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Service quality effect on satisfaction and word of mouth in the

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Article  in  Journal of Service Theory and Practice · March 2009

DOI: 10.1108/09604520910943206

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Service quality
Service quality effect on effect
satisfaction and word of mouth in
the health care industry
229
Ioannis E. Chaniotakis
Hellenic Open University, Papagou, Greece, and
Constantine Lymperopoulos
Business School, University of the Aegean, Chios, Greece

Abstract
Purpose – This paper aims to study the effect of service quality (SQ) dimensions on satisfaction and
word of mouth (WOM) for maternities in Greece.
Design/methodology/approach – Based on Parasuraman et al.’s SERVQUAL variables, the
authors tried to identify the effects of each variable to satisfaction and WOM. Data were collected
through field research among 1,000 mothers who have given birth to a child during the last five years,
and the data were analysed using SEM.
Findings – The results suggest that, in addition to “satisfaction”, the only service quality dimension
that directly affects WOM, is “empathy”. In addition, “empathy” affects “responsiveness”, “assurance”
and “tangibles” which in turn have only an indirect effect to WOM through “satisfaction”.
Research limitations/implications – Limitations relate to the use of a non-probability sample and
the restricted geographical area of the field research. This study contributes to the body of academic
knowledge by shedding more light into the role of SQ dimensions, and especially “empathy”, in the
WOM for maternities.
Practical implications – An understanding of the effect of SQ dimensions in satisfaction and WOM
is important to maternities’ marketing managers because it offers them the opportunity to take certain
actions for improving customers’ satisfaction and increase their intention to use positive WOM.
Originality/value – The paper manages to identify the effects of SQ dimensions on satisfaction and
WOM, especially in the health care marketing sector.
Keywords Maternity services, Customer satisfaction, Customer services quality,
Interpersonal communications, Greece
Paper type Research paper

Introduction
Word of mouth (WOM) refers to verbal communications between the actual or
potential consumer and other people, such as the product or service provider,
independent experts, family and friends (Helm and Schlei, 1998). These
communications may be either positive or negative.
Researchers argue about the importance of WOM in the purchase behaviour context
(Bansal and Voyer, 2000) and the formation of consumers’ attitudes (Bone, 1995).
Ennew et al. (2000), suggest that the value of WOM cannot be the same across
product, market and organisational contexts. For example, for products that have a
predominance of experience and credence qualities or for products whose purchase is Managing Service Quality
Vol. 19 No. 2, 2009
highly associated with perceived risk, the influence of WOM is greater. pp. 229-242
In this context, Murray (1991) confirms that service consumers take in mind the q Emerald Group Publishing Limited
0960-4529
opinions and experiences of other individuals before making service purchase DOI 10.1108/09604520910943206
MSQ decisions and suggests that WOM reduces the risk that is associated with buying
19,2 decisions. This is in accordance with Berry and Parasuraman’s (1991) suggestion that
WOM is especially critical for the success of service providers.
With respect to the factors that affect WOM, it has often been suggested that there
is relationship between satisfaction and the desire to make recommendations for the
service provider (e.g. Parasuraman et al., 1988). In addition, Lovelock et al. (1996)
230 propose that customer satisfaction and service quality promotes positive WOM.
Though these relationships, in pairs, have been extensively researched in the past,
there is a gap in the literature related to the effects that the each service quality
dimension has on satisfaction and WOM, especially in the health care marketing
sector.
In this context, this research aims to study the effect of service quality on
satisfaction and WOM in this sector. Specifically, based on Parasuraman et al.’s (1985)
SERVQUAL variables, the authors tried to identify the effects of each variable on
satisfaction and positive WOM for maternities in Greece.
The choice of maternities as a specific sector to study was based on the fact that
WOM effect is important for the promotion of maternities services as there are
difficulties in exploiting the traditional elements of promotional mix. In addition,
maternity hospitals’ customers, normally, have limited opportunities for repeated
purchases. Moreover, as Youssef et al. (1996) mentioned, in the healthcare industry,
hospitals provide the same types of service but they are differentiated based on the
quality of service.
To this end, in the first part of this paper, the literature relating to the WOM is
reviewed. In the second part, the methodology of the research is described and the
results from a survey questionnaire, administered to 1,000 mothers that used the
services of maternities during the last five years, are presented. Finally, conclusions,
implications for managers and limitations of the research are presented.

Literature review
WOM communication and services
Positive WOM could be considered by many marketers as, perhaps, one of the oldest
forms of marketing communication. Its value arises as a consequence of its impact on
actual and potential buyers. More specific, positive comments from satisfied customers
can increase purchases, while negative comments from dissatisfied customers can
decrease purchases (Ennew et al., 2000). Moreover, Gremler and Brown (1996) suggest
that customers who are willing to offer positive WOM messages are more likely to
become loyal customers themselves. So, WOM may have benefits both in terms of
retention and acquisition.
WOM offers consumers the ability to make more informed choices. As a result, they
can benefit from reduced perceived risk of a certain buying behaviour. Roselius (1971)
mentioned that more risk averse consumers found WOM to be a very useful strategy in
reducing most types of risk, and particular consumers were found to rate WOM
particularly highly.
Specifically, in the services industry, as a result of the special characteristics of
services (intangibility, inseparability, heterogeneity, perishability), consumers make
their evaluations about them using three distinct qualities. Nelson (1970) noted the
search qualities (attributes of a service that can be determined prior to purchase) and
the experience qualities (attributes that can be ascertained during the consumption or Service quality
after purchase). Darby and Karni (1973) added a third category – the credence effect
qualities, which are impossible to evaluate, even after purchase and consumption.
Services of the first category are easier to evaluate in contrast to the others. Bharadwaj
et al. (1993) argue that, when buyers cannot easily evaluate the qualities of the service
then reputation, stimulated through positive WOM, may serve as an important proxy
for more detailed evaluation. 231
Service quality and its dimensions
Parasuraman et al. (1985, 1988) and Grönroos (1984) defined service quality as an
attitude of the consumer relating to the results from comparisons between expectations
of service with his perceptions of actual performance.
The most widely reported set of service quality was offered by Parasuraman et al.
(1985, 1988), who condensed using factor analysis the dimensions of service quality
into five categories:
(1) tangibles (facilities, equipment and appearance of staff);
(2) reliability (ability to perform the promised service dependably and accurately);
(3) responsiveness (willingness to help customers and provide prompt service);
(4) assurance (knowledge and courtesy of staff and their ability to convey trust and
confidence); and
(5) empathy (caring, individualised attention the organisation provides to its
customers).

This multi-item scale is known as SERVQUAL.

Parasuraman et al. (1991) also differentiated service quality dimensions in core
aspects of the service (reliability), which are mainly concerned with the outcome of
service and process aspects of the service (tangibles, responsiveness, assurance and
empathy), which are related with the service delivery process.

The importance of service quality for hospitals

In today’s highly competitive healthcare environment, hospitals, like all other public or
private organisations and institutions, are confronted with the necessity of measuring
both their financial (costs, revenues, profitability) and non financial performance
(quality of their services), in order to improve their functions and increase their
competitiveness. Performance measurement is not an easy task in health services,
where a wide range of stakeholders is involved. Moulin (2004) suggests eight essentials
of performance measurement, including service quality.
Lim and Tang (2000) argue that customer based determinants and perceptions of
service quality play an important role when choosing a hospital. Therefore,
Wisniewski and Wisniewski (2005) mention that service quality from the patients’
perspective should be routinely monitored and assessed and Silvestro (2005) proposes
the development of a tool for measuring the gap between patients’ priorities and their
perceptions and the match between the patient and management perspective.
In Greece, recently there has been an increasing interest from academics and
practitioners for measuring the quality of health care services offered by public or
private hospitals. In their recent survey, Baralexis and Sophianou (2005) mention that
MSQ public hospitals managers should realise that in order to confront effectively the
19,2 increasing competition of private Greek hospitals, they should first measure the quality
of their services in order to improve their performance. In another survey, Moschidis
(2006), using correspondence analysis, proposes a comparative evaluation of the degree
of satisfaction of patients and doctors in Greece.
Nevertheless, the research related to the measurement of service quality in
232 maternity hospitals is limited. Hill and McCrory (1997) attempt to measure service
quality at an Irish maternity hospital and identified – among others – the importance
of staff in the level of the service quality offered.
In addition, Hirsch and Wright (1998), realised that “maternity health care is an
intangible product that cannot be easily defined, quantified, measured, costed and
justified”. In their effort to develop a quality model for measuring the effectiveness of
midwifery services, they isolated women’s perceptions related to tangible variables of
quality from the intangible ones and mentioned the importance of “caring/empathy of
professionals” as well as the “flexibility and assurance”.
Finally, Proctor and Wright (1998) focused their research on women’s responses to
their recent experience of maternity care, and suggested that staff attitudes were the
main source of positive comments in contrast to lack of information and poor
explanations that were related to negative ones.

WOM, satisfaction and service quality

According to literature review, research has proved the importance of consumer WOM
in the formation of attitudes (Bone, 1995), in a purchase decision-making context
(Bansal and Voyer, 2000) and in the reduction of risk associated with buying decisions
(Murray, 1991).
Furthermore, there is evidence from the literature of the relationship between
satisfaction and the desire to recommend (e.g. Parasuraman et al., 1988; File et al., 1994;
Shemwell, 1998; Söderlund, 1998; Sivadas and Baker-Prewitt, 2000; Hennig-Thurau
et al., 2002). More specific, as Ennew et al. (2000) mention, consideration of consumers’
motives for engaging in WOM has tended to highlight the importance of customer
satisfaction as a determinant of positive WOM.
In addition, dissatisfaction is related to the intention of customers to use negative
WOM. Walker (1995) reported that at least 90 per cent of dissatisfied customers from a
company are expected to express their disappointment to a minimum of nine other
individuals.
Moreover, there is a great volume of research supporting the fact that service
quality is an antecedent of consumer satisfaction (e.g. Cronin and Taylor, 1992).
Although the above relationships between WOM, satisfaction and service quality
have been extensively researched in the past, there is limited research related on the
effect that service quality dimensions have on satisfaction and WOM, at the same
moment. More specific, Macintosh (2007), who researched the relationships of business
travellers with their travel agents, suggested that “relationship quality” affects overall
customers’ satisfaction with the firm and positive word-of-mouth. He defined
“relationship quality” as the customer’s assessment of the interpersonal relationship
with the contact person.
Additionally, Arasli et al. (2005) proved, with their study, the impact of service
quality perceptions of Greek Cypriot bank customers, to overall satisfaction from their
bank and to positive word of mouth. For measuring service quality, they used Service quality
SERVQUAL dimensions as suggested by Parasuraman et al. (1985, 1988), but the scale effect
proved to be of a three dimensional structure. (“responsiveness”, “empathy” and
“reliability”). Reliability items were the ones that had the highest effect on satisfaction,
which in turn had a significant impact on the positive word of mouth.
Finally, Carpenter and Fairhurst (2005) studied the effect of utilitarian and hedonic
shopping benefits on customer satisfaction, loyalty, and word of mouth 233
communication in a retail branded context. They found that “utilitarian shopping
benefits” that derived from the consumer’s belief that specific goals for a shopping trip
were satisfied and “hedonic shopping benefits” that reflect the emotional or
psychological worth of the purchase, affected satisfaction which in turn had an indirect
effect to word of mouth, through loyalty.
According to the above findings, there is a gap in the literature related to the effect
of service quality dimensions on satisfaction and WOM and the interrelationships of
these variables, especially in the health care marketing sector (see Figure 1).

Methodology
Based on the main findings of the literature review, the authors decided to investigate
the relationships among service quality dimensions on satisfaction and WOM for
maternities in Greece, by designing a behavioural model.
In the proposed model, based on the work of Parasuraman et al. (1985) related to the
SERVQUAL model as well as of Youssef et al. (1996) and Fuentes (1999) for the
evaluation of healthcare quality, “service quality dimensions” were measured by using
five latent variables, namely tangibles, reliability, responsiveness, assurance and
empathy.
Each of these, and the indicators used to assess them, can be summarised as follows:
(1) “Tangibles” (TA). The indicators of this variable, which is related to the
facilities and the equipment of the hospital, incorporated the “comfortable and
friendly environment” (TA1), the “clean environment” (TA2), the “up-to-date
equipment” (TA3), and the “clean and comfortable rooms” (TA4).

Figure 1.
Potential relationships
among service quality
dimensions, satisfaction
and word of mouth
MSQ (2) “Reliability” (REL). The indicators of this variable, which is related to the ability
19,2 to perform the promised service dependably and accurately, incorporated the
“organisation” (REL1) and the “reliability of the maternity hospital” (REL2) as
well as, the “kept promises” (REL3), and the “right way to carry out services”
(REL4).
(3) “Responsiveness” (RES). The indicators of this variable, which is related to the
234 willingness to help customers and provide prompt service, incorporated the
“24-hour service availability” (RES1), the “staff willing to respond to any need”
(RES2), the “staff spends time with each one in order to answer their questions”
(RES3), and the “staff responds quickly” (RES4).
(4) “Assurance” (AS). The indicators of this variable, which is related to the
knowledge and courtesy of staff and their ability to convey trust and
confidence, incorporated the “knowledgeable and experienced staff” (AS1), the
“friendly and courteous staff” (AS2), the “treatment with dignity and respect”
(AS3), and the “staff explains thoroughly medical condition” (AS4).
(5) “Empathy” (EM). The indicators of this variable, which is related to the caring
and individualised attention the organisation provides to its customers,
incorporated the “staff understands specific needs of mothers” (EM1), the “staff
show sincere interest” (EM2), the “staff offers personalised attention” (EM3),
and the “staff looks for the best for the mothers’ interests” (EM4).

In addition to these latent variables, “Satisfaction” and “WOM” were included in the
model, as measurement variables. Specifically, for measuring “satisfaction”,
participants were asked to state their “level of their overall satisfaction from the
maternity hospital” and for “word of mouth” they stated their “intention to recommend
the maternity hospital to their friends and relatives”.
The pilot survey with ten women helped the authors to formulate the final
questionnaire by rephrasing vague questions. The latent variables of the certain model,
as shown in the Appendix, contained 20 statements.
All the responses for the above variables were measured on a five-point Likert-type
scale, ranging from 1 (“strongly disagree”) to 5 (“strongly agree”).
For the collection of data, a survey was designed and conducted between November
2006 and January 2007 in the greater area of Athens, the capital of Greece, in which
more than 50 per cent of the total Greek population lives. The target population
comprised women, over 18 years old, who had given birth to a child during the last five
years.
The size of the target population is difficult to be approached accurately, though
according to published data for the total number of births in Greece between the years
2001-2006, was 527,968 (Greek National Statistics, 2007). Making the hypothesis that
50 per cent of the births were in Athens and the fact that some mothers had more than
one child during this period, the total population is estimated to be less than 250,000.
The research questionnaire, which was in Greek, was finally administered by
personal interviews to 1,000 participants, representing different age groups.
Non-probability sampling was implemented due to time and budget restrictions.
Table I summarises the profile of interviewees.
Using Hair’s criterion (Hair et al., 1992) that a sample size should be at least five
times the estimated parameter, the sample size was considered adequate.
 Service quality
Sample demographics
Frequency % effect
Age
Up to 25 98 9.8
26-30 317 31.7
31-35 322 32,2 235
36-40 219 21.9
40 þ 44 4.4
Education
Up to Lyceum (up to nine years in school) 96 9.6
Secondary education 426 42.6
University 388 38.8
Postgraduate 90 9.0
Monthly family income (e)
Up to 1,000 155 15.5
1,001-2,000 433 43.3
2,001-3,000 305 30.5
More than 3,001 107 10.7
Number of children
1 361 36.1
2 434 43.4
3 163 16.3
4 34 34.0 Table I.
More than 4 8 8.0 Respondents’ profile

Analysis results
Descriptive statistics
For the analysis of consumer attitudes SPSS software was used. According to the
descriptive statistics that were generated, overall satisfaction (mean ¼ 4:03) and
intention to recommend (mean ¼ 4:02) is high and all the mean scores for the 20
statements related to service quality dimensions were above the median value of 3 (see
Table II).
Furthermore, there are strong attitudes towards the service offered by the hospital’s
staff. Specifically, mothers believe that the staff offered them personalised attention
(4.32), understood their specific needs (4.26), were knowledgeable and experienced
(4.24), were willing to respond to any need (4.16) and were friendly and courteous (4.10).

Model fit
For the scales’ reliability analysis, Cronbach’s alpha, average variance extracted (AVE)
and composite reliability (CR) were calculated for all latent variables’ measurement
scales. Results, as seen in Table III, revealed that all scales were reliable.
For the appropriate “goodness of fit” test, structural equation modelling (SEM)
analysis was performed using the “Amos 4.0” software. SEM, which is a multivariate
technique, was chosen for this study because it is able to analyse the relations between
both unobservable (latent) and observable variables and test the validity of a causal
structure.
MSQ
Mean Variance
19,2
Staff offer personalised attention 4.32 1.030
Staff understand specific needs of mothers 4.26 1.073
Knowledgeable and experienced staff 4.24 1.073
Staff spend time with each one in order to answer their questions 4.20 1.021
236 Staff willing to respond to any need 4.16 0.990
Clean and comfortable rooms 4.15 1.007
Staff respond quickly 4.13 0.948
24-hour service availability 4.10 1.038
Friendly and courteous staff 4.10 0.964
Staff explain thoroughly medical condition 4.07 0.948
Overall satisfaction 4.03 0.890
Intention to recommend 4.02 1.060
Keep promises 4.02 0.921
Well organised 3.93 0.947
Comfortable and friendly environment 3.92 0.891
Treatment with dignity and respect 3.87 0.887
Services carried out right 3.86 0.917
Up-to-date equipment 3.84 0.934
Staff show sincere interest 3.85 0.875
Very reliable 3.83 0.877
Staff look for the best for the mothers’ interests 3.82 0.877
Table II. Clean environment 3.82 0.921

Cronbach alpha AVE CR

Latent variable (Acc. value . 0:70) (Acc. value . 0:50) (Acc. value . 0:70)

Tangibles 0.7940 0.54 0.70

Reliability 0.8138 0.58 0.74
Table III. Responsiveness 0.8465 0.60 0.78
Reliability analysis of Assurance 0.8371 0.56 0.74
measurement scales Empathy 0.8610 0.61 0.79

Using the “model building technique”, the model was finalised by including in the
independent model the proposed modification indices paths. According to the results,
as presented in Table IV, all the important indicators of the model fit, as suggested by
Hoyle (1995), are above the accepted values. For this reason this model is considered as
an acceptable one (Figure 2).

Relative
Variable x2 p x2 GFI AGFI TLI IFI CFI RMSEA
Table IV.
Goodness of fit test Value 921.623 0.000 4.562 0.920 0.900 0.944 0.951 0.951 0.060
results for the model Accepted values , 5.00 . 0.90 . 0.90 . 0.90 . 0.90 . 0.90 , 0.080
 Service quality
effect

237

Figure 2.
The model

The most important relationships that derive from the final model, are:
.
“Satisfaction” has a statistically significant relationship with “WOM” (t ¼ 0:543,
p ¼ 0:000).
.
“Empathy” has a statistically significant direct relationship with “WOM”
(t ¼ 0:297, p ¼ 0:000).
.
“Tangibles” have a statistically significant relationship with “satisfaction”
(t ¼ 0:361, p ¼ 0:000).
.
“Assurance” has a statistically significant relationship with “satisfaction”
(t ¼ 0:355, p ¼ 0:000).
.
“Responsiveness” has a statistically significant relationship with “satisfaction”
at the 0.05 level (t ¼ 0:185, p ¼ 0:045).

Finally, “reliability” has no statistically significant relationship with “Satisfaction”

(p ¼ 0:282).

Conclusions and implications for managers

This research targeted to study the effect of service quality dimensions on satisfaction
and on positive WOM for maternities in Greece. In addition, this study examined the
interrelationships among these variables and provided statistical evidence for their
significance.
Data analysis proposed that the more satisfied new mothers are from their
maternity, the more willing they are to use positive WOM. This is in accordance with
MSQ prior research findings in the services sector (e.g. Parasuraman et al., 1988; Shemwell,
19,2 1998; Söderlund, 1998).
Considering service quality dimensions, “empathy” appears to be an important
variable in the model because:
.
it is the only one of the service quality dimensions that directly affects WOM;
238 .
it affects almost all the other dimensions of service quality, except reliability.

According to this, the more empathy mothers perceive that the staff show to them,
the higher their intention of using positive WOM is. This finding is important
because it highlights the role of employees, not only in the production of a service,
but also in the indirect promotion of it, through the effect on the users’ (mothers’)
intention to recommend the service. Understanding of needs, sincere interest,
personalised attention and the effort to look for the best of the mothers’ interests are
the specific actions that increase the “empathy” mothers feel that the maternities’
staff shows.
Moreover, perceived “empathy” is important as it influences mothers’ perceptions of
“responsiveness”, “assurance” and “tangibles”, the three SERVQUAL dimensions that
have an indirect effect – via satisfaction – on the positive WOM for maternities. As a
result, mothers who perceive a high level of perceived “empathy” also perceive that:
.
the quality of the environment and the equipment of the maternity (“tangibles”)
is high;
.
the personnel are willing to help them and provide prompt service
(“responsiveness”); and
. the personnel have the ability to convey trust and confidence (“assurance”).

Moreover, mothers who feel that the maternity staff shows empathy are also satisfied
and willing to recommend the maternity hospital.
The above findings are particularly relevant to practitioners of health care
marketing and especially those who work for maternity hospitals. More specific, in
order to exploit the opportunities for having satisfied customers and creating positive
word of mouth communications, they have to understand the importance of the staff in
the service process.
It should be noted though that maternity marketing managers may be able to
control the environment of the hospital or the pricing issues related to the service
offered, but they may find it difficult to – continuously – control the human factor of
their service, which is related to their staff.
For this reason, maternities’ managers should:
.
pay a great attention to the recruitment stage of the contact personnel on the
basis of their competence to manage interpersonal communication effectively;
.
focus on important areas of service quality by designing analytical blueprints
related to processes; and
.
act for the continuous training of the staff related to the way they should behave
and offer their services to mothers.
Furthermore, it is could be helpful to use, as a complementary tool, internal marketing Service quality
practices, such as the production and distribution of printed material (e.g. newsletters), effect
which will communicate to staff:
. the service quality policy of the hospital;
.
the good practices used by their colleagues during previous periods; and
.
tips about the right way to treat mothers. 239
Finally, quality of service controls based on mystery shopping and other techniques
could be employed for the continuous monitoring of all the stages for the services offered.

Limitations and further research

One limitation of this study comes from the fact that the field research was conducted
only in Athens, an urban area of Greece.
As far as the sampling method is concerned, limitations refer to the different types
of errors inherent in surveys, such as the non-response error and the inability or
unwillingness of interviewees to respond.
Moreover, although descriptive research calls for probability sampling,
non-probability sampling was used for this study; therefore, no assessment of
sampling error was possible.
Owing to the research sample limitations, it should be useful to analyse data from a
greater geographical sample that would include both urban and rural areas and
compare the differences.
Further research would be interesting to re-evaluate the proposed model variables
and their relationships with a sample from another country with different
characteristics (e.g. population, income, etc.).
In addition, it would be of particular interest to study maternities staff’s attitudes
towards the quality of the service they offer to their customers (mothers), as well as the
way they view their role with respect to the maternity total service quality.

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Appendix. Questions measuring service quality dimensions

Tangibility (T)
1. Comfortable and friendly environment.
2. Clean environment.
MSQ 3. Up-to-date equipment.
19,2 4. Clean and comfortable rooms.
Reliability (RL)
5. Well organised.

242 6. Very reliable.

7. Keep promises.
8. Services carried out right.
Responsiveness (RS)
9. 24-hour service availability.
10. Staff willing to respond to any need.
11. Staff spend time with each one in order to answer their questions.
12. Staff responds quickly.
Assurance (AS)
13. Knowledgeable and experienced staff.
14. Friendly and courteous staff.
16. Staff explain thoroughly medical condition.
Empathy (EM)
17. Staff understand specific needs of mothers.
18. Staff show sincere interest.
20. Staff look for the best for the mothers’ interests.

About the authors

Ioannis E. Chaniotakis is Tutor of Marketing in the Hellenic Open University. He holds a BSc in
Agricultural Economics from the Aristotle University of Thessaloniki, an MSc in Marketing
from the University of London and a PhD in Marketing from the University of the Aegean. He
has worked for Nestlé and ATEbank. Ioannis E. Chaniotakisis is the corresponding author and
can be contacted at: Ichaniotakis@yahoo.gr
Constantine Lymperopoulos has a BSc in Business Administration from the University of
Piraeus and a MSc and PhD from Kepler University, Linz, Austria. His work experience has been
in Henkel Hellas and the Ionian Bank of Greece. He is Assistant Professor at the University of the
Aegean, Department of Business Administration and adjunct Professor at the University of
Piraeus and the Hellenic Open University.

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