332 Organizacija, Volume 53 Issue 4, November 2020Research Papers 1 Received: 7th February 2020; revised: 20th October 2020; accepted: 26th October 2020 An Empirical Investigation of the Mediating Role of Customer Attachment in South African Private Hospitals Hester SPIES, Nedia MACKAY North-West University, WorkWell: Research Unit for Economic and Management Sciences, Potchefstroom, South Africa, hester.spies@nwu.ac.za (corresponding author), 12194778@nwu.ac.za Background and purpose: Relationship marketing literature acknowledges the important role of attachment in customer-organization relationships, but shows limited theoretical and empirical understanding of the factors that contribute to the development and maintenance of attached customers. To address this gap, this paper draws on the relationship marketing view and synthesizes important relationship constructs with the aim of developing a mediated attachment model for private hospitals in South Africa. Design/Methodology/Approach: A quantitative descriptive research design was implemented, collecting 303 use- able questionnaires via non-probability convenience sampling. Cronbach’s alpha coefficients and a confirmatory factor analysis were conducted to determine the reliability and validity of the measures respectively, and a SEM was conducted for the mediation analysis. Results: The results indicate that respondents’ relationship value was significantly related to attachment, loyalty and fear of relationship loss, and attachment was significantly related to loyalty and fear of relationship loss. More- over, the indirect effect of attachment in the relationship between relationship value and loyalty, as well as in the relationship between relationship value and fear of relationship loss was found to be significant. Conclusion: Attachment plays a significant role in both the direct and indirect relationships with key relationship marketing constructs. The importance of attachment in building patient-hospital relationships should therefore not be ignored, and private hospitals are encouraged to invest in their relationships with patients, with the aim of estab- lishing attachment. Keywords: Attachment, Fear of relationship loss, Loyalty, Private hospitals, Relationship value DOI: 10.2478/orga-2020-0022 1 Introduction The rationale behind building lasting customer rela- tionships is that retaining existing customer relationships cost less than continually attracting new customers, which contributes to higher profitability (Barber et al., 2018, p. 563). This cost-saving property of retaining customers mo- tivates hospitals to develop and implement successful re- lationship marketing strategies, as this would enable them to create a sustained competitive advantage (Kanthe et al., 2016:36; Poku et al., 2017:101). To establish and main- tain successful long-term customer relationships, various researchers are of the opinion that organizations should focus their relationship marketing strategies on those cus- tomers who have formed a bond with the organization, that is, customers with high levels of attachment to the organ- ization (Dwyer, Mudrick, Greenhalgh, LeCrom & Drayer, 2015, p. 578; Moussa & Touzani, 2017, p. 157). Beldona and Kher (2015, p. 363) note that customers’ attachment styles influence how they view their relationship with the organization, and that customers typically experience an emotional attachment to the organizations they can trust. A customer who trusts an organization generally displays a 333 Organizacija, Volume 53 Issue 4, November 2020Research Papers higher level of loyalty, and should have stronger intentions to continue in a relationship with the organization (Mende, Bolton & Bitner, 2013, p. 138). The value of attachment in building long-term profitable customer relationships should therefore not be undervalued (Bahri-Ammari, Van Niekerk, Khelis & Chtioui, 2016, p. 563; Mende et al., 2013, p. 139). To form a better understanding of attachment in cus- tomer-organizational relationships, Moussa and Touzani (2017, p. 157) and Verbeke, Belschack, Bagozzi, Pozhar- liev and Ein-Dor (2017, p. 51) suggest that the factors con- tributing to the development and maintenance of attached customers should be studied. Existing research indicates that customers’ relationship value may influence the level of their attachment. Beldona and Kher (2015, p. 363) and Danjuma and Rasli (2012, p. 99) explain that customers are also more likely to develop attachment when an organi- zation meets the conditions valued by them in the relation- ship. Moreover, organizations that operate in a competitive market regard both customer attachment, and sustaining it as important, because it offers various outcomes that contribute to building sustainable customer relationships. According to Bahri-Ammari et al. (2016, p. 574) and Ku- mar, Bohling and Ladda (2003, p. 670), customers who are emotionally attached to the organization have developed a bond with it and will consequently not only exhibit a fear of losing their relationship with their organization, but will also demonstrate resistance to switching organizations, en- suring the establishment of a loyal customer base, all of which contribute to the development and success of cus- tomer relationships. It can be inferred from the above discussion that var- ious relationship-specific constructs are related to cus- tomers’ attachment, including relationship value, fear of relationship loss, and loyalty. While a limited number of studies have examined the relationship between at- tachment and some of the abovementioned constructs in isolation, these studies have not yet investigated these constructs in relation with each other, limiting the under- standing of the customer attachment concept (Mende et al., 2013, p. 139; Moussa & Touzani, 2017, p. 157; Verbeke et al., 2017, p. 51). Determining the role of the abovemen- tioned constructs on customers’ attachment will not only enhance marketers’ understanding of attachment in cus- tomer-organizational relationships, but will also contribute to the growing body of research on customer attachment. Moreover, although the importance and contribution of customer attachment in building relationships is undisput- ed, according to the researchers’ knowledge no research has examined customers’ attachment in the South African private hospital sector. Gaining insight into patients’ at- tachment could, therefore, guide private hospitals in South Africa in their efforts to build relationships with patients. For these reasons, this study sets out to determine the in- terrelationships amongst respondents’ attachment and se- lected relationship marketing constructs (i.e. relationship value, fear of relationship loss, and loyalty) in the private hospital sector of South Africa. 2 Literature review 2.1 Attachment Ainsworth, Blehar, Waters and Wall (1978) and Bowl- by (1958) refer to attachment as individuals’ emotional and behavioral tendencies (bonds) captured in personal re- lationships, which are developed over time based on these individuals’ prior experiences. To describe and measure attachment, research in psychology has converged on the use of two dimensions, namely attachment avoidance and attachment anxiety. The avoidance dimension captures an individual’s fear of personal intimacy, dependence, and disclosure; whereas the anxiety dimension captures an individual’s fear of re- jection and abandonment (Yip, Ehrhardt, Black & Walker, 2018, p. 188). According to Dwyer et al. (2015, p. 571), both attachment avoidance and attachment anxiety can as- sist in forming an understanding of regulating human emo- tions, which forms the basis of the attachment theory. The attachment theory refers to people’s psychological instinct to form and maintain affectionate ties with specific at- tachment figures (such as father, mother, or organization). These attachment figures guide people’s expectations and perceptions in close relationships, which in turn determine their internal working models of relationships (mental rep- resentations of relationship partners and the self) (Sutton, 2019, p. 10; Yip et al., 2018, p. 187). Although most of the early research on attachment focused almost entirely on parent-infant (Ainsworth et al., 1978; Bowlby, 1958) and adult relationships (Sutton, 2019, p. 2), marketing studies have suggested that custom- ers’ internal working models (attachment representations) may be activated when they are engaging with particular brands, organizations or employees (Beldona & Kher, 2015, p. 362-363; Mende et al., 2013, p. 139). These re- searchers argue that customers’ internal working models of attachment will be activated when they are faced with certain emotional experiences (such as a service failure), seeing that the relationship between a customer and the representatives of an organization can be viewed as an adult relationship. Consequently, if attached adults are able to regulate their emotions during emotional experi- ences (Dwyer et al., 2015, p. 571), it can be expected that attached customers will do the same, which, in turn, will allow organizations to build sustainable customer relation- ships. 334 Organizacija, Volume 53 Issue 4, November 2020Research Papers 2.2 Relationship value Although research on value has traditionally focused on the value of physical products, recent studies have em- phasized the importance of the value of relationships (Cui & Coenen, 2016, p. 61; Sun, Pan, Wu & Kuo, 2014, p. 94). According to Corsaro, Fiocca, Henneberg and Tunis- ini (2013, p. 282), the need to introduce the relationship value concept stems from the fact that customer-organiza- tional relationships hold positive economic consequences for organizations. Ulaga and Eggert (2005, p. 81) define relationship value as a trade-off between the benefits (what is received) and the costs experienced or sacrifices (what is given) for a customer in their relationship with an organi- zation, also taking into consideration what competitors can offer. This definition highlights the balance or compensa- tion between benefits and sacrifices that the customer per- ceives in comparison to other providers. The benefits for which customers are searching origi- nate mostly from the existing relationship with an organ- ization in the form of benefits relating to the product, the service, the community, the supplier’s know-how, and the organization’s capacity to improve time-to-market for its customers. The sacrifices, on the other hand, include the price paid to the organization and the process costs (Cor- saro et al., 2013, p. 282; Ulaga & Eggert, 2005, p. 88). Moliner-Velazquez, Fuentes-Blasco and Gil-Saura (2014, p. 222) advocate that marketing managers should careful- ly manage the value of the relationship provided to their customers, as it could form the foundation for building, enhancing and maintaining relationships with them. If properly implemented, relationship value will be advanta- geous to organizations, as it will lead not only to positive economic outcomes, but also to satisfied customers (Cui & Coenen, 2016, p. 54). Moreover, customers who value their relationship with the organization will also develop a fear of losing this relationship with the organization (Bel- dona & Kher, 2015, p. 356; Blut, Beatty, Evanschitzky & Brock, 2016, p. 286) (discussed in section 2.4). 2.2.1 The link between relationship value and attachment Customers who value their relationship with an organ- ization will be more attached to the organization. The ra- tionale for this is that the presence or absence of different sources that customers value, such as a relationship, influ- ence the strength of their attachment to the organization. When an organization meets the conditions valued by their customers, the customers will become more attached to the organization (Aldlaigan & Buttle, 2005, p. 356-357; Cor- saro et al., 2013, p. 288). It is therefore hypothesized that: H1: Relationship value has a significant positive ef- fect on customers’ attachment to their private hospital. 2.3 Loyalty Customer loyalty can be defined as customers’ attach- ment to an organization with which they form a psycho- logical bond. They show continuous purchase intentions and behaviors towards this organization (Wirtz & Love- lock, 2018, p. 56). This definition incorporates both an atti- tudinal and a behavioral dimension of loyalty, which most researchers regard as the best measure of true customer loyalty (Bowen & McCain, 2015, p. 418; Khan, 2012, p. 260). The attitudinal dimension of loyalty delineates how customers think and feel about a brand, product, service, or organization (i.e. psychological bond and attachment formed). This is reflected, for instance, in customers’ preference for an organization, their commitment to it, and their willingness to recommend it to other customers (Khan, Humayun & Sajjad, 2015, p. 168-169; Zeithaml, Berry & Parasuraman, 1996, p. 35). In contrast, behav- ioral loyalty amounts to customers’ purchasing behavior over time. This is reflected, for instance, in customers’ commitment to frequently purchase from the organization and their willingness to spend more at this organization as compared to competing organizations (Khan et al., 2015, p. 168-169; Zeithaml et al., 1996, p. 36). Several scholars are in agreement that customer loyalty can be viewed as a core marketing activity for organiza- tions operating in fiercely competitive environments, as this yields various benefits for organizations in the form of higher repurchase intentions, an increased share of wallet, word-of-mouth and lowered acquisition costs, which ulti- mately result in higher organizational profits (Khan, 2012, p. 250-258; Wirtz & Lovelock, 2018, p. 375). According to Prayag and Ryan (2012, p. 9), one of the main factors contributing to the establishment of a loyal customer base is customers’ level of involvement with employees and organizational activities. These researchers argue that, through customers’ involvement with employees and or- ganizational activities, they form an emotional bond with the organization, which, in turn, may lead to loyal custom- ers. 2.3.1 The link between attachment and loyalty Customer loyalty can be regarded as an essential as- pect of customer attachment, seeing that attachment is developed gradually during service experiences over time (Wirtz & Lovelock, 2018, p. 386; Yim, Tse & Chan, 2008, p. 752,753). Yim et al. (2008, p. 752) explain that custom- ers develop feelings of intimacy, passion and commitment as they connect with the organization, which leads to stronger bonds and resistance to change (i.e. establishing loyalty). Research by Khan (2012, p. 246) and Levy and Hino (2016, p. 143) confirms the relationship between at- 335 Organizacija, Volume 53 Issue 4, November 2020Research Papers tachment and loyalty, and states that true customer loyalty can be established only through customers’ attachment to the organization. Therefore, it is hypothesized that: H2: Customers’ attachment has a significant positive effect on their loyalty to their private hospital. 2.3.2 The link between relationship value and loyalty Previous research by Chen and Myagmarsuren (2011, p. 969) reveal that customers who value their relationship with the organization are more likely to become loyal. Sun et al. (2014, p. 92) support this view by explaining that when customers perceive that they are receiving more value from the relationship with the organization, they are prepared to buy more from the organization and sustain a long-term relationship with it. Therefore, it is hypothe- sized that: H3: Relationship value has a significant positive ef- fect on customers’ loyalty to their private hospital. 2.4 Fear of relationship loss Customers’ motivation to build and maintain rela- tionships with organizations are rooted in the relation- ship benefits (confidence, social, and special treatment) (Hennig-Thurau, Gwinner & Gremler, 2010, p. 387; Wei, McIntyre & Soparnot, 2015, p. 16) and the relational bonds (financial, structural, and social) (Wang, 2014, p. 320) arising from such relationships. Hennig-Thurau et al. (2010, p. 379) and Yen, Liu, Chen and Lee (2015, p. 176) explain that customers choose to continue their relation- ship with the organization, as they know what to expect from this relationship (confidence benefits). Customers, therefore, develop a sense of familiarity and even a social relationship in the form of a friendship with their organi- zation (social benefits) and may even receive benefits in the form of economic or customization benefits (special treatment benefits). These relationship benefits facilitate the formation of a relationship bond between the customer and the organ- ization (Liang & Wang, 2006, p. 123; Spake & Megehee, 2010, p. 319). It is through the relationship bond created between the customer and organization that customers de- velop a fear of losing a relationship with the organization, as they have formed an emotional attachment to the organ- ization (Mende et al., 2013, p. 139). Huang, Fang, Huang, Chang and Fang (2014, p. 195) and Lee, Kim, Kim, Lee and Lim (2015, p. 838) argue that emotionally-attached customers fear losing their relationship with the organiza- tion owing to the money they are saving in the relationship (financial bond), value-added benefits which competing organizations cannot provide (structural bond), and feel- ings of familiarity, personal recognition, friendship and social support (social bond). Consequently, customers are motivated to stay and continue the relationship with the or- ganization because they fear losing the relationship bene- fits and bonds (Blut et al., 2016, p. 286; Kumar et al., 2003, p. 670). Kumar et al. (2003, p. 670) and Sutton (2019, p. 11) add that, in an attempt to maintain and restore a rela- tionship with an organization, customers not only exhibit a fear of losing the relationship with their organization, but also opt to forgive a transgression (such as a service fail- ure). 2.4.1 The link between attachment and fear of relationship loss Over time, customers become more motivated to de- velop a bond with an organization through their interac- tions with the organization as well as the relationship ben- efits they receive. It is through the bond created between the customer and organization that the likelihood of de- veloping a successful customer-organizational relationship increases (Liang & Wang, 2006, p. 123; Spake & Mege- hee, 2010, p. 316). Chelminski and Coulter (2011, p. 366), Kumar et al. (2003, p. 670) and Mende et al. (2013, p. 138) also note that customers who have developed a bond with an organization are also more emotionally attached to the organization and they may fear the possible consequences of losing their relationship (such as their relationship bond and relationship benefits). It is therefore hypothesized that: H4: Customers’ attachment has a significant positive effect on their fear of losing their relationship with their private hospital. 2.4.2 The link between relationship value and fear of relationship loss Previous research by Aldlaigan and Buttle (2005, p. 356-357) established that customers are encouraged to develop an attachment with an organization through the presence or absence of different sources that they value. These sources may appear in the form of customer-organ- izational relationships. When customers perceive that they are receiving more value from the relationship with the organization, they are more prepared to build a bond with the organization. By developing a bond with the organ- ization, the customer becomes more committed towards the organization, increasing the likelihood of developing a successful, long-term relationship (Chen & Myagmar- suren, 2011, p. 969; Sun et al., 2014, p. 92). According to Beldona and Kher (2015, p. 356), Chelminski and Coulter (2011, p. 366), and Kumar et al. (2003, p. 670), custom- ers who have developed a bond with an organization are emotionally attached to the organization and will exhibit fear of the possible consequences (relational benefits and 336 Organizacija, Volume 53 Issue 4, November 2020Research Papers bonds) of losing the relationship with the organization. It is thus hypothesized that: H5: Relationship value has a significant positive ef- fect on customers’ fear of losing their relationship with their private hospital. 2.5 The mediating effect of attachment The proposed positive relationships discussed in the previous sections shed further light on the possibility of attachment serving as a mediating variable in the proposed model on the positive relationship between relationship value and loyalty. Similarly, the positive relationship be- tween relationship value and attachment, as well as be- tween attachment and fear of relationship loss, also point towards the possibility of attachment serving a mediating role on the positive impact of relationship value on fear of relationship loss. Hence, it is proposed that: H6: Relationship value has a significant positive in- direct effect on customers’ loyalty towards their private hospital, as mediated by attachment. H7: Relationship value has a significant positive in- direct effect on customers’ fear of losing their relationship with their private hospital, as mediated by attachment. Figure 1 illustrates the hypothesized relationships be- tween the constructs under investigation, as proposed from the above literature discussion. Figure 1: Conceptual model 3 Methodology 3.1 Research context In general, healthcare can be viewed as highly com- plex, universally-used services that significantly influence economies, individuals’ quality of life, and their dispos- able income (Van de Schoot, Pavlova, Atanasova & Groot, 2017, p. 67). This is particularly the case for healthcare in the South African hospital industry, which is often re- garded as unaffordable, and therefore inaccessible to the majority of South Africans (Gray & Vawda, 2018, p. 8; RH Bophelo, 2019). Characterized by poor service deliveries, resource shortages, deteriorated equipment, limited avail- ability of qualified staff, and inconsistent management, the South African public hospital sector is ranked amongst the worst in the world, leaving the majority of South Africans without proper healthcare (Mutwali & Ross, 2019, p. 36). These challenges faced by the public hospital sector re- sulted in a demand for quality healthcare among South Af- ricans, which has led to the growth of the private hospital sector (Barber, Kumar, Roubal, Colombo & Lorenzoni, 2018, p. 562; RH Bophelo, 2019). According to Mutwali and Ross (2019, p. 35), the pri- vate hospital sector plays a pivotal role in South African healthcare owing to sustained profitability and its politi- cal and economic relevance, helping the government fulfil its constitutional mandate to provide quality healthcare. However, despite the significant financial contribution by the private hospital sector, it serves only 20% of the South African population, and has been exposed to con- siderable changes in the marketplace in the form of new technologies, more informed patients, and increased pa- 337 Organizacija, Volume 53 Issue 4, November 2020Research Papers tient demands for better service delivery, leading to a surge of competitors. Subsequently, these changes have forced private hospitals to actively compete for a share in the mar- ket. 3.2 Sample and data collection The sample for this research included residents of three South African provinces (i.e. Gauteng, KwaZu- lu-Natal, and North West) who made use of private hos- pital services during a three-year period. A quantitative descriptive (cross-sectional) research design was used to observe and investigate the behavior of respondents. The respondents were selected by means of a non-probabili- ty convenience sampling method, owing to the absence of a sampling frame and budget constraints. Respondents were approached by trained fieldworkers in convenient but high-traffic public areas, and requested to complete the structured self-administered survey. A total of 320 ques- tionnaires were distributed, of which 303 were useable for further analysis, resulting in a 94% response rate. As summarized in Table 1, respondents with various demographic characteristics participated in the research, of which most were White (78.5%) females (63.0%), aged 28 or younger (39.9%) and 50 or older (22.2%). The re- spondents were further requested to indicate the duration for which they had been making use of their hospital’s services. The results revealed that the majority indicated a period of less than one year (34.3%). Table 1: Sample profile Variables F % Gender Male 112 37.0 Female 191 63.0 Race Asian 5 1.7 Black 42 13.9 Colored 14 4.6 Indian 4 1.3 White 238 78.5 Age 28 or younger 121 39.9 29 to 37 years old 51 16.8 38 to 49 years old 64 21.1 50 or older 67 22.2 Length of time making use of hospital’s services Less than 1 year 104 34.3 1 to 3 years 75 24.8 4 to 6 years 60 19.8 Longer than 6 years 64 21.1 338 Organizacija, Volume 53 Issue 4, November 2020Research Papers 3.3 Measurement and analysis approach This research utilized a structured self-administered questionnaire, comprising three sections. The first section included a preamble, which indicated the objectives of the research, explained and ensured respondents’ confidenti- ality and anonymity, and indicated the approximate time of completion (which was 10 minutes on average). The preamble concluded with a screening question to ensure that only eligible respondents took part in the research (i.e. respondents who had made use of private hospital servic- es during the last three years). The second section of the questionnaire measured respondents’ socio-demographic elements, and the third section measured the constructs of the study. The constructs were measured by means of scales adapted from existing research, which were previously validated by the respective researchers. The items used to measure relationship value were adapted from the work of Ulaga and Eggert (2006, p. 134), attachment was meas- ured by adapting a scale from Mende et al. (2013, p. 130), fear of relationship loss was measured by adapting a scale from the work of Kumar et al. (2003, p. 675-676), and loyalty was measured by a scale adapted from the work of Dagger and David (2012, p. 468) who developed the scale based upon the work of Hennig-Thurau et al. (2010, p. 388), Oliver (2010, p. 378), Plank and Newell (2007, p. 66), and Zeithaml et al. (1996, p. 38). Questionnaire items are presented in the Appendix. Before commencing the data collection process, the questionnaire was first pre-tested among 30 respondents from the target population, resulting in some technical ad- justments. Data analysis was done using both the SPSS (version 24) and Mplus 8 programs. SPSS was utilized for the cal- culation of the descriptive statistics and Cronbach’s alpha coefficients, and Mplus for the mediation analysis. The SEM model in this study made use of Maximum Likeli- hood for parameter estimation, as this has been considered most suitable for multivariate normal data. The researchers were also allowed to investigate the correlations between the latent variables, as Mplus generated a zero-order cor- relation matrix. Effect sizes for the correlation values were considered to have a large practical effect with r ≥ 0.50 (Hair, Black, Babin & Anderson, 2014, p. 10). To evaluate the fit of the measurement model to the data, the following indices were considered: confirmato- ry factor analysis (CFA), the comparative fit index (CFI), the Tucker-Lewis index (TLI), and the root mean square error of approximation (RMSEA) (Van de Schoot, Lug- tig & Hox, 2012, p. 487-488). The cut-off values for both the CFI and TLI should be above 0.90 and the RMSEA requires a value of up to 0.10 to be considered acceptable (Hair et al., 2014, p. 580; Van de Schoot et al., 2012, p. 487). Finally, the model’s indirect function was specified in accordance with the hypotheses through Mplus, to in- vestigate the potential mediating variables in the research model. Using bootstrapping, the mediation was tested with requests for 5 000 draws and bias-corrected 95% confi- dence intervals in the output, focusing on the size and the significance of the indirect effects. An investigation was furthermore made to evaluate whether the indirect effects would not cross zero at that level. 4 Results 4.1 Reliability and validity assessment Cronbach’s alpha coefficients were calculated to assess the internal consistency reliability of attachment, loyalty, relationship value, and fear of relationship loss. According to Hair et al. (2014, p. 123), Cronbach’s alpha values of 0.70 or more can be considered reliable. The Cronbach’s alpha values for all the measures used in this research ranged from 0.82 to 0.95 (see Appendix), indicating ac- ceptable reliability. All scales were adapted from existing scales measuring attachment (Mende et al., 2013, p. 130), relationship value (Ulaga & Eggert, 2006, p. 134), fear of relationship loss (Kumar et al., 2003, p. 675-676), and loyalty (Dagger & David, 2012, p. 468). These respective researchers deter- mined the scales measuring these constructs to be valid in their corresponding studies, thus confirming face validity. With regard to the measurement model, both the CFI at 0.99 and the TLI at 0.98 surpassed the rule of thumb of 0.90 for indication of an acceptable model fit (Hair et al., 2014, p. 580). The acceptable model fit is also supported by the RMSEA with a value of 0.07, which is less than the cut-off point of 0.10 (Hoe, 2008, p. 78). The fit indices were followed by a confirmatory factor analysis, which revealed that the items loaded satisfactorily on the con- structs, with all exceeding 0.50, and with all correlations being significant (p-value ˂ 0.001) (Hair et al., 2014, p. 123). Taking into consideration the acceptable model fit and the positive significant loadings of all the items on the variables, convergent validity was also confirmed. 4.2 Correlation matrix A correlation analysis was conducted to measure the strength of the linear relationship between the latent varia- bles as indicated in Table 2. Table 2 indicates that large correlations were found be- tween all the variables used in the analysis. Even though the large correlations between the variables may possibly indicate a high degree of multicollinearity, all of the cor- 339 Organizacija, Volume 53 Issue 4, November 2020Research Papers Table 2: Correlation matrix of the latent variables Variables Attachment Relationship value Fear of relationship loss Loyalty Attachment – Relationship value 0.88* – Fear of relationship loss 0.66* 0.67* - Loyalty 0.87* 0.88* 0.64* - *Large effect size (r ≥ 0.50) relations were below 0.90, diminishing the concern with multicollinearity, which arises at correlations of 0.90 and higher (Tabachnick & Fidell, 2013, p. 90). 4.3 Assessing the structural model The structural paths were added to the measurement model after the correlation assessment and are presented in Table 3 in terms of the hypotheses (H), the path coef- ficients (β), the standard error (SE), the statistical signifi- cance at the 0.05 level (p-value), and the result. The results of the structural paths indicate that all the hypotheses were supported. Specifically, relationship value was statistically significantly related to attachment (β = 0.88; SE = 0.02; p ˂ 0.001; supporting H1), loyalty (β = 0.51; SE = 0.10; p ˂ 0.001; supporting H3) and fear of relationship loss (β = 0.37; SE = 0.16; p ˂ 0.017; sup- porting H5). Significant relationships also exist between attachment and loyalty (β = 0.42; SE = 0.11; p ˂ 0.001; supporting H2) and fear of relationship loss (β = 0.33; SE = 0.16; p ˂ 0.036; supporting H4). Lastly, the bootstrapping of the indirect effects indicat- ed that relationship value had an indirect relationship with loyalty (estimate = 0.37; 95% CI [0.19, 0.57] – did not cross zero) and fear of relationship loss (estimate = 0.29; 95% CI [0.02, 0.58] – did not cross zero) through attach- ment. Consequently, attachment can be viewed as a com- plementary (partial) mediator in these two relationships, as the direct relationships were also significant. Research hypotheses H6 and H7 are therefore supported. A summa- ry of the significant relationships identified in the SEM is presented in Figure 2. Table 3: Structural paths of the latent variables H Path β SE p-value Result H1 Relationship value → Attachment 0.88 0.02 0.001 Significant H2 Attachment → Loyalty 0.42 0.11 0.001 Significant H3 Relationship value → Loyalty 0.51 0.10 0.001 Significant H4 Attachment → Fear of relationship loss 0.33 0.16 0.036 Significant H5 Relationship value → Fear of relationship loss 0.37 0.16 0.017 Significant β: beta coefficient; SE: standard error; p-value: two-tailed statistical significance 340 Organizacija, Volume 53 Issue 4, November 2020Research Papers Figure 1: Summary of significant relationships 5 Discussion and conclusions The purpose of this research was to respond to scholars and marketing managers’ calls to form a better understand- ing of the role of attachment within customer-private hos- pital relationships. To achieve this goal, this study set out to determine the interrelationships amongst respondents’ attachment and selected relationship marketing constructs by means of a SEM analysis. The first result of the struc- tural paths indicated that patients’ relationship value was statistically significantly related to attachment. This find- ing concurs with the earlier work done by Aldlaigan and Buttle (2005, p. 356-357), who found that customers who value the relationship with their organization will also ex- hibit higher levels of attachment. Exhibiting higher levels of attachment can imply that private hospitals have met the conditions valued by patients. Relationship value was also found to influence loyalty statistically significantly. This finding is aligned with the research of Chen and Myagmar- suren (2011, p. 969) and Khan (2012, p. 246) who not only confirm the relationship between relationship value and loyalty but also argue that when customers perceive that they are receiving more value from the relationship with the organization, they are prepared to buy more from the organization and sustain a long-term relationship with it. The research findings also confirmed that relationship value statistically significantly influences fear of relation- ships loss. This finding is consistent with arguments of Beldona and Kher (2015, p. 356), Chelminski and Coulter (2011, p. 366), and Kumar et al. (2003, p. 670), who ar- gue that customers develop a fear of losing a relationship with an organization due to the value they receive from the relationship in the form of relational benefits and bonds. Despite the well-reasoned arguments supporting the rela- tionship between relationship value and fear of relation- ship loss, the relationship between these two constructs have not been empirically tested. This paper, therefore empirically contributes to the theory by confirming the relationship between relationship value and fear of rela- tionship loss. Taking into account the abovementioned results it is advised that private hospitals add value to their relation- ship with their patients in order to reap the benefits of pa- tients’ attachment, loyalty, and fear of relationship loss. Private hospitals might achieve this goal by increasing the relationship benefits (i.e. core benefits, sourcing benefits, and operations benefits) or decreasing the relationship costs (i.e. direct costs, acquisition costs, and operational costs). Specifically, private hospitals are advised to in- crease their relationship benefits by providing satisfac- tory service delivery and producing quality products and services (core benefits). They are also advised to provide high levels of support during service delivery and personal interaction (sourcing benefits) in order to understand their patients’ needs and wants and get along with them. By un- derstanding their patients’ needs and wants, private hospi- tals should be able to provide their products and services in time for marketing (operations costs). Private hospitals should also attempt to decrease their relationships costs by offering a fair market price and reducing prices when internal costs are reduced (direct costs). They should also aim to handle patients’ requests more efficiently and en- sure that the products and services provided exceed their patients’ expectations (acquisition costs). To decrease their 341 Organizacija, Volume 53 Issue 4, November 2020Research Papers operational costs, private hospitals could focus on reduc- ing the product costs and the process or the warranty costs of the existing products and services offered. Furthermore, the results of the structural paths also indicated that attachment was statistically significantly related to loyalty. This finding is aligned with the work of Levy and Hino (2016, p. 143) and Yim et al. (2008, p. 752) who have also found a positive relationship between these variables. This relationship has also been confirmed by Khan (2012, p. 246) who argues that true customer loy- alty can be established only through customers’ attachment to the organization. The results also revealed that patients’ attachment was statistically significantly related to fear of relationship loss. This finding is consistent with the argu- ments put forth by researchers like Chelminski and Coul- ter (2011, p. 366), Kumar et al. (2003, p. 670) and Mende et al. (2013, p. 138) that customers who have developed an attachment to the organization, may fear the possible consequences of losing their relationship (such as their relationship bond and relationship benefits). These stud- ies, however, have not empirically tested the relationship between these two variables. This paper, therefore, makes an empirical contribution to theory by confirming the argu- ments put forth by the aforementioned researchers. Considering the abovementioned findings, it is impor- tant for private hospitals to nurture bonds with their at- tached patient, seeing as patients’ attachment has an in- fluence on their loyalty and fear of relationship loss.. This can be done by providing social relationship marketing programs that comprises the personalization of the rela- tionships through social engagements with patients or by assigning special status to them (e.g. interactive websites, inviting patients to events, newsletters, birthday cards, phone calls, and face-to-face meetings). Private hospitals must also focus on their financial reward programs that of- fer patients economic benefits in exchange for their loyalty (e.g. loyalty programs, discounts, gift giving and free ser- vice samples) and their structural reward programs which create values (e.g. motivational programs and demonstrat- ing the quality of their services and products). Moreover, after testing the significant relationships between the constructs, two prospective mediating effects were possible, which necessitated further investigation. The results indicated that relationship value had an indi- rect relationship with loyalty and fear of relationship loss through attachment, establishing attachment as a com- plementary (partial) mediator. Attachment, therefore, not only plays an important role in the direct relationship with the key relationship marketing constructs, but also indi- rectly. These findings are valuable, as the mediating effect of attachment between various relationship marketing constructs have not been examined before. Subsequently, these results set the scene for further research on this top- ic, as it offers an initial understanding into the matter. The importance of attachment in building relationships should therefore not be ignored. These findings should encour- age private hospitals to spend their marketing resources on building long-term bonds with patients (as suggested in the discussion above) with the aim of establishing an attachment. Finally, the theoretical and practical contributions of this paper should be noted, as it enhances marketing re- searchers and managers understanding of the interrelation- ships amongst patients’ attachment and selected relation- ship marketing constructs. This paper also contributes to the support of the attachment theory and introduces a mod- el that assesses patients’ attachment in the private hospital sector. It develops testable hypotheses, and illustrates how these hypotheses may be used to guide a systematic anal- ysis of the state of patient-private hospital relationships. This paper also contributes towards the growing research on customer attachment and the empirical insight gained from this research will add to the existing body of litera- ture on the interrelationships amongst respondents’ attach- ment and selected relationship marketing constructs. 6 Limitations and directions for future research The research findings are based on the responses ob- tained from respondents from only one service setting (i.e. private hospitals), using non-probability convenience sam- pling. The results can therefore not be generalized, and it is therefore suggested that future research encompass differ- ent service settings, using probability sampling. Most research related to relationship marketing indi- cates that customer-organizational relationships are built over time. The relationship building constructs therefore relate to long-term measurements. Seeing as the data may differ over time with regard to the interrelationships of the constructs in this paper, it is suggested that this research be replicated over time, making use of a longitudinal study. Furthermore, although the model presented in this pa- per contributed towards clarifying and explaining the role of attachment in customer-organizational relationships, other relevant variables not included in this research ex- ist and need to be taken in consideration as it might of- fer additional insight into attachment and its role in cus- tomer-organizational relationships. For example, future research could examine the moderating role of customer demographics on the relationships between involvement, relationship value, and attachment. 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Journal of Services Marketing, 28(4), 319-330. https://doi.org/10.1108/JSM-11-2012-0217 344 Organizacija, Volume 53 Issue 4, November 2020Research Papers Wei, Y., McIntyre, F.S., & Soparnot, R. (2015). Effects of relationship benefits and relationship proneness on relationship outcomes: a three-country comparison. Journal of Strategic Marketing, 23(5), 1-21. https:// doi.org/10.1080/0965254X.2014.991347 Wirtz, J., & Lovelock, C. (2018). Essentials of services marketing (3rd ed.). Harlow: Pearson. Yen, C., Liu, L., Chen, C., & Lee, T. (2015). Customer re- lational benefits and relationship-marketing outcomes: comparing three transaction types of travel product. Asia Pacific Journal of Tourism Research, 20(2), 171- 190. https://doi.org/10.1080/10941665.2013.877042 Yim, C.K., Tse, D.K., & Chan, K.W. (2008). Strengthening customer loyalty through intimacy and passion: roles of customer-firm affection and customer-staff rela- tionships in services. Journal of Marketing Research, 45(6), 741-756. https://doi.org/10.1509%2Fjmkr.45.6.741 Yip, J., Ehrhardt, K., Black, H., & Walker, D.O. (2018). Attachment theory at work: a review and directions for future research. Journal of Organizational Behavior, 39(2), 185-198. https://doi.org/10.1002/job.2204 Zeithaml, V.A., Berry, L.L., & Parasuraman, A. (1996). The behavioral consequences of service quality. Jour- nal of Marketing, 60(1), 31-46. https://doi.org/10.1177 %2F002224299606000203 Hester Spies is a senior lecturer at the School of Management Sciences, North-West University, South Africa. Her research is focused on relationship marketing and services marketing. Her practical experience and teaching of digital marketing to her MBA students has led her to find an interest in the m-servicescape and the role of artificial intelligence and robotics in marketing. She is a reviewer for various national and international journals and conferences. She has authored and co- authored several accredited national and international articles in her fields of specialisation. ORCid: 0000- 0003-0710-2256. Nedia Mackay is an assistant professor at the School of Management Sciences, North-West University, South Africa. Her research is focused on services marketing, relationship marketing, and marketing research. She is a reviewer for national and international journals and conferences. She has written chapters for textbooks, and published in accredited journals and conferences. ORCid: 0000-0001-6456-2422. Empirična študija vloge navezanosti strank v južnoafriških zasebnih bolnišnicah Ozadje in namen: Literatura o odnosnem marketingu priznava pomembno vlogo navezanosti v odnosih med stran- ko in organizacijo, vendar kaže na omejeno teoretično in empirično razumevanje dejavnikov, ki prispevajo k razvoju in vzdrževanju navezanosti strank. Da bi zapolnili to vrzel, se članek opira na odnosni marketing in sintetizira po- membne konstrukte odnosov z namenom razviti posredni model navezanosti na zasebne bolnišnice v Južni Afriki. Zasnova / metodologija / pristop: Izvedena je bila kvantitativna deskriptivna zasnova raziskave. Z nenaključnim vzorčenjem med pacienti/strankami smo zbrali 303 uporabnih vprašalnikov. Za določitev zanesljivosti in veljavnosti podatkov sta bila izvedena Cronbachov koeficient alfa in potrditvena faktorska analiza, za mediacijsko analizo pa SEM. Rezultati: Rezultati kažejo, da je bila vrednost razmerja anketirancev bistveno povezana z navezanostjo, zvestobo in strahom pred izgubo razmerja, navezanost pa je bila pomembno povezana z zvestobo in strahom pred izgubo zveze. Poleg tega se je izkazal za pomembnega posredni učinek navezanosti na razmerje med vrednostjo razmerja in zvestobo ter na razmerje med vrednostjo razmerja in strahom pred izgubo razmerja. Zaključek: Navezanost igra pomembno vlogo tako v neposrednih kot posrednih odnosih s ključnimi konstrukti od- nosnega marketinga. Zato ne smemo prezreti pomena navezanosti pri vzpostavljanju odnosov med bolnikom in bol- nišnico, zasebne bolnišnice pa spodbujamo, da vlagajo v svoje odnose s pacienti, da bi vzpostavile to navezanost. Ključne besede: Navezanost, Strah pred izgubo razmerja, Zvestoba, Zasebne bolnišnice, Vrednost razmerja