The importance of medical personnel’s mental health is emphasized in the COVID-19 era. The characteristics of traditional Korean medicine (KM) may affect the mental health of nursing staff working at KM clinics. In this case series, we report the first attempt to apply an online mindfulness program to the nursing staff in a KM clinic in Korea. For three female nursing assistants, an online mindfulness program consisting of five sessions was offered for two months. After the program, a decrease in emotional labor was observed in two participants, and a decrease in the level of burnout was observed in all participants. One participant showed an increase in their emotional labor level, which was associated with an increase in deep acting. The participants expressed a high level of satisfaction with this program in terms of recommendations for peers and willingness to participate again. As this report is a case series, larger studies are needed to fully evaluate the benefits of the program on emotional labor and burnout of KM clinic nursing staff. However, the potential benefits of emotional labor and burnout, high satisfaction, and some challenges identified in this case series can be considered in future extensions and modifications of the program. In the coronavirus disease of 2019 (COVID-19) era, the mental health issues of medical personnel became more important. Nursing staff constitutes one of the most at-risk medical personnel in relation to mental health . Nurses There is a dualized medical system in Korea, comprised of conventional Western medicine (WM) and traditional Korean medicine (KM) , and theMindfulness is defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment” , by KabaHowever, there have been no documented attempts including mind–body modalities  to improve the mental health of nursing staff in KM clinic settings. As part of the university’s small business support program, we conducted an online mindfulness program of five sessions for two months, and three individuals working in a KM clinic participated. In this case series, we found beneficial effects and high satisfaction with the program, as well as challenges that need improvement for the nurses who participated in it.This case series complied with the 2013 CARE checklist . All subThe program involved three nurses from a KM outpatient clinic. The participants were not exposed to shift work. Their main tasks were to respond to patients and caregivers, assist with some KM procedures, including acupuncture, cupping, and moxibustion, dispose of medical waste, and manage patient appointment schedules. All three participants were female nursing assistants; two were in their 30s and one was in their 40s. They had no experience participating in specialized training or practicing meditation and mindfulness. Their clinical experiences were three months, one year and one month, and three years and three months. They had no underlying diseases regarding both physical and psychiatric disorders, and their subjective health status was normal before and after the program. In addition to the three nurses, five undergraduate students from a KM university who were interested in this program participated as observers, but they did not participate in the evaluation.The program was modified and used as follows based on mindfulness training . The purIn Session 1, the concept of mindfulness was explained. Psychological education was also conducted on the definition and purpose of mindfulness and the desired attitude when practicing mindfulness. In addition, participants practiced eating meditation and body scanning. In Session 2, participants practiced sitting meditation (static practice) and mindfulness yoga (dynamic practice). Mindfulness yoga is a kind of meditative movement that emphasizes awareness. Sitting meditation is a typical meditation practice that raises awareness of the five senses, emotions, and thoughts non-judgmentally. Both sitting meditation and yoga exercises are considered the formal practices of MBSR. In Session 3, the concept of compassion was introduced and practiced. Loving-kindness meditation was also practiced for cultivating compassion. In Session 4, psychological education and meditation practice on burnout were introduced under the theme of self-care. Compassion fatigue, commonly experienced by medical workers, such as nurses, was explained, and the stages of compassion fatigue and prevention methods were introduced. In Session 5, how to apply mindfulness practice in daily life was discussed. Each participant established a daily meditation practice plan suitable for them based on their own meditation practice experience and shared it with other participants.Participants in this program completed the following as a pre-and-post evaluation, including the emotional labor assessment tool described by Lee , Ham’s KAccording to the evaluation results after participating in the program, two participants, participant 1 (P1) and participant 3 (P3), showed a decrease in the level of emotional labor , while the other participant, participant 2 (P2), showed an increase (from 3.05 to 3.33). Specifically, P1 and P2 showed a decrease in both aspects of measured emotional labor, employee-focused emotional labor  and job-focused emotional labor . However, P2 showed an increase in employee-focused emotional labor (from 3.33 to 3.83) and both subscales of employee-focused emotional labor, surface acting (from 3.33 to 3.67) and deep acting (from 3.33 to 4). P2 also showed no change in all three subscales of job-focused emotional labor, including frequency of interactions, duration of interactions, and variety of expressions. P1 and P2 showed an overall decrease across the subscales of employee-focused emotional labor and job-focused emotional labor a,c.All three participants showed a decrease in the measured burnout levels . In the subscales of burnout, the participants showed an overall decrease, but P2 showed an increase in the subscale of personal burnout (from 3 to 3.14) d,e. Two Participants were asked non-mandatory, open-ended questions. One question was, “What has helped you the most while participating in this program?” P1 answered, “Everything was good.” P2 and P3 mentioned specific components of the program. P2 mentioned that the body scanning and loving-kindness meditation were helpful, and P3 mentioned that mindfulness and self-care were helpful. The participants were also asked, “What was the most difficult part of participating in this program?” P1 responded that it was difficult to concentrate on participating in the program because the program was conducted late . P2 responded that it was difficult to participate in yoga due to the lack of body flexibility. P3 responded that it was difficult to concentrate during the meditation process. The participants gave 4 points regarding the willingness to re-enter the program (“will participate again”) and the recommendation to other nursing staff (“will recommend this program to other nursing staff”) on the 1–5 Likert scale.In this case series, we report the first attempt to apply an online mindfulness program to nursing staff in a KM clinic in Korea. Given the emphasis on the mental health of nursing staff ,2,3,4 anGiven the context of COVID-19 and the working environment of the clinic, the program was conducted online from 8–10 p.m. (two hours) and consisted of five sessions for two months. Except for one participant who could not participate in the third session due to personal reasons, all others participated and showed a high participation rate in the program . Of the three female nursing assistants who participated in this two-month online mindfulness program, two had a decreased level of emotional labor while the other had an increased level of emotional labor. The increase in the emotional labor level was due to an increase in the subscale of employee-focused emotional labor. As suggested by Brotheridge et al., emotional labor can be largely divided into job-focused emotional labor  and employee-focused emotional labor  . To dateBurnout levels were reduced in all three participants after this program. Although supported by limited-quality evidence, mind–body modalities, including mindfulness-based interventions, may reduce burnout in healthcare workers  and nursWhen implementing the program for the first time in this population, suggestions for improvement were also raised. For example, one participant reported difficulty concentrating during the program because it was implemented late. Although the program was introduced late in the evening to accommodate the schedules of the participants working at the clinic, this may not be the optimal time for mindfulness training for participants who are potentially exhausted from work. If this program was implemented during working hours, and a set amount of time for mindfulness was officially allocated by the institution, the employee’s participation in the program would be a part of the normal workday, and the difficulty in concentrating might be reduced. This program was introduced once every two weeks because it was judged that a session held late every week could potentially lower the interest and motivation of the participants and negatively affect their participation in the program. However, since the frequency of mindfulness sessions conducted in this program is relatively rare compared to a conventional mindfulness-based program, typically conducted once a week , the parThe limitations of this study include the following. First, as this study is a retrospective case series, the number of participants is small and there was no control group in this study, so the possibility of generalization is highly limited. In other words, it is difficult to extend the results of this study beyond the meaning of the first case of applying online mindfulness training to nursing staff working in a KM clinic. Furthermore, the results of this study cannot be considered clinical evidence to prove the effectiveness of the mindfulness training program on nursing staff. Second, this case series did not assess the long-term impact of the program after its implementation. Moreover, although the last session of the program  encouraged the participants to apply mindfulness and loving-kindness in their daily lives, participants’ adherence to daily mindfulness practice was not assessed after the program ended. In a randomized controlled clinical trial that compared the effects of 8- and 4-sessions of mindfulness training on a non-clinical population, no significant differences were found between groups of different mindfulness facets in six-month follow-ups . HoweverAs this report is a case series, more studies are needed to fully evaluate the benefits of this program on emotional labor and burnout in nursing staff working in a KM clinic. Moreover, because the number of participants included was small and there was no control group, this study cannot be used to demonstrate the effectiveness of the online mindfulness program in nursing staff. However, based on this first attempt, our research team plans to expand the introduction of an online mindfulness program to improve the mental health of nursing staff working at KM clinics in Korea in the future. The potential benefits of emotional labor and burnout, feasibility, high satisfaction, and some challenges identified in this case series will be considered in future extensions and modifications of this program.


Caregivers are often financially impacted, through health care costs, long-term care costs, and decreased income. A financial literacy program, Managing Money: A Caregiver’s Guide to Finances, was developed to provide information on financial impacts in caregiving. The virtual program was delivered synchronously with a live presenter through an online platform and was rated with high acceptability. The virtual program was then shifted to an online format. Changes included removing the live presenter and group format in favor of a voiceover and self-paced movement, the addition of videos, and online resources. The asynchronous, self-paced online delivery of the program was evaluated through a survey of 146 caregivers. Participants had a mean age of 45.85 (SD=5.65); 55% female; 75% White; 46% cared for their grandparent and 45% to their parent. A Likert scale was utilized to indicate satisfaction with the program . Overall, participants indicated that the program provided important information on managing money ; helped to understand the content ; was easy to read and understand ; and would recommend the program . The explanation of content areas were rated on a Likert scale ; participants rated areas including having conversations about finances ; avoiding financial fraud and abuse ; covering care costs ; and organizing legal plans . Participants reported no difficulties that needed to be resolved when moving through the program. Overall, both the virtual and online formats were acceptable and feasible to caregiving populations.


Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges.To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence.Observational, cross-sectional study in public and private CR programs offered in Brazil.Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale.From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants , as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012).Publicly funded programs need to be tailored to meet their patients’ requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status. However, barriers in lower-resource settings have not been well-studied. A recent review identified only 13 studies globally,11 and there are also few studies in South America12 or Brazil to date.16 This is problematic, given the different contexts in these settings. Firstly, patients would be more socioeconomically disadvantaged, and hence face different barriers. Secondly, healthcare systems are more often two-tier.17 So, for example, half of CR programs in Brazil are solely publicly-funded (53.3%), a third privately-funded, and the remainder a mixture.18 It has been established that CR funding sources affect program characteristics, such as scale, healthcare providers on the team and component comprehensiveness.17 However, to our knowledge, it has yet to be investigated how barriers might differ for patients accessing privately and publicly-funded programs in any country worldwide.19The reasons for underuse of CR have been well-characterized in high-resource settings20 and offering privately funded programs may enable greater availability, the CR community needs to consider the inequities that this might raise.Therefore, the objectives of this study were to compare: (1) the sociodemographic and clinical characteristics of patients accessing publicly versus privately funded CR programs; and (2) multi-level barriers to adherence in each of these types of programs. While the world needs more CR,This was an observational cross-sectional study. Participants signed an informed consent statement. The local ethics committee approved all procedures on June 28, 2018 (CAAE number: 88504718.0.0000.5402).A convenience sample was recruited between March and August 2019. Participants in the public or private CR programs offered in the city of Presidente Prudente, São Paulo, Brazil, were approached with a view to inviting them to take part in this study and undergo assessments. These assessments were administered by physiotherapists who were not part of the programs.The publicly funded CR program for this study is offered by the Cardiology Division of the Center for Studies and Attendance in Physiotherapy and Rehabilitation, School of Technology and Sciences, Universidade Estadual Paulista (UNESP), Presidente Prudente, São Paulo, Brazil. The CR program is funded by the Brazilian National Health System and is delivered through the physiotherapy program. The program is indefinite in length (i.e. phase II and maintenance).21 Most patients who use the private program have a health plan, for which they pay a monthly fee. This health plan covers 36 sessions, after which it is necessary to request coverage of further sessions if the doctor perceives more are required. When the patient does not have a health plan, they pay out-of-pocket monthly (R$ 390.00).The privately funded CR program is offered through the city's Heart Institute. The program is funded by the patient or through medical health insurance .To start either program, patients require a written medical referral. The public program offers sessions three times/week, while the private program offers two to three per week, depending on the patient. In both programs, exercises are performed in groups; the public program serves on average 18 patients/session and the private one, 12 patients/session. With regard to staffing, in the private program, care is delivered by physiotherapy cardiology specialists; in the public program, care is provided by physiotherapy students supervised by professors.The programs are primarily centered on structured exercises, and the exercise prescriptions are quite consistent between programs: they are based on heart rate reserve, and are re-evaluated each month. Exercises in the public program are done on treadmills and stationary bikes. In the private program, there are also resistance exercises. In addition, in the public program, there are group educational lectures and patients are provided with written materials. In the private program, there is informal counselling regarding risk factor control during the one-to-one sessions only.The inclusion criteria were that the participants needed to be aged over 18 years, with a diagnosis of cardiovascular disease or with cardiovascular risk factors (as per the program inclusion criteria), and needed to have been in the CR program for ≥ 3 months (frequency of attendance was not considered). There were no exclusion criteria.https://sgrace.info.yorku.ca/cr-barriers-scale/crbs-instructions-and-languages-translations/).The independent variable of interest was CR program funding type (public or private), which was coded based on the program attended. For objective one, the participants’ sociodemographic characteristics  and clinical characteristics  were first assessed. The participants then completed psychometrically-validated scales assessing factors that are known to impact CR access and which may be particularly important in lower-resource settings, along with the CR Barriers Scale  was administered. This asks about education level, family income, possession of certain items (e.g. number of televisions) and services offered in patients’ homes.23 was used. The test scores were adjusted based on level of education24 and categorized based on the presence of any cognitive impairment (e.g. participants who had four years of education and scored less than 25 were considered at least mildly cognitively impaired).To evaluate cognitive function, the psychometrically validated Brazilian-Portuguese version of the Mini-Mental State Examination (MMSE)25 was administered.To quantify mental health symptoms, the psychometrically validated Brazilian-Portuguese version of the Hospital Anxiety and Depression Scale (HADS)13 This assesses patient perceptions of 21 barriers at the healthcare system, healthcare provider and patient levels on a scale from 1 (“strongly disagree”) to 5 (“strongly agree”). Higher scores indicate higher barriers to CR adherence.26 A total mean score is computed, and there are five subscales: comorbidities/functional status, perceived need, personal/family issues, travel/work conflicts and access.Lastly, CR barriers were assessed in relation to the second objective. The psychometrically validated Brazilian-Portuguese version of the Cardiac Rehabilitation Barriers Scale (CRBS) was administered.To investigate differences in patient characteristics and barriers between participants attending public versus private programs, Fisher's exact tests or independent-sample t tests were used , as appropriate. Statistical significance was set at 5%. The analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS) software, version 22.0 .During the period of this study, 178 patients were approached, of whom 174 (97.75%) participated; 57.5% were from the private program. The sample characteristics are shown in With regard to sociodemographic characteristics, the participants in the public program had significantly lower educational attainment and lower socioeconomic status (plus a trend regarding work status). With regard to clinical characteristics, the participants in the private program had more cognitive impairment, and in the public program more anxiety and depressive symptoms than their counterparts. Participants were in the public program for significantly longer durations than those in the private program. Moreover, the total barriers were higher, the longer the participants were in the program .As shown in As also shown in 11 In many of these countries, the healthcare systems are two-tier. It is known that there may be differences in program quality, and that there are significant differences in cost according to funding source,17 yet to our knowledge there has been no investigation of how this impacts patients. In this study, we began to investigate differences in the nature of patients accessing these programs, and how their barriers to adherence might differ, and indeed some important differences emerged.There have been few studies on CR barriers outside of Western, high-income settings.27It was promising to observe fewer differences than expected, in the characteristics of those accessing a publicly funded program rather than a privately funded program. For instance, there were no differences with regard to sex, age or diagnostic indication. As expected, the chief differences were socioeconomic, which are likely to explain the differences in mental health as well as cognition.28 They would also want to ensure that they have staff who can assess and treat mental health issues, or have a close relationship with a referral source that does not have a long waitlist. Private programs could serve as important settings where patients who need more staff time could safely receive CR. If so, staff would need to have specialized training to successfully work with these patient groups.The differences in the nature of patients accessing public or private programs, if replicated, hold implications for program delivery. Public programs would need to consider the health literacy of their patients, and tailor their educational programming accordingly.32 Overall, the barriers were low, which was consistent with other CRBS studies in enrollees.33 This was to be expected, given the sample was composed of patients who had already completed ≥ 3 months of CR. Still, the patients accessing public programs did report significantly more barriers to adherence than did their counterparts in private programs. Socioeconomic differences in the cohorts do seem to explain the differences; for example, factors such as transportation costs, distance, time constraints and not getting support from healthcare providers to attend were more strongly endorsed by patients in the public than in the private system. Efforts to tackle the social determinants of health continue to be needed.The top barriers observed here were consistent with those reported in other studies, in Brazil, South America and beyond.34 This study was also limited to participants who had been able to access CR and had adhered to the program for ≥ 3 months. Arguably these participants were among the few who had been able to successfully access and adhere to CR, even in a low-resource setting. In future studies, the barriers among participants should be investigated at the time of diagnosis ,18 as well as very early in their program. Lastly, the sample size was modest, and this was the first study examining these differences. Therefore, replication is warranted prior to implementing any changes based on these preliminary findings.Caution is warranted when interpreting these results. Their generalizability is limited, particularly given that we sampled from only one public and one private program. Moreover, the programs were of long duration, compared with other programs internationally.In summary, as expected, but for the first time, we have shown that within a two-tier healthcare system in a lower-resource setting, patients accessing publicly funded CR programs are of significantly lower socioeconomic status and have poorer mental health and cognitive ability than those accessing privately funded programs. Publicly funded programs will need to tailor their delivery to meet the needs of their patients through educational and psychosocial programming. While referral and time conflicts remain key barriers in these settings, once patients do access CR, the barriers are greater for those in publicly funded programs than in privately funded ones, particularly with regard to comorbidities/functional status, perceived need and access.


The North Dakota Aging in Community project has an overarching goal of creating programs that improve the quality of life of rural older adults by increasing community-level support to help them age in place in two rural communities. The progress of program development and implementation was assessed across the project’s first year through program data and steering committee surveys. Program data, including steering committee meeting minutes and monthly activity reports completed by program staff, were qualitatively analyzed for successes, challenges, and lessons learned by finding common themes within these data. Successes included the use of an apprenticeship/mentorship model utilizing consultants from similar grassroots, rural organizations, recruitment of an optimistic, enthusiastic, and collaborative steering committee, and employing patience to develop community-led efforts based on unique community needs. Challenges included hiring qualified staff in rural communities, limitations in infrastructure opportunities, and need for creative marketing strategies. Survey results aligned with these conclusions, yet demonstrated the strengths and challenges related to incorporating the ideas and needs of diverse stakeholders. These findings highlight the unique challenges in developing programs to support rural aging-in-place, yet also highlight unique strategies that leverage rural strengths. Based on the findings of this first-year evaluation, future directions include conducting needs assessments to identify new avenues for program development, ensuring local program ownership through continued development of local steering committees, and continuing the mentorship/apprenticeship model while creating strategies to successfully foster independence. By sharing lessons learned, this program may serve as a replicable model to foster rural aging-in-place.


Refugees often suffer from multiple mental health problems, which transdiagnostic interventions can address. STARC (Skills-Training of Affect Regulation – A Culture-sensitive Approach) is a culturally sensitive transdiagnostic group intervention that has been developed for refugees to improve affect regulation. In refugees with substance use disorders (SUD), the consideration of SUD-specific elements might improve the acceptance and effectiveness of such an intervention. We aimed to adapt the STARC program for refugees with SUD in a culturally sensitive way.The conceptual framework of Heim and Kohrt (2019) was used to culturally sensitively adapt the STARC program to the needs of Syrian refugees with SUD. The results of five focus group discussions with refugees on cultural concepts of SUD and their treatment informed the adaption. An expert group suggested adaptions and decided by consensus on their implementation. Two pilot groups were conducted with the adapted STARC-SUD program. Interviews with the therapists of these pilot groups informed further adaption.The concepts related to SUD identified in focus groups and therapists’ interviews that differed from Western concepts were integrated into the STARC intervention.Further studies should assess the acceptance and effectiveness of the culturally sensitive STARC-SUD program for refugees with SUD. The study offers insight into the adaptation process of a culturally sensitive group intervention.We report the adaptation of a group intervention for refugees with substance use.Cultural concepts of Syrian refugees related to substance use are considered in the adaptation. The rising global burden of forced migration is one of the most pressing public health issues . Forced While there is a need for SUD health care for refugees, this need often is not met . SeveralThe culturally sensitive adaption of the existing Western evidence-based interventions seems central to reduce barriers to mental health care in refugees. The adaption of the language, culture, and context of an intervention to be compatible with the user’s cultural patterns, meanings, and values  may enhaAs refugees often suffer from multiple mental disorders, the need for evidence-based transdiagnostic treatments has received increasing attention . TransdiA few transdiagnostic treatment approaches have been developed for non-Western cultures. Problem Management Plus PM+;  is a fivA culturally sensitive group intervention developed for refugees in the Western middle- or high-income countries is STARC  by consulting a mental health professional. In contrast to this approach, some refugees found it more appropriate to solve mental health problems collectively within the family system. Hence, we included psychoeducation about the concept of Western psychotherapy in the introductory session. Furthermore, the therapists stressed that the approach to talk about mental health problems in a group with other patients needed to be introduced. Therefore, we included psychoeducation about the group setting as a common intervention approach in Western cultures to support and learn from each other in the introductory session.Not all refugees shared the concept of SUD as a treatable mental disorder. Consequently, we added information on the Western concept of addiction as a recognized treatable mental disorder and the availability of professional addiction services to the STARC manual. Most refugees stressed that rules and norms differed between the host and home country; the greater availability of substances was perceived as contributing to SUD. The greater societal acceptance of substance use was frequently mentioned as another reason for SUD. Thus, we incorporated information about the substances commonly used in the host and home country, as well as their availability and acceptance in the STARC-SUD program.Refugees and therapists reported refugee-specific risk factors for SUD, e.g., traumatic experiences in the home countries or during flight, worries about family members that remained in the home country, and not feeling accepted by the host country. Refugee-specific risk factors for SUD were therefore included in the STARC-SUD program. In addition to these refugee-specific risk factors, refugees mentioned culture-specific protective factors for not developing SUD, such as societal and family norms, and social support. These factors were incorporated into the manual.The therapists reported that some of the male refugees hesitated to play a group dynamic game with a ball of wool to get familiar with other group members in the introductory session. These male refugees perceived the game as more appropriate for women. Hence, we changed the manual instruction recommending to be sensitive to gender-based preferences regarding group games.Some refugees participating in the pilot groups reported being unfamiliar with the relaxation exercises introduced in the program (breathing exercise and Progressive Muscle Relaxation) to regulate tension or intense feelings. Rather, they preferred more active strategies . We adapted the program to instruct the therapists to offer both relaxation exercises and alternative active strategies.According to the therapists’ feedback obtained in the interviews, some participants preferred religious statements of encouragement as a strategy to regulate emotions, while others preferred non-religious statements, as they were non-religious or persecuted for religious reasons. Therefore, it was more strongly emphasized in the manual to be mindful in proposing religious rituals, e.g., reading the Koran or Bible, or talking to God or Allah.Some refugees with a high level of education found that the easy language used in the STARC manual appeared unfamiliar to them. Therefore, we added an instruction to the manual that therapists could adapt the complexity of the language according to the language skills and education of the participants.The therapists reported that the translator needed to have read the manual before the session to translate the content correctly. In addition, therapists emphasized the need of having sufficient time to ensure that all participants correctly understood the translation of the session content, e.g., by asking comprehension questions and providing additional information as needed. A briefing of the translators on the translation procedure before the session might also be helpful. Therefore, we underlined these aspects more strongly in the introductory part of the program.Based on the focus group discussions with Syrian refugees on cultural concepts of SUD and its treatment, we integrated elements relevant for the treatment of SUD in a culturally sensitive way into the STARC program. After piloting the first version of the STARC-SUD prototype, we further adapted the program based on interviews with the therapists that conducted two STARC-SUD pilot groups.We found that some of the refugees were unfamiliar with the Western concept to solve mental health problems with a mental health specialist. This finding is in line with the results of previous research showing that the Western concept of psychotherapy, i.e., to consult a mental health professional to talk about mental health problems, may be unfamiliar to people from non-Western cultures . EarlierPsychoeducation about the Western concept of (psycho-)therapy as a common approach in German healthcare to cope with mental health problems seems important. This may include discussing the approach to solve problems individually in a professional setting with a health care specialist as an alternative or complementing strategy to collectivistic approaches to enhance understanding, acceptance, and adherence to the program.In the focus groups that were conducted prior to the cultural adaptation, refugees outlined several SUD-specific aspects as essential to be incorporated in a culturally sensitive intervention . These iGender-specific preferences for dynamic group games needed to be considered in the STARC-SUD program. Previous studies with refugees also reported gender-specific preferences for group therapy content that were related to gender-specific socialization experiences . These rWe also found that the type of exercises to regulate emotions needed to be chosen culturally sensitively. A study by The sensitive use of religious content in the program was another important finding of our study. While some refugees perceived religion as a source of strength, others experienced it as a source of threat. These results indicate the need to consider religious content carefully in mental health interventions for refugees. However, in refugees that perceive religion as a source of strength, religious content in a culturally sensitive intervention might be particularly helpful, as religious believes are an integral part of ones’ own understanding of the world in many non-Western cultures . ConsistWhile the easy language used in the program seemed essential to improve the comprehensiveness of the program content for non-native speakers, it became clear that easy language could appear artificial for high-educated refugees, indicating the need for individual adaption of the used language to the participants of the respective intervention.We also found that the translations improved if the translators read the program sessions beforehand. These findings are consistent with a previous qualitative study by Overall, this study identified a number of necessary adaptions of a therapeutic intervention, developed within Western cultures, to the needs of individuals from other cultural backgrounds. Attention should be payed to the clarification of the underlying concepts. For refugees, it might be an unfamiliar concept that speaking about one's problems in groups is appropriate, and learning from others might have healing effects. Moreover, if such therapies include skills-based approaches, there is a need to consider their appropriateness from a gender and culture-sensitive perspective.Our results indicate implications concerning offering support for SUD in refugees. When adapting Western therapeutic approaches to the needs of refugees with SUD, Western concepts of mental disorders underlying the intervention should be discussed, such as the concept of addiction as a recognized and treatable mental disorder. In addition, the different societal norms for substance use, the types of substances, and their availability and acceptance in the host and home countries should be addressed.There are limitations concerning the methodology of our cultural adaptation. The program was culturally adapted by integrating non-Western metaphors, opinions from non-Western cultures about diseases and healing, and easy-to-understand language. Nevertheless, it seems impossible to make psychotherapy a culture-free concept, as it is rooted in the Western culture. The database used for our adaption is limited by only considering male refugees. Future studies need to examine the appropriateness of the program for female refugees. Another limitation is that we did not assess sociodemographic characteristics except age to guarantee confidentiality for the study participants.According to the results obtained from focus groups  and the The Supplementary Materials contain the following items :Supplement 1 describes the adaptation steps of the STARC-SUD intervention.Supplement 2 summarizes the results of the focus group discussions with refugees and the interviews with therapists, as well as the adaptations of the STARC-SUD intervention decided by consensus. Supplement 3 provides an overview of the adapted sessions of the STARC-SUD intervention.10.23668/psycharchives.5185Supplement 1LotzinA.LindertJ.KochT.LiedlA.SchäferI. (2021). Supplementary materials to "STARC-SUD – Adaptation of a transdiagnostic intervention for refugees with substance use disorders"[Additional information]. PsychOpen. 10.23668/psycharchives.5185


Customers’ declining receptivity to conventional marketing tools has been a challenge for convenience stores. To overcome this, retailers are turning to social media as a new, potent marketing tool for creating business prospects and encouraging direct customer interaction. However, it is still unknown how social media marketing affects the shifts in customer behavior. This paper expands on the relationship of “loyalty program (LP) + virtual community experience → perceived value → customer loyalty” in the traditional convenience store scenario, refining the variables of virtual community experience, perceived value, and customer loyalty. It also compares the effectiveness of different LP design structures (reward amounts × reward time limits) and explores the mediation impact of program loyalty and the moderation effect of alternative attractiveness. The results demonstrate the superior performance of LPs with an expiry policy and differential returns and highlight the importance of enhancing members’ virtual community experiences in fostering customer perceived value and loyalty. The results also show the minor negative moderation impact of community group buying and prove that emotional value significantly impacts customer loyalty. Still, the social value does not affect program loyalty. The recommendations are offered, such as designing growing-oriented and periodical zeroing LPs, as well as using new social media marketing tools  to empower traditional marketing techniques (LP-based relationship marketing) and constructing a “convenience store + community group buying” model. The findings have substantial theoretical and practical implications for traditional convenience stores in properly implementing loyalty and social media marketing tactics to maximize customer value and loyalty with a limited budget. Internet and social media are progressively becoming an indispensable part of modern life, and they have significantly altered retail business potential, purchase procedures, and customer shopping behaviors . AccordiRetailers have relied on LPs as one of the most widely recognized marketing techniques to reward customers in long-term relationships and drive repeat purchases by delivering short-and long-term rewards. The quantity, size, and breadth of LPs have increased dramatically, and LP study has piqued the interest of many academics. Numerous academic studies have examined the appeal of LPs and the positive influence of programs on customer behavior . There hIntroducing social media marketing tools, such as virtual communities, presents more significant opportunities and challenges for traditional brick-and-mortar stores. Stores are disconnected from customers after they leave the store in an era without mobile Internet, so many stores rely on introducing LPs to build long-term customer relationships. With the development of mobile technology and the change in customer demand, only relying on traditional marketing tools cannot meet the needs of the new era of customer groups. Nowadays, many stores have established virtual communities relying on social media platforms , thus keeping in touch with customers anytime and anywhere. Compared with the traditional LPs, the store can publish product information and transfer the store’s core value in various forms such as text, pictures, voice, and video in the communities, so that customers can know more about the product and the store without going to the store . CustomePrevious studies have proved that the establishment of virtual communities can improve the value perception of customers and then enhance the purchase intention of customers, but there is little research on the specific mechanism of this phenomenon . MoreoveThe rise of the “home economy” due to the COVID-19 quarantine policy and the changes in spending habits has accelerated the community economy’s development. Residents’ reliance on community commerce has grown due to its convenience, high frequency, and rapid adaptation to changes. Their daily consumption is gradually sinking to the “last mile” with residents turning to community convenience stores, supermarkets, and some new social e-commerce models  developed based on social media technologies. The conventional offline community retail formats and new retail formats have influenced the traditional convenience stores’ market share. The growth rate of traditional convenience stores’ market share has decreased in recent years. Still, the downward trend is the least compared to other physical retail formats  and traditional marketing tools (LPs) significantly enhances customer perceived value and loyalty. Third, we illuminate the driving effect of different dimensions of perceived value on customer loyalty formation and discover that the loyalty to the program can transform into a more enduring form of loyalty to the store. Fourth, we also find that the emergence of new social e-commerce models such as community group buying impacts the relationship between customer perceived value and loyalty, but the impact is weak. These findings may help retailers to develop competitive LPs for success and fill a research void in the quantitative analysis on the impact of LP structure and social media marketing, the combination of different marketing methods, and the emergence of new social e-commerce.The remainder of the paper is organized as follows. Section Literature review and hypotheses reviews the relevant literature and develops hypotheses that capture how LP structure, virtual community experience, and attractiveness of new retail formats impact members’ value perception and loyalty behavior. We then conduct a 2 × 2 quasi-experimental design and introduce the questionnaire design and the measurement of items in section Methodology and data collection. Section Statistical analysis and results shows the empirical research analysis process and results. The last section highlights the theoretical and managerial implications, discusses our research’s limitations, and identifies future research directions.With the rapid advancement of social media technology and the widespread usage of the Internet, online virtual brand communities are becoming increasingly popular among retailers due to their benefits of being time and space free as well as low cost. To better understand the genuine feelings of members in virtual communities, this section delves into the concept and the dividing dimensions of members’ virtual community experience. Although there is no single definition of virtual community experience, they all highlight customers’ whole perceptions and feelings along the process. Some research describes the virtual community experience as a succession of customer sensations comprising cognitive, emotional, behavioral, sensory, and social experiences before, during, and after purchase . Some devia the virtual community. When members of the community encounter problems while choosing products or using products, they can seek information or assistance from stores and other members, which can help them make decisions and solve problems more effectively. Recreational enjoyment experience is the emotional feeling of pleasure, relaxation, and excitement generated through browsing virtual community content and participating in community interactions and activities. Social interaction experience reflects members’ experience of friendship, affection, and other forms of social support gained through participating in community interaction. Members actively form close bonds, interact with one another at the level of extensive information or interpersonal relationships, and share their consumption experiences, product use experiences, and life stories. These experience strengthens their favorable feelings and preference for virtual communities and enhances their identification with brand values and stores.This paper defines members’ virtual community experience as a collection of emotions and a comprehensive assessment of their interaction with stores or other members, the value of services, access to information, and the environment in the virtual community formed by stores. We then divided community experience into three dimensions, including information acquisition experience, recreational enjoyment experience, and social interaction experience. Information acquisition experience is the emotion generated by members’ access to knowledge about their needs and information sharing among them Perceived value significantly influences customers’ purchase decisions, social status perception, and the relationship between customers and stores . The resScholars continually study the dimensional structure of perceived value while providing a conceptual definition. Many previous studies have taken a one-dimensional approach and only measured economic benefit, failing to recognize its complex and multifaceted nature. However, financial benefits alone do not sustain long-term customer relationships, and customers can easily switch to competing offerings if competitors offer better financial benefits . RecentlThis study divides perceived value into four categories based on the actual situation of convenience stores: economic value, functional value, social value, and emotional value. Functional value refers to the value obtained from the perceived quality or function of products or services, including product quality, product promotion activities, and member-exclusive service experience . MembersMany scholars have studied the relationship between members’ virtual community experience and perceived value. Experience marketing is essential for organizations to meet customers’ individualized needs and enhance their perceived value in a market context where product homogenization is increasing . JoiningH1: Members’ virtual community experience significantly and positively affects their perceived value.via conversation with others through virtual communities, regardless of geographical and time constraints. According to prior research, sharing and exchanging information in the community gives customers pleasure and satisfaction, raises their functional value, and meets their high-level needs  functional value, (b) emotional value, (c) social value, and (d) economic value.The virtual community’s social interaction experience gives customers a sense of belonging, importance, and integration, as well as meeting emotional demands . More frH1e-g: Members’ social interaction experience in the virtual community has a significant positive impact on their (e) functional value, (f) emotional value, and (g) social value.Humans, as social animals, require social contact to belong to specific groups or organizations. Humans with the sociable human trait seek out organizational support and spiritual comfort. Keeping customers relying on product features in this customer-oriented era is becoming increasingly challenging. Improving the emotional value of customers is a more effective technique. Entertainment activities are needed for social humans to pursue happiness and relieve life pressure. Virtual communities’ intriguing interactions and many varied activities may promote joy and happiness or boost the feeling of enjoyment and meet members’ emotional requirements . TherefoH1h: Members’ recreational enjoyment experience in the virtual community has a significant positive impact on their emotional value.LP design structures are multifaceted and involve several elements, such as reward amount, type, timing, and redemption policies , 2021. TReward amounts (refer to the reward that the LP delivers to members each time) available to members may influence their attitudes and participation enthusiasm; hence research into this topic is of great importance . The rewH2: Compared with the equal returns, LPs with differential returns have a more substantial positive effect on members’ perceived value.H2a-d: Compared with the equal returns, LPs with differential returns have a stronger positive effect on the (a) functional value; (b) emotional value; (c) social value; and (d) economic value.Whether to impose a time limit on reward redemption has sparked debate. Businesses frequently set reward expiration dates to avoid financial liabilities and decrease active involvement among members. At the same time, the fear of unpleasant customer experiences prompted some to extend reward expiration periods or implement a no-expiry policy . This paAccording to previous studies, the duration of reward expiration time and the consequences of reward expiration strategy substantially impact LP performance. According to the target gradient theory, reward expiration has a beneficial impact on customer purchasing behavior, for it generates a time pressure mechanism by keeping customers engaged with LPs and leading to more purchases in the period leading up to the due date for award redemption . CustomeH3: Compared with the no-expiry policy, LPs with an expiry policy have a more substantial positive effect on members’ perceived value.H3a-d: Compared with the no-expiry policy, LPs with an expiry policy have a more substantial positive effect on the (a) functional value, (b) emotional value, (c) social value, and (d) economic value.The development of LPs has been motivated by the shift in marketing strategy toward a customer-centric emphasis. The introduction of LPs enhances sales revenue and establishes customer loyalty by encouraging repeat purchases, understanding customers’ purchasing preferences, and carrying out targeted marketing activities . HoweverProgram loyalty is economical and transactional and is fueled by program incentives . ProgramMany previous studies have researched the relationship between program loyalty and store loyalty. Attachment to LPs has been proved to influence the affective nature of the customer-store relationship and positively affect store loyalty . CustomeH4: Program loyalty has a significant positive impact on store loyalty.In terms of member perceived value and its relationship to loyalty, numerous empirical research has found a positive correlation between the two dimensions. Perceived value is a direct predictor of program loyalty and is critical in establishing brand loyalty . CustomeH5: Members’ perceived value has a positive influence on program loyalty.H6: Members’ perceived value has a positive influence on store loyalty.Previous research also suggests that each sub-dimension of perceived value impacts loyalty. The emotional connection between stores and customers is difficult to imitate by competitors, and the level of emotional value can significantly impact customer loyalty . TherefoH5a-d: Member perceptions of (a) functional value, (b) emotional value, (c) social value, and (d) economic value have a positive influence on program loyalty.H6a-d: Member perceptions of (a) functional value, (b) emotional value, (c) social value, and (d) economic value have a positive influence on store loyalty.Member perceived value is determined by their experience throughout the purchasing process, significantly impacting customer purchase intention and behavior. According to previous literature, perceived values and benefits accessible through LPs may cultivate loyalty toward the program, boosting loyalty to the store . CustomeH7: Program loyalty mediates the relationship between perceived value and store loyalty.H7a-d: Program loyalty mediates the relationship between (a) functional value, (b) emotional value, (c) social value, and (d) economic value and store loyalty.Previous literature defines alternative attractiveness as customers’ perceptions and assessments of viable competing alternatives, the heterogeneity among alternatives, and the benefits and costs of switching . AlternaWith the common attributes of social e-commerce and social media, community group buying adopts the “pre-sale + collection and sale + last-mile delivery + self-pickup at the store” and sells everyday necessities and life services . SimilarAccording to cognitive dissonance theory, appealing alternatives will lead to cognitive dissonance, further lowering perceived value and loyalty . NumerouH8: Alternative attractiveness negatively moderates the relationship between member perceived value and program loyalty.H8a-d: Alternative attractiveness negatively moderates the relationship between (a) functional value, (b) emotional value, (c) social value, and (d) economic value and program loyalty.H9: Alternative attractiveness negatively moderates the relationship between member perceived value and store loyalty.H9a-d: Alternative attractiveness negatively moderates the relationship between (a) functional value, (b) emotional value, (c) social value, and (d) economic value and store loyalty.Based on the prior literature review and research hypotheses, this paper employed LP design structures and members’ virtual community experience as antecedent variables, members’ multidimensional perceived value as the intermediate variable, alternative attractiveness as the moderating variable, and customer loyalty as the outcome variable to investigate the influence path of “LP design structures + virtual community experience → perceived value → customer loyalty” relationship of traditional convenience stores  × 2 reward time limits (expiry vs. no-expiry policy) quasi-experimental design, and the reward amounts and reward time limits were manipulated . RespondBefore conducting the final survey, two marketing research professionals, three experienced convenience store retailers, and five customers reviewed the draft questionnaire to ensure that the items were clear and relevant. After receiving the feedback, some minor changes were made to some items, removing ambiguity and improving understanding.We conducted the final survey and recruited 559 participants on a professional platform named Credamo from November 2021 to December 2021, which can provide large-scale data collection services and has been recognized by top international journals. After eliminating 26 invalid surveys , we acquired 533 valid questionnaires. The effective rate was 95.35%, covering 171 prefecture-level cities in 31 provincial-level administrative regions in China, which can accurately and comprehensively describe the psychology and behavior of Chinese citizens. p < 0.001]. The results indicate that 89.1% of participants correctly recalled the reward time limits in the condition with an expiry policy, and 91.6% of participants correctly recalled in the condition with a no-expiry policy. The main effect of the manipulated reward time type on the recalled reward time limits is statistically significant . Therefore, the manipulations of reward amounts and reward time limits were effective.The questionnaire asked participants to recall the LP structures mentioned at the beginning to check that the manipulated factors produced the desired effects. Participants need to answer the two items: “Which type of reward amounts do you acquire in this LP” and “Is there a time limit for rewarding benefits gained through this LP.” The manipulation of reward amount  and reward time limits  was checked with a dichotomous scale. Logistic regression was performed with the recalled reward amount (reward time limit) as the dependent variable and the manipulated reward amount (reward time limit) as the independent variable. The results indicated that 90.5% of participants correctly recalled the reward amount type in the LP with equal return condition, and 88.6% of participants correctly recalled in the LP with differential return condition. The main effect of the manipulated reward amount on the recalled reward amount is statistically significant [Wald Chi-Squared  = 227.741, Given that all items in this paper were measured using established scales, this section employed AMOS 24.0 to conduct a confirmatory factor analysis (CFA) of the measurement model to examine the questionnaire’s reliability and validity and the model’s fitness. The standard values of several fitted indicators are within the acceptable range, indicating that the model is a good fit , a single survey population , and a single project research approach  but fulfilled the variance Chi-square criteria (p > 0.05); thus, the Mann–Whitney U-test was used. As shown in The effectiveness of LPs with different reward amounts and reward time limits on members’ perceived value was investigated to test hypotheses H2a-d and H3a-d. We chose the Shapiro–Wilk test for normality analysis and the Levene test for Chi-square analysis of the data. According to the findings, the data did not follow a normal distribution  with PROCESS 3.4 software, which could analyze a variety of mediation, moderation, and combination models . Still, 2/df = 1.921, GFI = 0.902, IFI = 0.952, TLI = 0.947, NFI = 0.905, CFI = 0.952, RMSEA = 0.042), indicating a good overall fit of the model. p < 0.001), and the hypothesis H1a-d remained true. Social interaction experience had a very significant positive influence (p < 0.001) on functional value, emotional value, and social value, and the hypotheses H1e-g were confirmed. Recreational enjoyment experience had a very significant favorable influence on emotional value (p < 0.001), supporting hypothesis H1h. Hypothesis H4 held because program loyalty significantly positively affected store loyalty (p < 0.001). Hypotheses H5a-b and H5d remained true because functional, emotional, and economic value significantly positively affected program loyalty (p < 0.001). However, the standardized path’s coefficient of social value on program loyalty is 0.012 (p > 0.05), indicating that hypothesis H5c was not supported. Emotional value had a highly significant positive effect on store loyalty (p < 0.001), supporting hypothesis H6b. Both functional and economic value significantly positively affected store loyalty (p < 0.01), and hypotheses H6a and H6d held. Social value had a relatively significant positive effect on store loyalty (p < 0.05), supporting hypothesis H6c.The study conducted a structural equation model test of the main effects using Amos 24.0 to test the hypotheses. The fit indices of the model met the corresponding criteria (χp < 0.001) and store loyalty (p < 0.001). Social value had a non-significant effect on program loyalty (p > 0.05) but had a positive effect on store loyalty (p < 0.001). Program loyalty positively affected store loyalty . The mediation effect was tested by applying bootstrapping analysis  and on the relationship between functional value and store loyalty. The index of moderated mediation was significant . Alternative attractiveness had a negative moderation effect on the relationship between emotional value and program loyalty  and on the relationship between emotional value and store loyalty . The index of moderated mediation was significant . Alternative attractiveness had a negative moderation effect on the relationship between economic value and program loyalty  and on the relationship between economic value and store loyalty . The index of moderated mediation was significant . Alternative attractiveness had a negative moderation effect on the relationship between social value and store loyalty  but did not have a significant influence on the relationship between social value and program loyalty (p > 0.05). The index of moderated mediation was not significant . Hence, hypotheses H8a-b,d, and H9a-d were supported, but hypothesis H8c was not.The findings  revealedA simple slope test was also used to uncover alternative attractiveness’s moderation effect . AlthougWe further analyzed the moderation effect of alternative attractiveness under different conditions. As shown in p < 0.05), but it did meet the Chi-square criteria (p > 0.05), then the Mann–Whitney U-test was used  and the three-dimensional virtual community experience as the antecedent factors, the four-dimensional perceived value as the intermediate variable, and the two-dimensional customer loyalty as the outcome variable. This paper compares the effectiveness of different LP design structures using a non-parametric test. It also investigates the effect of members’ virtual community experience on perceived value and customer loyalty using AMOS and PROCESS software. In summary, we identify five critical findings as follows.First, we discover that LPs with different structures significantly differ in customer value perception. LPs with differential returns are more effective in increasing members’ perception of value than those with equal returns, consistent with via the community and form connections with other members, dramatically expanding their social circle and increasing their sense of belonging, thus having the most significant impact on enhancing their social value. Retailers’ sharing of product-related suggestions and store anecdotes in the community and emotional communication with other members can strengthen customers’ senses, emotions, and cognition, thus boosting their perception of emotional value.Second, a good experience in the virtual community is confirmed to be beneficial to customers’ perception of the benefits and value of the LPs. The information acquisition experience has a considerable positive influence on the four dimensions of perceived value. However, the degree of influence varies with the most substantial influence on economic value and the slightest influence on social and emotional value. The social interaction experience has a significant favorable impact on three dimensions: functional, emotional, and social value, but the degree of impact varies, with social value having the most significant impact. The recreational enjoyment experience has a substantial favorable impact on emotional value. The findings are consistent with those of Third, we find the critical role of perceived value in the formation mechanism of customer loyalty. Functional, emotional, and economic values have significantly influenced program and store loyalty, with emotional value having the most significant impact on store loyalty. The findings are consistent with the work of Fourth, program loyalty has a direct effect on store loyalty and a mediating effect on the relationship between perceived value and store loyalty. The results reveal that, in addition to social value, program loyalty partially mediates the relationship between functional, emotional, and economic value with store loyalty. The finding is in line with the findings of Finally, we discover the adverse moderating effects of the attractiveness of community group buying on the relationship between customers’ perceived value and loyalty, but the degree of impact is weak. Unlike the findings of previous studies, which advocate the strong influence of alternative attractiveness , we provThis study contributes to the literature in four ways. First, our research adds to LP and loyalty literature by exploring the effectiveness of LPs with different structures in enhancing members’ value and loyalty. Recent studies have emphasized the effectiveness of linear LPs in customer loyalty formation rather than nonlinear (multi-tier) LPs , 2021 anSecond, our study is one of the very few empirical tests that verify the effects of three dimensions of virtual community experience on four dimensions of perceived value in convenience store settings. The extant literature has intensively examined the influence of community experience on customer usage intention in the e-commerce context  . HoweverThird, we advance loyalty theory by exploring the internal linkage mechanisms of the relationship of perceived value-program loyalty-store loyalty. Unlike previous studies e.g., , we unfoFinally, this research fills the gap of quantitative research on the moderating role of community group buying from the perspective of the convenience store. With the rapid development of community group buying, its impact on the real-community commercial and its attractiveness in consumer decision-making should be taken seriously . We discOur research offers several practical insights for convenience store retailers to motivate and engage their LP members more effectively. First, we recommend convenience stores empower traditional marketing techniques (LPs-based relationship marketing) with new social media marketing tools to increase member activity and strengthen stickiness. This paper finds that different designed LPs have entirely different effects on customer value and loyalty cultivation. Thus convenience stores should pay attention to the structure and effectiveness of LPs. We also recommend Growth-oriented and Periodical zeroing LPs for retailers, which divide members into different levels based on their spending habits and encourage customers to reward the benefits as quickly as feasible. This paper also proves that creating a virtual community enhances customer value and loyalty. With the community’s help, retailers can build a communication bridge for members in the surrounding real communities and a private traffic pool for themselves. They can better advertise and promote LPs without increasing operating expenses, increase member involvement in LPs, and reactivate dormant members for secondary consumption. For example, retailers can break through time and space barriers to stay in touch with their members by creating a member-only virtual community. They can deliver product promotion information, share product usage advice, and recommend cost-effective products to members more quickly and effectively. Members can offer help, share shopping experiences, and exchange exciting life stories and practical life tips with other members. Members can also make friends with like-minded people and broaden their social circle to increase participation, enthusiasm, and loyalty toward the store.Second, we suggest convenience stores pay more attention to the emergence of new competitors and build a “convenience store + community group buying” model. This study discovers that the emergence of community group buying harms the formation of member loyalty, but the effect is minor. It also discovers that convenience stores’ participation in community group buying improves perceptions of customer value and loyalty but reduces the perception of alternative attractiveness. Therefore, A “convenience store + community group buying” model is suggested to innovate and overcome the development challenge. (1) Convenience stores can participate in community group buying and become group leaders. They can help send and receive orders and share information about fresh products in their exclusive member community, which provides members with benefits and convenience and effectively compensates for the lack of fresh products. (2) Convenience stores can learn from the community group buying’s development advantages and concept features to offer exclusive services to members in their virtual communities. For example, they can utilize a pre-sale mode to collect orders, provide home delivery services, and conduct promotional activities such as group buying and price-cutting in the virtual community. These strategies may reduce operational and inventory expenses, expand sales categories, and boost members’ desire to buy and join. (3) Convenience stores can take advantage of the preferential policies of community group buying platforms to provide members with additional preferential rights. They can also use self-pickup to attract customers to their offline store, allowing them to experience their service and product quality and potentially become their customers or join their LPs.Although the findings of this paper have significant implications for both loyalty research and convenience store development, several limitations of our research warrant future research. First, we tested the causal relationships between the variables using cross-sectional data. Future research may conduct longitudinal investigations to see the changes in the relationship between members’ virtual community experience, perceived value, and loyalty. Second, this study only looks at the convenience store portion of the retail business and only collects data from a single market, China. Future studies should include data from different sectors or countries and make comparisons of the findings between different industries or nations to improve the generalizability of the suggested model and outcomes.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.XX organized the database, performed the statistical analysis, and wrote the first draft of the manuscript. ZH contributed to conception and design of the study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


BCR::ABL1 mRNA levels is essential for the management of chronic myeloid leukemia (CML) patients. From 2016 to 2021 the European Treatment and Outcome Study for CML (EUTOS) explored the use of secondary, lyophilized cell-based BCR::ABL1 reference panels traceable to the World Health Organization primary reference material to standardize and validate local laboratory tests. Panels were used to assign and validate conversion factors (CFs) to the International Scale and assess the ability of laboratories to assess deep molecular response (DMR). The study also explored aspects of internal quality control. The percentage of EUTOS reference laboratories (n = 50) with CFs validated as optimal or satisfactory increased from 67.5% to 97.6% and 36.4% to 91.7% for ABL1 and GUSB, respectively, during the study period and 98% of laboratories were able to detect MR4.5 in most samples. Laboratories with unvalidated CFs had a higher coefficient of variation for BCR::ABL1IS and some laboratories had a limit of blank greater than zero which could affect the accurate reporting of DMR. Our study indicates that secondary reference panels can be used effectively to obtain and validate CFs in a manner equivalent to sample exchange and can also be used to monitor additional aspects of quality assurance.Standardized monitoring of  BCR::ABL1 mRNA relative to those of an internal reference gene, most commonly ABL1, GUSB, or BCR, thus controlling for variation in sample quality and quantity [BCR::ABL1 measurement, which is effectively the same as that used in the International Randomized Study of Interferon and STI571 (IRIS). On this scale, 100% BCR::ABL1IS corresponds to the IRIS standardized baseline derived from analysis of 30 pre-treatment chronic phase CML cases. [IS, MMR  as ≤0.1% BCR::ABL1IS, and levels ≤0.01% (MR4) as DMR. [BCR::ABL1 mRNA, or by using a laboratory-developed test (LDT) in conjunction with a laboratory-specific conversion factor (CF) to the IS derived by sample exchange [Molecular monitoring of chronic myeloid leukemia (CML) patients undergoing tyrosine kinase inhibitor (TKI) therapy provides important prognostic information for individual patients and is used to assess time-dependent treatment milestones, including early molecular response (EMR), major molecular response (MMR), and deep molecular response (DMR) , 2. Molequantity , 4. Currexchange –12.2-MR4.5  in both an established reference laboratory and a test laboratory followed by calculation of the mean difference by Bland–Altman analysis. The CF is then defined as the multiplication factor needed to correct for the difference [Sample exchange typically involves testing around 30 CML patient samples spanning the range from MRfference . This prfference . Althougfference , 15.BCR::ABL1 mRNA was developed as a primary, WHO-accredited standard for IS calibration [IS levels, with different values assigned to each depending on whether ABL1, BCR, or GUSB is used as a reference genes. To conserve this limited resource, the WHO panel is only available to manufacturers of BCR::ABL1 test kits and secondary standards [BCR::ABL1 secondary reference panel was produced. This is traceable to the WHO panel and has been produced using a similar format (lyophilized K562 and HL60 cell mixes) with the addition of a fifth sample corresponding to MR4.5. BCR::ABL1IS values were assigned to the secondary panel using reverse-transcription droplet digital PCR (RT-ddPCR) with reference to ABL1, BCR, and GUSB and the panel was successfully evaluated by 44 different BCR::ABL1 laboratories [ABL1 as a reference gene .In 2010, the first International Genetic Reference Panel for quantitation of ibration . The pantandards . In 2016ratories . RecentlIn addition to accurate measurement of detectable residual disease, it is also important to ensure that assays are sensitive enough to detect DMR on a routine basis. Many CML patients achieve sustained >2 years) DMR on TKI therapy and around half remain in treatment-free remission (TFR) after stopping therapy  years DM. StandarBCR::ABL1 and reference gene assays are stable over time, and monitor the ability of assays to detect DMR, testing laboratories need to perform rigorous internal quality control (IQC) and validate their CF regularly. IQC is important to monitor variation in assay performance over time and ensure that low level BCR::ABL1 detection is achieved consistently [c. 10% BCR::ABL1IS) and low (c. 0.1% BCR::ABL1IS) standards on a regular basis, and ideally on every run to check that BCR::ABL1 and reference gene assays are stable over time [To maintain confidence in a CF, ensure that istently . Branforver time , 20.BCR::ABL1 detection, a better understanding of the limits of BCR::ABL1 assay performance is crucial [BCR::ABL1 RT-qPCR molecular response (MR) guidelines assume that all laboratories are able to detect BCR::ABL1 with maximal efficiency [BCR::ABL1 assays between laboratories result in variation in the way that MR is reported [Given the increased technical sensitivity required for low level  crucial . The limficiency , but thireported .BCR::ABL1 reference panels to assign and validate CFs for testing laboratories. In addition, the ability of laboratories to detect MR4.5 reliably was assessed and approaches to IQC were explored. Here, we present the results of this study and EUTOS recommendations for ongoing standardization of molecular monitoring for CML using RT-qPCR.From 2016 to 2021 the European Treatment and Outcomes Study (EUTOS) for CML has explored the use of the newly available cell-based secondary n = 49; 2017, n = 48; 2019, n = 50; 2020, n = 49; 2021, n = 49). Three samples consisted of locally-prepared HL60/K562 cell line mixtures  at approximately 10%, 0.1% and 0.0032% (DMR cell line lysate) BCR::ABL1IS lysed in either Trizol , RLT  or Promega Homogenization Solution containing 1-Thioglycerol  according to the preferred RNA extraction method of each center. Plasmid DNA samples  were supplied as a mock “cDNA sample”. Each plasmid sample contained identical and precisely defined ABL1, GUSB, and BCR::ABL1 copy numbers [ABL1, GUSB, and BCR::ABL1 RT-qPCR assays were performing with equal efficiency. Plasmid samples with different copy numbers were provided for each annual round of testing. Secondary cell-based reference material panels were provided and were composed of five vials of lyophilized cells (HL60/K562) spanning the range 10% - 0.0032% BCR::ABL1IS and supplied by Novartis Pharmaceuticals Corporation (2016–2019) [™ BCR-ABL Panel, 2020, 2021). Both secondary panels have BCR::ABL1IS values assigned for the reference gene ABL1 and the Novartis panel also had BCR::ABL1IS values assigned for the reference gene GUSB. To enable the AcroMetrix™ BCR-ABL Panel to be used to assign CFs to laboratories using GUSB as a reference gene, BCR::ABL1IS values were assigned to the batch by calibrating the reagents with the WHO panel at the laboratory in Wessex [From 2016–2021 three batches of nine samples were distributed annually (5 distributions) from the Wessex Regional Genetics Laboratory, Salisbury to EUTOS reference laboratories who agreed to participate   or ThermAll samples were tested using RT-qPCR using standard laboratory protocols following the process shown in Supplementary Fig. BCR::ABL1 results from the secondary reference lyophilized cell line panels using the method described at https://www.nibsc.org/documents/ifu/09-138.pdf; : Previous panel CF/New panel CF = 0.83–1.2Satisfactory (+/− 1.6 fold): Previous panel CF/New panel CF = 0.63–1.58Unvalidated: Previous panel CF/New panel CF < 0.63 or >1.58The unvalidated category also included new laboratory assays where there was no existing CF for comparison.IS values of approximately 5% (high level control) and 0.05% (low level control). Participants were asked to use their established protocols to extract RNA from both controls on a monthly basis, prepare two independent cDNA samples and test by RT-qPCR. Each laboratory submitted a minimum of 12 results from both high- and low-level controls over the 6-month period of the study. Data were submitted for reference gene transcript number, BCR::ABL1 transcript number, %BCR::ABL1/reference gene and BCR::ABL1IS for each IQC sample type. Six batches of high- and low-level control samples were distributed to 46 laboratories and 43 data sets were returned from 41 laboratories at the completion of the study (89%).We aimed to measure variation in assay performance over time for individual laboratories and assess how this correlated with stability of CFs. We prepared high and low internal quality control standards by making mixtures of HL60 and K562 cell lines see  which weBCR::ABL1 RT-qPCR in a subset of experienced molecular monitoring laboratories (n = 12). The LoB is defined as the highest measurement result that is likely to be observed for a negative sample i.e., the likelihood of reporting a false positive BCR::ABL1 result at a defined probability (α). When α = 0.95, the likelihood of a true negative sample giving a result greater than zero  is 5%. To determine the LoB, the Clinical and Laboratory Standards Institute guidelines recommend the following minimum requirements: test four negative samples, using two reagent lots of qPCR master mix, on one instrument, on three independent days, analysing two replicates per sample, generating 60 blank replicate results per reagent lot [n = 360) were processed and pooled to generate BCR::ABL1 negative lysates with sufficient ABL1 copies . BCR::ABL1 negative samples (n = 4) were provided to each participating laboratory. After local RNA extraction and cDNA synthesis, 18 RT-qPCR replicates  were performed per sample, per reagent lot using their local standard protocols. Four BCR::ABL1 negative samples were analysed using two reagent lots of RT-qPCR master mix, on one instrument, on three independent days, analysing two replicates per sample. This generated 144 individual RT-qPCRs in total; 60 BCR::ABL1 and 12 ABL1 replicates for each reagent lot , X(2), …, X(60). The rank position corresponding to the chosen value of α was calculated using the equation: “Rank position = 0.5 + (B x α)” where B is the number of replicates and α was 0.95. For most laboratories, the rank position was assigned as 57.5 (B = 60). The LoB was the highest measurement value of the sample at the given rank position across both lots.We aimed to determine the LoB for gent lot . Prior ties n = 1. The LoB4.5, data from all test samples were analysed according to five categories of relevant technical measures: (i) median number of reference gene transcripts reported for cell line lysates, (ii) detection of BCR::ABL1 in the DMR cell line lysates and MR4.5 freeze dried reference panel samples, (iii) reference gene and BCR::ABL1 transcript numbers per µl cDNA, (iv) %BCR::ABL1/reference gene for cDNA sample and (v) quality of reference gene audit data. Each category was scored and arbitrarily weighted according to the perceived relevance of each component: cell line results and MR4.5 detection> reference gene copy number audit data >cDNA transcript values and cDNA ratio , amber  or red  as detailed in Supplementary Table Analysis of information collected from participating EUTOS reference laboratories showed that there is substantial variation in the methodology used to perform molecular monitoring for CML. Laboratories used different RNA extraction methods, reference genes, PCR machines and RT-qPCR methods . Where information was provided (n = 41), the laboratory-specific CFs had been obtained using sample exchange from 2014–2016 (93%) or 2012–2013 (7%). Figures ABL1 and GUSB reference gene data sets, respectively. Several laboratories submitted data for more than one reference gene or assay and therefore the number of data sets analysed is greater than the number of participating laboratories. The mean, median, maximum, and minimum laboratory CFs for each reference gene per year are shown in Supplementary Table ABL1 (interquartile range (IQR) = 0.480–0.780, n = 213) and 1.576 for GUSB   and 0.960 for GUSB  for CFs derived by the EUTOS sample exchange program between 2006 and 2016.CFs were calculated and provided to laboratories on an annual basis for RT-qPCR assays using 14–2016 9% or 201214–2016 9% or 201214–2016 9% or 201214–2016 9% or 2012BCR::ABL1/reference gene) from each laboratory were converted to the IS using the newly derived CF for the three test samples. For example, in the 2017 round, 72.3% of results were reported within 2-fold of the expected IS value when no conversion factor was applied. This increased to 95.5% of results when data were converted to BCR::ABL1IS using the newly derived CF  using data for 2019/2020 since this corresponded to the period when the variability data was collected. The stability of a CF is likely to be affected by variability in assessment of both the high and low standard and therefore we assigned a combined “variability score” using the following criteria:Overall, the degree of variability for BCR::ABL1us study . CVs for3 points: CV < 1st quartile2 points: CV between 1st quartile and median1 point: CV between median and 3rd quartile0 points: CV > 3rd quartileVariability Score (CbVar) = score high level standard + score for low level standard.IS CV of IQC samples is an important quality control metric for laboratories to record routinely.The data obtained Fig.  shows thn = 9, Laboratories A - I) the likelihood of a true negative sample giving a result greater than zero  was 5%  the likelihood of a true negative sample giving a result greater than zero ranged from 10–50% .The EUTOS molecular standardization study indicates that secondary reference panels can be used effectively to obtain and validate IS CFs over time in a manner equivalent to sample exchange. They can also be used to monitor additional aspects of quality assurance. Over the period of the study, the percentage of laboratories with CFs validated as optimal or satisfactory increased from 67.5% (2016) to 97.6% (2021) and 36.4% (2016) to 91.7% (2021) for ABL1 CF values was similar to that observed by the EUTOS sample exchange program between 2006 and 2016. However, the distribution of GUSB CF values showed an approximate 1.64-fold increase compared to those obtained using sample exchange. It is unclear why this difference occurs, but if the assumption is made that the level of GUSB transcripts is 2.4 fold higher than ABL1, as shown previously in patient samples [GUSB assays would be expected to be correspondingly higher. This suggests that the CF values obtained from the cell line panels are valid . In this study, laboratories using GUSB as a reference gene had a higher percentage of unvalidated CFs compared to ABL1 laboratories (2.4–32.6% ABL1 vs 8.3–63.6% GUSB). The GUSB assays also demonstrated a higher degree of variation (mean CbVar = 2) compared to ABL1 laboratories (mean CbVar = 3.14) when testing internal quality control material, suggesting that the GUSB assay may be more inherently variable. It should also be noted that the number of GUSB datasets was low for both studies and several GUSB laboratories reported technical difficulties using the lyophilized material, possibly due to inexperience in handling this material, resulting in low GUSB copy numbers.The distribution of  samples , then thGUSB assays observed in this study, we would suggest that laboratories using this reference gene should monitor the stability of their assays at least monthly using high- and low-level control samples. If instability is detected, the laboratory should consider switching to a validated ABL1 assay until investigations into the GUSB assay stability have been undertaken and successfully actioned. More data are required to fully investigate the use of the panels to derived CFs for GUSB assays. Unfortunately, the current AcroMetrix™ BCR-ABL Panel has not been calibrated to the primary WHO material for GUSB (or BCR) and therefore this panel cannot be used to directly derive CFs for this reference gene. Although other approaches may be possible, laboratories using GUSB (or BCR) as a reference gene will need to continue to perform sample exchange with a reference laboratory to derive a CF. Once a laboratory has established a CF, it should also be possible to revalidate that CF or derive a new CF using archived samples  with known IS values that span the range from MR1 to MR4.5 in a manner analogous to sample exchange with an external reference laboratory.Nevertheless, given the potential instability of BCR::ABL1 values. If the newly derived CF is classified as optimal or satisfactory then it is acceptable to continue to use the original CF, although some centers may prefer to adopt the newly derived CF. However, when a newly derived CF is classified as unvalidated (and the assay has remained unchanged) further investigations should be considered to improve the assay stability. If the method or equipment is changed, or assay drift is noted though ongoing IQC then a new CF will need to be derived [It is difficult to define exactly how frequently CFs should be revalidated, but we suggest it should be performed at least annually if ongoing IQC data demonstrates assay stability at high and low  derived , althougIS, reference gene copy number, BCR::ABL1 copy number) are at least less than the 3rd quartile value obtained in this study (Table TM BCR-ABL panel).For IQC procedures, it is recommended that laboratories attempt initially to optimize assays to decrease variability such that the CV for each category . In the case of a laboratory with an assay demonstrating high variability, e.g., a CV of 22.5%, the range for the same sample increases to 7.75–12.25%. For samples at MMR (0.1% BCR::ABLIS) the same laboratories would report a true MMR sample in the range 0.085–0.115% (CV 14.6%) and 0.071–0.129% (CV 28.9%) respectively.Laboratories should be aware of the variability of their assay and communicate this to clinical staff so that they are informed of the acceptable degree of variability of BCR::ABLBCR::ABL1 RT qPCR testing, and we recommend that laboratories establish their LoB. A major challenge was the production of truly BCR::ABL1 negative samples. Initially, material was prepared from several BCR::ABL1 negative human cell lines from different sources but in our hands these showed very low level but reproducible amplification with BCR::ABL1 EAC RT-qPCR assays. Therefore, the use of cell line derived material for LoB studies is not recommended. Preparation of pooled blood samples from non-leukemic patients was time consuming however provided good quality material for the study. Using this material, we found that 25% of laboratories had a LoB greater than zero which may have implications for the accurate reporting of DMR, thus demonstrating the importance of establishing a LoB. Laboratories with poorly optimized assays may either fail to detect BCR::ABL1 and erroneously conclude that a patient had achieved DMR (variation in LoD) or exhibit a low level false positive rate and erroneously detect BCR::ABL1 (variation in LoB). Laboratory LoBs and LoDs have not been examined comprehensively to date because of a lack of suitable control reagents and agreed methodology.Defining the LoB and LoD of quantitative assays is important for validation of molecular tests and is necessary for accreditation of a diagnostic test to ISO 15189 (2012). Our study provides a practical recommended protocol for determining the LoB for In summary, we provide a number of recommendations for optimal monitoring of residual disease in CML by RT-qPCR, including establishment of laboratory-specific CFs and maintenance of reporting on the IS. We anticipate that these recommendations will further help to improve the quality of molecular monitoring for CML, with resulting benefits for patient management.Supplementary InformationSupplementary spreadsheet