, 2000).

Versatility. Involves the characteristics displaying the model and features of the

product so that consumers can effortlessly distinguish the product with the previous models

(Brucks, Zeithaml, and Naylor, 2000).

Durability. The life of product that works. The life of a product under arduous

conditions and is related to the complete operating cycle of the product (Brucks, Zeithaml,

and Naylor, 2000).

Serviceability. The after sale service includes repair and maintenance. This

dimension is related to how easily a consumer can get the repair and maintenance service.

Performance

Features

Reliability

Conformance

Durability

Serviceability

Aesthetic

Perceived Quality

Performance. It is related to the operating characteristics of a product. How well a

product and all its functions operate (Brucks, Zeithaml, and Naylor, 2000).

Prestige. It is related to the equity, respect and admiration of customers towards the

product or service based on the perception of its quality (Brucks, Zeithaml, and Naylor,

2000).

Figure No. 4. Dimensions of quality (Brucks, et al, 2000).

Service Quality

Service quality is a worldwide verdict towards a particular service, the overall pros

and cons related to the firm and its services (Fogli, 2006). Parasuraman, et al, (1988)

argued that if the service quality of a company is average it means the company is average.

He also stated that customers can judge the services through learning and knowing. Good

service quality appeals new customers, creates a positive image of the company in the mind

of customers; a source of repurchase behavior, positive word of mouth, which gives

Dimensions

of Quality

Ease of Use

Versatility

Durability

Serviceability

Prestige

Performance

companies sustainable competitive advantage and increases profitability (Ladhari, 2009;

Negi, 2009; cited by Chingang and Lukong 2010).

Parasuraman et al,. 1988; Lewis & Mitchell,(1990) described service quality as the

gap between customer perception and expectation. If service providers deliver services

according to the anticipations of the customers, customers would be pleased, and if lower

than the belief the customer would be discontented. Berry, Parasuraman, & Zeithaml,

(1993) recommended 10 lessons for improving quality of services.

Listening. For the delivery of best customer service it is very important to listen to

the customer and comprehend as to what precisely is the customer seeing for. One can find

out customer anticipation through interaction. The more the employees interact with

customers the better they will get an idea about the customer’s expectations.

Reliability. The expertise of the employees to work steadfastly and accurately. The

supporting staff and doctor’s fidelity. The aptitude of the firm to deliver services as

assured.

Basic Service. Service oriented firms should emphasis on the basic services, for

which they are existing. For instance, if a company’s basic service quality is low and the

same company is concentrating on other value added services may not be able to attract

customers only for value added services.

Service Design. Service oriented companies should design service as a whole. They

should check all the aspects of the service they are about to offer to customers.

Recovery. There should be an appropriate system for customer’s grievance.

Companies should embolden customers to criticize in case of service performance failure.

Surprising Customer. Companies should astonish customers by offering services

graciously which is not common.

Fair Play. Companies providing services should be impartial to customers and

employees while providing services.

Teamwork. Service oriented companies should place emphasis on teamwork and

also reassure employees to work together for enhanced results.

Employee Research. Service oriented companies should work with their employees

and conduct research together as team in order to ascertain the glitches and its causes, to

thwart it before it is too late.

Servant Leadership. Leadership role is very imperative in inspiration of employees.

Leaders should set an example and work with the employees in the achievement of

organizational goals.

Professed service quality is an unvarying judgment towards a service. Parasuraman et

al, (1985), alleged service is the contrast between customer anticipations and observations.

Quality observed is a kind of attitude which is accompanying with satisfaction but not

precisely satisfaction (Lem and Taang, 2000; Parasuraman et al, 1988).

Service Quality Models

Considering the work done over the last decades or so, on the measurement of service

quality yet no unblemished, explicit and uniform service quality measurement model is

available. Service quality is one of the most important factors in service marketing. Hence,

numerous researchers had worked on service quality and recommended various models.

The subsequent paras will discuss some of the most relevant and important service quality

models.

Gronroos (1984) acknowledged a two dimensional service quality model; technical

and functional service quality model for service quality. Conferring to him, customer

gratification hinge on the gap of perceived and expected service quality. He discussed three

components of service quality in his model such as; technical, functional and Image. The

technical aspect of Gronroos service model refers to the routine working procedure that

includes operating hours and expertise to service providers. Furthermore, it refers to the

technical aspects of the equipment’s and the process. The functional aspect of Gronroos

service model related to the way the service is provided. Customers are directly intricate in

the functional level, hence assessment is easy as equated to technical skills. Whereas, the

image aspect of the service model is related to the generosity of service providers.

Figure No. 5. Two dimensional service quality model (Grönroos, 1984).

Haywood-Farmer, (1988) projected slightly different model for evaluating service

quality. Authors proposed three dimensional service quality model such as; tangible

facilities and processes, behavioral aspect and judgment. According to him, for ideal result,

service providers should give importance to all of the three components of service quality.

Expected

Service

Functional

Quality

Technical

Quality

Perceived Service Quality Perceived

Service

Figure No. 6. Attribute Service Quality Model (Haywood-Farmer, 1988).

Carman, (1990) inspected and reproduced the servqual model in 4 different service

setting than original test. The four service setting designated were, a dental school, business

school, acute care hospital and a tire shop. The essential 6 questions were debated with the

retailers;(1) The generality and number of dimensions, (2) Alteration of wording, (3)

Service situation, (4) The validity of the gap between expectation and perception, (5) The

point to collect expectation information and (6) The link of expectation with importance. It

was found that servqual is good enough with first two questions, whereas requires

adaptation with question no 2 to 6.

Cronin and Taylor, (1992) developed a service performance model after the

criticism on the expectation part of the Servqual model. Rendering to them, the Servperf

(Service Performance) model was developed on the concept of the Gap model designed by

Parasuraman, Zeithaml and Berry, (1985). They paralleled their model with three other

models and exposed that Servperf is the better model as compared to other three service

quality models.

Professional Judgment

Physical Facilities and

Processes

Behavioral Aspects

Evans & Lindsay, (2012) list eight service quality dimensions, however they did not

provide any empirical substantiation for such dimensions. Service quality dimensions

identified by them are the following:

i.Time

ii.Timeliness

iii.Completeness

iv.Courtesy

v.Consistency

vi.Accessibility & convenience

vii.Accuracy

viii.Responsiveness

Sower, Dufy, Kilborne, Kohars, & Joones, (2001) identified KQCAH dimensions for

service quality in healthcare and develop questionnaire to assess the service quality in

hospitals. They used qualitative and quantitative approach for the identification of key

quality dimensions in their study. They used focus group interviews with the stakeholders

consist of supporting staff of hospitals, doctors and recently discharged patients. They

designed instrument to measure the patient’s satisfaction against the key quality dimensions

by collecting data from 663 recently discharge patients. The purpose was to design

questionnaire to measure the patient satisfaction, for which they first identified the key

quality dimensions.

Brady and Cronin, (2001) suggested three dimensions of service quality which are;

interaction quality, physical environment quality and outcome quality. Each of the

dimensions have three more facets or sub dimensions. According to them, customer

perceived quality is based on primary dimension with the help of sub dimensions and then

of overall organization.

Figure No. 7. Three dimensional Service Quality Model (Brady & Cronin, 2001).

Sureshchander, Rajendran, Kamalanabhan, (2001) established five dimensional service

quality model. These dimensions comprise core services, human element, standards,

physical services and social responsibility. They developed 41 items instrument by adding,

eradicating and reshaping some of the Servqual scale.

Service Quality

Interaction

Quality

Physical

Environment

Quality

Outcome Quality Valence

Tangibles

Waiting Time

Social Factors

Ambient Condition

Design

Behavioral

Attitude

Expertise

Figure No.8. Service Quality Model (Sureshchandar et. al, 2001).

Zineldin, (2006) recommended service quality dimensions with the help of a

technical-functional service quality model and the Servqual model. He suggested five

quality dimensional model for the measurement of service quality in healthcare known as

the 5Q model. His proposed quality dimensions are the following;

Quality of Object. Object quality is linked to the technical aspect of the service

quality of healthcare. It is allied to the cure, for which the patients are going to the hospitals

or any healthcare institution.

Quality of Processes. It is the functional quality showing the way the service is

provided. The way the patients are being treated. In short, the way the technical quality is

instigated.

Quality of Infrastructure. Infrastructure quality is the overall quality of all the

important resources mandatory to perform the services. It embraces everything including

technical skills, machinery, experience and the way all these activities are coped.

Service Quality

Core Service

Non Human

Element

Social

Responsibility

Tangibles

Human Element

Quality of Interaction. It is related to the communication process with patients;

understanding a patient’s problem, listening unwearyingly to the patient. It also comprises

informing patients about a checkup.

Quality of Atmosphere. It is connected to the environment where patients and

doctors function. It includes the pleasant environment that the organization is providing to

the patients where they can share their glitches with doctors and other supporting staff

members.

Figure No. 9. 5 Qs Model (Zineldin, 2006).

Quality of Object

Quality of Process

Quality of Atmosphere

Quality of Interaction

Quality of Infrastructure Total Quality

Parasuraman et al,. (1985) presented the Servqual model with 5 different types of

GAP between service provider and receiver. These Gaps are:

Knowledge Gap. Knowledge Gap is also known as expectation Gap. It is a gap that

the management could not interpret correctly. The management does not have ample

knowledge of customer anticipations and provides services that fall below the expectation

of customers.

Standard Gap. Standard gap take place when no standards are defined. For

management perceiving customer’s expectation alone is not enough, they should also

established appropriate principles based on which they can appraise performances.

Delivery Gap. This is the difference between the standard set and actual

performance. After closing the knowledge and standard gap by ascertaining exact

requirements of customers and defining of standards, but what if employees are averse to

provide the services or are not properly trained to meet the expectations, this is when the

delivery gap occurs. For management it is very important to train, stimulate and embolden

their staff members by providing inducements and training programs in order to close such

Communication Gap. This gap is between what is promised and what is truly

provided. Companies in their marketing campaign promise a lot of things thereby raising

the customer’s hopes but when they are unable to deliver the same, communication gap

occurs, which create disappointments.

Customer Perceived Service Quality Gap. This gap takes place when customers are

getting services that are not according to their expectation. This gap is reliant on the first

four gaps and if these gaps are enclosed, the fifth gap will automatically be obscured.

According to them service quality can be measured by quantifying the gap. They suggested

the Servqual model for the service quality measurement.

Figure No. 10. Conceptual Model of Service Quality (Zeithaml et al,. 1990, p. 46).

Parasuraman et al,. (1985) conducted qualitative research by conducting focus group

interviews and acknowledged primarily 10 service quality dimensions which in 1988

contracted to five dimensions. The dimensions identified by them are tangibles, reliability,

responsiveness, assurance and empathy. The original 10 dimensions of service quality

identified by them are the following;

1. Tangibles

2. Reliability

3. Responsiveness

4. Communication

5. Credibility

6. Security

7. Competence

8. Courtesy

9. Understanding/knowing the customer

10. Access

There were 97 items scale planned for 10 different dimensions, each statement was of

two types of questions, one was expectation related and the second one was perception

related. However, Parasuraman et al,. (1988) worked again on the Servqual dimension and

curtailed the 10 dimensional Servqual model to five. The first three dimensions of the

traditional Servqual model remained the same, the remaining seven dimensions

amalgamated into two new dimensions of the new Servqual model. The new dimensions

they proposed for the Servqual model are the following

1. Tangibles

2. Reliability

3. Responsiveness

4. Assurance

5. Empathy

The communication, credibility, security, competence and courtesy dimensions of the

traditional Servqual model fused into assurance, and the last three dimensions of the old

Servqual model, understanding and access merged into empathy.

Figure No. 11. Servqual Model (Parasuraman et al,. 1988).

Servqual Model and Healthcare

Zineldin, (2006) proposed five dimensions of service quality for healthcare by taking

some of the dimensions from the technical-functional model and some from the Servqual

model. In the first two dimensions he has used the technical–functional service quality

model and the remaining three were taken from the Servqual model. Author proposed that

the service quality can be measured in healthcare with the help of five quality dimensions,

such as; quality of object, quality of process, quality of infrastructure, quality of interaction

and quality of atmosphere. The quality of object aspect of the Zineldin service quality

model has taken from the Gronroos, (1984) service quality model, that represents the

clinical procedure, quality of equipment etc. whereas the second aspect of Zineldin model

is related to the way of technical service quality implementation. Similarly quality of

infrastructure and atmosphere is related to all the pertinent resources and the pleasant

environment provided for patients and doctors interactions respectively. Moreover, the

Tangibles

Reliability

Empathy

Assurance

Responsiveness Perceived Service

Quality

quality of interaction aspect of Zineldin refers to the communication, interaction skills of

the service providers.

Lim, Tang, and Jackson, (1999) proposed two aspects of health related services;

technical and interpersonal skills. Technical means the monotonous working procedures,

and includes operating hours and abilities of doctors. Interpersonal skills are related to the

service providers and patient’s relationships, related to their hitches, communication and

giving complete information. For patients interpersonal skills are very essential as they are

not aware of the technical skills and therefore it is very hard to judge the technicality of the

doctors, because the internal matters are not exposed to patients (Vinagre & Neves, 2008).

Numerous research literature is presented on the measurement of service quality across

the world which is primarily done while using the Servqual scale (For example, Cronin &

Taylor, 1992, 1994; Parasuraman et al,. 1985,1988, 1991, 1993, 1994; Teas, 1993, 1994).

Alrubaiee & Alkaa'ida, (2011) established the Servqual Model as one of the best models for

the measurement of service quality for healthcare institutions. The Servqual model

acknowledged promising appraisals in the last two decades and was found to be an

appropriate scale for healthcare institutions (Andaleeb, 1998; Babakus and Mangold, 1992;

Canel and Fletcher, 2001; Jabnoun and Chaker, 2003; Lim and Tang, 2000; Pakdil, &

Harwood, 2005; Peprah & Atarah, 2014; Punnakitikashem, Buavaraporn, Maluesri, &

Leelartapin, 2012). Keeping in view the appreciation acknowledged by servqual model, the

researcher therefore decided to use the servqual as a theoretical foundation for the current

study. The famous servqual scale is adopted with slight modification made for healthcare

service quality measurement. Servqual scale also modified due to huge criticism done by

various authors on the expectation part (Babakus and Boller, 1992, cited by Jain and Gupta,

2004).

Servqual Model and Criticism

Besides the competitive benefits of the Servqual model, it also has confronted some

criticism and can be classified in the subsequent categories

Theoretical Bases. The Servqual model tackled the critique of the validity of being

generic to all service industries. The perception minus expectation formula, has got little

empirical indications, in such case, customers will draw their conclusions based on

anticipations rather than actual perceived service quality (Cronin and Taylor, 1992, 1994;

cited by Becser, 2007).

Process Oriented. The Servqual model is process oriented, which distillates on

service delivery rather than service encounter (Becser, 2007). According to Groonos,

(1984) service quality has two dimensions; technical and functional. Measuring service

quality based on the process alone would not be appropriate, as the technical portion should

also be considered while gauging service quality.

Dimensions. The dimensions of the Servqual model have also been criticized. Five

dimensions are not enough and universal for service industry, and researchers should take

care of the specific industry while using five dimensions of the Servqual model (Carman,

1990). Parasuraman (1994) also faced the same Servqual five dimensions problem while

determining the model repetitively.

Expectation. The Servqual model was further criticized regarding the expectation

aspects of the Servqual model; the P-E gap scores and long questionnaire (Babakus and

Boller, 1992, cited by Jain and Gupta, 2004). With the passage of time hopes change; a

person’s expectations ten years ago would not be same in the current era. A person might

expect more than what he/she was imagining before. Expectations may also plunge with the

passage of time (Buttle, 1995).

Table 1

Product/Service Dimensions

Authors Dimensions

Garvin, (1987)

Product Quality

Dimensions

Performance, Features, Reliability, Conformance,

Durability, Serviceability, Aesthetic & Perceived

Quality

Brucks, Zeithaml, Naylor,

(2000) Product Quality

Dimensions

Ease of Use, Versatility, Durability, Serviceability,

Performance, Prestige

Parasuraman et al. (1988)

Servqual Dimensions

Tangibles, Reliability, Responsiveness, Assurance

Empathy

Zineldin, (2006)

Service Quality Dimensions

Quality of Object, Quality of Processes, Quality of

Infrastructure, Quality of Interaction and Quality of

Atmosphere

Gronroos, (1984)

Service Quality Dimensions

Functional, Technical

Beside the theoretical background, numerous researchers have empirically

investigated the relationship of service quality with customer loyalty and advocacy, directly

and indirectly when trust mediated. The subsequent paragraphs presented some of the latest

and relevant literature on the association of service quality of health care with the variables

used in current study.

Irfan and Ijaz (2011) used the Servqual model with all five dimensions for the

comparison of service quality in private and public hospitals of Lahore, Pakistan. They

altered the Servqual scale to healthcare and discarded some of the items from the Servqual

instrument. They distributed data among those they had an opinion on both public and

private hospitals. They revealed that private sector hospitals in Lahore were offering better

service quality as compared to public hospitals.

Figen & Ebru, (2010) measured the service quality. Their study was to check the

Servqual model’s different dimensions in hospitals, to investigate the service quality of

public and private hospitals and patient’s satisfaction of Northern Cyprus. They exposed

three factors in the model that is reliability, empathy and tangibles. Their results did not

support the original five factors of the Servqual model. Bowers, Swan, & Koehler, (1994)

identified two more quality factors in the original five factors of the Servqual model. They

identified “caring” and “patient outcome”. They also found that customer satisfaction is

highly related to empathy, responsiveness, reliability, and communication and caring.

Youssef, Nel, & Bovaird, (1995) used the Servqual model to gauge the variance

between patient perception and satisfaction of NHS hospital in UK, and acknowledged that

reliability aspect of Servqual model was the important dimension that inclined patient’s

perception of quality, followed by empathy then responsiveness and assurance. He also

discovered that tangibility is the least important aspect of service quality in hospitals.

Lim & Tang, (2000) measured service quality by using the six dimensional Servqual

model in Singapore Hospitals. The dimensions used by them were all of Servqual model,

with an added dimension “accessibility and affordability”. They composed data from 252

patients and found a significant gap among all the six dimensions of the revised Servqual

model.

Kleynhans & Zhou, (2012) measured the service quality in South Africa’s selected

hotels while using the Servqual model. They found the average rating of expectations

higher than the average rating of perception in all five dimensions of the Servqual model.

Their findings revealed that tangibles had the largest gap (-0.5933) as compared to other

gaps. Yap & Kew, (2007) determined the relationship between customer satisfaction and

customers re-purchase intentions and service quality of restaurants. They surveyed 377

restaurant customers through a questionnaire. Using Pearson Correlation, they found that

customer’s re-patronage intentions are unswervingly associated to customer’s satisfaction

and service quality.

Similarly, Babakus and Mangold (1992) empirically tested the Servqual model in the

health sector. They composed data from the management of hospitals and discovered that

Servqual is an advantageous model in the health sector. They also revised the Servqual

scale by altering its questions to healthcare and erasing some of the questions from the

original Servqual scale. Rahaman, Abdullah, & Rahman, (2011) gauged the services of

private banks of Bangladesh using the Servqual model. They found that five dimensions of

the Servqual model are not sufficient, and advocated an additional dimension which

embraces the solution of customer problems, timeliness, prompt response, safe transactions

and empathy.

Likewise, Solayappan, Jayakrishnan, & Velmani, (2011) surveyed the contrast

between perceived and expected service quality of hospitals while using the Servqual

model in India. They composed information through a questionnaire from 300 patients, and

found the gap in physical appearance, lack of interest in problem solving and personal care.

Karassavidou, Glaveli, & Papadopoulos, (2009) appraised the service quality in NSH

(National Service Hospital) in Greece while using the Servqual model to gauge the gap

between customer perceived quality and expectations. They designed an instrument of 26

pairs of questions both for expectation and perception, and dispersed it among 137 patients

in six hospitals in Northern Greece.

Manaf & Nooi,(2009) used the Servqual dimensions to analyze the service quality

and the patient satisfaction in Malaysia’s Hospitals. They used the quantitative approach

and designed an instrument. They conducted their survey on outpatients and inpatients, and

got the data from 570 outpatients and 646 inpatients. They used the factor analysis for both

outpatients and inpatients. They come up with two factors, clinical and physical dimensions

of service. Mostafa, (2005) used the factors of the Servqual model to judge the service

quality in Egypt’s hospitals. He circulated 500 questionnaires and got the data from 332

respondents, and revealed that perceived quality was different than expectations.

Pakistan Health System

A hospital is an institution providing healthcare treatment to diverse types of patients.

It consists of professional doctors/physicians who provide treatment with supporting staff

like administration and nurses, to serve the patients and take care of administrative

activities. Hence the service quality delivered is very imperative for patients.

There are two types of health systems that run together in Pakistan; public and private

health system. Public hospital comprises of primary, secondary and tertiary health systems.

Primary and secondary levels are controlled by the district management. Tertiary level

health system includes large hospitals, intensive care units and diagnostic units. The private

health sector is composed of maternity hospitals, dispensaries, diagnostic centers and

doctors (Ministry of Finance 2014). The private health sector of Pakistan is the foremost

source of health service provider in Pakistan because of state of the art technology, and

specialized professional team (Ministry of Finance 2014). Rendering to the National Health

Survey of Pakistan, the number of public hospitals are 1096, doctors 16775, 13716 dentists

and 86183 nurses by the year 2013. Conferring to the numbers stated above, the Pakistan

Bureau of Statistics bring the ratio of one doctor for 1099 patients, 13441 patients for one

dentist and one hospital bed for 1647 patients. The numbers of patients are increasing

which results in scarcities (Ministry of Finance 2014).

Pakistan Health system is facing various problem, such as weak regulatory

mechanism, no accreditation or quality maintenance tool, assessing and reporting

performances and no proper patients’ safety procedures (Nishter, 2006). According to the

report of Nishter, (2006) on Pakistan Health System, she pointed out that weak regulatory

mechanism of health sector has weakened the quality delivery in healthcare. Furthermore

she argued that there is no proper standards for measuring service quality and reporting

procedures. Moreover, she claimed that there is no accreditation that set the quality

principles against which quality can be measured. Under the lights of above observations,

researcher has decided to measure the perception of customers’ regarding the healthcare

quality, in order to enhance the level of trust.

Table 2

Heath Facilities in Pakistan

Health Human Force 2011-12 2012-13 2013-14

Registered Doctors 152, 368 160,880 167, 759

Registered Dentists 11,649 12,692 13,716

Registered Nurses 77,683 82,119 86,183

Population per Doctor 1,162 1,123 1,099

Population per Dentist 15,203 14,238 13,441

Population per Bed 1,647 1,617 1,647

Note: Data Developed from Pakistan Bureau of Statistics; cited in Ministry of Finance

(2014)

Customer Loyalty

In today’s global and competitive environment, companies are not just racing against

each other, but are also considering for a sustainable competitive advantage. Getting new

customers for companies are vital, but for endurance, companies must keep them for a

longer period by making them devoted customers. According to Reichheld & Sasser

(1990) companies can enrich their profit by 100% if they retain only 5% of their customers.

Most researchers had focused on customer satisfaction, but are only satisfied customers

abundant? According to Thomas and Tobe, (2012), most of the pleased customers have

picked a new supplier, which indicates that only satisfaction is not enough. For a viable

competitive advantage, companies must produce loyal customers.

Loyalty is the attitude of a customer towards a specific company, and purchases again

and again from the same company, and talks good about the company and provides

referrals (Pearson, 1996). Customer loyalty according to Hamid, Ebrahimpour, Roghanian,

& Gheysari, (2013) is a very important component of an effective business strategy.

Customer loyalty is a source of competitive advantage and advances a company’s

performance (Singh & Kotler, 1981; Woodruff and Gardial, 1996) and lessens transaction

cost (Morgan and Hunt, 1994; Doney and Cannon, 1997). Bowen and Shoemaker (2003)

described customer loyalty as the loyal customer who voices a positive opinion about the

firm and its product, and makes repeated purchases and commends it to others. Customer

loyalty is a dependable tool as compared to customer satisfaction (Griffin, 2005). Loyal

customers are very important for companies, as it is very difficult for competitors to pinch

them, hence a source of competitive advantage. Other than that, loyal customers do the

marketing for companies they are loyal to and recommend others (Kotler and Keller, 2009).

Conferring to Reichheld and Detrick, (2003) loyal customers and the firm share

mutual benefits; loyal customers are getting the anticipated product or service and the firms

get customer life time value. Customer loyalty is not simple repurchase intentions or repeat

purchase, but it is a multi-dimensional factor that supports organizations (Dick and Baso,

1994). Bloemer and Odekerken-Schroder (2002) describe different dimensions of customer

loyalty which contain; referrals, purchase intentions, paying a high price, and talking good

about the company etc. Oliver, (1997) portrays’ customer loyalty when a customer

becomes an advocate of the company voluntarily. According to Dehghan and Shahin,

(2011) loyal customers use positive words for the company, and praise it to others and

make repeat purchases. A company’s cost of searching for new customer diminishes by

having loyal customers because loyal customers do the marketing for the company (Rowley

& Dawes, 1999).

There is a great deal of work done by researchers on service quality and customer

loyalty; however very limited work has been done on this matter in healthcare. Loyalty to a

hospital is as important as in any other organization. Patients, who receive better service

quality, are more likely to return to the same hospitals, praise the services and recommend

it to others (Taner and Antony, 2006). Positive word of mouth is more effective than

traditional marketing envisaged by the marketing personnel of healthcare (Beckham, 2001).

Customer loyalty has two different types of dimensions which are; active and passive

loyalty (Ganesh, Arnold, Reynolds, 2000). Bestowing to them, active loyalty is taken

deliberately and can be seen in both purchase behavior and intentions, whereas passive

loyalty is affected by variation in price and switching cost. Lam, Shankar, Erramilli, &

Murthy, (2004) elucidated two other facets of loyalty; repurchase intentions and

recommendations whereas Fullerton, (2005) defined repeat purchase and advocacy as the

dimensions of customer loyalty. Kumar and Shah (2004) portray behavioral and attitudinal

facets of loyalty. Bowen and Chen, (2001) illuminated three dimensions of customer

loyalty; behavioral, attitudinal and composite loyalty. Composite loyalty is the combination

of behavioral and attitudinal loyalty.

Rendering to marketing literature, customer loyalty has different facets; behavioral,

attitudinal composite, cognitive and affective loyalty. Some of the valuable facets of loyalty

has been described in the subsequent paragraphs;

Behavioral Loyalty. Behavioral loyalty refers to the repurchase pattern of a buyer.

Behaviorally loyal customers are very essential for companies, as it means the company is

in business and generating revenue. Some people buy from a certain shop grudgingly as

they don’t have any other choice (Jacoby and Chestnut, 1978). According to Rauyruen and

Miller (2007) behavioral loyalty is the buyers repurchase intentions and lifelong association

with service providers. Curtis, (2009) also pronounced behavioral loyalty as the customer’s

repurchases intentions.

Attitudinal Loyalty. Attitudinal loyalty as per marketing literature is a loyal

customer who talks optimistic about the brand and the company and endorses it to others.

Attitudinally loyal customers are also very imperative and expedient for companies. They

talk virtuous about company and do the publicizing of the company by commending the

company to others. Dekimpe, Steenkamp, Mellens, & Vanden, (1997) said that behavioral

loyalty is diverse from attitudinal loyalty. Attitudinal loyalty is not simply repurchasing

intentions; it is encouraging sensations towards a brand. According to Curtis 2009,

attitudinal loyal customers feel positive about the company and talk confidently about the

company and also refer or praise the company to friends and others.

Composite Loyalty. Composite loyalty is the blend of behavioral and attitudinal

loyalty. Rendering to Dick and Basu (1994) both behavioral and attitudinal loyalty are

significant for companies. Repeat purchase is imperative for the progress of the company,

but some people may make a purchase for a number of reasons (Jacoby and Chestnut,

1978). Numerous researchers favored composite loyalty; as it is the mixture of behavioral

and attitudinal loyalty, hence it carries measure of true loyalty (Rundle-Thiele, 2005b;

Shoemaker and Lewis, 1999; cited by Kaur and Soch, 2012).

Affective Loyalty. Blut, Evanschitzky, Vogel, & Ahlert, (2007) narrate effective

loyalty to a positive attitude towards a service/product or a company. According to Sinha,

Mishra, & Kaul, (2014) effective loyalty plays a strong role in customer consummations

and long lasting relationships.

Service Quality and Customer Loyalty

Proliferation in competition and role of technology has made customers cleverer than

before. Customers have countless alternatives and are approached by many competitors

with the same or better offers, which shows the importance of customers are for companies.

Hence companies are making numerous marketing strategies to get and hold customers for

a lengthier period, make them loyal in order to get competitive advantage and endure their

market position. Good service quality can lead to customers’ loyalty; hence a great deal of

research work has been carried out by several authors on the association of service quality

and customer loyalty.

Countless researchers worked on recognizing the association between service quality

and customer loyalty. For example Cronin and Taylor, (1994) did not find a constructive

relationship between service quality and customer loyalty. Boulding, Kalra, Staelin and

Zeithaml, (1993) worked on service quality and customer loyalty as to their repurchase

intensions and inclination to mention others, and found a promising link of service quality

with repurchase intensions and referral. Bloemer, Ruyter, & Peters (1998) worked on the

mental picture, service quality, customer satisfaction and customer loyalty. They

discovered an indirect impact of the mental picture on customer loyalty. They also found

that service quality effects customer loyalty directly and indirectly through customer

satisfaction. On the other hand Caruana, (2002) worked on service quality, customer

satisfaction and customer loyalty and revealed that service quality indirectly effects

customers’ loyalty through customers’ satisfaction.

Customer Advocacy

Just like customers’ loyalty, advocates are very important for customer and supplier

long term relationship (Anderson, 1998; Fullerton, 2003; White and Schneider, 2000).

Advocates are very important for long term competitive advantage for organizations

(Urban, 2004). According to Maklan, Knox and Peppard, (2011), traditional customer

relationship approaches are not enough to gain trust and produce and loyal customers and

argued that customer advocacy is the best approach to gain consumer trust and loyalty.

Customer advocacy is a recent conception in marketing. Conferring to marketing literature,

advocacy is a positive word of mouth, praising a brand/service and company. Advocates

commend the company and do the marketing of company’s products and services to others

(Peck, Payne, Christopher, Clark, 1999). Urban (2005) defines advocates as a person who

honestly working for customers best interest by providing authentic and complete

information. Yamaoka, (2004) argued that companies have shifted their marketing

strategies from traditional push-based to trust-based advocacy marketing. Optimistic word

of mouth is subject to how pleased a customer is with the service or product he/she

practiced (Westbrook, 1987). Hayes, (2008) reflects advocates on the progression of the

company; when customers are speaking well about the company and applaud the company

to their friends, who later on become customers.

However, for Walz, & Celuch, (2010) advocacy is more explicit than word of mouth,

as word of mouth can be constructive and adverse about a brand, service and company,

whereas advocacy is positive word of mouth. Advocates are those they talk good about the

company (Andreassen and Lindestad, 1998; Zeithaml, Berry, and Parasuraman, 1996); and

provide recommendations (Stum and Thiry, 1991), persuade others, (Bettencourt and

Brown, 1997); Kingstrom, 1983) and preserve the service providers (Kingstrom, 1983).

According to Jaffe, (2010) marketers are spending big amount of money on traditional

marketing campaigns to acquire new customers. He further advised that companies should

distillate on customers, impart trust and confidence in them and make them advocates.

Positive word of mouth is nine times more effective than advertising (Day, 1971).

According to Walz, & Celuch, (2010) positive word of mouth is more effective in the

service sector, where customers cannot touch and practice the service before its purchase.

Customer advocacy is a new term evolved in marketing literature, but most important

element for long term customer-supplier long term relationship (Roy, 2015). However very

limited empirical literature is available on customer advocacy such as Roy, (2015)

investigated the association of trust and advocacy. Partial least square path modelling used

for analysis purpose that content 575 respondents and conclude that trust has a positive

impact on customer advocacy. Similarly Afridi and Khattak, (2015) investigated the

association between trust and advocates in health sector. They used quantitative technique

by circulated 492 questionnaire. Confirmatory factor analysis through AMOS were used to

check the reliability and validity of the instrument. Path analysis was used to check the

association and their finding revealed a positive and direct association between trust and

advocacy.

Baksi and Parida (2013) investigated the moderating effect of service recovery and

customer relationship management (CRM) on customer trust, repurchase behavior and

customer advocacy in banking sector. Their finding revealed the moderating effect of

service recovery and CRM on customer trust, repurchase intentions and customer

advocacy. On the contrary Susanta, Alhabsji, Idrus, Nimran, (2013) evaluated the effect of

relationship quality on customer advocacy with loyalty as a mediating variable on

commercial banks of Indonesia. They used confirmatory factor analysis to test the

reliability and validity of the instrument and test the hypotheses through structural equation

modelling comprising of 178 customer responses. Their finding revealed a positive and

direct association between relationship quality and customer advocacy, but trust hasn’t.

Further they revealed that loyalty intervene between trust and customer advocacy.

Since customers’ loyalty and advocacy are very imperative specifically for service

oriented industry, because of its repurchase intention, positive word of mouth and referrals

and a source of competitive advantage. However, it is not easy to produce loyal customers

and advocates instantly. There are some factor that will lead to loyalty and advocacy.

According to Caruana (2002) customers’ satisfaction and trust are very important for

making customers’ loyal. Various writers have written on service quality, customers’

satisfaction and loyalty, however limited work done on the linkage of service quality with

customers’ loyalty and advocacy via trust as a mediator.

Trust is a belief or confidence that one party has on another party to deliver the

service or product according to beliefs (Anderson and Narus, 1990, Dwyar, Schur and Oh,

1987, Morgan and Hunt, 1994, Morman, Dashpande and Zaltman, 1993; Sanzo, Santos,

Vezquez, and Alvarez, 2003; Schurr, & Ozanne, 1985). Trust plays central part in customer

re-purchase behavior; once customers believe that another party is trustworthy it can

stimulate them for future correspondence with the same firm (Dwyer, Schurr and Oh,

1987). Mishra, Karen, and Li (2008) designated four dimensions of trust, i.e. reliability,

competence, openness, and concern and communication is imperious for demonstrating all

aspects of trust. Trust is believed to be a significant factor for customer observations

concerning company and its product/service (Aaker, 1997). Trust is good for both; buyer

and seller, for the buyer it lessens the perception of jeopardy and for the company it

upsurges sale, reduces cost and creates positive word of mouth and repurchase intentions

(Moorman, Dashpande and Zaltman, 1993; Schurr & Ozanne, 1985). Trust is vital for

seller-buyer long term association and advantageous for both parties (Zaheer, Mcevily and

Perrone, 1998).

Morgan and Hunt (1994) found trust and commitment the imperative factors between

two parties in building and preserving long lasting relationships. Whereas, Coulson (1998b)

focused on the importance of trust in upholding long term relationships between parties,

which would be unmanageable without trust. Similarly, Jarvenpaa and Tractinsky, (1999)

and Sotgiu and Ancarani, (2005) endorsed the importance of trust and found that customers

are normally disinclined to do business with those they do not trust. Reichheld and

Schefter, (2000) also applaud trust as the important factor of business between two parties.

In healthcare, the most significant factor is the interaction between the service

provider and the patient. Trust is a very important aspect in doctor and patient affiliation.

Those patients that trust their doctors then they listen to their doctor’s instructions (Safran,

Kosinski, Tarlov, Rogers, Taira, Lieberman & Ware, 1998; Thom, Ribisl, Stewart, & Luke,

1999). Research on public trust in healthcare is not generally written about by the

researchers; however it might be very important for governments as they can measure the

performance of a healthcare institution from the patient’s point of view (Goudge and

Gilson, 2005; cited by Schee, Groenewegen and Friele, 2006). Trust in healthcare is

defined as “the optimistic acceptance of a vulnerable situation in which the trustier believes

the trustee will care for the trusties’ interests” (Hall, Dugen, Zheng and Mishra, 2001; sited

by Schee, Groenewegen and Friele, 2006). Public trust is pretentious in two ways; by their

personal involvement with the service provider or by their representative, and also effected

by media images (Mechanic and Schlesinger, 1996; cited by Schee, Groenewegen and

Friele, 2006).

Trust is correlated with satisfaction even though it is considered a more sensitive

indicator of performance as compared to satisfaction (Sefaran, et al, 1998; Thom, Hall and

Pawlson, 2004; Thom, Ribisel, Stewart and Luke, 1999; cited by Calnan and Rowe 2004).

Numerous studies recommended that trust also associates highly with patient loyalty

(Arksey and Sloper, 1999; Keating, Green, Kao, Gazmararian, Wu and Cleary 2002;

Sefaran, et al, 1998; sited by Calnan and Rowe 2004) which further generates inspiration

for repurchase and commending to others (Joffe, Manocchia, and Weeks, 2003;

Caterinicchio, 1979; cited by Calnan and Rowe 2004).

Trust fascinated fabulous consideration for the last two decades that emerged

different meanings and dimensions of trust. Mechanic, (1998a) derived five different

dimensions of trust in his research on healthcare. He carried telephonic interviews from

three groups of respondents which are; breast cancer, Lyme disease and mental illness. The

questions were asked concerning competence, fiduciary, control, disclosure and

confidentiality grounded on their conceptual frame work. He found “competence” the most

common aspect of trust and “disclosure and confidentiality” the slightest common concern.

The overall trust dimensions identified by him are the following;

Competence (Technical and Interpersonal). It is related to the proficiency of doctors

and supporting staff. Abilities of doctors are very important and one of the major

apprehension of patients, but in their limited capacity they can’t appraise the technical

skills of doctors. Therefore, patients are evaluating the interpersonal skills of doctors, (such

as, caring or dealing with patients in a respectful manner, clear and complete

communication).

Fiduciary Responsibility and Agency. Taking care of the patient and working for

the best interest of the patient without taking advantage of his problems or serious situation

due to which he entails medical treatment.

Control. Control dimension is related to how well the doctors control one’s health

plan according to the patient’s condition.

Disclosure. This dimension is related to how well doctors are revealing different

alternative prescriptions and treatment plan to patients.

Confidentiality. Confidentiality is related to the privacy of the patient’s information.

Doctors and supporting staff of the hospitals are getting secret information from the patient

in order to provide the best treatment, but it is their responsibility not to leak any secret

information that may cause disrespect.

Mayer, Davis, and Shoorman, (1995) anticipated three dimensions of trust and

presented a trust model that unequivocally separates trust from its experience and its result.

Rendering to their theory, it is due to the perceptions of trustee’s behavior that make the

party trustworthy affect the real level of trust in that trustee. They proposed three

dimensions of trust which are the following;

Integrity. This dimension is related to the honesty of the physicians and supporting

staff. It also refers to the believability of the doctors, and how honest they are with the

patients.

Competency. The skills of doctors and supporting staff. This dimension

acknowledged relevant importance, as the expertise of the doctors are the major

apprehension of patients, as it is related to the treatment itself.

Benevolence. It is linked to the generosity of the doctors; the kindness and

compassion of the doctors.

Hall, Dugan, Zeheng, & Mishra, (2001) enlightened five dimensions of trust, which

are the following.

Fidelity. Working for the furtherance of the patients without taking the benefit of the

problem they are facing.

Competence. It is related to the abilities of the doctors and supporting staff. It refers

to how accurately the service providers deliver the service without making errors.

Honesty. This dimension is related to actuality, it is related to whether service

provider is telling truth to the patient or hiding some information or providing false

information.

Confidentiality. This dimension is related to the privacy and secrecy of the

information got from the patient. Doctors and supporting staff of the hospitals are getting

the secret information from the patient in order to provide the best cure, and it is their

obligation not to disclose any information that may cause disrespect.

Global Trust. Which can be associated to many areas, but cannot be fixed to only

one specific area. It is the most important dimension of trust as according to Hall, Dugan,

Zeheng, & Mishra, (2001) global trust is the “soul of trust”.

Whereas Mishra, Karen, and Li. (2008) explained the following four dimensions of

trust by further elaborated Mayer, Davis, and Shoorman, (1995) aspects of trust. They

added openness and concern by replacing benevolence and. According to them the sincerity

and professionalism of doctor are very important factor to impart trust instead of kindness

and compassion. They further, argued that most of the people are using emotional way to

deceive customers. Therefore they proposed trust as reliability, competence, openness and

concern. The proposed dimensions of trust are elaborated in the succeeding para.

Reliability. It is related to the dependability. How much a consumer hinge on and

relies on the service provider. In healthcare, reliability is related to the trustworthiness of

doctors, nurses and other supporting members.

Competence. It is related to the skills of the doctors, and other professionals. It is the

primary concern of the patient as it is related to the treatment of the patient.

Openness. This dimension is related to the uprightness of the professionals and their

sincerity. It shows how much truth the professionals are telling to the patients regarding the

disease and treatment time.

Concern. Concern is related to the care, it shows how the professionals care for the

patient and their problems and about the treatment.

Table 3

Trust Dimensions

Authors Dimensions

Hall, Dugan, Zeheng, &

Mishra, (2001)

Fidelity, Competence, Honesty, Confidentiality and

Global Trust

Mechanic, (1998a, b) Competence, Fiduciary Responsibility and Agency,

Control, Disclosure and Confidentiality

Mayer, Davis, and Shoorman,

(1995)

Integrity, Competency and Benevolence

Mishra, Karen, and Li. (2008) Reliability, Competence, Openness and Concern

Trust and Customers’ Loyalty

Even though service quality increases the image of the company and has an

affirmative link with the company’s performance, it is not a surety that it will convert

current buyers into loyal customers that will persist with the company for a longer period

and makes purchases again and again (Reichheld, 1996). Hence to develop long term

associations with customers there must be something influential between buyer and seller,

and according to Sharma, (2003) trust is the important factor that assures company-

customer long term affiliation. Trust is the facet of customer loyalty (Aydin and Ozer,

2005; Kenning, 2008; Morgan and Hunt, 1994; Rample, Eberhardt, Schutte, Kenning,

2012). Trust gained substantial reputation in marketing literature and is seen as the

mediating variable of customer loyalty. Conferring to Ribbink, Dina, Allard, Van (2004)

trust is mediating between customer loyalty and service quality.

Reichheld and Schefter (2000) deliberate trust as a condition for loyalty. According

to them, companies must inculcate trust in customers to make them loyal. Bitner’s (1995)

study revealed, that loyal customers increase when customers’ trust the company and its

products and services. For Ribbink, Liljander and Streukens, (2004) trust is the factor

behind customer purchases and is also a source of producing loyal customers. Rauyruen

and Miller, (2007) revealed that higher the trust in a company will upsurge the loyalty and

customer willingness to stay with the company for a longer period. Chaudhari and

Holbrook, (2001) found a direct relation of trust with behavior and attitudinal loyalty. For a

strong relationship between two parties, trust is one of the most important conditions

(Peppers, & Rogers, 2012). According to Pepper & Rogers, (2012) 83% customers trust

their friends approvals, less than 50% trust online recommendation and only 14 % trust

traditional advertising.

According to Ribbink, Dina, Allard & Van (2004); Kassim & Asiah (2010) it is not

only customer satisfaction that leads to a loyal customer but trust and commitment also

play a vital role in customer satisfaction. Ouyang (2010) found that customer satisfaction

does not significantly affect customer loyalty.

Hence, trust plays an important role in customer loyalty. Various authors braced the

role of trust in customer loyalty. Moorman, Deshpande & Zaltman (1993) found that trust

plays a noteworthy role in producing loyal customers and considered it very imperative in

creating loyalty in customers. Though customer’s satisfaction is powerfully correlated with

trust, but still trust is a stronger element in creating loyalty, because, satisfaction is related

to the past performance whereas trust is for future correspondence (Chaudhari & Hallbrook

2001); Garbarino and Johnson 1999); Singh and Sirdeshmukh 2000); Sirdeshmukh, Singh

and Sabol 2002).

Parasuraman et al, (1988) concluded that companies providing enhanced service

quality can increase customers’ loyalty. Atkins, Marshall, & Javalgui (1996) in their study

revealed that hospital service quality leads to loyal patients. In the succeeding paragraphs,

the researcher fleetingly deliberated the empirical work done by numerous authors in such

regard.

Kheng, Mahamad, Ramayah, Mosahab, (2010) scrutinized the service quality and its

impression on customer loyalty in the banking sector of Malaysia. They used the Servqual

model with five dimensions, to check the effect of service quality on customer loyalty.

They revealed that better service quality can lead to customer loyalty. Poku, Zakari, &

Soali, (2013) analyzed service quality impact on customer loyalty in the hotel industry of

Ghana. They used the Servqual five dimensional model to assess the service quality

influence on loyalty. They found that service quality leads to customer satisfaction, and has

a straight association of customer satisfaction with customer loyalty.

Arab, Tabatabaei, Rashidian, Forushani, & Zarei, (2012) used the Servperf model

of Cronin & Taylor (1992) to appraise the service quality and its bearing on customer

loyalty in the hospitals of Iran. They found a constructive connection of service quality

with customer loyalty. Bloemer, Ruyter, and Wetzels, (1999) conducted a research on

service quality and loyalty dimensions. The five dimensions of service quality and

structural questionnaires were used for conducting interviews of 708 people in four

different service industries comprising healthcare. Their study revealed 4 different

dimensions of service loyalty; word of mouth, purchase intension, price compassion and

complaining behavior.

Dean, (2002) worked on service quality, customer orientation and customer loyalty of

a call center of Australia. He conducted a mail survey, and found that service quality and

customer orientation has a constructive link with customer loyalty. He also exposed that

service quality associate customer orientation with customer loyalty. Caruana (2002)

inspected the relationship of service quality and customer loyalty with the mediating role of

customer satisfaction. The author designed a 37 items instrument that shelters all the three

variables. Her conclusions confirmed the mediating role of customer satisfaction between

service quality and customer loyalty.

Lei and Mac (2005) tested the service quality influence on customer loyalty in

Macau. They questioned 550 people on the road and got 387correct responses. After

running regression and correlation analysis, they revealed that four dimensions of service

quality such as; tangibles, assurance, empathy and responsiveness are certainly linked with

service quality. Mosahab, Mahamad, & Ramayah, (2010) investigated the impression of

service quality on customer loyalty, with customer satisfaction as a mediator in the banking

sector of Iran. They composed data from 147 bank customers and exposed that customers’

satisfaction is mediating service quality and customer loyalty.

Akbar, & Parvez, (2009) studied the effect of perceived service quality, trust and

customers’ satisfaction on customers’ loyalty. They poised data from 304 customers in the

telecommunication industry, and used the structural equation modeling (SEM) for the

analysis of the conceptual framework. Their findings publicized that customer satisfaction

and trust have an affirmative impact on customer loyalty. According to them, customers’

belief in the company and its product is an imperative factor in creation of customer

loyalty.

Patawayati, Zain, Setiawan and Rahayu, (2013) questioned the mediating role of

patient satisfaction, trust and commitment between service quality and customer loyalty in

public hospitals of Indonesia. They used the structural equation modeling (SEM) to

scrutinize the data, and found a positive influence of service quality on customer

satisfaction, trust and commitment. They also got positive impact of customer satisfaction

and trust on customer loyalty. Furthermore, they discovered that customer satisfaction and

trust are the mediators of service quality and customer loyalty.

Kim, & Kandampully, (2011) tested the role of trust and commitment between

perceived justice and customer loyalty in restaurants. Their findings open that trust and

commitment are the strong mediators of perceived justice and customer loyalty. DeWitt,

Nguyen, & Marshall, (2008) worked on the intervening role of trust and emotion between

perceived justice and customer loyalty. They used the structural equation model (SEM) to

investigate their data and found that perceived justice is effecting customer loyalty

positively but indirectly through trust and emotion.

Madjid, (2013) examined the relationship between customer satisfaction and

customer loyalty with the mediating role of trust. He used convenience sampling and

placid the data from 150 clients of the bank in Indonesia, and analyzed the data with

variance based structural equation model (SEM) and least square analysis. He discovered

that customer satisfaction is confidently related to trust and loyalty. He also institute that

trust is the imperative mediator between customer satisfaction and loyalty.

Trust and Advocacy

Some work has done on trust and word of mouth association. However, limited

literature is available on trust and advocacy. However, Roy, (2015) argued that

organizations need to instill trust and confidence in customers and in return customers

advocate for organizations. Walz, & Celuch, (2010) separated advocacy from word of

mouth communication by saying that advocacy is not simply word of mouth

communication but persuading others. Advocates are those who are contented with the

company, they trust the company and talk respectable about the company, (Andreasson &

Lindestad, 1998; Zeithaml, Berry, & Parasuraman, 1996). Advocates not only use

optimistic words regarding the company but also acclaim other customers to the company

(Stum and Thiry, 1991), they are convincing and inspiring others to purchase, (Bettencourt

and Brown, 1997); Kingstrom, 1983) and advocating service providers (Kingstrom, 1983).

A patient that is praising doctors or hospitals is the result of a patient’s trust on that specific

doctor and health service provider. Gremler, Gwinner, & Brown, (2001), extend the

thinking to patient-hospital service quality, and the researcher expects that service quality

will instill trust, which further affects customer advocacy. Based on the available literature

regarding the mediating role of trust, it is expected that better service quality will instill

trust and confidence in the patient, and those they trust in supplier service quality will

purchase the service again and will inspire others as well.

Service Quality, Trust, Customer Loyalty and Advocacy

Service quality has a significant effect on customer trust and loyalty (Eisingerich and

Bell, 2007). Trust is connected to word of mouth communication. Customers if confident

that the exchange party will perform according to expectations will talk good about the

service provider (Alrubaiee and Alnazer, 2010). Rendering to Ribbink, Dina, Allard, Van,

2004; Kassim & Asiah 2010) it is not only customer satisfaction that leads to a loyal

customer, but trust and commitment also play a vital role in customer satisfaction.

According to Ribbink, Dina, Allard, Van (2004) trust is the mediating factor between

customer loyalty and service quality. Bitner (1995) stated that trust and loyalty are directly

related; customers’ trust increases, and effects loyalty positively. According to Ribbink,

Liljander and Streukens, (2004) when customers trust the service provider, they purchase

the services and eventually become loyal. According to them trust is the main factor that

inspires prospective customers to purchase and also the factor behind loyal customers.

According to Hart and Johnson, (1999) trust is the main factor behind loyalty, after

satisfaction.

Trust creates loyalty, and faithful customers stay with the company for a longer

period and become advocates of the company and talk good about the company (Gizaw &

Pagidimarri, 2013). According to Maxham (2001) service quality affects customer’s trust,

and trust has a positive influence on customer advocacy. Customer advocacy is more

effective than traditional advertising (Jaffe, 2010). Though advocacy is more effective than

traditional advertising, it got very little empirical consideration from the researchers.

Empirical investigation of customer advocacy is scant, whereas much work has done

on word of mouth. Customer advocacy is not simply word of mouth, but it is positive word

of mouth and recommending others (Walz, & Celuch, 2010). The marketing literature

reveals a close link between service quality, trust, customer loyalty and advocacy. Service

quality affects trust, thereby affecting loyalty and customer advocacy. This study will work

out on the association of service quality with customers’ loyalty and advocacy; it will also

identify the mediating role of trust between service quality and customer loyalty and

advocacy.

Rational of the Study

It is imperative to ascertain the major factors effecting service quality in hospitals, to

improve the performance and build trust. It was therefore decided to find out those factors,

spell out their association with service quality, and put into practice the delivery of service

quality based on customer perceptions. For more than two decades service quality got

promising attention. Several authors worked on service quality and its impact on customer

satisfaction, loyalty, organizational performance, reputation etc. The subsequent paragraphs

are related to the work done by authors on service quality, with different but important and

associated variables.

Figen & Ebru, (2010) used the Servqual model’s different dimensions in hospitals, to

scrutinize the service quality of public and private hospital and patient satisfaction of

Northern Cyprus. Solayappan, Jayakrishnan, & Velmani, (2011) examined the distinction

between perceived and expected service quality of hospitals while using the Servqual

model in India. Karassavidou, Glaveli, & Papadopoulos, (2009) evaluated the service

quality in NSH (National Service Hospital) in Greece while using Servqual to gauge the

gap between customer perceived quality and expectations. Mostafa, (2005) used the factors

of the Servqual model to judge the service quality of hospitals in Egypt. He circulated 500

questionnaires and congregated data from 332 respondents which showed that perceived

quality was different than expectations.

Alrubaiee, & Alkaa'ida, (2011) worked on the healthcare sector to find out the

association between perceived quality, patient satisfaction and trust. They also considered

the relationship between service quality and trust, with the mediating role of customer

satisfaction. Their findings revealed that all the variables are certainly related to service

quality. They also found patient satisfaction a resilient mediating factor in the relationship

of service quality and patient’s trust. Akbar, & Parvez, (2009) analyzed the impression of

perceived service quality, trust and customer satisfaction on customers’ loyalty. They

composed data from 304 customers in the telecommunication industry and used structural

equation modeling (SEM) for the investigation of the conceptual framework. They revealed

that customer satisfaction and trust have an optimistic influence on customer’s loyalty.

Patawayati, Zain, Setiawan and Rahayu, (2013) scrutinized the intervening role of patient

satisfaction, trust and commitment between service quality and customer loyalty in public

hospitals of Indonesia. Kim & Kandampully, (2011) tested the role of trust and

commitment between perceived justice and customer loyalty in restaurants. They revealed

that trust and commitment are the strong mediators of perceived justice and customer

loyalty. Madjid, (2013) inspected the connection between customer satisfaction and

customer loyalty with the mediating role of trust. He used convenience sampling and

collected the data from 150 clients of a bank in Indonesia.

Yap, Fen, Kew & Lian, (2007) acknowledged the service quality and its control on

customer satisfaction and repurchase behavior in restaurants. They collected the data from

377 respondents, and discovered a positive link of service quality on customer satisfaction

and repurchase intentions. They also erudite that satisfied customers have greater

propensity to purchase again, as compared to service quality. Kheng, Mahamad, Ramayah,

Mosahab, (2010) examined the service quality and its impact on customer loyalty in the

banking sector of Malaysia. They used the Servqual model with five dimensions, to check

the influence of service quality on customer loyalty. They revealed that better service

quality can lead to customer loyalty. Poku, Zakari, & Soali, (2013) analyzed service quality

impact on customer loyalty in the hotel industry of Ghana. They used the Servqual five

dimensions model to assess the service quality impression on loyalty. Dean (2002) worked

on service quality, customer orientation and customer loyalty of a call center of Australia.

He conducted a mail survey, and found that service quality and customer orientation has a

positive link with customers’ loyalty.

Wu, (2011) worked on corporate brand image, and its impact on customer loyalty,

with the mediating role of service quality and customer satisfaction in Taiwan. The results

showed affirmative link of hospital image with service quality, patient satisfaction and

loyalty. Abd-El-Salam, Shawky, & El-Nahas (2013) questioned the service quality with

customers’ satisfaction as a mediator of corporate image and reputation on customers’

loyalty. They found that corporate image and reputation is definitely related to customers’

loyalty. They also rated customer satisfaction as a strong mediator in the relationship

between corporate image and reputation and customer loyalty.

Naik, Anand & Bashir, (2013) identified the relationship of service quality and word

of mouth with patient satisfaction in Indian hospitals. They gathered data from 145

respondents, and found an optimistic association between service quality and word of

mouth communication. Khan and Khan, worked on service quality in the health sector of

Pakistan. They scrutinized in their study the influence of service quality on a patient’s trust.

They found an optimistic influence of service quality on a patient’s trust. Patawayati,

DjumilahZain, MargonoSetiawan and MintartiRahayu (2013) scrutinized the association of

service quality and customer loyalty with the mediating role of patient satisfaction, trust

and commitment in Southeast Sulawesi public hospitals. They used structural equation

modeling (SEM) and revealed that service quality is absolutely related to patients’

satisfaction, trust and commitment and patients’ loyalty. Conferring to their results,

patients’ satisfaction is positively related to patient trust and commitment, but found no

noteworthy effect of patient satisfaction on patient loyalty.

Rendering to Hayes, (2008) the progress of the company is extremely effected by

advocates, more advocates results in more growth. Westbrook, (1987) relates customers’

advocacy with customers’ satisfaction. According to him, positive word of mouth is

conditional to customers’ satisfaction. Walz, & Celuch, (2010) stated that advocacy has

larger impact than traditional advertisement. According to them, satisfied customers talk

good about the company and its services they practiced, and become advocates of the

company by referring others with positive word of mouth. Conferring to marketing

literature, customers’ advocacy is very imperative to get customers and is more effective

than the traditional way of advertising, but got limited consideration by the researchers.

Empirical investigation of customers’ advocacy is insufficient, as compared to word of

mouth and customer repurchase intentions. Customers’ advocacy is not simply word of

mouth, but it is positive word of mouth and indorsing others (Walz, & Celuch, 2010) and

according to Jaffe, (2010) companies should focus on customers, instill trust and

confidence in them and make them advocates. Positive word of mouth is nine times more

effective than advertising (Day, 1971; Walz, & Celuch, 2010).

After reviewing marketing literature, the researcher concluded that several authors

worked on service quality, trust and loyalty, separately or in some combination. However,

customers’ advocacy and customers’ loyalty on the other hand got very limited literature,

particularly in healthcare. Keeping in mind the prominence of advocates in such a

challenging environment with limited empirical evidence, the researcher decided to

conduct this research on service quality, customers’ loyalty and advocacy with mediating

role of trust.

Hence, there is little empirical substantiation available that relates service quality,

with loyalty and advocacy in healthcare globally and particularly in Pakistan, give me an

insight into customer advocacy’s potential.

Conceptual Framework

This section will appraise the preceding literature and the researcher’s contribution

for this study. According to the literature, service quality, trust and customers’ loyalty are

related to each other. However, limited empirical evidence is available on service quality

and customers’ advocacy. Hence, this study will examine the role of service quality and

customer advocacy with mediating role of trust. Advocacy is a new term in marketing

terminology with limited literature. According to Maxham (2001) service quality effect’s

customer’s trust and trust has a positive impact on customers’ advocacy. Customers’

advocacy is more effective than traditional advertising (Jaffe, 2010). After reviewing the

literature, the researcher is trying to fill the gap by finding out the relation of service quality

and customers’ advocacy. Parasuraman, Ziethaml & Berry, (1985, 1988, and 1994)

identified 5 dimensions of service quality and proposed the Servqual model. Servqual

model dimensions are Tangibles, Reliability, Responsiveness, Assurance and Empathy.

Numerous authors had adopted servqual scale to measure the service quality of healthcare

institution such as; Babakus and Mangold (1992); Figen & Ebru, (2010); Irfan and Ijaz

(2011): Karassavidou, Glaveli, & Papadopoulos, (2009); Lim & Tang, (2000); Manaf &

Nooi,(2009); Mostafa, (2005); Solayappan, Jayakrishnan, & Velmani, (2011) and Youssef,

Nel, & Bovaird, (1995). In this study the researcher is trying to find out the impact of these

dimensions on customers’ advocacy. Hence, this lead to the researcher’s first hypothesis.

H1. Service quality with all its dimensions (Tangibility, Reliability, Responsiveness,

Empathy and Assurance) has a significant impact on customers’ advocacy

Figure No. 12. The First Hypothesis of the Study

Customers are swamped with many options by many competitors with the same or

better offers. Thereby demonstrating how important customers are for companies. Hence

companies resort to different marketing strategies to get and retain customers for a longer

period, and make them loyal in order to get competitive advantage to sustain the market

position. Upright service quality can lead to customers’ loyalty; hence a great deal of

research work has been done by many authors on the relationship of service quality and

customers’ loyalty. Poku, Zakari, & Soali, (2013) investigated service quality and its

impact on customer loyalty in the hotel industry of Ghana. They used the Servqual 5

dimensional model to gauge the service quality impact on loyalty. Kheng, Mahamad,

Ramayah, Mosahab, (2010) analyzed the service quality and its impact on customers’

loyalty in the banking sector of Malaysia. Bloemer, Ruyter, and Wetzels, (1999) conducted

research on service quality and loyalty dimensions. They used 5 dimensions of service

quality and used structural questionnaires for conducting interviews of 708 people in 4

different service industries, including healthcare. Caruana (2002) examined the relationship

of service quality and customers’ loyalty with mediating role of customers’ satisfaction. Lei

SERVQUAL

1. Tangibility

2. Reliability

3. Responsiveness

4. Empathy

5. Assurance

Customers’

Advocacy

and Mac (2005) examined the service quality impact on customers’ loyalty in Macau. In

the light of the above literature, the researcher prepared his second hypothesis which is:

H2. There is a positive association between service quality and customers’ loyalty

Figure No.13. The Second Hypothesis of the Study

Trust between service providers and consumers is very imperative for long-term

relationship (Laaksonen et al., 2009). Trust is very crucial for patient doctor association in

health-care services. Similarly Kowalski et al., (2009) said that trust is very important

between doctor and patient for the treatment to be successful and it also determines the

patients’ gratification level. Gremler et al., (2001) argued that patients talk good about their

doctors is because of trust and when they don’t trust their doctors they switch to another

doctor when services required. Thus, for long term patient-doctor relationship trust plays a

positive role, therefore the subsequent hypothesis can be built.

SERVQUAL

1. Tangibility

2. Reliability

3. Responsiveness

4. Empathy

5. Assurance

Customers’

Loyalty

H3. The higher perception of service quality leads to higher customers’ trust

Figure No.14. The Third Hypothesis of the Study

Service quality built the image of the company and also has a positive impact on

firm’s performance but it cannot alone always convert the current buyers into loyal buyers

(Reichheld, 1996). Customers trust is a source of transaction for customers and it is directly

related to customer loyalty (Ribbink, Liljander & Streukens, 2004). Rauyruen & Miller,

(2007) stated that it is trust that increase the level of loyalty and loyal customers remains

with the company for a longer period. For Kenning, (2008) trust is a dimension of customer

loyalty. Hence trust plays a vital role in producing loyal customers, it provide the base to

build the 4th hypothesis of the study;

H4. The customers’ score high on trust exhibit enhanced customers’ loyalty

Figure No.15. The Fourth Hypothesis of the Study

TRUST LOYALTY H 4

Advocates use positive word of mouth, persuade others and also make repeat

purchases (Payne et al., (1999). Advocates with its extreme form of positive word of mouth

can bring more customers to company and thus enhance the market share of the company

(Hayes, 2008). According to Walz, & Celuch, (2010) positive word of mouth is more

effective in the service sector, where customers cannot touch and practice the service

before its purchase. Advocates are those who are pleased from the company, they trust

company and talk respectable about the company, (Andreasson & Lindestad, 1998;

Zeithaml, Berry, & Parasuraman, 1996). Advocate is a new term evolved in marketing

hence very little empirical work is available. Trust is positively associated with advocacy

(Afridi and Arif, 2015). Previous work done on trust and word of mouth communication,

however very limited empirical evidence is available on trust and advocacy relationship.

Therefore the author designed the fifth hypothesis of the study.

H5. The greater the level of trust, the greater the level of customers’ advocacy

Figure No.16. The Fifth Hypothesis of the Study

Service quality alone does not always produce loyal customers (Reichheld, 1996).

Hence to mature a long term relationship with customers there must be something tangible

between buyer and seller, and according to Sharma, (2003) trust is the important factor that

assures company-customer elongated relationship. Trust has gained significant importance

in marketing literature and seen as mediating variable of customers’ loyalty. According to

Ribbink, Dina, Allard, Van (2004) trust intervenes between customers’ loyalty and service

quality. Reichheld and Schefter (2000) declared trust as a condition for loyalty and it is

imperative for companies to first instill trust and confidence in customers in order to make

TRUST ADVOCACY H 5

them loyal. Hence trust plays a vital role in mediating between service quality and

customer loyalty. The above literature has given the base for making the third hypothesis

for this study.

H6. Trust mediates the relationship between service quality and customers’ loyalty

Figure No. 17. The Sixth Hypothesis of the Study

A new term in marketing terminology is customers’ advocacy which is very

significant as advocates talk confidently about the company, recommend others and

purchase again from the company (Payne, Christopher, Clark & Peck, 1999). Positive word

of mouth depends on how much a customer is contented with the service or product he/she

experienced (Westbrook, 1987). Hayes, (2008) links company’s growth with advocates.

More advocates means that more people are doing the marketing for the selected company

and recommending it to others. Literature highlights the importance of “advocates” of a

company in the market. However very limited literature is available that links service

quality with customers’ advocacy directly, and also limited work was found on the impact

of service quality on customers’ advocacy with mediating role of trust, thus it lead the

researcher to the 7th hypothesis.

SERVQUAL

CUSTOMER

LOYALTY

H7. Trust intervenes the association between service quality and customers’ advocacy

Figure No.18. The Seventh Hypothesis of the Study

Numerous studies on the measurement of service quality has been done in both

public and private sector hospitals in several countries. Andaleeb (2000) measured the

service quality of public and private hospitals of Bangladesh and found private hospitals

service better than public ones. Similarly, Arasli, Ekiz and Katircioglu (2008) found that

private hospitals in Northern Cyprus are providing better service quality than public

hospitals. Irfan and Ijaz (2011) analysed the service quality in both public and private

hospitals of Pakistan and found that private hospitals are providing superior service quality

than public hospitals. Keeping in view the importance of service quality for hospitals,

researcher designed the 8th hypothesis for the current study

H8: The perception of patients regarding the service quality, trust, advocacy and loyalty is

higher in private sector than in public sector hospitals.

SERVQUAL

CUSTOMER

ADVOCACY

Conceptual Model

Based on the available literature, the researcher designed the theoretical framework for this

study as;

Figure No. 19. The Theoretical Framework of the Study

SERVQUAL

1. Tangibility

2. Reliability

3. Responsiveness

4. Empathy

5. Assurance

Customers’

Advocacy

Customers’

Loyalty

CHAPTER 3

RESEARCH METHODOLOGY

This section of the thesis explicates the methods used to accomplish research

objectives and answers to research questions. Research philosophies, research approach,

research strategy and research design all are deliberated by the researcher. Survey design,

data collection, instrument’s reliability validity and methods of statistical analysis are

presented. Discussion related to quality principles and ethical values are also conversed in

this chapter.

Research Philosophy

Research philosophy is associated to the expansion and nature of knowledge

(Saunders, Lewis, Thornhill, 2009). Research philosophy for business and management

researchers, is very imperative to know, because research philosophy will lead them to pick

the right research strategy (Johnson and Clark, 2006; cited in Saunders, Lewis, Thornhill,

2009). Research philosophy comprises of three types of philosophies; positivism,

interpretive and realism. (Bryman and Bell, 2007, p. 4-26; cited in Saunders, Lewis,

Thornhill, 2009)

This research is grounded on positivism assumptions, as the researcher is testing a

theory through hypotheses. The researcher is optimistic in his assumptions based on

practical experience and prior knowledge. The researcher got a broad vision about the

Servqual model and its influence on trust. The researcher undertakes that better service

quality will build trust in society, which will further create loyalty and advocacy.

Research Approach

Every researcher will use a research approach for his/her study. Research approach

entails two types of approaches; deductive and inductive research approaches, and can be

nominated conferring to the selected research philosophy (Saunders, Lewis, Thornhill,

2009).

Inductive approach is used when the researcher is trying to present or proposes a new

theory based on literature. It will be conducted while using qualitative data collection

techniques. Whereas in deductive approach, the theory is previously available, researchers

are trying to test that theory through quantitative data collection technique. For this

research, the researcher uses the positivism research philosophy, hence using the deductive

approach, in which the researcher is testing the theory already available.

Survey Design

Researchers can use several strategies for their study grounded on personal

preferences and the nature of their studies. The strategy used for this study is Survey, which

is related to deductive approach (Saunders, Lewis, Thornhill, 2009; cited by Hussain &

Rehman 2012). Hence this study adopted the deductive and quantitative approach,

therefore the survey strategy favored to collect data (Bryman & Bell, 2015; cited by

Hussain & Rehman 2012).

Research Strategy

Research strategy is a plan that permits researchers to best pick their research

questions and suitable research methodology to answer the research questions (Saunders,

Lewis, and Thornhill, 2009; cited by Hussain & Rehman 2012). There are two research

strategies i.e. qualitative and quantitative research strategies. Quantitative research results

in numerical data can be conducted via questionnaires, graphs and statistics, whereas

qualitative techniques can be conducted via interviews (Saunders, Lewis, and Thornhill,

2009; cited by Hussain & Rehman 2012)

For this study, the researcher has used the quantitative research strategy and designed

a questionnaire with the help of literature. The motive behind using the quantitative

research strategy is that this research is using positivism research philosophy and hence a

deductive approach by testing a theory that is previously available.

Data Collection Procedure

There are two common bases of data collection, which are; primary and secondary

source. Primary data is the information gathered by the researchers/scientists for the first

time (Sekaran, 2003), and new data explicitly for research purpose (Saunders, Lewis,

Thornhill, 2009: cited by Hussain & Rehman 2012). Secondary data is the data that is

previously obtainable on various sources such as; books, Internet, newspapers, journals,

articles, web pages etc (Ghauri & Gronhog, 2005), and the data that is already collected for

other purpose is called secondary data (Saunders, Lewis, Thornhill, 2009).

For the current study, the researcher used both the sources; primary and secondary for

data collection. The instrument adopted for survey to get the patients’ responses is the

primary data (Saunders, Lewis, Thornhill, 2009). This research is based on deductive

approach, hence quantitative technique used, and therefore primary data source is adopted

for data collection. The researcher also used secondary data for this study, the data

collected from several books, journals, articles and official websites.

Sampling Technique and Sample Size

Non probability convenience sampling technique used for the circulation of

questionnaires because of the lack of complete record of the patients’ attendants therefore

the result acquired from it may not be completely generalized for the whole population

(Cooper and Schindler, 2003). Non probability sampling technique also used because the

study was based on health institutions and the data need to be filled by the patients,

attendants and recently discharged patients. A total of 600 questionnaires were circulated

for this study in various public and private sector health institutions of Peshawar. A self-

administered structured instrument was used to collect the data from patients and their

attendants. Patients were approached by visiting the OPD, and other departments including

Cardiology, Ear and Throat, Nephrology, Neurology and Orthopedic departments. Data

was collected from Peshawar Hospitals only, because Peshawar is the capital and the

largest city of the Province, and also because all major hospitals are placed in Peshawar

city. Out of 600 circulated instruments 510 responses were collected by the researcher with

18 missing values, hence the researcher got 492 responses with response rate of 82%.

Measures and Instruments

In order to measure the affiliation of service quality, customers’ loyalty, customers’

advocacy and trust, a survey was conducted by using a structured instrument in private and

public sector hospitals. The instrument comprises of two key portions, in the first part the

questions requested were concerning the demographic profile, such as; age, gender,

education, profession, type of treatment, source of cure and type of hospital i.e., private or

public. Part two of the instrument was designed to measure the effect of elucidated

variables in the study on each other.

For measurement of service quality, the instrument designed by Parasuraman, Berry

and Zeithaml, (1988) was used with slight amendments done by Babakus and Mangold,

(1992). The revised instrument entails 15 items out of which three items for “Tangibles”,

three for “Reliability”, three for “Responsiveness”, two for “Empathy” and four for

“Assurance”. The Servqual model faced much criticism, particularly the expectation

aspects of servqual model; the P-E gap scores, long questionnaire and the validity of the

dimensions (Babakus and Boller, 1992, cited by Jain and Gupta, 2004). Expectations keep

changing; a person’s expectations 10 years ago would not be same in the current era. A

person might expect higher than what he/she was expecting before. Hopes may also dump

with passage of time (Buttle, 1995).

Cronin and Taylor, (1992) were among those who criticized the measurement scale of

the Servqual model. According to them the Servqual scale was marginally perplexing

regarding customer’s gratification. They proposed that the expectation part of the Servqual

scale should be detached and quality can be measured by using only perceived quality

(Cronin and Taylor, 1992, cited by Jain and Gupta, 2004). Due to more calculation required

while computing the difference between perception and expectations of service quality,

numerous researchers had used the perception part of the Servqual scale alone (Jones and

Leonard, 2007; Lee and Lin, 2005; Van Dyke, Kappelman and Prybutok, 1997; Wu, Lin

and Cheng, 2009; cited by James, Jiang, Klein, Parolia and Li, 2012).

Keeping in mind the nature of computing of the difference of perception, expectation,

the length of the Servqual scale and changing conduct of expectations, the researcher

decided to use only the perceived performance part of the Servqual scale for ascertaining

service quality.

The measurement scale used by Alrubaiee & Alnazer (2010) for patient’s trust is

assumed for the measurement of patient’s trust in this study. Patient’s trust measurement

scale comprises of nine items.

Customers’ loyalty contains three parts; attitudinal, behavioral and affective loyalty.

The measurement scale used by Foster and Cadogan, (2000) preferred to measure

“Attitudinal Loyalty” and Behavioral “Loyalty” with minor adjustments done for the health

sector. Behavioral and Attitudinal Loyalty scales consist of three items each. The Pedersen

and Nysveen, (2001) Affective Loyalty scale is elected for the analysis of Affective

Loyalty in this study with slight modification done for the health sector.

The measurement scale used by Maxham-III, (2001) for customer advocacy is

selected to gauge customers’ advocacy for this study. The advocacy scale consists of four

items. A five point Likert scale used to measure all the variables; from one “Strongly

Disagree” to five “Strongly Agree”.

Operational Definitions of Variables

Service quality. Service quality is assessment of the service by the customer

(Eshghe, Roy, & Gangoli, 2008) or the degree to which the customers’ perceived the

service quality (Cronin and Taylor, 1992).

Customer loyalty. Customer loyalty is defined as a loyal customer talking upright

about the firm and its product/service purchases repeatedly and recommends the company

to others (Bowen and Shoemaker, 2003).

Trust. Trust is defined as a belief or confidence that one party has on another party

that will deliver the service or product according to anticipations (Anderson and Narus,

1990; Dwyar, Schur and Oh, 1987; Morgan and Hunt, 1994; Morman, Deshpande and

Zaltman, 1993; Sanzo, Santos, Vezquez, and Alvarez, 2003; Schurr & Ozanne, 1985).

Advocacy. An advocate is defined as “someone who actively recommends you to

others, who does your marketing for you” (Payne, Christopher, Clark, Peck, 1999). White

and Schneider (2000) defined advocates as “happy customers who enthusiastically

participate themselves in positive word of mouth while marketing for an organization”.

Statistical Analysis

Statistical examination further consists of Descriptive and Inferential statistics.

Descriptive statistics is used for simple portrayal of the variables such as what the data is or

what does it shows, whereas inferential statistics support in reaching to a conclusion that

may not be conceivable with the instant data alone. Descriptive statistics is very imperative

to recognize the pattern of responses in the instrument. They help us to present the

quantitative description in a systematized form, making it logical. Descriptive statistics

describes the frequency distribution, center tendency of measures (Mean, Median and

Mode), Standard Deviation and tests of internal consistency (Cronbach’s Alpha).

Inferential Statistics

Inferential statistics help in reaching a conclusion that may not be possible with the

abrupt data alone. Through inferential statistics, one can inspect the model through various

tests in order to reach to a conclusion. It consists of Structural Equation Modeling (SEM),

Linear Regression, Multiple Regression, T-tests, and Analysis of Variance (ANOVA) etc.

For this research the research used SEM and CFA to check the model and hypotheses.

Social science research constructed on theoretical concept always faces measurement

errors, and that is either because of the researcher, or respondents understanding of the

concept. Cheng (2001) suggested a solution to researchers, and that is to test the

hypothesized association among the variables before computing the model. The core

objective behind the testing of the model is to get a close goodness-of –fit between the

empirical sample and theorized model. For such purpose the researcher tests the variables

separately, and at the end all together. In order to diagnose whether or not the data fits the

hypothesized model, the researcher conducts Confirmatory Factor Analysis (CFA).

Structure Equation Modeling has been used for CFA using AMOS 21.

Hence, the instruments are purely adopted, therefore Confirmatory Factor Analysis

performed instead of Exploratory Factor Analysis. Exploratory Factor analysis used for

exploratory research, where the researcher is trying to identify the factors and its constructs

(Child, 1990). In CFA, many statistical tests were used to determine how well the model

fits the data. The fit indices include Chi-Square, Comparative Fit Index (CFI), Goodness-

of–Fit Index (GFI), Root Mean Square Error of Approximation (RMSEA) and Root Mean

Square Residuals (RMR).

The Chi Square test indicates the gap between observed and expected covariance

matrix. The closer the value to zero shows a better fit (Gatignon, 2010). Here the

significant Chi Square doesn’t mean a fit model; in fact, an insignificant Chi-Square will

lead to a fit model. But unfortunately Chi-Square alone cannot tell the entire story. As with

small sample size the researchers may accept a bad model, and in a large sample size it may

reject a good model. Hence, in a large sample size the Chi square value would be

significant, but it doesn’t mean that the model is not a good fit. For such reasons there are

other fit indices such as GFI, CFI, RMSEA and RMR (Hooper, Coughlan & Mullen, 2008).

Comparative Fit Index provides full co-variation in the data and values greater than

0.9, show an acceptable fit to the data (Hu & Bentler1999). It reflects the variation of the

empirical data with the theoretical model and values close to one indicates less variation of

the empirical data with the theoretical model. Goodness of Fit is another index of a fit

model. GFI provides the complete degree of fit and it ranges from 0 and 1. Value close to 1

is considered as a good model. Value more than 0.9 indicates acceptable model, and value

equal to 1 is considered as fit model (Baumgartner & Homburg, 1996).

Another fit index is RMSEA which avoids issues of sample size, and range from 0 to

1, where the value closest to zero is considered as a good fit. RMSEA value 0.06 or less

indicates an acceptable model (Hu & Bentler1999). Root Mean Square Residual (RMR) is

“square root of the mean of the squared residuals”. RMR value from zero to one, value less

than 0.05 is considered as a good fit (Hu & Bentler1999).

Structural Equation Modeling

Structural Equation Modeling also called Confirmatory Factor Analysis, Covariance

Structure Analysis, Latent Variable Analysis and LISREL Analysis. The use of SEM

application across several disciplines is just because it offers a simple method of dealing

with multiple associations, and is more efficient than other applications. It is also very

convenient as it appraises the relationships absolutely, and help the researchers to move

from the exploratory to confirmatory analysis (Hair, Black, Babin, Anderson, & Tatham,

2006).

Structural Equation Modeling is testing a model in order to figure out the goodness-

of-fit between the hypothesized model and sample data. If the goodness-of –fit is tolerable,

then the model is fit, and on the other side, if the goodness-of-fit is intolerable then the

model is not fit (Byrne, 1998).

Statistical Software

Statistical software packages have made the job easy for the analysis of Descriptive

and Inferential Statistics. These packages have not only made the researcher’s job easy but

also give error free results with great efficiency. Statistical Package for Social Sciences

(SPSS) has been used for descriptive analysis such as frequency distribution, Mean,

Standard Deviation etc. For Inferential statistics such as Structural Equation Modeling

(SEM) Analysis of Moment Structures (AMOS) has been chosen.

Pilot Study of the Survey Instrument

A pilot study was accompanied in order to check the internal reliability of the

measures and to examine the readability of the questions. Around 80 questionnaires were

circulated while using non probability sampling technique for this purpose. A total of 60

questionnaires were returned with response rate of 75 %.

Validity and Reliability of the Instrument. The validity of the instrument is the

extent to which a test is subjectively discovering all the relevant-and only relevant aspects

of the measures. In order to check how accurately the measures related to its construct the

researcher perform face validity of the instrument. Face validity is the content of a measure

appears to reflect the construct being measured (Burns and Bush, 2004). For this purpose

the questionnaire was discussed with two experts, some doctors and administrative staff of

the hospitals. The comments and suggestions were incorporated and then the instrument

was used for survey.

Reliability of the instrument is the degree to which it is free from random error. A

reliable instrument increases the chances of error free results (Kirby, 2011, p. 69). For the

current study instrument reliability tests of internal consistency (Cronbach’s Alpha) was

conducted. The values of Cronbach’s alpha ranged from 0.838 for trust and to 0.861 for

advocacy (Table 4). According to Burns & Bush, 2003, values of Cronbach’s alpha close to

1.00 shows more reliability of the scale. The lower limit for Cronbach’s alpha values is 0.6

(Hair, Black, Babin, Anderson & Tatham, 2006).

Table 4

Descriptive Statistics and Reliability of the Instrument (N=60)

Minimum Maximum Mean Std. Deviation Alpha

Servqual 15 75 45.95 11.15 .86

Tangibility 3 15 9.25 2.87 .85

Reliability 3 15 9.00 2.87 .84

Responsiveness 3 15 8.75 2.87 .85

Empathy 2 10 5.65 2.07 .85

Assurance 4 20 13.12 2.68 .84

Trust 9 45 27.56 6.65 .83

Loyalty 9 45 28.05 6.16 .84

Advocacy 4 20 13.33 2.83 .86

Confirmatory Factor Analysis for Service Quality

For the validation of servqual instrument, Confirmatory factor analysis run in AMOS.

The model was found fit with chi square value of 5.44, 5 degree of freedom. Other fit

indices like relative chi square (CMIN/DF) value of 1.3, goodness of fit (GFI) 0.96,

comparative fit index 0.992, root mean square residual (RMR) 0.05 and root mean square

error of approximation 0.07. All the values of fit indices were found within threshold

marks, illustrates a good fit.

Figure No. 20. Confirmatory Factor Analysis for Service Quality (Pilot Study)

Table 5

CFA for Service Quality (N=60)

Standardized Loadings* Std. Error Mean

Tangibility .74 .37 9.25

Reliability .77 .37 9.00

Responsiveness .76 .37 8.75

Empathy .75 .26 5.65

Assurance .89 .34 9.30

Chi Square=5.54, DF=5

, CMIN/DF=1.3

GFI=0.96, CFI =0.92

RMR=0.05, RMSEA=0.07

Note. *=All values significant at p<0.05

Confirmatory Factor Analysis for Trust

Confirmatory factor analysis was also conducted for trust to check the reliability and

validity of the instrument. After conducting CFA for trust, finding revealed that the chi

square value of 41.854, with 27 degree of freedom and value of relative chi square

(CMIN/DF) of 1.55. The value of GFI 0.92, CFI 0.94, RMR 0.06and RMSEA 0.07 all

found within threshold region. In the lights of above mentioned goodness of fit indices the

trust instrument was found fit.

Figure No. 21. Confirmatory Factor Analysis for Trust (Pilot Study)

Table 6

CFA for Trust (N=60)

TRT1 .48 .14 3.08

TRT2 .49 .14 2.80

TRT3 .58 .13 3.21

TRT4 .58 .14 2.70

TRT5 .77 .13 3.05

TRT6 .74 .12 3.15

TRT7 .78 .14 3.10

TRT8 .60 .12 3.31

TRT9 .75 .13 3.15

Chi Square=41.854, DF =27

CMIN/DF=1.55

GFI=0.92, CFI =0.90

Note. *=All values significant at p<0.05, TRT=Trust

Confirmatory Factor Analysis for Customer Loyalty

Similarly confirmatory factor analysis investigated for customer loyalty for pilot

study. The fit indices for customer loyalty model were not satisfactory initially. The model

was then considered in the lights of modification indices and found that the item no 2 and 3

of behavioral loyalty were highly correlated. The correlation between the 2nd and 3rd item

of behavioral loyalty was drawn with the help of path diagram and run CFA again. This

time the model was found fit with chi square value of 77.9, with 22 degree of freedom,

CMIN/DF 2.99, GFI 0.92, CFI 0.90, RMR 0.065and RMSEA value of 0.074. All the

indices found within their respective range that shows an acceptable model.

Figure No. 22. Confirmatory Factor Analysis for Customer Loyalty (Pilot Study)

Table 7

CFA for Customer Loyalty (N=60)

ATLOY1 .70 .14 3.25

ATLOY2 .73 .13 3.28

ATLOY3 .63 .14 3.25

BEHLOY1 .64 .14 3.03

BEHLOY2 .08 .13 2.98

BEHLOY3 .31 .15 3.10

AFFLOY1 .62 .12 3.20

AFFLOY2 .71 .14 3.01

AFFLOY3 .65 .13 2.93

CMIN/DF=2.99

GFI=0.92, CFI =0.90

Note. *=All values significant at p<0.05, ATLOY=Attitudinal Loyalty,

BEHLOY=Behavioral Loyalty, AFFLOY=Affective Loyalty

Confirmatory Factor Analysis for Customer Advocacy

Confirmatory factor analysis was also checked for customer advocacy for pilot study.

After running CFA, the chi square value of 4.95 with 2 degree of freedom, CMIN/DF

2.478, GFI 0.961, CFI 0.972, RMR 0.042 RMSEA 0.06 was found fit, which further

illustrate that the instrument is a valid instrument.

Figure No. 23. Confirmatory Factor Analysis for Customer Advocacy (Pilot Study)

Table 8

CFA for Customer Advocacy (N=60)

Items Standardized Loadings* Std. Error Mean

ADV1 .79 .14 3.23

ADV2 .83 .13 3.20

ADV3 .83 .14 3.10

ADV4 .65 .13 2.93

Chi Square=4.95, DF = 2

CMIN/DF=2.47

GFI=0.99, CFI =0.97

Note. *=All values significant at p<0.05, AD=Advocacy

Confirmatory Factor Analysis for Overall Measurement Model of Pilot Study

After verifying the individual scales through CFA, this time the researcher investigate

the overall measurement model to check the similarity between the proposed theoretical

model and empirical model. In other word to know how much latent variables fit to their

measures. After running the CFA for overall measurement model, it was found fit with chi

square value of 1210, df 318, CMIN/DF 3.8, GFI 0.93, CFI 0.91, RMR 0.06 and RMSEA

0.077. All the fit indices were within the acceptable zones, which illustrate that the model is

a reasonable fit model. In the lights of above goodness of fit indices, it can be concluded

that the empirical model fits the theoretical model, hence can be analyzed for overall

structural model.

Figure No. 24. Confirmatory Factor Analysis for Overall Measurement Model (Pilot

Study)

Confirmatory Factor Analysis for Overall Structural Model for Pilot Study

Confirmatory factor analysis was investigated for overall structural model. Initially

the model fit indices were not satisfactory and the model was checked in the lights of

modification indices. After considering the model through modification indices it was

found that the behavioural loyalty second and third item highly correlated. Hence with the

help of path coefficient correlation were made and run the CFA again. This time the model

was found fit with chi square value of 1080, df 290, CMIN/DF 3.7, GFI 0.945, CFI 0.921,

RMR 0.07 and RMSEA 0.08. all the goodness of fit indices were within acceptable zones,

hence it can be concluded that the structural model is a reasonable good model.

Figure No. 25. Confirmatory Factor Analysis for Structural Model (Pilot Study)

Table 9

Model Fit Indices for Pilot Study

Instrument Chi Square DF CMIN/DF GFI CFI RMR RMSEA

Service Quality 5.44 5 1.3 0.96 0.992 0.05 0.07

Trust 41.85 27 1.5 0.92 0.94 0.06 0.07

Loyalty 77.9 26 2.9 0.92 0.90 0.065 0.07

Advocacy 4.95 2 2.4 0.96 0.97 0.04 0.06

Measurement Model 1210 318 3.8 0.93 0.91 0.06 0.07

Structural Model 1080 290 3.7 0.94 0.92 0.07 0.08

Pearson Correlation of Pilot Study

Pearson correlation Matrix of the pilot study illustrates that all the variable are

positively correlated. It concludes that changes in one variable effect other variable

positively. R-Square is the coefficient of determination that indicates how healthy that data

fits a statistical model. It ranges from 0 to 1, where 0 indicates no variation caused by

endogenous variable, and 1 specifies the variation in exogenous variable fully explained by

endogenous variables (Draper, Smith, 1998; Glantz, Stanton, Slinker, 1990; Steel, Torrie,

1960). The results of Pearson correlation for the pilot study shows that service quality,

trust, customers’ loyalty and customers’ advocacy are positively correlated.

Table 10

Correlation Matrix of Pilot Study (N=60)

SQ Loyalty Advocacy TRUST

Service Quality Pearson Correlation ----

Loyalty Pearson Correlation .555** ----

Advocacy Pearson Correlation .427** .716** ----

TRUST Pearson Correlation .683** .591** .473** ----

Note, **=significant at p<0.001, SQ=Service Quality

Ethical Consideration

Rendering to Sekaran (2006) ethics for research are the adequate moralities that a

researcher espouses while conducting a research. This means that ethics in research is

focusing and following on research standards. A researcher should follow the standards of

the research from start to end.

Hence, the current study is a quantitative in nature and has a straight influence on the

participant, consequently ethical values have been taken care of. Participants were

informed about the objective of the study which was purely for educational purpose. They

participated voluntarily and their privacy has been protected. Ethics had also been followed

by conducting the research according to research standards.

CHAPTER 4

RESULTS AND ANALYSIS

Findings and Analysis are absolutely indispensable for research. In this chapter the

researcher investigated the results of data composed in response to the research problems

specified in Chapter one. In the succeeding sections of this chapter, the researcher will

deliberate the descriptive analysis and the inferential statistics of the data in detail.

Response Rate

A total of 600 questionnaires were circulated among new patients, out patients,

hospitalized patients their attendants and recently discharged patients of different public

and private hospitals of Peshawar. Out of 600 disseminated questionnaires, 510 were

returned by respondents with 18 instruments having missing values. Hence the valid 492

questionnaires with response rate of 82% were got back by the researcher for investigation

purpose. The questionnaire was separated into two parts, in the first part, questions were

enquired regarding demographic profile of respondents, while the second portion contained

questions concerning different variables used for this research. Demographic variables used

for this study are; the age, gender, education level, profession etc. Descriptive statistic,

frequency and percentage of the data is discussed in the subsequent section of this chapter.

Descriptive Statistics of the Demographics

Gender. Table 11 shows the gender description of the respondents. The data shows

that both male and female partaking were almost equal. The number of male respondents

are 250 comprising 50.8% of the total sample size, whereas females also participated in

large numbers of 242 with a valid 49.2 % of the total sample size.

Table 11

Gender Specification of the Respondents (N=492)

Frequency Percent Valid Percent Cumulative Percent

Male 250 50.8 50.8 50.8

Female 242 49.2 49.2 100.0

Total 492 100.0 100.0

Age. Age for this study is segmented into five groups, starting from below 20, 21-30,

31-40, 41-50 and 50+. Table 20 shows that the mainstream of the respondents are of the

age group 21-30 holding 47.8% of the total respondents. The second highest number of

respondents is from the age group 31-40, and comprises 27.4% of the total sample size.

Table 12

Age of the Respondents (N=492)

Less than 20 46 9.3 9.3 9.3

21-30 235 47.8 47.8 57.1

31-40 135 27.4 27.4 84.6

41-50 54 11.0 11.0 95.5

50+ 22 4.5 4.5 100.0

Total 492 100.0 100.0

Hospital. The data for the current study comprised of public and private sector health

institutions. A total of 212 questionnaire were collected from private sector health

institutions that covered around 43% of the total respondents of the data, whereas 280 no of

questionnaire returned from public sector health institutions and covered around 57% of

total respondents.

Table 13

Public and Private Health Institutions

Private 212 43.1 43.1 43.1

Public 280 56.9 56.9 100.0

Total 492 100.0 100.0

Education. The education segment was further alienated into “Elementary education,

Secondary Education, Graduate, Diploma and University. Table 14 shows that the majority

of the respondents were university graduates (n=234), comprising 47.6 % of the total

respondents, followed by graduate level (n=127) with 25.8 %.

Table 14

Educational Level of the Respondents (N=492)

Elementary School 33 6.7 6.7 6.7

Secondary Education 68 13.8 13.8 20.5

Graduate 127 25.8 25.8 46.3

Diploma 30 6.1 6.1 52.4

University 234 47.6 47.6 100.0

Total 492 100.0 100.0

Profession. Table 15 shows the profession profile of the respondents, and it is vibrant

that majority of the respondents are those that are unemployed, or studying, or depending

on other family members (n=222) comprising 45.1 % of the total sample size. The second

highest number of respondents are private employees (n=137) comprising valid percentage

of 27.8. Government servants are 72 in the respondent list with 14.6% of the sample size.

Table 15

Profession of the Respondents (N=492)

Government Servant 72 14.6 14.6 14.6

Private Employee 137 27.8 27.8 42.5

Entrepreneur 59 12.0 12.0 54.5

Other 222 45.4 45.4 100.0

Total 492 100.0 100.0

Descriptive Statistics of the Variables

Table 16 shows the descriptive investigation of the variables used for this study. the

Cronbach’s alpha score is above 0.6 shows that all instrument selected for current study are

valid. However, alpha value is sensitive to number of items, therefore the validity and

reliability is also analyzed through confirmatory factor analysis in the subsequent section.

Table 16

Internal Consistency and Reliability (N=492)

Minimum Maximum Mean Std. Deviation Alpha

Servqual 15 75 46.69 9.44 .87

Tangibles 3 15 9.36 2.52 .83

Reliability 3 15 9.25 2.45 .84

Responsiveness 3 15 9.32 2.31 .83

Empathy 2 10 5.99 1.64 .84

Assurance 4 20 12.75 3.11 .82

Trust 9 45 28.48 5.76 .84

Loyalty 9 45 28.97 5.25 .85

Advocacy 4 20 13.24 2.37 .84

Inferential Statistical Analysis

In the above descriptive analysis section, the researcher pronounced the sample data,

which was important to know the pattern of the data and the profile of the respondents.

However, descriptive analysis alone cannot conclude the research. For the conclusion one

might need inferential statistical analysis. In the succeeding section the researcher

discussed the various tests performed in order to reach to a conclusion.

Confirmatory Factor Analysis for Service Quality

Confirmatory factor analysis used to validate the servqual scale with all its

attributes; such as Tangibility, Reliability, Responsiveness, Empathy and Assurance. The

model got the Chi square value of 316.759, with 80 degree of freedom, significant at p 0.01

level. But chi square is sensitive to sample size, therefore relative chi square (CMIN/DF)

was also considered to appraise the model. The value of relative chi square equal to 3.95

shows that the model is reasonable fit (Marsh & Hocevar, 1985). Further, the other fit

indices such as; the RMR and RMSEA values of 0.048 and 0.078 respectively found within

the acceptable range (Hu & Bentler, 1999) that validate the model fitness. Likewise, the

CFI and GFI of the model were close to one (0.910 and 0.920 respectively) indicate less

variation of the data with the model hence an acceptable fit (Baumgartner & Homburg,

1996; Hu & Bentler, 1999).

Figure No. 26. Confirmatory Factor Analysis of Service quality Dimensions (AMOS)

Table 17

CFA for Service Quality Dimensions

Standardized Loadings* Mean Std. Error

TAN1 0.64 3.02 .05

TAN2 0.78 3.25 .04

TAN3 0.76 3.09 .04

REL1 0.79 3.07 .04

REL2 0.65 3.08 .05

REL3 0.57 3.10 .04

RES1 0.67 3.14 .04

RES2 0.54 3.05 .04

RES3 0.72 3.13 .04

EMP1 0.58 2.97 .04

EMP2 0.50 3.01 .04

ASS1 0.66 3.18 .04

ASS2 0.73 3.26 .04

ASS3 0.75 3.15 .04

ASS4 0.60 3.15 .04

CMIN/DF=3.959

GFI=0.92, CFI =0.91

Note: * All t-values significant at p<.05. TAN=Tangibles, REL= Reliability,

RES= Responsiveness, EMP= Empathy, ASS= Assurance.

Confirmatory Factor Analysis for Customers’ Loyalty

Similarly the customers’ loyalty scale was validated via CFA (see figure no. 27). The

CFA was run and the model got the Chi- square value of 120.937 with 5 degree of freedom,

significant at p< 0.05. The model was checked in the lights of other fit indices, such as;

relative chi square, CFI, GFI, RMR and RMSEA. The CFI and GFI values of 0.947 and

0.905 respectively found well placed in acceptable range (Baumgartner & Homburg, 1996).

Root mean square residual value of 0.052 also placed in acceptable zone, but RMSEA

value of 0.09 was a bit on higher side. Therefore the model was re-examined in the lights of

modification Indices and found that the second and third item of behavioral loyalty were

highly correlated. Hence, with the help of path diagram a correlation was made and then

the model was re-investigated. This time researcher got favorable values of the respective

indices. Relative chi square value of 3.59 indicates reasonable fit model (Marsh & Hocevar,

1985), GFI 0.96, CFI 0.94 found well RMR value 0.038 lie well under the acceptable zone

along with good value of RMR 0.038 and RMSEA value of 0.072 shows an acceptable

model (Hu & Bentler, 1999).

Figure No. 27. Confirmatory Factor Analysis of Customer Loyalty (AMOS)

Table 18

CFA of Customer Loyalty

Indicators Standardized Loadings* Mean Std. Error

ATLOY1 0.73 3.26 .04

ATLOY2 0.67 3.29 .04

ATLOY3 0.63 3.21 .04

BEHLOY1 0.65 3.10 .04

BEHLOY2 0.20 3.01 .04

BEHLOY3 0.34 3.37 .04

AFFLOY1 0.62 3.28 .04

AFFLOY2 0.77 3.20 .04

AFFLOY3 0.69 3.21 .04

CMIN/DF=3.54

GFI=0.96, CFI =0.94

RMR=0.038, RMSEA=0.07

Note: * All t-values significant at p<.05. Note; ATLOY = Attitudinal Loyalty,

BEHLOY= Behavioral Loyalty, AFFLOY= Affective Loyalty

Likewise trust instrument testified with the help of CFA (See figure No. 28). In the

first attempt of validation, other than RMSEA the model fit indices were found within the

threshold values. For instance the GFI and CFI values equal to 0.941 and 0.913

respectively found fit. Similarly the value of RMR 0.048 shows acceptable fit, but the

RMSEA score of 0.091 found higher than the acceptable zone, suggest a poor fit. The

model was retested under the lights of modification indices and found that the first and

second items of trust were correlated. Hence with the help of the path diagram the

correlation was made and the model was run again. This time the researcher got promising

values of the respected indices. Relative chi-square value of 4.1 shows an acceptable fit

(Marsh & Hocevar, 1985). Root mean square residuals value 0.042 drop well in the

acceptable zone along with respectable values for RMSEA value of 0.080 (Hu & Bentler,

1999). Goodness of fit index value of 0.954 and CFI value of 0.936 this time better than

before shows an acceptable model (Baumgartner & Homburg, 1996). Hence all the above

indices values lies in the acceptable zones indicate an acceptable fit.

Figure No. 28. Confirmatory Factor Analysis for Trust (AMOS)

Table 19

Items Standardized Loadings * Mean Std. Error

TRT1 0.56 3.17 .04

TRT2 0.49 3.02 .04

TRT3 0.63 3.16 .04

TRT4 0.54 2.94 .04

TRT5 0.66 3.18 .04

TRT6 0.69 3.22 .04

TRT7 0.71 3.20 .04

TRT8 0.52 3.36 .04

TRT9 0.61 3.19 .04

CMIN/DF=4.1

GFI=0.95, CFI =0.93

Note: * All t-values significant at p<.05. TRT=Trust

Confirmatory Factor Analysis for Customer Advocacy

Customers’ advocacy scale was also validated with the help of CFA (see figure No.

29). The model was found fit by getting all the required fit indices within their acceptance

zone. For instance the Chi-Square value of 9.35 and 2 degree of freedom, non-significant at

p>0.001. The other fit Indices also supported the model with RMR value of 0.033, GFI

equals to 0.991, CFI equals to 0.977 and RMSEA equals to 0.068.

Figure No 29. Shows Confirmatory Factor Analysis for Customer Advocacy

Table 20

CFA for Customer Advocacy

Items Standardized Loadings* Mean Std. Error

AD1 0.66 3.07 .04

AD2 0.81 3.08 .05

AD3 0.75 3.10 .04

AD4 0.30 3.05 .04

CMIN/DF=4.67

GFI=0.99, CFI =0.97

RMR=0.033, RMSEA=0.06

Note: * All t-values significant at p<.05. AD= Advocacy

Confirmatory Factor Analysis for Overall Measurement Model

Once the model was verified via CFA in Amos individually, now the researcher

tested the measurement model. The measurement model consists of Servqual dimensions,

such as Tangibles, Reliability, Responsiveness, Empathy and Assurance. It also contains

Trust as the mediating variable, and customers’ loyalty and advocacy as dependent

variables. In the first attempt of measurement model validation the values of some relevant

indices indicated a poor fit, with Chi- square value of 1188.359 with 293 degree of freedom

significant at p<0.05. Root Mean Square Residuals at 0.095 on higher side, GFI at 0.849

indicated an acceptable fit, but CFI at 0.819 was below the threshold mark of 0.9. Similarly

RMSEA found 0.079 also indicates a reasonably good fit. Then the model was checked in

the lights of Modification Indices and found that some of the error terms of the variables

were highly correlated. Error terms of “Tangibles” correlated with “Reliability” and error

terms of “BEHLOY2” was correlated with “BEHLOY3”. With the help of the path

diagram when the correlations were made the model was run again and found a reasonably

good fit with Chi- square 1067.938, DF =289, CMIN/DF=3.695, RMR = 0.06, GFI =

0.949, CFI= 0.919 and RMSEA = 0.070. The fit statistics also showed the value for

Expected Cross Validation Index (ECVI), which is used to check the cross validation of the

study. ECVI is defined,” as an approximation of the goodness of fit of what the estimated

model would achieve in another sample of the same size” (Hair, Sarstedt, Pieper, & Ringle,

2012). The lower the value of the ECVI would have better likelihood of replication (Byrne,

1998). The ECVI value of this study is on the lower side and indicates greater potential for

replication.

Figure No.30. Confirmatory Factor Analysis for Overall Measurement Model

Pearson Correlation of the constructs

Table 21 shows the Pearson Correlation of the constructs. It shows that all the

constructs are absolutely associated with each other. That shows if one variable increases

other variable will also increase. All the values are significant at p<0.001.

Pearson correlation Matrix of the main study illustrates that all the variable are

positively correlated. It concludes that changes in one variable effect other variable

positively. R-Square is the coefficient of determination that indicates how healthy that data

fits a statistical model. It ranges from 0 to 1, where 0 indicates no variation caused by

endogenous variable, and 1 specifies the variation in exogenous variable fully explained by

endogenous variables (Draper, Smith, 1998; Glantz, Stanton, Slinker, 1990; Steel, Torrie,

1960). The results of Pearson correlation for the pilot study shows that service quality,

trust, customers’ loyalty and customers’ advocacy are positively correlated with each other.

Table 21

Mean Std. Deviation and Pearson Correlation Matrix of the Constructs

Mean S.D TRT ADV TN RL RS EM AS CL

TRT P C 3.16 0.64 ---

AD P C 3.31 0.79 .37** ---

TN PC 3.12 0.84 .49** .23** ---

RL PC 3.08 0.81 .54** .14** .55** ---

RS PC 3.10 0.77 .61** .25** .49** .52** ---

EM PC 2.99 0.82 .56** .34** .38** .35** .55** ---

AS PC 3.18 0.77 .64** .36** .49** .56** .57** .53** ---

CL PC 3.21 0.58 .60** .55** .41** .33** .38** .42** .49** ---

**. Correlation is significant at the 0.001 level (2-tailed). TRT =Trust, AD=

Advocacy, TN=Tangibles, RL=Reliability, RS=Responsiveness,

EM=Empathy, AS = Assurance, CL= Customer Loyalty

Confirmatory Factor Analysis for Structural Model

Confirmatory factor analysis for structure model was also conducted over AMOS.

The overall measurement model consists of Servqual dimensions, such as Tangibles,

Reliability, Responsiveness, Empathy and Assurance. It also consists of Trust as the

mediating variable, and customers’ loyalty and customers’ advocacy as dependent

variables. In the structural model, the Servqual is the exogenous variable whereas

Customers Advocacy, Customers’ Loyalty and Trust as Endogenous variables. Figure 30

shows the result of CFA for structural model. Chi- square 1188.359, DF = 2933,

CMIN/DF=4.056, RMR = 0.071, GFI = 0.901, CFI= 0.899 and RMSEA = 0.079 indicate

reasonably good fit.

Figure No. 31. Confirmatory Factor Analysis for Structural Model (AMOS)

Table 22

Model Fit Indices

Model Chi-Square* DF CMIN/DF RMSEA RMR GFI CFI

Measurement Model 1067.93 289 3.65 0.07 0.06 0.94 0.91

Structural Model 1073.35 293 4.05 0.07 0.07 0.90 0.90

R-Square for Endogenous Variables

Variables R Square

Customer Loyalty 0.54

Customer Advocacy 0.54

Trust 0.77

Note: * All Chi-square tests were significant at p<0.01

Explanation. R-Square is the coefficient of determination that indicates how

healthy that data fits a statistical model. It ranges from 0 to 1, where 0 indicates no

variation caused by endogenous variable, and 1 specifies the variation in exogenous

variable fully explained by endogenous variables (Draper, Smith, 1998; Glantz, Stanton,

Slinker, 1990; Steel, Torrie, 1960).

Overall Model Fit

Table 23 shows the fit statistics of the measurement model and structural model. The

Chi- square of the measurement model is 1067. 938 with 289 degrees of freedom, and for

the structural model it is 1073.359 with 293 degrees of freedom. The difference of Chi-

square of the two models is 5.421 with 4 degrees of freedom. The critical value of Chi-

square with 4 degrees of freedom at p=0.05 is 9.488; hence the difference is non-

significant, which shows that the structural model successfully accounted the observed

relationships among the endogenous variables (Anderson and Gerbing, 1988).

Table 23

Comparison of Goodness-of-fit Indices for the Structural Model

Goodness of Fit Acceptable Fit Level Measures of this Study Acceptability

Chi Square Statistical test of

Significance Provided

Chi- square = 1073.35

Significance Level:000

Root Mean

Square Residuals

Range 0-1. Values less

than 0.05 best fit. Up to

0.08 acceptable fit

RMR= 0.07 Acceptable

Goodness of Fit

Higher values indicate

better fit, values close to

1 consider as better fit.

GFI= 0.90 Acceptable

Comparative Fit

Values greater than 0.9

indicates better fit

CFI = 0.90 Acceptable

Root Mean

Square Error of

Approximation

(RMSEA)

Value up to 0.05 best fit.

Acceptable rang is up t-

0.07 Acceptable

Hypotheses Testing

Structural Equation Model was used for hypothesis testing. Path analysis was

conducted in order to spell out the effect of endogenous variables on exogenous variables.

In this study, Service Quality is the exogenous variable whereas Customers’ Loyalty, Trust

and Customers’ Advocacy are the endogenous variables.

H1. Service quality with its attributes has a significant impact on customers’ advocacy

Hypothesis 1 defines the positive and direct impact of service quality on customers’

advocacy. It was tested via path analysis in AMOS and got the standardized path

coefficient of 0.45 with p-value of 0.001 found highly significant at p<0.01, therefore the

data support the first hypothesis of the study.

Figure No. 32.The First Hypothesis of the Study

H2. Service quality with its dimensions is positively associated with customers’ loyalty

Hypothesis 2 determines the influence of service quality on customer loyalty

unswervingly and confidently. Hence it was tested in AMOS through path analysis and got

the standardized path coefficient value 0.53, p-value of 0.001 found significant at p<0.01,

which specifies that the data sustained the second hypothesis of the study.

Figure No. 33. The Second Hypothesis of the Study

H3. Service quality with its dimensions is directly and positively associated with trust

The third hypothesis of the study is to investigate the straight and affirmative

association between service quality and trust. For examining the association of service

quality and trust the equation was tested in AMOS by conducting path analysis. After the

analysis the R-Square value of 0.65, beta value of 0.81 with p-value=0.001 found

significant at p<0.01. In the lights of the findings it can be concluded that service quality

has a direct and positive link with trust, hence that data supports the 3rd hypothesis of the

study.

Figure No. 34. Path Analysis of Service Quality and Trust (AMOS)

H4. There is a direct and positive impact of Trust on Customers’ Loyalty

Hypothesis No 4 of the study investigates the straight and positive impact of trust and

customer loyalty. For this purpose the equation was examine via path analysis in AMOS.

After the investigation, the researcher got the R-square value of 0.36, beta 0.600 with p-

value of 0.001 found highly significant at p<0.01. Findings illustrates a positive and

unswerving relationship between trust and customer loyalty, hence support the 4th

hypothesis of the study.

Figure No. 35. Path Analysis of Trust and Customer Loyalty (AMOS)

H5. The greater the level of customers’ trust, the greater the level of customers’ advocacy

The fifth hypothesis of the study is to determine the positive and direct impact of trust

with customer advocacy. The equation was tested in AMOS by performing path analysis.

After the analysis the R-square value of 0.14, beta value of 0.375 with p-value of 0.001

found highly significant at p<0.01. Finding revealed that there is a positive and direct

relationship between trust and customer advocacy, hence the data supports the 5th

hypothesis.

Figure No. 36. Path Analysis of Trust and Customer Advocacy (AMOS)

H6.Service quality with trust as a mediator is undoubtedly linked to customers’ loyalty.

Hypothesis No. 6 determines the impact of service quality on customers’ loyalty

indirectly through trust as a mediator. To check the mediating effect, it is important that the

direct impact of service quality on customer loyalty is significant, therefore the association

was tested directly with no mediation and found significant. For the indirect association the

model was run again in AMOS. This time the impact of service quality on customer loyalty

was found nonsignificant after analyzing the p value while performing bootstrap in AMOS.

The standardized direct effect estimate of customer loyalty 0.198 found nonsignificant in

the indirect model at p<0.05 shows a full mediation hence testifies a full mediation and

supports the 6th hypothesis of the study.

Figure No. 37. Path Analysis of Service Quality, Trust and Customers’ Loyalty (AMOS)

H7. Trust plays a mediating role between service quality and customers’ advocacy, thereby

proving its positive relationship.

Hypothesis 7 will spell out the role of trust between service quality and customers’

advocacy. It checked the indirect impact of exogenous variable service quality on the

endogenous variable customers’ advocacy. The researcher repeated the same procedure for

this hypothesis as carried out for hypothesis 6. Path analysis was first analyzed for the

direct association and found significant estimates, hence the association can be examined

for the indirect effect. The indirect effect was examined and found that the standardized

estimate of service quality and customer advocacy reduced as compare to a direct impact.

The standardized direct effect estimate of customer advocacy 0.148 found nonsignificant in

the indirect model at p<0.01 shows a full mediation therefore the data supports the 7th

hypothesis of the study.

Figure No. 38. Path Analysis of Service Quality, Trust and Customers’ Advocacy (AMOS)

Table 24

Results of Hypothesis

Hypothesis Direct Effect Indirect Effect Results

SQ CA 0.45 (0.001)** N/A Significant

SQ CL 0.58 (0.001)** N/A Significant

SQ TRT 0.81 (0.001) N/A Significant

TRT CL 0.60(0.001) N/A Significant

TRT CA 0.37(0.001) N/A Significant

SQ TRT CL 0.19(0.455) 0.333** Full Mediation

SQ TRT CA 0.14(0.266) 0.195** Full Mediation

Note, **=P<0.01, ns= nonsignificant,

H8. The perception of patients regarding the service quality, trust, advocacy and loyalty is

higher in private sector than in public sector hospitals.

Hypothesis no. 8 was to compare the service quality, trust, customers’ loyalty and

advocacy in public and private sector hospitals. After running the independent t test, it was

found that the mean scores of service quality, trust, loyalty and advocacy in private

hospitals, are higher than the mean scores of said variables in public sector hospitals and

found highly significant (see table no 25). Results illustrate that majority of the respondents

perceive that private sector hospitals are providing better service quality, their level of trust

on private hospitals is high. This is because the private hospitals acquired state of the art

equipment, hire competent doctors and supporting staff that are genuinely concerned for

their patients. The difference is statistically significant but relatively small, which is mainly

because of the Provincial Government initiative such as; Sehat Ka Etihad Programme for

Eradication of Polio, 2015; Mobile health service and health cards; Independent Monitoring

Unit; Provision of Free Emergency Service worth RS 1.00 Billion 2014; Provision of

Incentives for Maternal Health Services worth Rs. 300.00 Million; Provision of Incentive

for Immunization Services worth of Rs. 200 Million (Department of Health, Government of

Khyber Pukhtunkhwa, 2017).

Table 25

Results of Independent Sample T-Test

Variables Public Hospitals .

Mean SD N

Private Hospitals .

Mean SD N

Servqual 45.59 10.05 280 48.15 8.37 212 3.00**

Tangibility 9.13 2.48 280 9.67 2.55 212 2.36*

Reliability 9.05 2.43 280 9.51 2.22 212 2.06*

Responsiveness 9.22 2.37 280 9.44 2.22 212 1.03(ns)

Empathy 5.88 1.69 280 6.13 1.57 212 1.66(ns)

Assurance 12.28 3.17 280 13.37 2.93 280 3.94**

Loyalty 28.4 5.5 280 29.7 4.7 212 2.73**

Advocacy 9.6 2.4 280 10.3 2.1 212 3.38**

Trust 27.6 6.08 280 29.5 5.1 212 3.53**

Note; *=p<0.005, **=p<0.01, ns=non-significant

Table no. 25 shows the results of independent t test to determine the difference

between the service quality offered by public and private hospitals of Peshawar. The results

of independent t test interprets that the mean score of service quality of public and private

hospitals are different. The individual constructs of service quality in both public and

private hospitals were checked through independent t test. The subsequent paras contain the

discussion on the individual aspect of service quality.

Tangibility. Independent sample t-test performed to compare the tangibility aspects

of service quality of public and private sectors hospitals of Peshawar. The t- value of 2.36,

significant at p<0.01 shows that tangibility aspect of service quality is better in private

hospitals than in public hospitals. Private hospitals in Peshawar have better infrastructure,

latest equipment and provide clean environment to attract more customers by their

presentation. Other than that private hospital also provide indoor facility for x-ray, MRI,

ECG etc, to save time and energy.

Reliability. Similarly independent sample t-test performed for comparison of

reliability aspect of service quality in public and private hospitals of Peshawar. Result

shows that reliability aspect in private sector is better than in public hospitals with t value

of 2.03 significant at p<0.01. Private hospitals hiring professional members that delivers

best treatment in pleasant environment. Doctors and supporting staff are very polite and

honest with patients, provide services promptly. Patients rely more on private hospitals

doctor as compare to public sector.

Responsiveness. Likewise, the responsive aspect of service quality tested in private

and public hospitals. The mean score of responsive aspect of service quality found better

but insignificant. The result shows that the perception of patients in private sector is higher

regarding responsiveness aspect of service quality, however the findings are not significant

as the probability value is equal to 0.13, shows 13% probability or error.

Empathy. Independent sample t-test also performed to compare the empathy aspect

of service quality in public and private hospitals. The mean score of empathy found higher

in private than in public, but insignificant. It shows that the perception of patients regarding

the empathy aspect of service quality in private hospitals is higher than in public sector

hospitals of Peshawar, however the result is not significant with probability of error equals

to 10%.

Assurance. Likewise, for the comparison of assurance aspect of service quality,

independent sample t-test performed. The t value of 3.92 significant at p<0.01 shows that

assurance aspect of service quality is better in private hospitals as compare to public sector

hospitals. Private hospitals hire professional doctors in all field which assure the patients

that they have been examined thoroughly and the best treatment is provided. Public

hospital’s recruitment system are highly influenced by political interference, due to which

most of the supporting staff at public sector hospitals lack proper skills and professionalism

that lead to dissatisfaction.

Table 26

Summary of Hypotheses Testing

Hypotheses Results

H1 Service quality is positively and directly influencing

customers’ advocacy

Supported

H2 There is an optimistic and straight effect of service

quality on customers’ loyalty

Supported

H3 Service quality is directly and positively associated with

Supported

H4 There is a direct and positive impact of Trust on

Customer Loyalty

Supported

H5 Trust and Advocacy are directly and positively linked Supported

H6 Service quality is positively related to customer loyalty

with trust as a mediator

Supported

H7 Service quality is positively related to customer advocacy

with mediating role of trust

Supported

H8 The perception of patients regarding the service quality,

trust, advocacy and loyalty is higher in private sector

than in public sector hospitals.

Supported

Service Quality, Customers’ Loyalty, Customers’ Advocacy and Trust

After evaluating the various hypotheses of the current study, the overall impact

of service quality on customer loyalty, advocacy with trust as a mediator was also

inspected. The overall association was analyzed through path analysis and it was

found that trust fully mediates the association between service quality, customer

loyalty and advocacy. The standardized beta values of 0.198 and 0.148 for direct

impact of service quality, trust, customer loyalty and advocacy respectively found

nonsignificant at p<0.01. Whereas the values of standardized beta of 0.333 and

0.195 were found significant at p<0.01 in the indirect impact of service quality on

customer loyalty and advocacy through trust as a mediator. Hence the finding

illustrates that trust fully mediates that association.

Figure No. 39: Path Analysis of Service Quality, Trust and Customers’ Advocacy (AMOS)

Table 27

Results of Direct and Indirect Effects

Hypothesis Direct Effect Indirect Effect Results

SQ Trust CL 0.198(ns) 0.333** Full Mediation

SQ Trust CA 0.148(ns) 0.195** Full Mediation

*=p<0.05, **=P<0.01, ns= nonsignificant

CHAPTER 5

DISCUSSIONS AND CONCLUSION

In this chapter, the researcher presents the discussion on the results derived in the

preceding chapter. Core elements of this chapter include; introduction, research results,

discussion based on results derived, implication of research and future recommendations.

The primary objectives of this study includes the perception of service quality, trust,

loyalty and advocacy in public and private hospitals of Peshawar. Moreover, to investigate

the impact of service quality on customers’ loyalty and advocacy directly and through trust

as a mediator. This research was to answer the following research questions. 1) How do

patients consider the relationship between the perceived service quality and their level of

advocacy? 2) What is the degree of relationship between service quality and customers’

loyalty? 3) Whether service quality has any effect on customers’ trust in public and private

hospitals of Peshawar? 4) What is the prevalent level of trust on customers’ loyalty? 5)

How does trust and customers’ advocacy associated? 6) Does trust intervene between

service quality and customers’ loyalty association? 7) How does service quality affect

customers’ advocacy when trust mediates? And 8) Is there any difference worth mentioning

between the mean scores of service quality, trust, loyalty and advocacy of private and

public sector hospitals?

Discussions

The current study inspects the influence of service quality on customers’ loyalty and

advocacy with trust as a mediator. Besides that, this study also investigates the service

quality of various public and private sector health institutions for comparison purpose. The

target papulation for the current study was all the hospitalized and recently discharged

patients and their attendants. Famous service quality model “Servqual” was used to

measure the service quality. The reliability and validity of all the instrument were verified

through confirmatory factor analysis. The results of CFA illustrate that all the measures are

fit to use for the current study. Furthermore, hypotheses were designed and investigated

with the help of path analysis. In the subsequent paragraphs the researcher elaborated all

the hypotheses of the current study.

The first hypothesis of this study was the constructive impact of service quality on

customer’s advocacy. Empirical evidence was in favor of the hypothesis. Findings of the

said assumption showed that there is an optimistic and direct link of service quality with

customers’ advocacy. It illustrates that if hospitals provide better service quality, they can

produce advocates who will talk confidently about the hospital and endorse it to others.

Empirical work on service quality and advocacy is not plentiful, but still the findings of the

current study support the previous researchers’ work (Walz, & Celuch, 2010).

This study was theorized that service quality has an optimistic impact on customers’

loyalty. The results were in favor of the hypothesis after investigating the data. Result

shows an affirmative and direct impact of service quality on customers’ loyalty. It

concludes that when customers are being paid of better service quality from hospitals, their

loyalty will upsurge. The outcomes of this study backing the preceding research on the

impact of service quality on customer loyalty (Cronin, Taylor 1992; Kheng, Mahamad,

Ramayah, Mosahab, 2010); Lei and Mac 2005); Poku, Zakari, & Soali, 2013).

The third hypothesis was concerning the straight and optimistic impact of service

quality on trust. After empirically probing the association of trust and service quality, data

revealed that service quality has an optimistic and straight influence on trust. Trust is very

imperative for long-term relationship between patient and doctor. Enhanced service quality

can inculcate trust in patient, which further steered to long term affiliation. Those patients

they trust their doctors, obey their doctors, select same services when required and

persuade others (Safran et al., 1998; Thom et al., 1999). Findings of the current study back

the former researcher’s work (Alrubaiee, & Alkaa'ida, 2011; Patawayati et al., 2013).

The fourth hypothesis of the study was to inspect the positive and significant

influence of trust on customer loyalty. After inspecting the association it was found that

trust optimistically and directly influencing customer loyalty. The empirical data supports

the hypothesis and thus it can be concluded the higher the trust level in patients will

enhance patients’ loyalty. Loyal customers use positive word of mouth and practice same

hospital services when obligatory. Outcomes of the current study supports the previous

researcher’s work such as; (Miller, 2007; Peppers, & Rogers, 2012; Reichheld and Schefter

2000; Sharma, 2003)

The fifth hypothesis of the current study scrutinized the constructive and undeviating

impact of trust on customer advocacy. After empirically investigating the association

between trust and advocacy, a direct and constructive link was found. Based on the findings

of current hypothesis it can be concluded that higher the level of trust in patients will

upsurge the level of advocacy. Patients will talk good about the hospital, persuade other

and use the same services when required. Though very limited literature is available on

trust and advocacy relationship, but still the findings are consistent with Afridi and

Khattak, (2015).

The foremost objective of this research is to check out the mediating effect of trust

between service quality and customers’ loyalty and advocacy. Findings of the path analysis

pointed out that trust fully intervenes between service quality and customer loyalty. It

demonstrates that service quality will impart trust in patients which will further lead to

customers’ loyalty. Findings of this study support the previous researchers work on trust as

a mediator between service quality and customer’s loyalty (Akbar, & Parvez, 2009; Kim, &

Kandampully, 2011; Madjid, R. 2013; Patawayati, Zain, Setiawan and Rahayu, 2013).

Another important objective of this study was to examine the role of trust as a

mediator between service quality and customers advocacy. Empirical data favored the

model, with trust as a mediator. Finding shows that trust fully mediates the association

between service quality and patient’s advocacy. Finding of this study suggests that service

quality alone may not be enough to produce advocates. In order to harvest customers who

talk good about the hospital and come constantly when services are necessary or

recommend others. Hospitals should first cultivate trust, as according to the findings of this

study, trust positively mediates between service quality and customers’ advocacy.

Customers’ advocacy is the cutting-edge terminology in marketing literature; hence very

limited work has been done on it. However the findings of this research support the

previous researchers work on word of mouth and advocacy (Gizaw & Pagidimarri, 2013;

Maxham, 2001).

This study was a comparative study in order to investigate the perception of service

quality, trust, loyalty and advocacy in private and public hospitals. Independent sample t

test was performed to determine the difference of the mean scores and found that the

patient’s perception regarding service quality, trust, loyalty and advocacy in private health

institutions of Peshawar is more as compared to public sector health intuitions. Private

sector health institutions hired professional doctors, supporting staff and are well equipped

to provide better service to patients. The comparison results of the current study are similar

to the findings of Irfan and Ijaz (2011). Likewise, individual sample t test performed for the

constructs of service quality, to investigate how customers’ perceive these service quality

attributes in public and private hospitals of Peshawar. Results revealed that all the attributes

perceived more in private than in public hospitals, however responsiveness and empathy

difference was not statistically significant.

The current study also inspects the overall impact of service quality on customers’

loyalty and advocacy with trust as a mediator. The results showed that trust completely

mediates the relationship between service quality and customer loyalty and advocacy. The

findings illustrate that better service quality imparts trust in patients which further plays an

optimistic role in making them loyal. Loyal patients appraise the services of the hospitals to

others and also select the same hospital when it is required. Similarly trust plays a concrete

role in making advocates. Advocates use positive word of mouth, persuade others and

consume same hospital’s services when needed.

Limitations

The limitations of current study offer various opportunities for future research. This

study has failed to use various dimensions of service quality, trust, customer loyalty and

advocacy. There is extensive literature available on service quality which demonstrates the

importance of this topic. It has taken care of in the literature review to deliberate all the

relevant valuation on the topic. Service quality has many facets, however it is very difficult

for a researcher to pick all the dimensions and analyze at same time. Therefore this research

was limited to the servqual model with its five dimensions such as; tangibility, reliability,

responsiveness, empathy and assurance (Parasuraman, Zeithaml and Berry, 1988).

Similarly, customer loyalty elaborated with many dimensions, such as behavior loyalty,

attitudinal loyalty, composite loyalty, active loyalty, passive loyalty, Cronin and Taylor

1992; Blut, et l., 2007; Erramilli & Murthy, 2004; Fullerton, 2005; Ganesh, Arnold,

Reynolds, (2000); Kumar and Shah 2004) but again it was not possible for researcher to use

all of them in a single research. Therefore researcher based on theoretical background

picked only three facets of loyalty, which are; attitudinal loyalty, behavioral loyalty and

affective loyalty. Customer advocacy explained with many dimensions by researchers, such

as; positive word of mouth, persuading others, recommending to others (Bettencourt and

Brown, 1997; Kingstrom, 1983; Stum and Thiry, 1991; Walz, & Celuch, 2010). Trust

explained in various ways. Some authors used the word trust as a confidence, integrity,

benevolence, while other use as honesty, competency, and fidelity (Hall, Dugan, Zeheng, &

Mishra 2001; Mayer, Davis, and Shoorman, 1995; Mechanic, 1998); Mishra, Karen, and

Li, 2008). Grounded on the available literature, one can clinched that the topic is very

multifarious and has many dimensions. Numerous scholars discussed various dimensions

which cannot cover the topic in one study. Hence this study is primarily, constrained to

one aspect-the impact of service quality on customers’ loyalty and advocacy with

mediating role of trust. Furthermore, the existing study verdicts are based on 492 patients,

and the limitation is that the perceptions of the patients are recorded with the help of an

instrument. Their perceptions could not be essentially the illustration of reality, as

individual observation cannot be treated as complete reality.

Delimitation

It is obvious from the topic of this study that it is about the private and public

hospitals of Peshawar. Hence the conclusions of this study should be limited only to

hospitals and can scarcely be generalized with other institutions. It was an effort by the

researcher to find out the reality through research questions, and the conclusions were

based on the result of the analysis. It was an effort to contribute in the field of service

quality, customers’ loyalty and advocacy; hence it should be believed with all its

limitations of individual perceptive.

Contribution to Knowledge

Before commencing this study, there were very rare studies available on customers’

advocacy, and explicitly very limited on service quality and patients’ advocacy relationship

in the health sector. There were studies available on the importance of customer advocates

(Andreasson and Lindestad, 1998; Christopher, Clark, 1999); Hayes, 2008); Westbrook,

1987); Zeithaml, Berry, and Parasuraman, 1996), but no study was found by the researcher

that inspects that impact of service quality on customers’ advocacy in healthcare with trust

as mediator. This study will provide a framework that links service quality with customers’

loyalty and advocacy, which is very rarely discussed before. This study also elaborates the

importance of trust in the association of service quality with customer loyalty and

advocacy. Moreover, this study will offer literature regarding customers’ advocacy,

customers’ loyalty, service quality and trust in general and particularly in healthcare.

Implications of the Study

Quality has become the number one concept of management and marketing related

literature. Quality was initially considered only for tangible goods, but with the passage of

time, it was considered for all the elements of the production process entailing in-bond

logistics, operations, out-bond logistics, marketing, sales and service. Quality is the hope of

a customer regarding marketing, designing, manufacturing, repairing and maintenance of

product or service (Feigenbaum, 1991). Quality is excellence, value, conformance to

specification, and meeting or exceeding customer expectation (Reeves and Bednar, 1994).

According to Tenner and DeToro (1992) quality is a business strategy through which

corporate satisfy their employees and customers by providing a product or service that

encounter their expectations.

Good service quality appeals new customers, creates positive image of a company in

the mind of customers; a cause of repurchase behavior and positive word of mouth that

gives a defensible competitive advantage and escalation in profitability (Ladhari, 2009;

Negi, 2009; cited by Chingang and Lukong 2010). The implications of the current study are

divided into two parts; theoretical and practical implications, which are discussed in the

subsequent paragraphs.

Theoretical Implication. The current study institutes a critical linkage between

service quality, customers’ loyalty and advocacy, by incorporated customers’ trust as a

mediator. Firstly, the current research determines the association between service quality

and customers’ loyalty with trust as a mediator. Secondly, it also illustrates the relationship

between service quality and customer’s advocacy with trust as a mediator. Though service

quality is debated enormously by several researchers in the past (Fogli 2006; Ladhari,

2009; Lewis & Mitchell,1990; Negi, 2009; Parasuraman, Zeithaml and Berry, 1988;

Zineldin, 2006), but the key emphasis of this research was on the part of trust as a mediator

between service quality and customers’ loyalty. This study also inspected the importance of

trust in producing loyal customers. Trust is a belief or confidence that one party has on

another party that will deliver the service or product conferring to the beliefs (Anderson

and Narus, 1990; Dwyar, Schur and Oh, 1987; Morgan and Hunt, 1994; Morman,

Dashpande and Zaltman, 1993; Sanzo, Santos, Vezquez, and Alvarez, 2003; Schurr &

Ozanne, 1985). Morgan and Hunt (1994) found trust and commitment the vital factors

between two parties in building and keeping long lasting affiliations.

Focus was also given to the customers’ advocacy; the new term in marketing.

Limited work has been done on positive word of mouth, whereas customer advocacy is not

limited to only positive word of mouth, but it is also the repeat purchase manner of the

patient and praising to others (Walz, & Celuch, 2010). This study proposed a model based

with the help of theories related to service quality, trust, customers’ loyalty and advocacy.

Similarly, the current study subsidized theoretically in the form of a healthcare model by

adding more variables that contributed in literature of service quality in healthcare, by

providing more evidence about service quality and diverse variables, such as trust,

customers’ loyalty and advocacy.

Practical Implication. Practical repercussions of the current study are; it recognizes

the relationship of service quality with trust. It also spells out how service quality generates

trust, which further produces loyalty and advocacy. This study may have some stimulating

facts for marketing experts. They may get some significant facts concerning the role of

trust and the importance of advocates for the health sector which they may contemplate

while making rationale marketing decisions. The current study observes the positive impact

of service quality on customers’ loyalty and advocacy, but the relationship was stronger

when trust mediated. This would be very supportive to the management as they would

emphasis more in building trust through which they may generate loyalty and advocacy, a

competent way from traditional marketing (Jaffe, 2010). Furthermore, this study also very

worthwhile for hospital management, as they would be able to judge the impression of each

service quality variable on customer satisfaction and distillate on those areas where

perfections are obligatory. Likewise, the current study would also be very suitable for the

administrators of hospitals and the government in the improvement of auditing, and can

check the performance of the hospitals and will offer assistance where service retrieval is

mandatory. This study pronounces the prominence of customer advocacy, positive word of

mouth which is more effective than conventional advertising (Walz, & Celuch, 2010).

Advocates acclaim the company to others and do the marketing of the company’s products

and services to others (Payne, Christopher, Clark, and Peck, 1999). Constructive word of

mouth is conditioned to customer gratifications (Westbrook, 1987). Rendering to Jaffe,

(2010) marketers spend considerable amount of money on traditional marketing campaigns

to entice new customers. Furthermore he suggested that companies should focus on

customers, impart trust and confidence in them and make them advocates. Positive word of

mouth is nine times more effective than advertising. This study spells out the impact of

service quality on advocacy, making it very handy for the marketing department of the

health sector to condense the traditional advertisement cost by refining service quality,

building trust that would be helpful in producing advocates in the market. Advocates are all

praise for the services they experienced and indorse it to others. At the end this study will

develop a new model on the basis of current theoretical models and theories by adding

more variables like, trust, customer loyalty and customer advocacy.

Future Research Recommendations

This research offers the theoretical framework for service quality, trust, customers’

loyalty and advocacy. This study has tried to develop a link of service quality with

customers’ loyalty and advocacy through trust. Empirical results of this study have shown

that enhanced service quality builds trust that will create loyalty and advocacy. This study

has contributed in literature of customers’ advocacy; however more work is obligatory in

order to explore the term advocacy in the health sector. Future research should evaluate the

impact of service quality on customers’ advocacy, with mediating role of customer loyalty.

This study investigates the mediation role of trust, however trust should also be consider as

a moderator. The current study was purely quantitative based on survey; however there is a

need of qualitative research in order to explore the key service quality elements for the

health sector, explicitly for Pakistan. This would improve the key quality characteristics,

based on which one would appraise the service quality. The key quality characteristics

would be the benchmark for evaluating service quality, as these would be designed in

Pakistan and would be based on both patients and doctors perceptions. The socio-

economics, cultural or demographic context may apply difference in the importance of the

different dimensions of service quality. The study could also be extended geographically by

adding more cities of Pakistan that might bring changes to the results.

Research Conclusion

This research was to design a model based on available theoretical literature. The

model was then tested in order to check the intervening role of trust between service quality

and customers’ loyalty and advocacy. The outcomes of the current study provided

satisfactory evidence that link service quality to customers’ loyalty and advocacy. The

result of the study specified a positive relation of service quality directly to customers’

loyalty and advocacy; however the empirical data illustrate that trust fully mediates the

association between service quality, customers’ loyalty and advocacy. This study also

appraises the service quality of private and public hospitals and found that private

hospital’s service quality is slightly superior to public sector hospitals.

The current study worked on a relatively new marketing term “Customers'

Advocacy”, they talk good about the company and make repeat purchases and also endorse

the same services to others, which provide a base to policy makers to keep in mind

customers’ advocacy while designing marketing strategies. This study has shown an

optimistic linkage of service quality and customers’ advocacy through trust as a mediator.

This provides substantiation that by improving service quality the management can create

trust and can make advocates; advocates will talk respectable about the service and will

attract more and hence can reduce marketing cost.

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APPENDIX A

Survey Questionnaire

Dear participant,

Assalam o Alaikum,

I am a PhD Scholar and doing my research on Hospital’s Service quality and its impact on

customer loyalty and advocacy, and collecting data for this purpose. It is therefore kindly

requested to please cooperate to fill in the questionnaire. I assure you that the information

provided would remain absolutely confidential.

There is no right and wrong answer in this questionnaire. I want to know your view. This

research is purely for academic purpose, and the data collected will be analyzed and

reported as a group data and will only be accessed by the researcher.

Please read the instruction carefully and select an appropriate number from 1-5 based on

your personal experience. 1 represents strongly disagree, whereas 5 represents strongly

agree.

Thanks you for your co-operation.

Yours Sincerely,

Sajjad Ahmad Afridi

PhD Scholar

Part I

Please choose the answer that best matches your perceptions. Be sure to answer one

question.

Strongly Disagree (SD) Disagree (D) Neutral (N) Agree (A) Strongly Agree (SA)

1 2 3 4 5

The subsequent statements are concerning the Service Quality of your selected hospital. It

consists of “Tangibility”, “Reliability”, “Responsiveness”, “Empathy” and “Assurance”.

Please specify to which level you think you agree or disagree with the statements.

SERVQUAL SD D N A SA

Tangibility

1 The hospital has up-to-date equipment. 1 2 3 4 5

2 The hospital employees are neat. 1 2 3 4 5

3 The hospital physical facilities are visually appealing. 1 2 3 4 5

Reliability

4 The hospital provides services at the time it promises to

1 2 3 4 5

5 When patients have problems, hospital employees are

sympathetic and reassuring.

1 2 3 4 5

6 Hospital is accurate in its billing 1 2 3 4 5

Responsiveness

7 Employees of hospital tell patients exactly when

services will be performed

1 2 3 4 5

8 Patients receive prompt service from hospital employees 1 2 3 4 5

9 Hospital’s employees are always willing to help patients 1 2 3 4 5

Empathy

10 Hospital employees give patients personal attention 1 2 3 4 5

11 The hospital has patient best interest at heart 1 2 3 4 5

Assurance

12 Patients feel safe in their interaction with hospital

employees

1 2 3 4 5

13 Hospital’s employees are knowledgeable. 1 2 3 4 5

14 The hospital employees are polite 1 2 3 4 5

15 Employees get adequate support from the hospital to do

their job well

1 2 3 4 5

Part II

The following statements are regarding “Trust” of your selected hospital. Please specify to

which level you think you agree or disagree with the statements.

SD D N A SA

1 The selected hospital provides high quality services. 1 2 3 4 5

2 The selected hospital treated patients without

discrimination.

1 2 3 4 5

3 I feel safe in my relationship with employees of the

selected hospital

1 2 3 4 5

4 The selected hospital provides error free service 1 2 3 4 5

5 The selected hospital can be trusted 1 2 3 4 5

6 The selected hospital provided services efficiently 1 2 3 4 5

7 The selected hospital’s employees look out for

patient satisfaction

1 2 3 4 5

8 Employees of the selected hospital are well qualified

(can be relied on)

1 2 3 4 5

9 The selected hospital’s employees provided services

ethically

1 2 3 4 5

Part III

The following statements are regarding “Customer Loyalty” of your selected hospital. It

consists of “Attitudinal Loyalty”, “Behavioral Loyalty” and “Affective Loyalty”. Please

specify to which level you think you agree or disagree with the statements.

Customer Loyalty

SD D N A SA

Attitudinal Loyalty

1 I considered the selected hospital as my first choice

when health services were required

1 2 3 4 5

2 In comparison to other hospitals, the selected hospital

is growing in popularity

1 2 3 4 5

3 The selected hospital is different from other hospitals 1 2 3 4 5

Behavioral Loyalty

4 If I need health services, I intend to go to the selected

hospital again

1 2 3 4 5

5 If I need health services, my intentions are not to go to

the selected hospital again

1 2 3 4 5

6 I may change the selected hospital if others provide

me better prices

1 2 3 4 5

Affective Loyalty

7 I have a positive emotional relation to the hospital I

have chosen

1 2 3 4 5

8 I feel attached to the hospital I have chosen 1 2 3 4 5

9 In the future I would like to remain with the same

hospital I have chosen

1 2 3 4 5

Part IV

The following statements are regarding “Customer Advocacy” of your selected hospital.

Please specify to which level you think you agree or disagree with the statements.

Customer Advocacy SD D N A SA

1 I shall volunteer positive word of mouth advocacy

about selected hospital services

1 2 3 4 5

2 I shall recommend the services of the selected

hospital to anyone seeking guidance on health services

1 2 3 4 5

3 I shall advocate trial run of the selected hospital

services for patients using/used services of other

hospitals

1 2 3 4 5

APPENDIX B

List of Questionnaire Received from Subject Hospitals with Response Percentage

Sr. No. Name of Hospital Questionnaire

Sent Received

Response %

1 Govt. Lady Reading Hospital, Peshawar 80 64 80

2 Khyber Teaching Hospital, Peshawar 80 57 71

3 Naseer Teaching Hospital Peshawar 60 44 73

4 Aman Hospital Dabgari Garden Peshawar. 40 35 87

5 Hayat Abad Medical Complex, Peshawar 80 75 93

6 Rehman Medical Institute, Peshawar 80 75 93

7 North West Hospital Peshawar 80 74 92

8 Cantonment Hospital Saddar, Peshawar 40 34 85

9 Kuwait Teaching Hospital, Peshawar 60 52 86

Total 600 510 85 %

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