Client Retention Research Articles

RURAL MICROFINANCE AND CLIENT RETENTION: EVIDENCE FROM MALAWI

Microfinance institutions (MFIs) have largely focused on urban markets, leaving the rural poor underserved. The high costs of serving rural markets has often been identified as the key impediment to serving these markets, resulting in saturation and heavy competition in urban markets while poor rural clients remain unserved. In this paper, we provide evidence from a sample of over 10,000 microfinance loans in Malawi, that the cost argument has an important flaw. Results show that client retention, a critical aspect of financial sustainability, is significantly higher in rural markets. In addition to being a key financial indicator in an industry where annual client exit rates can exceed 50 percent, client retention is also a key measure of social impact. By operating in rural markets, MFIs may be able to increase both social impact and financial performance.

Opioid substitution: improving cost–efficiency

The United Nations Office of Drugs and Crime in its 2012 World drug report estimates that 0.6% of the world’s adult population – some 27 million people – are problem users of illicit drugs.1 This represents about 10% of all people who used illicit drugs in 2011 and suggests that most people can use drugs recreationally without becoming dependent. What makes these 10% different is the subject of active research and remains poorly understood, but whatever the reason, drug dependency frequently has damaging effects to the user and society and is therefore stigmatized both socially and legally. Opioids (heroin, morphine and prescription opioids) may be the most harmful of the illicit drugs used.2 Fortunately, treatment is available and has been for some decades. In the late 1940s methadone was tested as an abstinence treatment for opioid dependence and later as a maintenance treatment3 under the hypothesis that at high, sustained doses methadone could block both the euphoric and adverse effects of opioids to a sufficient level that patients could stabilize their lives, find employment and reintegrate into society.4 Worldwide, its use has increased considerably since the onset of the HIV epidemic5 and it is now recognized as an important component of any strategy to control HIV infection among injecting drug users. Among 120 countries that report HIV transmission among people who inject drugs, 97 countries support a harm reduction approach and 78 have a methadone programme or are piloting one.6 The worldwide scale-up of methadone maintenance treatment has been largely facilitated by the generosity of programmes such as the Global Fund to Fight AIDS, Tuberculosis and Malaria as well as through bilateral foreign aid agreements. However, in the current economic climate, the stability of these sources of funding is precarious. The Global Fund has already announced reductions in its funding capacity and without financial support from their own governments, many low- and middle-income countries may not be able to continue to support methadone maintenance programmes. Few countries are in the same position as China where the shortfall in Global Fund support was, commendably, met by the central government. While methadone maintenance has been repeatedly shown to be an effective intervention for reducing drug-associated harms, no programme is without its problems. Chief among these is client retention. By definition, methadone maintenance is a long-term treatment typically requiring at least one year to achieve positive outcomes.7 Retention is strongly predicted by the methadone dose administered,8 but most programmes routinely under-dose their clients, ignoring evidence from the initial methadone maintenance trials which used 100 mg/day4 and even ignoring later recommendations to maintain clients on 60 mg/day.9 But under-dosing is not the only reason clients leave treatment. Many may never have intended to stay in treatment for the long term. To satisfy policy-makers, programmes may attempt to enrol as many clients as possible, disregarding screening criteria that might have ensured the client was ready for long-term therapy. The frequent enrolment of short-term clients or re-enrolment of prior clients is at enormous cost to the clinics in terms of staff members’ time. Similarly, staff retention is a problem for many programmes. Limited job satisfaction as well as stigma contribute to high staff turnover, adversely affecting client retention and therefore programme effectiveness. Drug dependency is not an illness which can be cured with pharmaceuticals alone. It requires a comprehensive package of services, of which methadone maintenance is just one. As such, clinics require staff who are able to provide quality services not only in dispensing but skills in training and psychosocial support, which can be difficult to achieve in low- and middle-income countries. While many programmes claim to provide such services, their quality may be too poor to be effective. Thus the cost–benefits of investing in staff development also need greater appreciation. This special issue of the Bulletin includes a range of papers describing various aspects of methadone maintenance programmes from around the world. While methadone maintenance may be the most effective treatment currently available, in a precarious funding environment, programmes will need to explore options for increasing the cost-efficiency of service delivery while improving client outcomes.

Can Auditors be Independent? Experimental Evidence on the Effects of Client Type

Recent regulatory initiatives stress that an independent oversight board, rather than the management board, should assume the role of auditors' client. In an experiment, we test whether the type of client affects auditors' independence. Unique features of the German institutional setting enable us to realistically vary the type of auditors' client as our treatment variable: we portray the client either as the management preferring aggressive accounting or the oversight board preferring conservative accounting. We measure auditors' perceived client retention incentives and accountability pressure in a post-experiment questionnaire to capture potential threats to independence. We find that the type of auditors' client affects auditors' behaviour contingent on the degree of the perceived threats to independence. Our findings imply that both client retention incentives and accountability pressure represent distinctive threats to auditors' independence and that the effectiveness of an oversight board in enhancing auditors' independence depends on the underlying threat.

Evaluating the Effect of Abnormal Audit Fees on Future Restatements

SUMMARY This article summarizes our recently published article, “Abnormal Audit Fees and Restatements” (Blankley et al. 2012), which discusses the relationship between abnormal audit fees and future restatements. We find that there is a negative relationship between the two; specifically, unusually low audit fees are associated with an increased likelihood of a future restatement (i.e., one or two years in the future). This relationship has important implications for auditors in terms of audit planning, pricing, and client retention. After summarizing the published study, we discuss how examining abnormal audit fees may be useful for audit professionals and audit committees.

Association of Cotherapy Supervision With Client Outcomes, Attrition, and Trainee Effectiveness in a Psychotherapy Training Clinic

Cotherapy supervision has been hypothesized to enhance client outcomes and trainee effectiveness, but there is little empirical evidence relevant to either claim. This study tested both hypotheses, using data from the supervision of psychology doctoral students conducting cognitive behavioral therapy in a university-based clinic. Groups of clients treated by supervisor-trainee duos and groups of clients treated by solo trainees with varying exposure to cotherapy supervision were compared on changes in symptoms as measured with the Outcome Questionnaire (OQ-45) and on dropout rates. Clients showed statistically significant reductions in symptoms from pretreatment to posttreatment. However, there were no significant group differences in the magnitude of change or in client retention. No support was obtained for the hypothesized benefits of cotherapy supervision. Clients treated by a cotherapy (supervisor and supervisee) team did not improve more than did clients treated by solo trainees. Furthermore, clients treated by (solo) trainees who had received cotherapy supervision did not improve more than did clients treated by trainees who had not received cotherapy supervision.

Adolescent Psychotherapy Outcomes in Community Mental Health: How Do Symptoms Align with Target Complaints and Perceived Change?

This study examined the relationship between clinically significant symptom change (rated by youth and parents), severity of client-defined primary presenting problems (i.e., Target Complaints), and perceived change in therapy. Participants were 117 adolescents receiving outpatient therapy and their parents. Participants completed the following measures at intake and 3 months into treatment: Ohio Scales, Target Complaints, and Perceived Change. Results indicate significant correspondence between clinically significant symptom change and other outcomes, offering preliminary evidence that global symptom measures represent change that is meaningful to adolescent clients. However, the modest magnitude of the correspondence also suggests that such measures as perceived change and individualized Target Complaints may offer unique utility in capturing the multidimensional nature of outcomes in youth therapy and provide useful avenues for future research focused on enhancing client engagement and retention. Recommendations for outcome assessment in community mental health centers are provided.

Client Retention and Health Among Sex Workers in Nairobi, Kenya

It is still a small body of research that directly addresses female sex workers' relationships with their regular commercial male partners. I used ethnographic data from Nairobi, Kenya to interrogate motivations and strategies for recruiting and retaining regular male clients among female sex workers (FSWs). Regular commercial male partners, popularly called customer care, wera or wesh by Nairobi's FSWs, played diverse roles in their lives. Client retention enabled sex workers to manage the risk of reduced marriage prospects, guaranteed them steady work, livelihoods, and incomes, and prevented their victimization and harassment. To retain clients, sex workers obliged them a great deal, pretended they had quit prostitution, and sometimes resorted to magical practices. However, these strategies were also accompanied by risks that reinforced the vulnerability of sex workers. Lack of critical attention to sex workers' practices for managing perceived risks in their particular type of work may hamper current programmatic efforts to make their job safer.

Functional Analytic Psychotherapy as an adjunct to cognitive-behavioral treatments for posttraumatic stress disorder: Theory and application in a single case design.

Posttraumatic Stress Disorder (PTSD) is an anxiety disorder resulting from the experience of a traumatic event (e.g., sexual assault, military combat, natural disaster) with resulting emotions of fear, helplessness, or horror (Diagnostic and Statistical Manual of Mental Disorders 4th edition, Text-Revision; DSM-IV-TR, American Psychiatric Association, 2000). PTSD is characterized by re-experiencing symptoms (e.g., flashbacks, nightmares), avoidance (e.g., avoiding thinking or talking about the trauma, avoiding situations that remind one of the trauma), and hyperarousal (e.g., hypervigilance, irritability). Nearly 70% of Americans have experienced a traumatic event and approximately 6.8% of the population meets criteria for PTSD (Kessler et al., 2005), with higher prevalence rates among women and combat veterans (Kulka et al., 1990; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993; Tanielian, & Jaycox, 2008). Cognitive-behavioral interventions have been developed to help individuals who are struggling with PTSD. The most widespread and empirically supported are Prolonged Exposure (PE; Foa, Hembree, Rothbaum, 2007) and Cognitive Processing Therapy (CPT; Resick & Schnicke, 1993). PE is an empirically supported behavioral treatment for PTSD that has been demonstrated to help alleviate symptoms of PTSD through in-vivo and imaginal exposure exercises. In-vivo exposure involves the client approaching avoided situations gradually to learn skills to cope with anxiety. Increased exposure to feared situations makes it more possible to engage those over time (i.e., habituation to evocative stimulus conditons). Imaginal exposure involves the repeated processing of the traumatic memory during therapy sessions in order to experience the trauma related feelings and thoughts that have been avoided. By repeated exposure to the feared memory and other private events, clients gain new skills in tolerating anxiety and learn ways to experience these private behaviors without avoiding. CPT is a cognitively-focused intervention that also can contain an emotional processing component where clients write about the traumatic event in detail. This allows clients to experience the natural emotions that rise from the process without engaging in avoidance coping. In addition, CPT focuses on restructuring trauma-related maladaptive thoughts about the meaning of the traumatic event, the self, others, and the world that maintain symptoms (e.g., No one can be trusted, Because I walked down the street with him and he raped me, I cannot keep myself safe). While these treatments have been shown to greatly benefit those who suffer from PTSD in reducing targeted symptomatology (Chard, 2005; Foa et al., 2005; Resick, Nishith, Weaver, Astin, & Feuer, 2002), retention of clients in treatment has been a concern; approximately one-fifth of clients drop out of cognitive-behavioral treatments for PTSD (Hembree et al., 2003). In a review of dropout in studies of PTSD treatments, Schottenbauer and colleagues (2008) reported dropout as high as 50% for PE, CPT and other cognitive-behavioral interventions. Although researchers suggest symptom exacerbation after beginning imaginal exposure in PE does not lead to attrition (Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002), it is unclear why so many clients dropout of these intensive treatments. Nevertheless it is important for clinicians and researchers to examine how to reduce dropout rates through enhanced cognitive-behavioral approaches. Strategies to accomplish this may focus on building trust between the therapist and client. THERAPEUTIC ALLIANCE In cognitive-behavioral interventions for PTSD, clinicians ask clients to discuss feelings and thoughts they are trying to avoid. In essence, clients are asked to approach the situations they fear the most. It seems reasonable to assume that a strong therapeutic alliance must be at the core of this type of cognitive-behavioral intervention, especially since compared to those without PTSD, individuals with PTSD report more effort strategically attempting to avoid emotional expression around others (Roemer, Litz, Orsillo, & Wagner, 2001). …

Forms of growth: How SMEs combine forms of growth to achieve high growth

AbstractThe majority of the literature on high-growth firms focuses on two main aspects: growth factors and rates of growth, but little information exists on how SMEs grow. Past research has implicitly considered high-growth firms as a homogeneous category of businesses, however, in reality, they use different forms of growth: domestic and international geographical expansion, the launch of new related and unrelated products, product improvement, client retention and the acquisition of new clients. This work attempts to identify how high-growth SMEs benefit from different combinations of forms of growth to perform successfully. A sample of 89 high-growth SMEs was selected – with an annual growth rate of more than 10% over a 5-year period – and, by means of a cluster analysis, we found four significantly different combinations of forms of growth. To externally test the robustness of those combinations, a group of demographic variables was considered (size, age, sector), as well as a set of variables related to the growth strategy (personnel involvement, the extent to which growth is a priority, perceived growth with respect to competitors), which support the existence of significant differences between the groups.

Forms of growth: How SMEs combine forms of growth to achieve high growth

AbstractThe majority of the literature on high-growth firms focuses on two main aspects: growth factors and rates of growth, but little information exists on how SMEs grow. Past research has implicitly considered high-growth firms as a homogeneous category of businesses, however, in reality, they use different forms of growth: domestic and international geographical expansion, the launch of new related and unrelated products, product improvement, client retention and the acquisition of new clients. This work attempts to identify how high-growth SMEs benefit from different combinations of forms of growth to perform successfully. A sample of 89 high-growth SMEs was selected – with an annual growth rate of more than 10% over a 5-year period – and, by means of a cluster analysis, we found four significantly different combinations of forms of growth. To externally test the robustness of those combinations, a group of demographic variables was considered (size, age, sector), as well as a set of variables related to the growth strategy (personnel involvement, the extent to which growth is a priority, perceived growth with respect to competitors), which support the existence of significant differences between the groups.

Client-Provider Relationship and Treatment Outcome: A Systematic Review of Substance Abuse, Child Welfare, and Mental Health Services Research

This systematic review reports on the association of the client-provider relationship with service outcomes across 3 service sectors: substance abuse, child welfare, and mental health. The review includes 60 research reports meeting inclusion criteria: 25 in substance abuse, 7 in child welfare, and 28 in mental health. For each social service sector, we analyze the association of the client-provider relationship to intermediate and ultimate outcomes. In addition, we examine potential moderating mechanisms of rater type (i.e., client, provider, and observer) and treatment setting (i.e., inpatient, outpatient, other). Social services research increasingly seeks to identify the active elements that affect outcomes common to all interventions. Results suggest the client-provider relationship is a consistent predictor of client retention in treatment and a somewhat less-consistent predictor of ultimate outcome across the 3 service sectors. These results contrast with recent findings from the psychotherapeutic literature in which the client-provider relationship demonstrated a weaker association with treatment retention (measured as drop out) than with other outcome measures. Findings indicate a clear need to refine the conceptualization and measurement of key service mechanisms and outcomes, particularly in the area of child welfare given that services research is less developed in that sector. The discussion includes recommendations for future research, including the use of selection criteria to enable researchers to conduct formal meta-analyses and expand the moderational framework with additional moderator variables relevant to social service delivery.

Retención de clientes en agencias de eventos

Retención de clientes en agencias de eventos

Risk factors for premature termination of treatment at a child and family mental health clinic

Objective: Premature termination of treatment amongst children and families attending mental health services is a significant problem for both outcomes research and clinical practice in South Africa and elsewhere. This study investigated factors that are associated with premature termination of treatment at a public service child and family clinic in Cape Town. Method: A retrospective archival analysis of clinic files from 2002–2009 was conducted. Administrative, child and family factors, and type of treatment were explored as risk factors for premature termination. Results: A single-parent household and the presence of a child or oppositional defiant disorder were risk factors for premature termination of treatment, while the presence of a maternal psychiatric diagnosis was associated with a lower likelihood of terminating treatment prematurely. Conducting a scholastic assessment with the child was associated with a lower risk of premature termination, while there was a trend towards a higher risk of premature termination when individual child therapy was the recommended treatment. Conclusions: This study offers recommendations for how these findings could assist South African clinicians to enhance client retention in child and family mental health services, and suggestions for future research.

Identifying variables that predict clients' propensity to end their checking accounts

PurposeThis study aims to investigate which variables can predict clients closing their checking accounts in a commercial bank and to validate the model used in this research.Design/methodology/approachThe theoretical basis of the study has contemplated satisfaction, loyalty, change mediators, switching costs and client retention. A total of 2,000 account holders plus 2,000 clients who closed their checking accounts were selected by simple probabilistic sample. The samples were probabilistic, without repetition, with an error margin of approximately 2.2 percent and trust interval of 95 percent with random drafting of the account holders' database from a large institution based in all Brazil. The variables were tested using the Binary Logistic Regression and the variables between the account holder and former account holder groups with indication of checking account closing request were compared.FindingsAccount holder's age, time of the account, investor/taker profile, internal relationship, long term assets contracts, risks in other banks, quantity of products, product canceling, average amount of entries and the existence of a joint client are the variables which better identify clients' propensity to end their relationship.Practical implicationsThe obtained results make it possible to identify the clients' propensity to abandonment and contribute to directing future marketing actions.Originality/valueThe model is relevant on the theoretical point of view because it can measure the importance of each independent variable and provides elements to compare all of them in the same base (meta‐analysis). It deals with 14 independent variables and had a good adjustment once was capable to classify correctly 89.8 percent of the account holders and 87.2 percent of the former account holders. The K‐S value was 79 percent with p<0.005 and value of ROC curve was 0.947. Models like this are unknown.

Methodological Issues in Evaluating Auricular Acupuncture Therapy for Problems Arising from the Use of Drugs and Alcohol

Auricular acupuncture is an accessible, non-confrontational therapy that appears to be effective when used in drug and alcohol treatment facilities, hospitals and prisons in the UK, Europe and the USA. Despite being popular, research evidence on its effectiveness is lacking, and as a result services are underfunded and risk being withdrawn. There are methodological problems in researching auricular acupuncture. In these days of evidence-based medicine, most studies in this area are explanatory randomised controlled trials, which is limited in capturing the complete benefits of the intervention. Furthermore, there is lack of consensus over definitions of the concept of ‘addiction’ and whether or not this should be perceived as a ‘disease’ that can be ‘cured’ by an intervention such as auricular acupuncture. Basic concepts such as these need to inform development of outcome measures, which should include retention of clients in treatment as an indicator of success.It is argued here that the best approach will integrate research on physical effects with research on subjective experience of those with drug and alcohol problems. The challenge is to design large scale, high quality, pragmatic randomised controlled trials to assess the effectiveness of auricular acupuncture over the longer term in settings that mimic the delivery of treatment in practice and are informed by acupuncture's own diagnostic traditions, using a combination of objective, quantitative methods and subjective, qualitative methods.

Implementation of free cotrimoxazole prophylaxis improves clinic retention among antiretroviral therapy-ineligible clients in Kenya

To determine whether implementation of free cotrimoxazole (CTX) provision was associated with improved retention among clients ineligible for antiretroviral therapy (ART) enrolled in an HIV treatment program in Kenya. Data were obtained from a clinical cohort for program evaluation purposes. Twelve-month clinic retention was compared among ART-ineligible clients enrolled in the time period before free CTX versus the time period after. Statistical comparisons were made using Kaplan-Meier survival curves, log-rank tests, and multivariate Cox proportional hazards models. To exclude potential temporal program changes that may have influenced retention, ART clients before and after the same cut-off date were compared. Among adult clients enrolled between 2005 and 2007, 3234 began ART within 1 year of enrollment, and 1024 of those who did not start treatment were defined as ART-ineligible. ART-ineligible clients enrolled in the period following free CTX provision had higher 12-month retention (84%) than those who enrolled prior to free CTX (63%; P < 0.001). Retention did not change significantly during these periods among ART clients (P = 0.55). In multivariate analysis, ART-ineligible clients enrolled prior to free CTX were more than twice as likely to be lost to follow-up compared to those following free CTX [adjusted hazard ratio (aHR) = 2.64, 95% confidence interval 1.95-3.57, P < 0.001]. Provision of free CTX was associated with significantly improved retention among ART-ineligible clients. Retention and CD4-monitoring of ART-ineligible clients are essential to promptly identify ART eligibility and provide treatment. Implementation of free CTX may improve retention in sub-Saharan Africa and, via increasing timely ART initiation, provide survival benefit.

If the Supplier's Human Capital Walks Away, Where Would the Customer Go?

Purpose: Professional service firms' clients often develop stronger attachments to their key contact employee than to the service firm. Since professionals are highly mobile, buyers of professional business services constantly have to decide whether to follow their key contact employee or remain with their incumbent firm, while service firms face the threat of losing customers if the employee leaves. This study examines how the key contact employee's human capital, the social capital between the contact employee and the client, and the service company's structural capital affect the decision whether to follow the key contact employee to another professional service firm. Methodology/approach: The model is tested on a sample of 120 organizational buyers of advertising services by using partial last squares, a structural equation modelling technique. Findings: Professional service firms' investments in company-specific structural capital create a deterrent for clients to follow the contact employee, because remaining with the service firm will increase clients' return on the service providers' structural capital. Furthermore, higher levels of structural capital reduce the value of the contact employee's investments in human capital should the employee leave. Conversely, human capital creates motivation to follow the contact employee, while social capital only provides value in combination with human capital. Research implications: This study employs concepts developed in economics and economic sociology rather than relationship marketing variables to examine attachments to individual professional service providers and to professional service firms. Practical implications: The findings underline the importance of competence, both at the company and individual level, for retaining clients of professional services. These results contrast previous studies emphasizing close interpersonal relationships and service firms' relationship-building activities. Originality/value/contribution: Human, social, and structural capital provide value to clients and therefore apply well to professional services. Hence, these variables provide alternative explanations to service firms' client retention or desertion than traditional relationship marketing variables do. The findings add to our understanding of service provider–client relationships in professional services and knowledge intensive firms.

Retaining clients in an outcome monitoring evaluation study: HIV prevention efforts in community settings

The Centers for Disease Control and Prevention (CDC), Division of HIV/AIDS Prevention (DHAP) conducted outcome monitoring studies on evidence-based interventions (EBIs) provided by CDC-funded community-based organizations (CBOs). Critical to the success of outcome monitoring was the ability of CBOs to recruit and retain clients in evaluation studies. Two EBIs, Video Opportunities for Innovative Condom Education and Safer Sex (VOICES/VOCES) and Healthy Relationships, were evaluated using repeated measure studies, which require robust follow-up retention rates to increase the validity and usefulness of the findings. The retention rates were high for both VOICES/VOCES CBOs (95.8% at 30 days and 91.1% at 120 days), and Healthy Relationships CBOs (89.5% at 90 days and 83.5% at 180 days). This paper presents an overview of the retention of clients, challenges to follow-up, and strategies developed by CBOs to achieve high retention rates. These strategies and rates are discussed within the context of the CBOs’ target populations and communities.

Book Reviews

Book Reviews

Teaching Entrepreneurship: Impact of Business Training on Microfinance Clients and Institutions

Can one teach basic entrepreneurship skills, or are they fixed personal characteristics? Most academic and development policy discussions about microentrepreneurs focus on their access to credit, and assume their human capital to be fixed. The self-employed poor rarely have any formal training in business skills. However, a growing number of microfinance organizations are attempting to build the human capital of micro-entrepreneurs in order to improve the livelihood of their clients and help further their mission of poverty alleviation. Using a randomized control trial, we measure the marginal impact of adding business training to a Peruvian group lending program for female microentrepreneurs. Treatment groups received thirty to sixty minute entrepreneurship training sessions during their normal weekly or monthly banking meeting over a period of one to two years. Control groups remained as they were before, meeting at the same frequency but solely for making loan and savings payments. We find that the treatment led to improved business knowledge, practices and revenues. The program also improved repayment and client retention rates for the microfinance institution. Larger effects found for those that expressed less interest in training in a baseline survey. This has important implications for implementing similar market-based interventions with a goal of recovering costs.