Customers’ Perspectives of Service Quality in Community Pharmacies in Nigeria: A Cross-Sectional Survey

Background: There is a growing need to understand the determinants of service quality in community pharmacy from the viewpoint of customers. Objectives: The study explored customer perspectives of pharmacy services using quality indicators and proposed a path for quality improvement. Methods: A questionnaire-based cross-sectional survey was conducted on 704 conveniently selected customers of community pharmacies between August and October, 2019. The exit survey examined customer expectations compared to actual services received. Questionnaire items were drawn from service quality domains of reliability, assurance, tangibles, equity, and responsiveness. Descriptive statistics was used to summarize demographic characteristics of respondents. To explore gaps between expected and perceived service quality, each domain was subjected to a pairwise t-test. Results: Customers’ response rate was 91.2% (n = 642) while their mean age was 52.1±3.55 years. Majority 60% (n = 259) were females, 62.5% (n = 401) had spent five years or less as customers of individual pharmacies. There was significant gap between expected and perceived service quality (t =13.55, p = 0.047). Domains of responsiveness (t = 162.67, p = 0.004) and reliability (t = 27.96, p = 0.023) contributed significantly to this gap with responsiveness being disproportionately impactful. Conclusion: There was significant gap between customer expectations of responsiveness and reliability of pharmacy teams and service fulfilment. This demands improved willingness to prioritize customer needs, serving them promptly, accurately, and as promised.


Introduction
The customer configuration of community pharmacies is evolving rapidly. Recent advances in information communication technologies continue to erode the asymmetry of medicines-related information between the pharmacist and the average patient. Increasingly enlightened patients driven by rising consumerism expect more and more from every caregiver in the healthcare value chain. Competitive forces in the practice environment now demand community pharmacists to embrace customer perspectives of service quality as an important organisational strategy (Ihekoronye, Osemene, Erhun & Afolabi, 2020). This approach becomes critical considering that all pharmacies offer homogeneous products and only differ in the variety and quality of professional services. However in most developing countries, including Nigeria, information on the determinants of service quality in community pharmacy is currently inadequate.
In many healthcare systems, quality of pharmaceutical services may be assessed based on structure, process and outcomes (Alhusein & Watson, 2019). Service quality in pharmacy practice has been conceptualized to comprise technical and functional dimensions (Holdford & Schulz, 1999;Moulin et al, 2013). The pharmacist draws on his expertise in the core pharmaceutical sciences to offer the technical components of professional services such as prescription handling, patient counseling, and medicines use review, among others. Even with shrinking knowledge gap between the professional and laity, most pharmacy customers are ill-equipped to assess these technical aspects of services. However, there are functional dimensions of pharmacy services comprising the process and setting of the service encounter. Most customers easily make their judgments of the service quality based on these functional attributes (Moulin et al, 2013).
Available evidence suggests a strong correlation between service quality, customer satisfaction and organizational performance in service markets (Ascarza, Fader & Hardie, 2017). Extant literature offers no consensus on the best approach to measure service quality in every context (Ghotbabadi, Feiz & Baharun, 2015). However, several models have been developed including the Gronroos model (Gronroos, 1984), the service quality (or ServQual) model sometimes referred to as Gap theory of service quality (Parasuraman, Zeithaml & Berry, 1985), the Extended Gap model (Luk & Layton, 2002), Changing focus of Marketing (Harwood & Garry, 2008), among others. The ServQual model however, seems most popular among scholars and appropriate to capture the quality of services in community pharmacies (Xu, 2002;White & Klinner, 2012;Gurl, Blankart & Stargardt, 2019). Many scholars consider the model as robust, hence its growing influence. It measures the perceived gap between expected and actual quality of service delivered to customers. Smaller gaps indicate higher service quality and vice versa. The ServQual model measures five dimensions of gaps in service quality, namely

Knowledge gap
When a community pharmacy has inadequate knowledge of customer expectations, it becomes impossible to craft professional services to satisfy them.

Standards gap
Service quality is usually measured against set standards, policies and accompanying rules that guide service delivery. Standards gap arises when the pharmacy draws up quality policies and rules based on false assumptions and ideas about customer expectations. Any service strategy based on such assumptions will be defective and incapable of delivering customer satisfaction.

Delivery gap
Even with appropriate service strategies based on accurate knowledge of customer expectations, a gap may still exist if, in the opinion of the customers, the delivery of professional pharmacy services falls short of their expectations. This may be the result of poor execution of the service strategy as may occur when a pharmacy staff carries out professional service tasks without following established guidelines and protocols.

Communications gap
A community pharmacy may wrongly contrive the marketing communication for its services in such a way as to be easily misunderstood by customers, creating wrong expectations of service quality. A communication gap may also arise when the pharmacy organisation promises things beyond its capacity to deliver.

Satisfaction gap
A satisfaction gap arises whenever, in the opinion of customers, there is a significant difference between the quality of service received and the quality they expected irrespective of the drivers of the pre-purchase expectations. The ServQual model measures service quality based on five dimensions including reliability (extent to which the service is delivered accurately, dependably, and as promised); assurance (extent to which the service inspires trust and confidence); tangibles (physical elements of the service); empathy (extent to which customers are treated as valued individuals); and responsiveness (extent of readiness/willingness to provide prompt service and help customers).
Studies have shown that customers with positive perception of service quality are more likely to be satisfied and this affects the quality of relationship with their service providers (Ascarza, Fader & Hardie, 2017). Relationship marketing efforts such as communication, competence, trust, commitment, conflict handling and accessibility by providers equally influence customer perceptions of service quality (Harwood & Garry, 2008). Evidence suggests that the interplay of these variables influence customer repurchase intentions. Customers that exhibit positive behavioral intentions to repurchase the services often advance to become loyal customers (Hohenberg & Taylor, 2020).

Study Design
A cross-sectional survey of community pharmacy customers was carried out between August and October, 2019. Study instrument was a structured questionnaire on a five-point Likert scale.

Study Participants
Sample size for the study was calculated to be 587 at 5% margin of error, 95% confidence level and 80% power using an automated online Raosoft calculator (Raosoft Inc. 2004). As was done in a related study (Ong et al, 2020), 20% overage was added to make up for possible attritions, bringing the sample size to 704. Consenting customers who were 18 years old and above were conveniently selected and surveyed in the premises of the pharmacies located across six States in Southwestern Nigeria. The States were chosen for feasibility of data collection and

Study Instrument
The questionnaire was adapted from the standard ServQual instrument (Butt and Cyril de Run, 2010;Ghotbabadi, Feiz and Baharun, 2015). It initially had 23 items which were reduced to 17 following thorough scrutiny by two senior faculty members (experts in pharmacy practice and service management research) who ensured face and construct validity. A local language (Yoruba) translation was provided for customers who could not communicate effectively in English. Back-translation was used to ensure conceptual equivalence. Test-retest validation technique was employed using 20 customers outside the study area to ensure clarity and feasibility of data collection. A Cronbach's alpha value of 0.74 showed strong internal consistency of the instrument.

Ethical Approval
The Health Research Ethics Committee of the Institute of Public Health, Obafemi Awolowo University, Ile-Ife Nigeria, gave ethical approval (HREC:IPHOAU/12/1437) for the study and all respondents gave their written informed consents before taking the survey.

Data Collection
Six research assistants who were proficient in both written and oral English and Yoruba languages were recruited and trained for five days on relevant aspects of the study and their roles as data collectors. Goals of the study and methods of data collection were first explained to pharmacy managers to obtain their permission. Then customers who had already carried out their transactions with the pharmacy were invited to participate in the survey. Those who consented were given questionnaires to fill and return before leaving the premises. Customers spent an average of 12.55 minutes to complete the surveys.

Data Analysis
Data collected were analyzed at p<0.05 using IBM SPSS version 22 (IBM Corp, Armonk, NY, USA). Demographic characteristics of respondents and reported performance for attributes of service quality (expected and perceived) were summarized using frequency and percentages. Means ± SD (standard deviation) were used to present expected and actual service qualities while pairwise t-test was employed to test if there were significant differences. Association of demographic variables with perceived service quality was examined using chi square test.

Customer Characteristics
Response rate of the customers was 80.1% (n = 642) while their mean age was 52.1±3.55 years (Table 1). Majority (60%) were females. As many as 9 out of 10 respondents were educated to the secondary school level and beyond.
Only 13 (2%) of the responses were in the Yoruba translation of the instrument. While 18 (3%) of customers reported that they have remained loyal to particular community pharmacies for up to 20 years, about 63% (n = 401) were in the first 5 years of consistent patronage to individual pharmacies. Chi square test showed no significant variations of perceived service quality along demographic lines.

Expected Service Quality
Almost every customer (99%) had high or very high expectations that the physical outlook of the pharmacy should be appealing (Table 2). Over 90% expected the pharmacy to be well-stocked with the staff well-dressed. Every single customer expected the pharmacy to perform the services right the first time and as promised. Hence none reported a low expectation on these service items. The transition of pharmacy clients from "patients" to "consumers" is seen in the evidence that 98.5% (n -632) had high or very high expectations to be given prompt attention while 97.6% (n -628) had high or very high expectations that pharmacy staff could never be too busy to attend to their needs. Only 4 respondents reported not expecting special attention. None of the respondents had a low expectation of the level of knowledge (competence) of the pharmacy staff.

Perceived Service Quality
In terms of service performance, respondents did not score the pharmacies very low on most items. Only 4 (0.6%) individuals reported very low rating of the stocking, 4 (0.6%) gave very low rating of equipment in the pharmacies while 2 (0.3%) scored the pharmacies very low on giving them special attention (Table 3). About 87% (n = 556) scored the pharmacies high or very high in physical layout. However, the fact that as high as 20% (n = 126) rated pharmacy staff dressing low or couldn't say seems significant. A similar percentage perceived that the pharmacies were not well-stocked. It is significant to note that 132 (21%) of respondents reported "can't say" when asked if the pharmacy staff had their best interest at heart, 120 (19%) reported same about their feeling of safety following the service encounter, while 116 (18%) reported same about the consistency of service received. While 578 (90%) scored the pharmacies high or very high on prompt attention, 604 (94%) reported high or very high on being given special attention by the pharmacy staff.

Contribution of Service Domains to Overall Service Quality in Community Pharmacy
Pairwise t-test of the performance of service quality domains (Table 4) showed significant overall difference between expected and actual service quality (t = 19.89, p = 0.001). All domains of service quality had significant contributions to this difference (p = 0.001) but the greatest contribution came from the tangibles (t = 24.91, p = 0.001) followed by assurance (t = 14.70, p = 0.001) while the least was the reliability domain (t = 10.29, p = 0.001). There were no significant difference in scores along gender and educational qualification lines.

Discussions
The finding that 60% of respondents were females may be due to some random sampling bias and not a superior health-seeking behavior among females as no previous evidence suggests this. The mean age of respondents (52.1±3.55 years) may be explained that most young people are relatively healthy and utilize less of community pharmacy services compared to the elderly. Yet, Nigeria community pharmacists must evolve services that target the bulging young populations. Only 13 (2%) responses being in the local language translation reflects the level of literacy whereby about 90% of the respondents had at least the secondary school level of formal education. The fast growing population of Nigeria with attendant rapid urbanization means most community pharmacies are relatively young. Hence majority 401(63%) of respondents reported being customers to selected pharmacies for only five years or less with only 18 (3%) being up to 20 years as customers of their pharmacies.
The study found significant gap between customer expectations and service fulfilment in agreement with previously established local evidence (Oparah and Kikanme, 2006). The drivers of this gap are complex as many customers do not know what to expect from their service encounters in community pharmacy (Jayaprakash, Rajan and Shivam, 2009). This confusion reflects ambiguities about the role of pharmacists in health systems. Notwithstanding, community pharmacists must aim at customer satisfaction and loyalty via service fulfilment. Customer satisfaction here entails a favorable post-consumption evaluation of perceived service quality relative to pre-purchase expectations (Jayaprakash, Rajan and Shivam, 2009;Al-Mhasnah et al, 2018). Satisfied customers tend to uphold good relations with the pharmacy, adhere to treatment, and achieve better health outcomes (Al-Ali, Bazin and Shamsuddin, 2015). While customer satisfaction has been found to depend on store quality image; service and convenience; and monetary value (Abu-Alhaija et al, 2018;Aziz et al, 2018), it remains a poor predictor of customer loyalty. In fact, customer loyalty has broader antecedents including perceived service quality, customer satisfaction, trust, perceived value, contextual variables, cultural norms and even religious factors in the target market (Nikolova, Dyankova and Petkova, 2017;). Customer loyalty is a commitment to continue using the pharmacy services, and from the same community pharmacy even in the presence of situational factors or marketing efforts intended to cause a switching behaviour (Nikolova, Dyankova and Petkova, 2017;Hohenberg and Taylor, 2020). The significant gap in perceived service quality found in this study calls attention of pharmacy managers to critically evaluate and improve on relevant service quality domains (Osemene and Ihekoronye, 2019).
Responsiveness contributed disproportionately to perceived gaps in service quality (t = 162.67, p = 0.004). This affirms the increasing sophistication of community pharmacy customers who demand greater readiness of pharmacy teams to serve them promptly and deliver value for their time. This finding agrees with evidence from Australian (White and Klinner, 2012) and German studies (Gurl, Blankart and Stargardt, 2019). However, the finding that the domain of reliability was the second highest contributor to perceived gaps in service quality (t = 27.96, p = 0.023) runs contrary to the cited German study in which reliability had insignificant influence on perceived customer value. Tipton (2009) had earlier argued that of all the dimensions of service quality in community pharmacy, reliability which connotes "just do what you say you will do" was the most highly valued and rated construct by customers. Obviously this is at variance with the outcome of our study where responsiveness which represents "willingness to help customers and provide prompt service" was revealed as the most highly valued dimension. Reasons for such disparity in study outcomes could be the nature and peculiarities of the study settings and populations; the ever-changing customer expectations; and varied experiences of customers arising from previous exposure to many services. All these reinforce the widely-held view that the standard of measuring quality of services by customers is largely based on a psychological premise (Parasuraman, Zeithml and Berry, 1994). Consumer expectations of services are based on desirability and adequacy of such services. This is clearly expressed in the quality-of-service equation where customers constantly carry out their assessment of their expectations for a service against their perceptions of that service.
The trust and confidence inspired by the community pharmacists was high (assurance: t = 12.55; p = 0.052). In line with the vision of International Pharmaceutical Federation (FIP, 2015), this finding underscores the opportunity and responsibility of community pharmacists to improve public confidence in their competences as healthcare professionals, making clients feel safe to share their health concerns and adhere to medication plans under the guidance of their pharmacists. Respondents felt treated like valued individuals (empathy: t = 8.83; p = 0.072), and were significantly impressed with the physical evidence of the pharmacies (tangibles: t = 4.95; p = 0.127). These three domains did not contribute significantly to perceived gaps in service quality, affirming previous ratings (Holdford and Schulz, 1999;Moulin et al, 2013;Gurl, Blankart and Stargardt, 2019). Tangibles were closest to customer expectations, affirming Good Pharmacy Practice (GPP) guidelines which emphasize pharmacy location, ambience, provisions for private consulting areas, packing lots, inventory merchandizing practices, among others (GPP, 2012).
Evidence from Australia and Southern Africa suggest a pattern of strong connection between service quality and customer loyalty in community pharmacy (White and Klinner, 2012;Chiguvi, 2016). In the competitive business environment, achieving and sustaining customer loyalty requires accurate calibration and satisfaction of the everchanging needs of clients. This entails constant improvements in service quality in such a manner that delivers superior customer value (Gurl, Blankart and Stargardt, 2019). Quality improvements here may be understood in terms of constant efforts by community pharmacy teams to make the changes necessary for better patient outcomes (health), better system performance (care) and better professional development (learning) (Batalden and Davidoff, 2007). We posit that quality improvements in community pharmacy must go beyond customer satisfaction to calibrating and maximizing customers' behavioral intentions to re-purchase pharmacy services. Hence there is need to pay close attention to indicators such as cross-buying behavior, positive word of mouth behavior, price increase tolerance, and actual repurchase behavior (Mortimer, Grimmer and Fazal-E-Hasan, 2019). These antecedents of customer loyalty are important given that about 70% of sales in community pharmacy are derived from repeat purchases and retaining loyal customers have been shown to cost the pharmacy organization much less than attracting and serving new ones (Lee, Godwin and Kim, 2015). Available evidence shows that such quality improvements enhance health-seeking behavior and adherence by customers, while the pharmacy enjoys better customer satisfaction, customer loyalty and competitive advantage (Ross, 2013). In this era of rising consumerism (Harwood and Garry, 2008) and as previously highlighted by the authors (Osemene and Ihekoronye, 2019), relationship marketing practices must become the new norm in community pharmacy, making each customer feel special, understood and valued by the entire pharmacy team at every service encounter.

Conclusions
Responsiveness and reliability contributed significantly to perceived gaps in service quality while empathy, assurance and tangibles did not. The wide disconnect between customer expectations of responsiveness and service fulfilment implies there is urgent need for community pharmacists to demonstrate improved readiness and willingness to prioritize customer needs, serving them promptly, accurately and as promised.

Acknowledgement
We appreciate the State Chairmen of the Association of Community Pharmacists of Nigeria (ACPN) for their contributions in mobilizing community pharmacists to allow research teams interact with their customers.