The Mediating Role of Customer Relationship Quality between the Customer Value Co-creation Behavior and Customer Loyalty

Abstract

The purpose of this study was to determine the role of customer relationship quality in mediating the relationship between customer value co-creation behavior and customer loyalty in Egyptian private hospitals and medical centers in Assiut Governorate. The descriptive analytical method was used in the study. 445 of the 500 patients in the sample were collected by a questionnaire, which was valid for statistical analysis. The study’s findings supported the mediating role of customer relationship quality in the relationship between customer value co-creation behavior and customer loyalty. Implications, recommendations, and potential future studies in the subject of study were discussed.

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European Journal of Business and Management Research
Vol 9 |Issue 2 |March 2024
ISSN 2507-1076
RESEARCH ARTICLE
The Mediating Role of Customer Relationship
Quality between the Customer Value Co-creation
Behavior and Customer Loyalty
Adel R. M. Rayan 1,*, Ahmed Sayed Mohamed Sebaie2, Yasser S. A. Hussien 3,
and Hadeer Murad Mabrouk2
ABSTRACT
The purpose of this study was to determine the role of customer relationship
quality in mediating the relationship between customer value co-creation
behavior and customer loyalty in Egyptian private hospitals and medical
centers in Assiut Governorate. The descriptive analytical method was
used in the study. 445 of the 500 patients in the sample were collected
by a questionnaire, which was valid for statistical analysis. The study’s
findings supported the mediating role of customer relationship quality in
the relationship between customer value co-creation behavior and customer
loyalty. Implications, recommendations, and potential future studies in the
subject of study were discussed.
Keywords: Customer loyalty, customer relationship quality, customer
value co-creation behavior, private hospitals and medical centers.
Submitted: July 30, 2023
Published: March 15, 2024
10.24018/ejbmr.2024.9.2.2131
1Egypt-Japan University of Science and
Technology (E-JUST), Egypt.
2Assiut University, Egypt.
3South Valley University, Egypt.
*Corresponding Author:
e-mail: adel.rayan@ejust.edu.eg
1. Introduction
With the increasing role of the service industry in the
economy and the entry of new organizations in the services
market that provide convergent services, contemporary
service organizations face a significant challenge reflected
in the difficulty of survival in light of environmental vari-
ables characterized by dynamic and continuous change.
Service organizations realized the requirement to develop
strong relations with their customers and strengthen their
loyalty to the organization to sustain their future compet-
itive position (Zeithaml et al., 2011).
Customer loyalty is essential for successful marketing
plans and strategies, as it ensures the survival and continu-
ity of organizations by attracting new customers through
customer endorsement and positive comments (Reich-
held, 1993). Value co-creation is an anticipated area of
development that entails cooperation between firms and
customers to accomplish both parties’ mutual objectives.
Participation results in a better understanding of consumer
requirements and needs, a greater ability to provide them,
and the possibility to create relationships that inspire loy-
alty and lower the likelihood of customers terminating
their engagement with the business. This engagement will
help to create value and gain a competitive advantage
(Revilla-Camacho et al., 2015).
Customer relationship quality is essential for orga-
nizational performance and one of the most effective
consequences of marketing practices (Kuo & Ye, 2009).
It involves building long-term relationships with cus-
tomers by responding to their needs, enhancing service
efficiency, and paying attention to the customer’s interests
to represent the social aspect of organizations (Singh &
Sirdeshmukh, 2000). This raises customers’ satisfaction
and trust with the business, which leads to increased loyalty
(Chu & Yao-bin, 2009).
The health services sector occupies a distinguished posi-
tion among the service sectors due to the importance of
the services it provides and its direct connection to the
health and life of community members. The sector con-
flicts with the stakeholders’objectives, as the reduced costs
and time associated with treatment no longer fully explain
the value of the health service provided and ignore the
vital role of the client. As a result, healthcare professionals
should design services based on patients’ perspectives to
improve service quality by understanding how patients
participate in shared value creation (Zhang et al., 2015).
As a result, healthcare providers should design services
based on patients’ perspectives to improve service quality
by understanding how patients participate in shared value
creation (Zhang et al., 2015).
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The Mediating Role of Customer Relationship Quality Rayan et al.
Based on the preceding, the current study seeks to iden-
tify the role of customer relations in the organization in its
two dimensions in the relationship between their value co-
creation and loyalty to it, applying to hospitals and private
medical centers.
1.1. Study Overview (Study Problem)
Customer loyalty is one of the best intangible assets
an organization can possess, as loyal customers are more
likely to buy the organization’s products and services and
bear the price increase. This leads to achieving profit
for the organization and a marketing and promotional
force by making positive recommendations to others that
strongly influence the opinions and behavior of other cus-
tomers (Ali et al., 2017). So, many researchers have been
interested in studying the variables that lead to the develop-
ment of customer loyalty to the organization, particularly
those that emerged from modern marketing theories such
as the variable value co-creation (Yi & Gong, 2013).
The evolution of organizational workplaces and inter-
organizational competition has given rise to modern
marketing theories. According to Vargo and Lusch (2004),
the idea of participation in value creation refers to the
collaboration and integration of efforts between the client
and the service provider during the provision of the ser-
vice in order to produce value for both parties. As a
result, customer involvement in adding value to the service
could directly impact customer loyalty to the company
(Cossío-Silva et al., 2016;Vargo & Lusch, 2004).
Modern marketing theories have resulted from the
changes that have occurred in the work environment of
organizations and the competition between them. The con-
cept of participation in value creation, as referred to by
Vargo and Lusch (2004), is the cooperation and integration
of efforts between the customer and the service provider in
the process of providing the service to create value for both
parties. On the final product of the service, therefore, the
participation of customers in creating value may directly
affect customers’ loyalty to the organization (Cossío-Silva
et al., 2016;Vargo & Lusch, 2004).
It is observed that the related studies have focused on
developing customer loyalty with value co-creation for
contributing to customer loyalty. Studies by Grissemann
and Stokburger-Sauer (2012),Nysveen and Pedersen
(2014),Revilla-Camacho et al. (2015),Cossío-Silva et al.
(2016),Nguyen (2017),Revilla-Camacho et al. (2017),
Khan and Hussainy (2017),van de Scheur (2017),and
Delpechitre et al. (2018) found that customer participation
in service delivery positively affects their loyalty to the
organization. The studies of Lin et al. (2003),van Dijk
et al. (2014),Chiu et al. (2017),andMariyudi and Matriadi
(2018) indicated that there is no relationship between the
two variables. Stokburger-Sauer et al. (2016) also found
a negative relationship between customers’ participation
in the service’s production as one of the dimensions of
customer value co-creation and loyalty to the organization.
Many studies were conducted on the relationship
between customer value co-creation behavior and cus-
tomer relationship quality (Ammari & Jaziri, 2016;Banyte
& Dovaliene, 2014;Choi, 2015;Clauss et al., 2019;Kim
& Lee, 2018;Omar et al., 2018;Pantoja Díaz et al., 2016;
Revilla-Camacho et al., 2014,2017;Vega-Vazquez et al.,
2013;Yang et al., 2019;Zhang, 2010). These studies indi-
cated that there is a positive relationship between these two
variables, as those studies indicated that customers value
co-creation activities, which contributes to increasing ser-
vice providers’ awareness of their needs, Which contributes
to reducing the gap between the desires and expectations of
customers about the service and the actual performance of
the service and thus achieving customer satisfaction, and
increasing their trust in the capabilities and credibility of
the organization.
On the other hand, other studies, such as Worley (2001),
Yin and Yang (2009),andFledderus (2015a),haveclarified
that there is no relationship between the variables, which
means the customer’s participation in service production as
one of the dimensions of customer value co-creation does
not necessarily lead to his satisfaction or trust, and there-
fore does not lead to high-quality relationships with the
organization. In contrast, a negative effect of customers’
participation in the service’s production and their satisfac-
tion has been noted by Bendapudi and Leone (2003) and
Fledderus (2015b), aside from Guo et al. (2013), who con-
cluded a negative effect of customer citizenship behavior
represented in feedback on customer satisfaction as one of
the dimensions of customer relationship quality.
By reviewing previous studies that dealt with the rela-
tionship between customer relationship quality in its two
dimensions (customer satisfaction and customer trust) and
customer loyalty to the organization, we concluded that
several studies have proven a positive relationship between
customer relationship quality and loyalty to the organi-
zation (e.g., Dai et al., 2023;Kuhn & Mostert, 2018;
Rahmani-Nejad et al., 2014;Saleem et al., 2018;Ying
et al., 2018;Yu & Tseng, 2016). However, no effect was
reported between the customer relationship quality and
their loyalty to the organization in other studies such as
Eakuru and Mat (2008),Alejandro et al. (2011),Chen and
Chen (2017),van de Scheur (2017),andSayil et al. (2019).
Besides the diversity in the findings of previous studies,
we noticed a scarcity of studies that collectively dealt with
the concept of customer value co-creation through its two
dimensions. Creating value in its two dimensions on the
customer relationship quality, but we dealt with its impact
on only satisfaction or trust.
Considering the literature review related to the study
variables, the research problem can be illustrated in the
following questions:
1. What is the nature of the relationship between
the customers’ value co-creation behavior and their
loyalty to hospitals and private medical centers?
Moreover, what is the relative impact of the dimen-
sions of customer value co-creation behavior on their
loyalty to those organizations?
2. What is the nature of the relationship between cus-
tomer value co-creation behavior and the quality of
their relationships with hospitals and private med-
ical centers? Moreover, what is the relative impact
of the customer value co-creation behavior and the
customer relationship quality?
3. What is the nature of the relationship between the
customer relationship quality and their loyalty to
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Rayan et al. The Mediating Role of Customer Relationship Quality
hospitals and private medical centers? Moreover,
what is the relative impact of the dimensions of the
customer relationship quality and their loyalty to
these organizations?
4. Does customer relationship quality as a mediating
variable affect the relationship between customer
value co-creation behavior and loyalty to hospitals
and private medical centers?
2. Theoretical Framework
2.1. Value Co-Creation
Ostrom et al. (2010) referred to value co-creation as
a close relationship between the service provider and the
customers. This means the creation of value by both cus-
tomers and service providers. Prahalad and Ramaswamy
(2004) stated that the customer plays a vital role in value
co-creation by integrating the customer’s role with the
organization’s to achieve value. Ind et al. (2013,p.9)
also addressed value co-creation as “an active, creative
and social process based on collaboration between orga-
nizations and participants that generates benefits for all
parties and creates value for stakeholders.” Heidenre-
ich et al. (2015) pointed out that the value is created
jointly by both the organization and its customers dur-
ing the production and consumption of the service. We
can define value co-creation as the collaborative process
between the customer and the organization so that each
has a specific and compelling role in achieving the desired
goals.
2.2. Customer Value Co-Creation Behavior
Sweeney et al. (2015) and Payne et al. (2008) referred
to customer value co-creation behavior as the cognitive
and behavioral activities customers perform to achieve
certain goals through the value creation. According to
the co-creation of value, customers become partners, and
organizations must collaborate with them to create value
creation. Stakeholders are more likely to participate in
joint value-creation activities if they perceive it will bring
them high value.
Therefore, organizations must provide a sound basis
to build interactions with customers and thus exchange
experiences (Ramaswamy & Gouillart, 2010).
2.3. Dimensions of Customer Participation Behavior in
Value Creation
2.3.1. Customer Participation Behavior in Service Pro-
duction and Delivery
Rodie and Kleine (2000) refer to customer participa-
tion from a behavioral perspective as the actions and
resources customers supply for service production or
delivery. This definition emphasizes the importance of
customers as human resources for the organization and
partial employees without whom the service cannot be
completed. We can define customer participation behavior
as the degree to which the customer produces and delivers
the service. The following four dimensions collectively con-
stitute consumer participation in service production and
delivery.
2.3.1.1. Information Seeking
Yi and Gong (2013) referred to information seeking as
a set of activities customers perform to access information
about the essential characteristics of the service they will
receive. Kelly et al. (1990) illustrated that customers’ ini-
tiative can be taken into account by asking others (such as
other customers or employees) for information or observ-
ing clients’ behavior during the service encounter.
2.3.1.2. Information Sharing
Yi and Gong (2013) described it as the customers shar-
ing information about services with service providers. It
also includes sharing information about the needs they
wish to satisfy and the service specifications they expect
to receive. This will help the service provider provide ser-
vices more effectively and sufficiently and facilitate the
co-creation process of value to meet customer needs.
2.3.1.3. Responsible Behavior
Bettencourt et al. (2002) addressed the concept of
responsible behavior. It indicates the extent to which the
customer performs his responsibilities promptly, elabo-
rately, and responsively, reflecting a sense of personal
commitment toward the service’s success. Yi and Gong
(2013) referred to responsible behavior as customer behav-
ior, which is represented in cooperation with employees by
observing the rules and policies of the organization during
the service meeting and following the employees’directives
to create value successfully.
2.3.1.4. Personal Interaction
This dimension means customer interaction behaviors
with front-line employees, which involve cordiality, cour-
tesy, and respect, and these personal interactions are a
necessary factor for the success of the process of partici-
pating in value creation, as the value creation process, like
other marketing operations, is surrounded by a social envi-
ronment that affects and is affected by it. Moreover, the
more positive this environment is, the greater the desire of
customers to participate in value creation, and this climate
is achieved through good relations between customers and
workers that are respectful and cooperative (Claycomb
et al., 1970;Yi & Gong, 2013).
2.3.2. Customer Citizenship Behavior
Groth (2005) stated that customer citizenship behavior
is the voluntary behavior of customers, which is indirect,
unpredictable, and unrewarded, but in the aggregate, leads
to service quality and enhances work effectiveness in ser-
vice organizations. Also, Yi and Gong (2008) referred to
it as voluntary behaviors that are not required for suc-
cessful service production and delivery but, on the whole,
help service organizations in general. Yi et al. (2011) see
customer citizenship behavior as the voluntary action of
some clients. Customers do not need to strictly comply
with these behaviors to create a successful service and are
free to do so at their discretion. We can define customer
citizenship behavior asthedegreetowhichthecustomer
is psychologically ready to provide a set of positive and
voluntary behaviors that benefit the organization. The
concept of customer citizenship behavior consists of the
following dimensions:
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The Mediating Role of Customer Relationship Quality Rayan et al.
2.3.2.1. Feedback
Feedback means that customer behavior includes pro-
viding suggestions and instructions to employees after the
customer has experienced the service and gained experi-
ence. This information may be positive or negative which
ultimately helps the organization in improving its service
operations in the long run (Yi & Gong, 2013).
2.3.2.2. Advocacy
Fullerton (2005, p. 100) defined it as “recommend busi-
ness (of the organization or its employees) to other people
such as friends or family.” On the other hand, Walz and
Celuch (2010) stated that advocacy includes promoting
the organization and defending the organization against
criticism, mainly when non-clients (non-members) attack
the organization. Yi and Gong (2013) referred to advocacy
as the customer activities that include recommending the
organization or its employees to other people such as
friends, family, or relatives. Advocacy refers to the value
that customers create when they voluntarily share detailed
information about an organization’s services, features, or
promotions that go beyond a simple recommendation.
2.3.2.3. Helping
Assisting in co-creating a service refers to “customer
behavior aimed at helping other customers who may have
difficulties behaving in the way expected of them” (Yi &
Gong, 2013, p. 1281) and, therefore, giving them a sense of
accomplishment.
2.3.2.4. Tolerance
Toleranceisreferredtoascustomerbehaviorthat
includes being patient when the service delivery process
does not meet their expectations and accepting the ser-
vice delay due to any shortage or unforeseen problem by
the organization,” such as accepting customers to wait
longer to receive the service or overlooking the error that
may occur while receiving the patient for medical service
(Johnson & Rapp, 2010;Yi & Gong, 2013). Moreover,
Bettencourt et al. (2002) indicated that forgiveness effec-
tively treats problems and frustrations. From a functional
point of view, less anger energy is wasted when facing those
problems.
2.3.3. Customer Relationship Quality
Fynes et al. (2005) defined relationship quality as the
degree to which the two parties engage in an effective and
long-term relationship, which forms the basis for assessing
the service flow chain. That is, the quality of the relation-
ship is a measure of the validity of the relationship between
the exchange parties. Also, Han et al. (2008) referred to
relationship quality as the situation in which clients rely on
the organization’s integrity for its future performance due
to its satisfactory and consistently recurring past perfor-
mance levels.
According to Oly Ndubisi (2007), relationship quality
is a bundle of intangible and immeasurable values that
maximizes the value of goods and services and leads to
the expected exchange between sellers and buyers. Kim
et al. (2011) see customer relationship quality as the degree
of cooperation between the parties (customers and service
providers) and the tendency towards building long-term
relationships. This reflects the extent of the interest of
the service provider or the commodity in maintaining the
continuity of the relationship with the consumer. We can
define customer citizenship behavior as the degree of the
overall perception of the quality of an exchange relation-
ship with the customer. The dimensions of the customer
relationship quality are discussed as follows.
2.3.3.1. Customer Satisfaction
Customer satisfaction is an essential factor for the suc-
cess of any business system, and this importance increases
when these businesses depend more on relationships with
customer service organizations; they need to understand
how to satisfy customers because customer satisfaction is
crucial to establishing a long-term relationship with them
(Kotler, 2005). Westbrook (1987) pointed out that satisfac-
tion is traditionally defined as a perceptual phenomenon.
An affective response results from a cognitive evalua-
tion process in which actual perceptions are compared
to client expectations. Roberts-Lombard (2009) described
satisfaction as the degree to which a business organization’s
product or service performance conforms to customer
expectations.
According to Krystallis and Chrysochou (2014),cus-
tomer satisfaction results from the customer’s evaluation
of both tangible and intangible brand characteristics after
purchase. We can define customer satisfaction as the degree
to which a company’s products, services, and overall cus-
tomer experience meet customer expectations.
2.3.3.2. Behavioral Loyalty
Høst and Knie-Andersen (2004) stated that the cus-
tomer’s actual repurchase behavior and repeat purchase
behavior are expressed by the number of times a spe-
cific brand is purchased compared to the total number
of brands purchased or the total actual expenses spent
on the product or service, and behavioral loyalty is based
on loyalty outcomes such as repurchase (Komunda &
Osarenkhoe, 2012;Marshall, 2010).
In this context, it should be noted that the models
that study loyalty through buy-back behavior depend on
the application of the market orientation perspective (the
brand’s share of the market, its penetration, the frequency
of its purchase) rather than the customer itself, and accord-
ing to these models, the brand loyalty is achieved/provider
service measured by repeated purchase as a result of satis-
faction. However, the consumer may repeat the purchase
process while he does not have any substantial positive
attitudes towards it because looking for an alternative may
not be worth the trouble (Uncles et al., 2003). Thus, we can
define behavioral loyalty as the degree to which a customer
keeps returning to repurchase or use the same product.
3. Previous Studies on the Relationship between
Customer Value Co-creation and Their Loyalty to
the Organization
Several studies have investigated the relationship
between customer value co-creation in its two dimensions
and customer loyalty (e.g., Ali et al., 2017;Cossío-Silva
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Rayan et al. The Mediating Role of Customer Relationship Quality
et al., 2016;Delpechitre et al., 2018;Grissemann & Stok-
burger-Sauer, 2012;Khan & Hussainy, 2017;Mariyudi
& Matriadi, 2018;Nysveen & Pedersen, 2014;Polo Peña
et al., 2014;Revilla-Camacho et al., 2015;Sweeney et al.,
2015;van de Scheur, 2017;van Dijk et al., 2014;Zhang,
2010), most of them found There is a positive relationship
between the two variables.
Grissemann and Stokburger-Sauer (2012) agreed with
Polo Peña et al. (2014) by reporting in the tourism sector
that value co-creation has a direct moral effect on customer
loyalty, which includes both increased desire for repeat
purchase and increased intent to recommend the organi-
zation, he added, customers show higher levels of loyalty
towards self-designed services compared to standard ser-
vices. Therefore, when customer engagement activities go
beyond self-design, it positively impacts their behavior.
However, van Dijk et al. (2014) find that customer
value co-creation does not directly inf luence repurchase
behavioral intentions and that it does not necessarily
increase customers’ behavioral intentions toward brands in
which customers practice behaviors of co-creation of value
greater than those brands of less co-creation of customers.
The study of Revilla-Camacho et al. (2015) indicated
that value co-creation negatively affects the intention of
customers to leave the organization and thus increases the
intention of customers to continue the relationship with
the organization. This study concluded that the customer
value co-creation strengthens their relationship with the
organization. If the organization’s relationship with its
customers continues for extended periods, it can achieve
more profitability.
van de Scheur’s (2017) study aimed to test the relation-
ship between customer value co-creation and customer
loyalty to the organization and concluded a significant
positive relationship between them. To customers who are
willing to participate in the production and share their
opinions and suggestions with the organization, while
Mariyudi and Matriadi’s (2018) study found that there is
no direct relationship between customer value co-creation
and customer loyalty to the organization, and also con-
firmed that there is an indirect relationship between them
from through perceived quality.
Halbesleben and Stoutner’s (2013) study found a pos-
itive and statistically significant relationship between
customer participation in service production and delivery
as one of the dimensions of customer value co-creation
and customer loyalty. It explained the reason for the pos-
itive relationship that the customer and service provider
relationship develops as the customer co-creation in ser-
vice exchange as a result of increasing its awareness of
the quality of service. Bryce et al. (2015) examined the
Japanese tourism sector. They found that the visitor who
participates in the service experience has a greater tendency
to commit and become emotionally attached to that orga-
nization, which leads to loyalty.
In another direction, the study of Stokburger-Sauer
et al. (2016) examined the non-linear relationship between
the level of joint production and customer loyalty, and they
found that the effect of joint production on customer loy-
alty, after the point of the optimal level of joint production,
is negative. As loyalty increases by increasing customer
participation to a certain point, loyalty begins to decline as
participation increases.
The results of the study of Ali et al. (2017) contrasted
with the previous study, which found that the dimension
of customer participation in the production and delivery
of service does not affect customer loyalty, while customer
citizenship behaviors have a positive, significant effect on
customer loyalty. The study of Lin et al. (2003),which
was applied to banking services, indicated no effect on
customer participation in production service, customer
loyalty, and customer retention.
The studies of Choi (2015),Madani et al. (2015),and
Revilla-Camacho et al. (2017) found that customer citizen-
ship behavior as one of the dimensions of customer value
co-creation has a positive impact on customer loyalty,
except the study of Chiu et al. (2017), which indicated
that there is no relationship between customer citizenship
behavior and their loyalty to the organization.
The study of Delpechitre et al. (2018) also indicated that
value co-creation is the process that organizations often use
to enhance and support competitive advantage. That study
found that the behavior of customers valuing co-creation
has a positive impact on the commitment of customers to
continuing the relationship with the service provider as one
of the dimensions of customer loyalty.
In the field of the relationship between customer
value co-creation in its two dimensions and customer
relationship quality with its two dimensions, some stud-
ies concluded that customer value co-creation positively
affects customer relationship quality (Ammari & Jaziri,
2016;Banyte & Dovaliene, 2014;Omar et al., 2018).
The study of Revilla-Camacho et al. (2014) added that
value co-creation is one of the most important ways orga-
nizations can gain customers’ trust and then achieve a
competitive advantage in light of the intense competition
faced by small-sized organizations. This study attributed
the positive impact of value co-creation on customer
trust to enhance personal interaction between customers
and employees for mutual understanding. This interaction
leads organizations to meet better their customer’s desires
and awareness of the organization’s fairness in distributing
service production responsibilities to the customer. These
factors reduce customers’ fears of opportunistic behavior,
leading to increased trust in the service organizations.
Several studies dealt with the relationship between cus-
tomer value co-creation and customer satisfaction as one
of the dimensions of relationship quality in various educa-
tional institutions and services such as public and private
universities, vocational schools, and English language edu-
cation centers (e.g., Giner & Peralt Rillo, 2016;Nguyen,
2017;Pantoja Díaz et al., 2016), and its results concluded
that there is a positive, statistically significant relationship
between the two variables, and the same result was reached
by some studies in different service contexts, such as health
care, (Sweeney et al., 2015) and the banking sector (Cam-
bra-Fierro et al., 2017).
In another direction, Worle y ’s (2001) study tested the
effect of customer co-creation behavior in service produc-
tion and provision as one of the dimensions of customer
value co-creation on the customer relationship quality
through two stages. The results conflicted between the first
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The Mediating Role of Customer Relationship Quality Rayan et al.
and second stages, where the results of the first stage found
that customer co-creation behavior has a direct positive
impact on the quality of the customer relationship with the
organization. In contrast, the second-stage results showed
no effect of customer co-creation on the relationship qual-
ity, and the study recommended conducting more research
to explain this discrepancy in the results.
Zhang’s (2010) study also found a positive, statistically
significant relationship between customer co-creation in
service production and delivery and customer relationship
quality in the two dimensions of trust and satisfaction in
hairdressing services. The study of Chu and Wang (2012)
found that customer information sharing as one of the
dimensions of customer participation behavior in provid-
ing service has a positive impact on customer relationship
quality.
The studies of Yim et al. (2012),Halbesleben and
Stoutner (2013),Hsu and Chen (2014),andYang et al.
(2019) agreed that the more customers participate in ser-
vice production and delivery, The higher the customer
satisfaction and therefore this recommended the need to
provide employees with interest in customer co-creation,
and also design service patterns that allow customers to
participate in the customization, allowing faster and less
costly completion of the service so that the customer is
satisfied with the service and the organization provided.
Despite the multiplicity of studies that found a positive
relationship between customer participation in the pro-
duction and delivery of service and the two dimensions
of relationship quality (satisfaction and trust), studies by
Lin et al. (2003) and Fledderus (2015a) found that cus-
tomer co-creation is not significantly related to customer
satisfaction. The study of Lin et al. (2003) attributed
the absence of a relationship between the co-creation of
tourists in providing the service and their satisfaction with
the tourist parks in Taiwan to external factors such as bias
for certain characteristics that occurred in the relation-
ship between customer co-creation and satisfaction. Also,
individual customer differences, such as personal motives,
may weaken the relationship between the two variables.
The study of Claycomb et al. (1970), which was applied
to YMCA services, attributed the absence of significant
differences in customer satisfaction across different levels
of customer participation to the small sample size used in
the study.
Fledderus’s (2015a,2015b) studies aimed to deter-
mine whether co-production for public service provision
enhances customer trust. Over half a year, the results of his
studies concluded a significant decrease in the level of trust
among participants in co-production. Fledderus (2015b)
and Bendapudi and Leone (2003) reported a negative
relationship between customer participation and customer
satisfaction in case the service results are better or less than
expected.
Kim and Lee’s (2018) study aimed to determine the
impact of customer co-creation on customer trust in an
organization in the field of smartphone services. Their
study concluded a positive relationship between them, as
exchanging information through communication between
organizations and their customers strengthens the relation-
ship and builds customer trust.
Some studies examined the relationship between cus-
tomer citizenship behaviors and customer satisfaction and
trust in the organization as dimensions of the quality of
customer relations. Madani et al. (2015) and Song and
Huh (2012) indicated that customer citizenship behavior in
financial services such as banks positively affects customer
satisfaction with the organization and increases the trust
and reliability of customers in this organization.
In the same context, Choi’s (2015) study examined the
relationship between customer citizenship behavior and
their outcomes in three different service contexts rang-
ing in specialization and communication from the high
level through the medium level to the low level. That
study found that customers who participate in citizenship
behavior are satisfied with service results and front-line
employees. Also, it explained that the customers’ value
of co-creation develops their feelings of achievement and
increases their trust in their skills and abilities. Developing
the relationship between the customers and employees
and forming personal relationships through interaction
increases feelings of belonging and customer satisfaction
with the organization. This result has been supported by
the study of Chiu et al. (2017).
On the contrary, the study of Guo et al. (2013) did not
support the positive relationship between the citizenship
behavior represented in the feedback component and cus-
tomer satisfaction with the organization. The customers
are interested in developing the organization’s services
by participating in providing suggestions and feedback
on the organization’s performance. And its employees
are more likely to perceive discrepancies between the
expected service performance after submitting proposals
for improvement and the actual performance. This causes
them more significant disappointment, reflected in their
low satisfaction rate with the organization, which nega-
tively impacts them.
Several studies have examined the relationship between
customer relationship quality with its two dimensions
(customer satisfaction and trust in the organization)
and customer loyalty. The studies of Kim et al. (2001,
2006),Roberts et al. (2003),andMosavi and Ghaedi
(2012) indicated that there is a positive moral relationship
between customer relationship quality and loyalty to the
organization.
In a different direction, the study of Eakuru and
Mat (2008), applied to banking services, found no effect
between the dimensions of relationship quality (sat-
isfaction, trust) and the loyalty of customers to the
organization. In the same context, Alejandro et al. (2011)
did not indicate that there is a relationship between the
quality of the relationship with the organization and the
loyalty of customers. They indicated the importance of
providing strong support and incentives to customers to
increase the likelihood of accepting the standard proce-
dures, processes, and management systems proposed by the
organization.
On the contrary, the study of Ben Naoui and Zaiem
(2010) found partial support for the effect of relationship
quality on customer loyalty. Where the regression coef-
ficient analysis showed that loyalty is positively affected
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Rayan et al. The Mediating Role of Customer Relationship Quality
by customer satisfaction only, while trust does not affect
customer loyalty.
The studies of Abdul Rahman and Ramli (2016),Yu
and Tseng (2016),Kuhn and Mostert (2018),Saleem et al.
(2018),andDai et al. (2023) indicated that the customer
relationship quality has a positive and significant impact
on customer loyalty. These studies confirmed the impor-
tance of creating a good customer experience and positive
feelings about the organization in a way that supports
customer satisfaction, trust, and commitment toward the
organization. Also, it will lead to the development of
strong customer loyalty. So, it must implement strategies
to improve the relationship’s quality to retain customers.
In another direction, the study of Sayil et al. (2019)
demonstrated a significant positive relationship between
customer satisfaction with banks as one of the dimen-
sions of relationship quality and customer loyalty to
banks. However, the study concluded that no relation-
ship exists between the second dimension of relationship
quality, trust, and customer loyalty. On the contrary, van
de Scheur’s (2017) study, applied to social housing ser-
vices, concluded that a positive, statistically significant
relationship exists between clients’ trust and loyalty to the
organization. The client’s total satisfaction with the orga-
nization has little effect on his loyalty, and he attributed
this to the availability of alternatives and the possibility of
transformation to other housing associations.
4. Study Model and Measurement
4.1. Study Model and Hypotheses
According to the review of the previous literature, the
proposed model can be formulated as follows: The first
hypothesis aims to test the nature of the relationship
between customer value co-creation as a whole (one-
dimensional variable) as an independent variable and their
loyalty to the organization as a dependent variable. This
central hypothesis was built on the results of most pre-
vious studies, where studies of Song and Huh (2012),
Halbesleben and Stoutner (2013),Nysveen and Pedersen
(2014),Sweeney et al. (2015),Choi (2015),Chen and Wang
(2016),van de Scheur (2017),andDelpechitre et al. (2018)
indicated that there is a significant positive relationship
between customers value co-creation and their loyalty to
the organization. Based on the preceding, the first hypoth-
esis was formulated as follows:
H1: There is a positive, statistically significant correlation
between customer value co-creation and their loyalty to
hospitals and private medical centers.
The nature of the relationship between the behavior of
customer value co-creation and the customer relationship
quality can be tested based on the results of previous
studies (e.g., Giner & Peralt Rillo, 2016;Hsu & Chen,
2014;Nguyen, 2017;Song & Huh, 2012;Sweeney et al.,
2015;Vega-Vazquez et al., 2013;Yang et al., 2019;Zhang,
2010). Based on these studies, we formulated the following
hypothesis:
H2: There is a positive, statistically significant correlation
between of customer value co-creation behavior and the cus-
tomer relationship quality with hospitals and private medical
centers.
To test the nature of the relationship between the
customers’ relationship quality and their loyalty to the
organization, Rahmani-Nejad et al. (2014),Yu and Tseng
(2016),andKuhn and Mostert (2018) indicated that there
is a positive correlation between the customer relationship
quality and their loyalty to the organization. Based on that,
this hypothesis was formulated as follows:
H3: There is a positive, statistically significant correlation
between the quality of customer relationships and their loy-
alty to hospitals and private medical centers.
The last hypothesis aims to test the role of customer rela-
tionship quality as a mediating variable in the relationship
between customer value co-creation and their loyalty to
the organization, and this hypothesis was formulated as
follows:
H4: The relationship quality significantly mediates the
relationship between customers’ value co-creation as an
independent variable and customer loyalty as a dependent
variable in hospitals and private medical centers.
These relationships are illustrated in Fig. 1.
4.2. Variable Measurement
According to the proposed study model and its hypothe-
ses, this study includes two main variables.
4.2.1. Customer Value Co-creation Behavior
The independent variable is the behavior of customer
value co-creation, and the current study adopts the defi-
nition of Yi and Gong (2013), which refers to customer
behaviors in the value creation process as the activities and
behaviors that customers perform to achieve special goals
during the co-creation process. These behaviors consist of
two types of consumer behavior: customer participation
in service production and delivery, and customer citizen-
ship behavior.” Accordingly, this variable consists of two
dimensions, and the operational definition of each is pro-
vided in the following subsections.
4.2.2. Customer Participation in Service Production and
Delivery
Customer participation behavior reflects “the set of
basic behaviors that are mandatory and explicitly required
of the customer during the service encounter (con-
frontation and interaction between the customer and the
employee during the service production) to provide the
service successfully. These behaviors include information
Fig. 1. The research model.
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The Mediating Role of Customer Relationship Quality Rayan et al.
seeking, information sharing, responsible behavior, and
personal interaction” (Yi & Gong, 2013, p. 1280).
4.2.3. Customer Citizenship Behavior
Customer citizenship behavior refers to the additional,
voluntary, or positive customer behavior that can create
higher value for the organization and improve the co-
creation of value, behaviors that are complementary to
co-delivery behaviors and consist of feedback, endorse-
ment, helping other customers, and tolerance (Yi et al.,
2011).
The variable of customer value co- creation behaviors
measured in its two dimensions (customer participation
in service production and delivery, customer citizenship
behavior) based on Yi and Gong’s (2013) scale, which
includes 28 statements, so that statements from 1–15 mea-
sure the dimension of customer behavior participation
of customers in providing the service, while statements
from 16-28 measure the dimension of customer citizenship
behavior using a five-point (Likert scale,) ranging from
agree entirely “5”to not agree at all “1”.
4.2.4. The Customer Relationship Quality with the
Organization
The mediating variable is the customer relationship
quality with the organization, which is defined as the over-
all evaluation of the strength of the customer relationship
with the organization so that the customer is confident that
he can rely on the integrity of this service-providing orga-
nization and its future performance because the previous
performance level of this organization was continuously
satisfactory. It is evaluated through satisfaction cus-
tomers about the organization and customers’ trust in the
organization.
In this study, customer satisfaction with the organization
will be measured through the overall satisfaction with the
organization and its services, which is the emotional state
of the customer resulting from a comprehensive cognitive
and emotional evaluation of all aspects of the relationship
with the organization and its services over time-based on
their personal experiences in all service encounters.
Trust is measured through two aspects: the integrity and
credibility of the organization on the one hand and the
organization’s benevolence on the other hand. Therefore,
the client’s trust in the organization is represented in the
client’s overall perceptions of each of:
•Integrity and credibility (the client’s realization that
the organization has honesty and integrity and
delivers on its promises),
•The organization’s tendency to benevolence and
altruism (the client’s realization that the organiza-
tion considers his interest when making decisions;
Ganesan & Hess, 1997).
To measure the customer relationship quality with the
organization, the scale of Moliner et al. (2007) was relied
upon, which includes 13 phrases so that phrases 1–6
indicate customer satisfaction with the organization, and
phrases 7–13 refer to clients’ trust in the organization.
4.2.5. Customer Loyalty
The dependent variable is the loyalty of customers to the
organization. The current study adopts the composite view
of loyalty (attitudinal loyalty, behavioral loyalty, composite
loyalty), so compound loyalty is defined as the positive
attitude and behavior of the customer towards a particu-
lar organization, which prevents them from switching to
another service provider despite the efforts marketing to
competitors who provide alternative services in the market.
Behavioral loyalty is related to transactions and is mea-
sured through the intention or willingness of the customer
to repurchase the service from the same and to stay with the
organization and continue the relationship with it. Attitu-
dinal loyalty is related to the hidden internal beliefs related
to the tendency and psychological connection towards the
organization. It is measured in this study with each of the
long-term commitment of the customer towards the orga-
nization, insensitivity to price, and customer resistance to
attempts to persuade competitors to switch.
The scale proposed by Pritchard and Howard (1997),
and later revised by Tanford and Malek (2015),isusedto
measure complex loyalty, which includes 6 statements so
that statements from 1–3 indicate behavioral loyalty and
statements from 4–6 indicate attitudinal loyalty.
4.3. Study Population and Sample
The study population consists of all clients (patients)
who visit hospitals and private medical centers frequently
in Assiut Governorate, where the research community con-
sists of all private hospitals and medical centers distributed
over all regions in Assiut Governorate. The health sector is
considered one of the most essential applied sectors char-
acterized by a high level of customer co-creation in creating
the service because it requires direct interaction between
patients and service providers. These services cannot be
created in isolation from the active co-creation of patients.
Therefore, the behavior of patients has a significant role
in the success of providing these services. This interaction
increases in health organizations. The patient’s choice from
among the available alternatives is voluntary.
According to the statistical tables, the maximum sample
size is 384 (Krejcie & Morgan, 1970). This number has
been increased to 500 individuals due to the low response
rates of the respondents concerning social sciences and
humanities research, which amount to 52.7% in most cases.
Baruch and Holtom’s (2008) questionnaire was distributed
to 100 hospitals and private medical centers in Assiut
Governorate. The returned questionnaires were 445, with
a response rate of 89%.
4.4. Statistical Methods
The data were tabulated and analyzed using the Statis-
tical Package for Social Sciences (SPSS) software. Data
analysis and testing of the study hypotheses required the
application of the following statistical methods:
Cronbach’s Alpha Scale to test the reliability of the
questionnaire used in data collection. Descriptive statistic
measures were used to learn about the sample statis-
tics—the linear correlation coefficient between the study
variables. Simple and multiple regression analysis was used
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Rayan et al. The Mediating Role of Customer Relationship Quality
to determine the strength and direction of the relationship
between the study variables.
5. Results
This part deals with an analysis of the study results.
5.1. Description of the Study Sample
Table I shows the distribution of participants into dif-
ferent characteristics. The male percentage reached 55.7%
of the total sample size, which is slightly higher than the
percentage of females, which amounted to 44.3% of the
total sample size.
The most significant proportion of the sample was con-
centrated in the age group (from 30 years to less than 45
years), with 48.1% of the sample size, followed by the age
group (from 45 years to less than 60 years), with 26.1% of
the sample size, which is close to the percentage obtained
by the age group (less than 30 years old), which amounted
to 25.4% of the total sample size, while the age group (from
60 years and over) does not exceed 0,4%.
The category of BSc holders represents the vast majority
of the sample, representing about 76.4% of the total sample
size. In comparison, about 17.3% of the sample size had
technical diplomas, and the percentage of postgraduates
was 6.3%.
Table II shows a description of the study variables rep-
resented in the arithmetic averages of the variables on a
quintile scale and their standard deviations, as follows:
The average values of the study variables range from
3.85 to 4.45, reflecting the perception of customers to
participate in value creation, customer relationship quality
with the organization, and loyalty to it. Pearson’s corre-
lation illustrates a significant positive correlation between
all variables, where value co-creation and customer loyalty
correlation r =0.699, and r =0.788 for the correlation
between customers value co-creation and the relationship
quality. That means the higher the quality of customers’
relationship with the organization (represented in their
satisfaction with and trust in it), the higher their loyalty.
According to Table II, the correlation coefficients (r)
indicate a positive correlation between value co- creation
and customer loyalty, value co-creation and customer rela-
tionship quality, customer relationship quality, and their
loyalty to the organization.
Based on the results shown in Table III, the coefficients
of determination (R2) indicate that the customer value
co-creation contributes by (48.8%) in explaining the vari-
ance in loyalty customers of the organization. Meanwhile,
customer participation in service production and delivery
is the most important variable in explaining customer
loyalty, accounting for 36.8% of the variation. Customer
citizenship comes in second, with an estimated 12.3%
of the variation. The two independent variables explain
49.1% of the variation in customer loyalty. Moreover, cus-
tomer value co-creation explains about 62% of the variance
in customer relationship quality. Customer participation
in service production and delivery is vital in explaining
the variance in relationship quality. It explains 51.1% of
TABLE I: The Characterization of the Study Sample
Demographic variables Frequency Percentage
Gender
Male 248 55.7
Female 197 44.3
Total 445 100
Age
Less than 30 years 113 25.4
30 <45 214 48.1
45 <60 116 26.1
60 and above 2 0.4
Total 445 100
Education
Technical diploma 77 17.3
Bachelor’s degree 340 76.4
Postgraduates 28 6.3
Total 450 100
TABLE II: Correlation Analysis Results of the Study Variables
Variables MSD1234567
1. Customer participation in service production and
delivery
4.31 0.216 (0.594)
2. Customer citizenship behavior 3.96 0.200 0.470∗∗ (0.510)
3. Customer value co-creation behavior 4.15 0.179 0.888∗∗ 0.822∗∗ (0.701)
4. Satisfaction 4.15 0.372 0.607∗∗ 0.507∗∗ 0.652∗∗ (0.723)
5. Trust 4.45 0.299 0.650∗∗ 0.592∗∗ 0.726∗∗ 0.549∗∗ (0.787)
6. Customer relationship quality 4.34 0.288 0.715∗∗ 0.631∗∗ 0.788∗∗ 0.832∗∗ 0.920∗∗ (0.857)
7. Customer loyalty 3.85 0.281 0.606∗∗ 0.595∗∗ 0.699∗∗ 0.651∗∗ 0.794∗∗ 0.831∗∗ (0.835)
Note: M: mean; SD: standard deviation; ∗p<0.05, ∗∗p<0.01, ∗∗∗p<0.001. Numbers in parentheses refer to the reliability coefficients.
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The Mediating Role of Customer Relationship Quality Rayan et al.
TABLE III: Results of All Regression Analyses to Predıct Customer Loyalty
Model Variables R R2R2Adjusted
R2BBetaT Sig.
1 Customer value co-creation 0.70 0.49 0.49 0.49 1.10 0.70 20.56 <0.001
2 Customer participation in service production delivery 0.61 0.37 0.37 0.79 0.42 16.06 <0.001
Customer citizenship behavior 0.70 0.49 0.12 0.49 0.56 0.40 10.34 <0.001
3 Customer value co-creation 0.79 0.62 0.62 0.62 1.27 0.79 26.90 <0.001
4 Customer participation in service production and
delivery
0.72 0.51 0.51 0.72 0.54 16.20 <0.001
Customer citizenship behavior 0.79 0.62 0.11 0.62 0.54 0.38 11.43 <0.001
5 Customer relationship quality 0.83 0.69 0.69 0.68 0.81 0.83 31.41 <0.001
6 Trust 0.79 0.63 0.63 0.59 0.63 19.96 <0.001
Satisfaction 0.84 0.70 0.07 0.70 0.23 0.31 9.79 <0.001
7 Customer relationship quality 0.83 0.69 0.69 0.72 0.74 17.33 <0.001
Customer value co-creation 0.83 0.70 0.01 0.69 0.18 0.12 2.75 <0.001
8 Customer relationship quality 0.83 0.69 0.69 0.74 0.76 22.48 <0.001
Customer citizenship behavior 0.84 0.70 0.01 0.70 0.17 0.12 3.49 <0.001
the variance, followed by customer citizenship behavior
(11.1%), making the two independent variables together
explain 62.2% of the variance. Moreover, the relationship
quality variable explains the variance in customer loyalty
by 69%.
According to the dimensions of customer relationship
quality (customer satisfaction, customer trust), the values
of customer trust represent the most substantial variable in
explaining 63.1% of the variation in customer loyalty, fol-
lowed by the customer satisfaction variable, which explains
6.6% of the variance in customer loyalty, with a total
explanation power equal (69.7%).
According to the customer relationship quality medi-
ation between the customer value co-creation and
customers’ loyalty, the multiple regression analysis method
as used to determine the mediation role in this relationship.
We can refer to:
•The relationship quality variable has additional
content to explain part of the variation in customer
loyalty due to the significant correlation between
value co-creation and customer relationship quality
(r =0.834).
•The mediation role can be illustrated by shifting
the contribution percentage in explaining the cus-
tomer loyalty variation from (48.8%) to (69.5%)
after mediating the quality of customer relationship
between value co-creation and customer loyalty.
•After involving the mediating variable, the regres-
sion coefficients for value co-creation reduced from
(1.098) to (0.184). Moreover, R2was reduced from
(0.488) to (0.005), indicating that the quality of the
relationship contributes to partial mediation in the
relationship between customer value co-creation
and customer loyalty. So, the fourth main hypothe-
sis can be accepted as valid.
6. Discussion
Based on the previous data analysis, customer value
co-creation has a significant relationship with customer
loyalty to the organization, explaining 48.8% of the
variance. This result agreed with Grissemann and Stok-
burger-Sauer (2012),Halbesleben and Stoutner (2013),
Polo Peña et al. (2014),Nysveen and Pedersen (2014),
Bryce et al. (2015),Revilla-Camacho et al. (2015),van de
Scheur (2017),Ling-Yee Lin et al. (2017),andDelpechitre
et al. (2018). This indicates that good customer value
co-creation activities help significantly in deepening under-
standing of their needs, which improves service quality
and promotes customer loyalty to this firm. Furthermore,
the greater the customers’ co-creation in value-creating
activities, the greater their influence on the service outputs
in the way they desire. This is reflected in the customers’
sense of commitment to the organization and, thus, their
loyalty to the organization.
In another context, the results of the validity of this
relationship differed from the findings of the study of
van Dijk et al. (2014) and Ali et al. (2017) in terms of
the absence of a relationship between customer value co-
creation and customer loyalty to the organization, as well
as the study Mariyudi and Matriadi (2018) applied to
mobile applications. The dissimilarity of the results may be
due to the difference in the field of application.
The study by Lin et al. (2009) did not prove that cus-
tomer participation in service production directly affects
customer loyalty. This dissimilarity in the result can be
justified by the fact that banking services are character-
ized by a medium co-creation rate of customers, meaning
customers may feel their role is not sufficient and pay to
remain loyal to the bank.
Also, the study of Stokburger-Sauer et al. (2016) dif-
fered from the current study, as its results indicated that
co-creation negatively affects customer loyalty to the orga-
nization after the optimal level of joint production, and this
is due to the phenomenon of diminishing returns, which
indicates that the customer’s continued use of his resources
in service provision activities reduces his loyalty to the
organization.
There is also a study by Chiu et al. (2017), which found
that customer citizenship behavior as one of the dimen-
sions of customer value co-creation did not directly affect
behavioral loyalty, and this difference may be due to the
variance, the sampling unit, the statistical method used in
data analysis, or a field application.
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Rayan et al. The Mediating Role of Customer Relationship Quality
In addition to all of the above, it was found through
multiple regression analysis of the relationship between
the dimensions of customer value co-creation (customer
participation behavior in service delivery, customer citizen-
ship behavior) and customer loyalty to the organization
to determine the relative importance of those dimensions
and to know which are more influential and related to
customer loyalty, the existence of a relationship. A positive,
statistically significant correlation exists between the two
dimensions and customer loyalty to the organization.
Customer participation in service production ranked
first in terms of affecting customer loyalty. In contrast,
customer citizenship behavior came after in the second
place, and this sequence of dimensions may be logical
because, undoubtedly, the customer’s essential roles will
contribute more to achieving his loyalty. The organization
is compared to the customer’s citizenship behavior. After
all, they are indispensable behaviors for successful service
delivery. Any shortcoming or defect in it will, in turn, lead
to a defect and failure of the service provided. Therefore, it
will have the most significant impact on customer loyalty.
The results of the second hypothesis test showed that
there is a positive, statistically significant correlation
between customer value co-creation and customer rela-
tionship quality, where the value of the coefficient of
determination R2indicates that the customer co-creation
variable in value creation explained about (62%) of the
variance in customer relationship quality, and indicates
This result is that the more customers participate in value-
creating activities, the higher the customer relationship
quality with the organization represented by their sat-
isfaction with the organization and their trust in the
organization.
This result agrees with the findings of some studies
(e.g., Ammari & Jaziri, 2016;Banyte & Dovaliene, 2014;
Omar et al., 2018), which indicated that there is a direct
positive significant relationship between customer value
co-creation and the customer relationship quality.
This positive relationship can be explained by the fact
that value co-creation depends on the philosophy of infor-
mation flow between the customer and the organization,
commitment to the desires and needs of customers, inter-
action, and communication between customers and the
organization, all of which create opportunities for the
organization to benefit from the process of co-creation
in enhancing the quality of its customer relationship in
terms of building trust customer satisfaction with the
organization.
The current study results also agreed with the results
of several studies (e.g., Cambra-Fierro et al., 2017;Clauss
et al., 2019;Giner & Peralt Rillo, 2016;Grissemann &
Stokburger-Sauer, 2012;Nguyen, 2017;Nysveen & Ped-
ersen, 2014;Pantoja Díaz et al., 2016;Vega-Vazquez et
al., 2013), which found a positive significant relationship
between customer value co-creation and customer satis-
faction with the organization as one of the dimensions of
customer relationship quality, and the results of the current
study were in agreement with the results.
AstudybyRevilla-Camacho et al. (2014) demonstrated
that customer value co-creation significantly positively
impacts customer trust in the organization as one of the
dimensions of customer relationship quality.
The results of the current study are also in line with
the results of the studies of Zhang (2010) and Chu and
Wang (2012) regarding the existence of a positive, sig-
nificant relationship between customer participation in
service production and delivery as one of the dimensions of
customer value co-creation and the customer relationship
quality. The results of the study also agreed with the results
of several previous studies (e.g., Chen & Wang, 2016;
Halbesleben & Stoutner, 2013;Hsu & Chen, 2014;Ya n g
et al., 2019;Yim et al., 2012) in terms of a positive relation-
ship between customer participation in service production
and delivery and customer satisfaction as dimensions of
customer relationship quality.
The results of the current study also contradicted the
findings of Gao and Liu (2008) and Lin et al. (2003),
which found that the behavior of customer participation
in the production of the service is not significantly related
to customer satisfaction. This difference in results can be
attributed to the difference in the field of application where
this study was applied to the banking sector field, which
is characterized by the average co-creation of customers.
In contrast, the current study was applied to the health
services sector, which is characterized by a high level of
customer co-creation.
This difference extended to include studies of Bendapudi
and Leone (2003) and Fledderus (2015b), which found
that if the results of the service exceed or less than the
expectations of customers, the impact of customer co-
creation will be negative on their satisfaction. Moreover,
this may be due to subjective bias, where the customers
attribute service success to themselves while attributing
service failure to service providers.
The results of the current study also agreed with the
study of Kim and Lee (2018) in terms of the significant
effect of customer participation in service production and
delivery on customer trust, while the results of the current
study differed from the studies of Yin and Yang (2009)
and Fledderus (2015a,2015b), where it was found that
customer participation in service production activities does
not necessarily lead to building customer trust in the orga-
nization and that there is no relationship between the two
variables. This difference may be due to the difference in
the sampling unit, the field of application, or the variable
measurement method.
The current study also agreed with the results of Song
and Huh (2012),Madani et al. (2015),Choi (2015),and
Chiu et al. (2017) regarding the existence of a positive rela-
tionship between customer citizenship behavior. Moreover,
the dimensions of customer relationship quality (satisfac-
tion, trust) differed from the study of Guo et al. (2013),
which proved the existence of a negative relationship
between feedback as one of the dimensions of citizenship
behavior and customer satisfaction.
In addition, it was found through the use of multiple
regression analysis of the relationship of the dimensions
of customer value co-creation: customer participation
in service production and delivery, customer citizenship
behavior with the customer relationship quality to deter-
mine the relative importance of those dimensions and to
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The Mediating Role of Customer Relationship Quality Rayan et al.
know which are more influential and related to the cus-
tomer relationship quality, the existence of a correlation
Positive and statistically significant between (customer
participation in service production and delivery and cus-
tomer citizenship behavior) on the one hand, and the
customer relationship quality on the other.
The dimension of customer participation in service pro-
duction and delivery ranked first in affecting customer
relationship quality. In contrast, customer citizenship
behavior came second regarding customer relationship
quality. This arrangement is logical due to the nature
of these dimensions in customer participation in service
provision and delivery, which are mandatory behaviors all
customers perform to complete the service correctly. In
contrast, the behaviors of customer citizenship are volun-
tary. These voluntary behaviors help the organization in
several aspects, but they do not depend on the completion
of the service, so it is not required that all customers do
it. As a result, it is logical that the percentage of the con-
tribution of the basic behavior s that are indispensable to
successful service delivery is greater than the percentage of
additional optional behaviors that customers voluntarily
perform.
The results of the current study agreed with the results of
Zhang (2010) and Chu and Wang (2012) on the existence
of a positive, statistically significant relationship between
customer participation behavior and customer relation-
ship quality. While the current study differs from Wor l ey ’s
(2001) study in terms of no effect of customer participation
behavior on relationship quality, the study urged further
research on this inconsistency.
The results of testing this hypothesis showed that there
is a positive, statistically significant correlation between
the customer relationship quality as a total variable and
the loyalty of customers to the organization, where the
value of the coefficient of determination R2indicates that
the relationship quality variable has contributed to the
explanation of the variation in the responses of the respon-
dents concerning customer loyalty by (69%), which means
that 69% of customer loyalty is due to the quality of the
relationship.
The results of testing the validity of this hypothesis are
in line with the findings of several studies (e.g., Dai et al.,
2023;Kim et al., 2006;Kuhn & Mostert, 2018;Roberts
et al., 2003;Saleem et al., 2018;Ying et al., 2018)interms
of the existence of a positive statistically significant rela-
tionship between relationship quality and customer loyalty
to the organization, where the results of the current study
can be explained that the strong relationships between
customers and the organization that create in customers A
feeling of satisfaction with the organization and its services
and trust in its integrity and capabilities that contribute
to the customer’s assessment of the value of the service
positively, which positively reflects their loyalty to the
organization.
The results of the current study support the findings of
Yu and Tseng (2016), which were applied to life insurance
services, that there is a significant positive relationship
between customer relationship quality and behavioral loy-
alty as one of the dimensions of compound loyalty, and
this can be explained that good relationships between cus-
tomers and the organization will It creates a desire among
customers to repeat purchase from these organizations and
a commitment to deal with them when they need these
services in the future.
In the same direction, the results of the current study
agreed with the study of Mosavi and Ghaedi (2012),which
was applied in the luxury restaurants sector, where it
indicated that the customer relationship quality with the
organization has a significant positive impact on customer
loyalty as measured by the customer’s cognitive, emotional
and volitional commitment to the organization, and this
indicates the result is that customers who have a good rela-
tionship with the organization are more likely to remain
loyal to it, as well as the study of Abdul Rahman and
Ramli (2016), which was applied to Islamic banks. Its
results found a positive, significant relationship between
customer relationship quality and directional loyalty as
one of the dimensions of customer loyalty. This makes
sense since most banks offer almost identical products, so
a bank that wants to benefit from customer loyalty should
focus on relational standards that generate customer sat-
isfaction and trust and develop their relationship with the
organization.
Contrary to the above, the results of the current study
did not agree with the findings of Ben Naoui and Zaiem
(2010), which found that there is partial support for the
impact of customer relationship quality on customer loy-
alty. This study proved that loyalty is positively affected by
customer satisfaction, while there is no effect of customer
trust on their loyalty to the organization.
In the same context, the results of the current study
did not agree with the findings of the study of Alejandro
et al. (2011), which was applied in the field of the auto
parts industry, where it found that there is no relationship
between the customer relationship quality and their loy-
alty to the organization, while it concluded that there is
an indirect relationship between them by investing in the
relationship, and this can be explained that when organi-
zations spend effort, time and other resources in satisfying
the desires and needs of their customers, this proves to
customers the good intentions of the organization and the
extent of its appreciation for them, which makes customers
feel distinguished and that they are valuable to the orga-
nization and this is reflected in the continuation of their
relationship organization and their loyalty to it.
7. Conclusion
According to the current study, a positive, significant
relationship exists between customer value co-creation
and customer loyalty to the organization. When investi-
gating the value co-creation, it is vital to consider both
dimensions.
The results of this study indicated that the co-creation of
customers in creating value through mandatory behaviors
and voluntary activities that go beyond the obligatory
behaviors would build high-quality relationships with
customers, characterized by their satisfaction with the
organization and their trust in it. The dimension of cus-
tomer participation in service production is greater than
Vol 9 | Issue 2 | March 2024 20

Rayan et al. The Mediating Role of Customer Relationship Quality
the effect of customer citizenship behavior on customer
relationship quality, which indicates the importance of
addressing this concept through both dimensions. The
relationship is sufficiently in the literature of marketing
thought.
The apparent impact of customer relationship quality
on customer loyalty highlights the importance of devel-
oping strong relationships and bonds with customers that
support customer relationship quality by achieving their
satisfaction and increasing their trust in the organization.
Previous studies focused on customer loyalty through one
of its directional or behavioral dimensions only, while
other studies dealt with customer loyalty through indica-
tors such as frequency of dealing with the organization
and others and neglected the study of loyalty through
the hybrid approach that combines it between its two-
directional sides. The most comprehensive and accurate
indicator of loyalty to customers is behavior.
What was confirmed by the current study in terms of
the existence of an impact on the customer relationship
quality in its dimensions as an intervening mediator in the
relationship of customer value co-creation and customer
loyalty indicates that the impact of customer relationship
quality may be more important than the impact of cus-
tomer value co-creation on customer loyalty. Perhaps this
result is an addition to the relatively few available literature
in this regard, as no studies have been collected (within the
researcher’s knowledge) that dealt with the role of relation-
ship quality in an overall way, as well as its dimensions as
a mediating variable in the relationship of customer value
co-creation in an overall way, as well as its dimensions
on the composite customer loyalty that combines between
Attitudinal and behavioral loyalty, especially in Arabic
studies in general and Egyptian studies in particular.
8. Implications and Suggestions
8.1. Managerial Implications
The positive relationship between customer value co-
creation in its dimensions and their loyalty to private health
organizations illustrates the need for health care organiza-
tions to be interested in involving customers in all activities
of basic and additional value creation as a strategy to
positively influence their loyalty to them, especially the
behaviors related to the primary role of customers, as it was
found that what makes customers loyal to the organization
is its co-creation in creating value through the behaviors
of the primary role, and to ensure the effectiveness of the
process customer co-creation. These organizations must
find appropriate incentives for customer engagement and
provide them with the knowledge and skills to carry out
the required service tasks, such as providing the necessary
decision inputs so that service outcomes can better meet
their expectations.
The customers value co- creation contributes directly to
enhancing the customer relationship quality with health
organizations, as well as emphasizing that customers evalu-
ate the customer relationship quality with the organization
to a greater degree when they are more involved in the
behavior of the primary role, while the importance of
behavioral co-creation from During the additional role, it
is relatively more minor, reflecting an essential indication
of the need to pay attention to these variables according
to their relative importance from the point of view of their
customers and also the need for health organizations to
interest in facilitating the creation of relational values with
patients and meeting their needs to enhance the benefits
of customer co-creation behavior in creating value as well
as developing tools that allow patients by participating
in developing their trust and satisfaction and achieving
competitive advantage through this.
The customer relationship quality is positively related
to their loyalty to the organization. The customer trust
variable came to the fore in terms of affecting loyalty,
followed by the satisfaction variable, which practically
proves that the trust component of its customers is the
main driver that drives patients of health organizations to
return to it whenever they require this type of service. This
indicates the importance of organizations’ awareness that
they will not be able to survive and continue without solid
relationships with customers that achieve their satisfaction
and trust in the organization, which is sure to increase their
loyalty, which ensures a long-term relationship between
customers and the organization.
The mediation role of customer relationship quality
between customer value co-creation and customer loyalty
indicates that the impact of customer value co-creation
in its dimensions on customer loyalty is not effectively
achieved except by achieving a high indicator of customer
relationship quality with the organization. This indicates
that this depends on the importance of the relationship
quality variable. Therefore, health organizations’ interest
in facilitating and supporting the behavior of customer
value co-creation may not achieve the desired results con-
cerning the level of customer loyalty to them. Therefore,
they must develop strategies that support building positive
relationships with customers that ensure the promotion of
their trust in the organization and their satisfaction with it
and create the appropriate environment to achieve this.
8.2. Avenues for Future Research
The researchers confirm that the field of value co-
creation needs more research and study through its
connection with other variables that were not covered
before, whether they were re-applied to the same study
sample or to other sectors. Future research could extend
the scope of this study to include service providers’
behaviors in the value-creation process, thus clarifying
the comprehensive concept of value-creation processes
resulting from interactions between customers and service
providers.
The current study recommends applying the study
model in different environments and other service contexts
to overcome the limitation of the generalizability of the
results:
•Different results can be expected to test the model
in the context of tangible goods (industrial sectors)
and should be an area of future research.
•The current study recommends using other statisti-
cal methods to enrich and deepen the study results
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The Mediating Role of Customer Relationship Quality Rayan et al.
and provide more ideas, such as structural equation
modeling (SEM).
•A comparison can be made between the behavior
of co-creation in hospitals and private and pub-
lic medical centers to find their similarities and
differences.
Conflict of Interest
The authors declare that they do not have any conflict
of interest.
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