Development and evaluation of diagnostics for diseases of epidemic potential are often funded during epidemics, but not afterwards, leaving countries unprepared for the next epidemic. United Nations Children's Emergency Fund (UNICEF) partnered with the United States Agency for International Development (USAID) to address this important gap by investing in an advance purchase commitment (APC) mechanism to accelerate the development and evaluation of Zika rapid diagnostic tests (RDTs) for case detection and surveillance. This paper describes the performance evaluation of five Zika RDTs eligible for procurement.A network of European Union-funded ZikaPLAN sites in Africa, Asia, Latin America with access to relevant serum specimens were selected to evaluate RDTs developed for the UNICEF APC mechanism. A standardised protocol and evaluation panels were developed and a call for specimens for the evaluation panels issued to different sites. Each site contributed specimens to the evaluation from their biobank. Data were collated, analysed and presented to the UNICEF Procurement Review Group for review.Three RDTs met the criteria for UNICEF procurement of sensitivity and specificity of 85% against a refence standard. The sensitivity/specificity of the ChemBio anti-Zika Virus (ZIKV) immunoglobulin M (IgM) test was 86.4 %/86.7% and the ChemBio ZCD system for anti-ZIKV IgM was 79.0%/97.1%, anti-dengue virus (DENV) IgM 90.0%/89.2%, anti-Chikungunya virus (CHIKV) IgM 90.6%/97.2%. The sensitivity/specificity of the SD Biosensor anti-ZIKV IgM was 96.8 %/90.8%, anti-DENV IgM 71.8%/83.5%, the DENV nonstructural protein 1 (NS1) glycoprotein 90.0%/90.2%, anti- yellow fever virus (YFV) IgM 84.6%/92.4%, anti-CHIKV IgM 86.3%/97.5%.Three RDTs fulfilled the performance thresholds set by WHO and were eligible for UNICEF procurement. These tests will improve the diagnosis of ZIKV and other arboviral infections as well as providing countries with better tools for surveillance and response to future epidemics.This work was supported by the USAID grant GHA-G-00-07-00007 and ZikaPLAN (European Union's Horizon 2020 Research and Innovation Programme under Grant Agreement No. 734584). We searched MEDLINE and PubMed on July 31 2021 and references from relevant articles on September 30, 2021 for the performance of IgM rapid diagnostic tests (RDTs) for Zika virus infections using the search terms “Zika”, “IgM”, “serologic”, “tests”, “evaluation” and “diagnostics” for articles published in English between Jan 1, 2015 and September 30, 2021. We found 56 articles, of which only two articles reported independent evaluation of the performance of two Zika immunoglobulin M (IgM) rapid tests, none of which were found to have satisfactory performance.This work presents data on the independent evaluation of three Zika RDTs made by two companies under the United Nations Children's Emergency Fund (UNICEF) Advanced Purchase Commitment (APC) funding mechanism to incentivise companies to continue the development of tests after the Zika epidemic was over. The evaluations were performed using well-characterised specimens archived at a pre-established network of quality laboratories in low- and middle-income countries as part of the EU-funded ZikaPLAN biobanking and evaluation network. One anti-Zika IgM test and two multiplex tests that can detect IgM antibodies against Zika and other arboviral infections were found by the UNICEF Procurement Review Group to have satisfactory performance and eligible for UNICEF procurement for use in countries as surveillance and case detection tools.This study suggests the value of the APC mechanism to incentivise companies to continue the development of tests needed for epidemic preparedness beyond the current epidemic. A pre-established quality-assured biobanking and evaluation network of laboratories in Zika virus endemic countries expedited the independent evaluations of diagnostics to ensure that they are fit for purpose as case detection and surveillance tools. This model has now been adopted by the Africa Centres for Disease Control and Prevention as part of their epidemic preparedness plan for the continent.Alt-text: Unlabelled box,Development and evaluation of diagnostics for diseases of epidemic potential are often funded during epidemics and left unfinished once the epidemic is over, leaving countries ill-prepared to combat the next epidemic.Accurate diagnostic tests for arboviral infections play a critical role in case detection and surveillance to provide early warning of potential outbreaks.The association of ZIKV infections with congenital birth defects, including microcephaly, and other neurologic complications and its potential spread through sexual transmission has made the diagnosis and surveillance of ZIKV infections an important priority, especially for case management and counselling for pregnant womenAfter WHO declared that ZIKV was no longer a PHEIC, new laboratory-based diagnostic assays were reported in the published literature but accurate, affordable and accessible diagnostic tests that can be used by health providers in community settings were not available.,,Under these agreements, procurement was conditional on satisfactory performance of the new products in independent evaluations relative to standards set out by WHO and UNICEFThis paper describes the results and significance of these evaluations as an important component of an innovative financing mechanism for test development to ensure that countries have diagnostic tools for clinical management of ZIKV infections and for surveillance, providing early alert against future outbreaks.A total of five different anti-ZIKV IgM RDTs from three companies were submitted for evaluation after two tender rounds. Some of the tests submitted in the second round were slightly modified versions of tests assessed in the first round. Tests were either singleplex or multiplex – a singleplex test refers one that detect a single test target only, which in this case is ZIKV, while a multiplex test refers to one that can detect several different targets, which in this case are ZIKV plus other arboviruses transmitted by the same Aedes mosquito species. For this tender, UNICEF adopted the World Health Organization (WHO) Target Product Profile (TPP) for ZIKV diagnostics and set mandatory requirements of 85% for sensitivity and specificity of ZIKV singleplex and multiplex tests compared to a laboratory reference standard.,,The focus of this evaluation is on immunoglobulin M (IgM) tests which can be used by countries as an aide for case detection, surveillance and outbreak alert. In a ZIKV-infected patient, anti-ZIKV IgM antibodies can usually be detected within the first 2 weeks of symptoms and continue to be detectable in some patients for as long as 5 or 6 months.The Chembio Dual Path Platform (DPP)® Zika IgM/IgG System is a rapid 10–15 min immunochromatographic test for the detection and differentiation of IgM and IgG antibodies to ZIKV in 10 µl fingerstick whole blood, Ethylenediaminetetraacetic acid (EDTA) anticoagulated venous whole blood, serum, or EDTA-anticoagulated plasma samples . ResultsThe Chembio DPP® ZCD IgM/IgG (Zika/Chikungunya/Dengue IgM/IgG) System is a similar rapid immunochromatographic test for the detection and differentiation of IgM and IgG antibodies to ZIKV; the detection and differentiation of IgM and IgG antibodies to CHIKV; and the detection and differentiation of IgM and IgG antibodies to DENV .The top and bottom window lines labeled 1, 2, 3 are for the detection of IgM or IgG antibodies against DENV, ZIKV and CHIKV, respectively while line C is the control line. The reading of the results is similar to the Chembio DPP® Zika IgM/IgG System. Results are read 10–15 min after adding buffer and using the DPP micro reader and cassette adapter, as the order of the test lines in the readout windows may be different than the order of the letters Z, C and D in the product name. The DPP ZCD Micro Reader has been individually adapted for specific use with the DPP ZCD IgM/IgG Assay System.The SD Biosensor (SDB) STANDARD Q Arbo I (Z/D/C/Y) Panel Test is an immunochromatographic lateral flow test to detect anti-ZIKV, CHIKV, DENV or YFV IgM specific antibodies and the DENV nonstructural-1 (NS1) glycoprotein in human whole blood, serum and plasma. The test is comprised of five separate cartridges . Each caAll three assays described are intended for use in clinical and POC settings to aid in the differential diagnosis of infection in patients with clinical symptoms consistent with ZIKV infection. A recent history of travel to geographic regions during a period of active ZIKV transmission at the time of travel; and/or other epidemiologic criteria for which ZIKV testing may be indicated as part of public health response. These tests are intended to provide a preliminary result. Results of these tests should therefore not be used as the sole basis of patient management decisions and should be used in combination with clinical observations, patient history, epidemiological information, and other laboratory determined criteria. The results must be confirmed by using the current CDC or local guidelines for the diagnosis of ZIKV or other arboviral infections.,LSHTM has developed a network of specimen and strain biobanks and diagnostic evaluation sites as part of the European Union funded project, ZikaPLAN.To qualify, all sites must be proficient in performing reference standard testing for ZIKV and other arboviruses and compliant with Good Clinical Practice/Good Clinical Laboratory Practice.At the time of the call for specimens for the UNICEF evaluation, three sites from the ZikaPLAN network responded: the Institut Pasteur Dakar, Senegal (IPD), Instituto Pedro Kouri, Habana, Cuba (IPK), and the Universidad del Norte, Barranquilla, Colombia (UNO). IPD and IPK are both WHO Collaborating Centres with biobanks of well-characterised patients’ ZIKV and DENV positive and negative specimens and specimens from individuals vaccinated against the Yellow Fever Virus (YFV). IPD have specimens from surveillance and outbreak investigations of infections caused by haemorrhagic fever viruses. IPK and UNO have large numbers of well-characterised anti-DENV specimens of all serotypes.Additional sources of well-characterised specimens for CHIKV IgM positive specimens had to be sought as most of the biobanking and evaluation sites within the ZikaPLAN network did not have access to sufficient numbers of confirmed specimens to perform the evaluations of the CHIKV components. Two additional sites with CHIKV-positive samples were therefore identified – Institut Pasteur in Vientiane, Laos (IPL) and Institut Pasteur du Cambodge in Phnom Penh, Cambodia (IPC). Site assessment visits to the IPC and IPL were conducted in April 2019 and both sites fulfilled the quality criteria to join the biobanking and evaluation network.In Brazil, the Chembio DPP ZCD assay had already received Agência Nacional de Vigilância Sanitária (ANVISA) regulatory approval. This data was shared by the FioCruz National Institute of Quality Control (INCQS) and INCQS was included as part of the ZikaPLAN network. The origins of the samples used for this evaluation at each site are summarised in When a test was submitted for evaluation, evaluation panels were designed by LSHTM according to the intended use, diagnostic target and the format of the test. A call for specimens went out to all the sites to identify sites having specimens that they were willing to contribute towards the evaluation panel . Each siAll tests under evaluation were assessed at two or more sites to ensure adequate geographic representation of the specimens in the evaluation panel and also to ensure the evaluation of the operational characteristics, such as ease of use were assessed by at least two teams of test users.The sites were reimbursed by the companies for all the cost associated with the evaluations. Each site entered into an agreement with the companies and invoiced them for the expense of performing the evaluation on a cost recovery basis plus an estimated cost of replenishing the specimens used from its biobank.,The design of our ZIKV evaluation panel was based on that of the dengue evaluation panel recommended by the TDR Expert Advisory Committee on performance evaluations of arboviruses.The specificity of the RDTs under evaluation was assessed using challenge panels composed of sera from patients with infections that may cause potential cross-reactive antibody responses or conditions that could produce interfering substances such as rheumatoid factor autoantibodies produced from patients with rheumatoid arthritis. Since well-characterised patients’ serum samples are a precious resource and are often only available in small volumes, the consensus by the network was that the evaluation should be divided into two stages so that these precious samples may be conserved to maximize the number of evaluations which could be performed and streamline a more expedited evaluation process. A test under evaluation was first assessed at IPD against small panels of healthy controls which were negative for all arboviruses. If a test passed this Sudden Death Panel with a score of 80% for specificity, then the laboratories would proceed with the full anti-ZIKV IgM evaluations. If the test scored less than 80% with this Panel, then the evaluation would not proceed further, hence the term, ‘Sudden Death Panel´.The Sudden Death Panel for the anti-ZIKA IgM antibody test comprised of 10 serum samples from healthy donors and 10 anti-ZIKV IgG positive/IgM negative samples. The anti-ZIKV IgG positive samples were confirmed by obtaining ZIKV-positive, but DENV, YFV and West Nile virus (WNV) negative 90% plaque reduction neutralization test (PRNT) at 1/8 specimen dilutions.30,The healthy donors’ samples were serum samples characterized as negative for both IgM and IgG antibodies against the following seven viruses: ZIKV, DENV, CHIKV, WNV, YFV, Rift Valley fever virus (RVFV) and Crimean Congo haemorrhagic fever virus (CCHFV) using IgM-capture ELISAs (MAC-ELISAs).,,IgM reference methods used by IPD for ZIKV and other arboviruses were assays used at WHO Collaborating Centres which included the US Centers for Disease Control and Prevention (CDC) MAC ELISA, with specificity confirmed by PRNT.The LSHTM was responsible for the collation of results across the ZikaPLAN network. All statistical analyses are performed in collaboration with IPD using R.4.1.0 software (2021-05-18). The  Statistical method used to quantify uncertainty is the Binomial Test. It's an exact test of a null hypothesis about the probability of success in a Bernoulli experiment. We use the R-fonction binom.test  to perform this test.  This fonction provides  several values including the probability of success under the null (0.5), alternative hypothesis (two.sided) and the confidence intervals for the probability of success. Confidence intervals are obtained by a procedure first given in Clopper and Pearson (1934).The specificity of these RDTs were analysed against other arboviruses. Values for overall specificity included test specificity against arboviruses as well as against healthy controls and IgG positive specimens where available. The specificity values obtained in this evaluation were intended to alert users of these serologic test of potential cross-reactivity against arboviruses and were not meant to be interpreted as representing specificity of these tests in any real-life settings. Similarly the evaluation of these RDTs against specimens positive for malaria and rheumatoid arthritis are intended to inform manufacturers of non-specific binding events which they need to mitigate. The results were shared with manufacturers and they were given 30 days to respond with comments or questions. In collaboration with the ZikaPLAN Scientific Steering Committee, data was analyzed for presentation to UNICEF and USAID, as well as other UNICEF designated stakeholders.in vitro diagnostic evaluation.This study is a laboratory-based evaluation which used left over samples from surveillance, outbreaks and research from the network of biobanking and evaluation sites. The laboratories in the network have institutional approval for the use of left-over samples for diagnostics evaluations. All the samples were not individually identifiable and therefore no informed consent was required for their use for This work was supported by the USAID grant GHA-G-00-07-00007 and ZikaPLAN (European Union's Horizon 2020 Research and Innovation Programme under Grant Agreement No. 734584). The funders have no role in the writing of the manuscript nor the decision to publish the results. The corresponding author, RWP, have accessed and verified the data, and RWP and DB were responsible for the decision to submit the manuscript.All but one test passed the initial Sudden Death panel. The test that failed was allowed to be re-tested after the manufacturer adjusted the test cut-off. When this did not improve the test performance, the test was disqualified from the full evaluation. Full evaluation was performed for three RDTs.A summary of the performance of the Chembio DPP® ZIKV IgM/IgG test is shown in . The sensitivity/specificity for anti-ZIKV IgM test was 96.8%/90.8%, for anti-DENV IgM test was 71.8%/83.5%, for the DENV NS1 glycoprotein was 90.0%/90.2%, for anti-YFV IgM was 84.6%/92.4%, and for anti-CHIKV IgM was 86.3%/97.5%.A summary of the performance of the SD Biosensor STANDARD Q Arbo I Panel (Z/D/C/Y) IgM Tests across all sites is shown in Table 5,In summary, the sensitivity of the three anti-ZIKV IgM antibody RDTs ranged from 79.0 to 96.8% while specificity ranged from 90.8 to 97.1% with tests showing the highest sensitivity having the lowest specificity and vice versa. The sensitivity and specificity of the anti-DENV IgM tests ranged from 71.8% to 90% and 80.7% to 89.2%, respectively. Anti-DENV IgM tests has been recommended to be used in combination with DENV NS1 antigen tests to increase the sensitivity of detection of acute dengue infection.Rapid and accurate diagnostics are essential during disease outbreaks to identify cases and guide patient management, map the extent of the outbreak and monitor the effectiveness of interventions.On the basis of the evaluation described here along with financial and other considerations, the Chembio ZIKV IgM/IgG RDT, the Chembio ZCD IgM/IgG RDT and the SD BioSensor Standard Q Arbo I Panel were recommended by the UNICEF Procurement Reference Group for purchase under the UNICEF-USAID APC mechanism. This evaluation was expedited through a network of biobanking sites with well characterised samples already established through an EU-funded ZikaPLAN project. The variety of biobanking sites ensures that specimens used for this evaluation comprised of specimens collected from primary and secondary arbovirus infections through outbreak investigations, from sentinel surveillance sites and from research studies in countries where these RDTs would be used. This evaluation provided a template for setting up biobanking and evaluation mechanisms for epidemic preparedness which was rapidly adapted for the COVD-19 pandemic by the Africa Centres for Disease Control and Prevention.The anti-ZIKV IgM sensitivity of 79% observed with the Chembio DPP® ZCD IgM test was lower than the 86.4% observed for the ChemBio DPP Zika IgM/IgG test. This could partly be the cut-off for a multiplex test has to be balanced with the other tests in the system. The higher specificity for the ChemBio ZCD IgM RDT of 97% versus that of 86% for the singlex test came at the expense of a lower sensitivity of 79% compared to 86% for the singlex IgM tests. These thresholds can be further adjusted with more field experience of using these tests.,The SD BioSensor anti-DENV IgM showed suboptimal sensitivity of 71.8% and specificity of 80.7% but its DENV NS1 antigen (Ag) detection test showed excellent sensitivity and specificity for the detection of acute DENV infections. Studies have shown that combined use of an anti-DENV IgM plus NS1 Ag test can result in highly accurate detection of acute DENV infections with longer detection window than either test used alone.For this tender, UNICEF adopted the WHO TPP for Zika diagnostics and set mandatory requirements of 85% for sensitivity and specificity of ZIKV singleplex and multiplex tests compared to a laboratory reference standard. Hence, the Chembio DPP® Zika IgM/IgG, Chembio DPP® ZCD IgM/IgG test and SD Biosensor STANDARD Q Arbo I (Z/D/C/Y) Panel test should all be considered acceptable for multiple use cases, such as an aide to diagnosis and surveillance to provide outbreak alerts. As these RDTs are intended only as an aid to diagnosis and for surveillance, positive results should be confirmed with more specific laboratory-based assays for a definitive clinical diagnosis and as part of outbreak investigations. The specificity of these tests is expected to be much better in real life settings since not all cross-reactive conditions used in the challenge panel would be expected in any one geographic location. UNICEF has started to pilot studies to determine the feasibility of using these RDTs for ZIKV surveillance at both arboviral sentinel surveillance sites and at antenatal clinics. It is anticipated that the results of these studies will inform whether these tests are satisfactory to aid clinical management and for surveillance.The current evaluation has limitations in terms of obtaining a sufficiently large sample size for some of the sensitivity and specificity panels, especially for anti-YFV IgM positive specimens. It is anticipated that the biobanking network will continue to expand to improve both in terms of specimens available for evaluation as well as better geographical representation. On the other hand, the advantage of the evaluation process described for this APC mechanism is that it leverages the combined power of a network of quality sites to contribute well-characterised archived specimens towards an evaluation without costly transport of specimens across borders or potential compromise of sample quality in transport. This mechanism allows the rapid evaluation of new tests that are developed in response to an outbreak of emerging, re-emerging or novel pathogens of epidemic potential.  It is not meant to replace more in-depth evaluations of the clinical performance or clinical utility of tests that would still be required when time allows.According to the WHO, The global incidence of dengue has grown dramatically in recent decades with about half of the world's population now at risk.This UNICEF-USAID APC mechanism to fund the development and evaluation of more accurate and accessible ZIKV tests after ZIKV is no longer a PHEIC is an important and much needed initiative. The results reported here show that the UNICEF APC mechanism did achieve its goal of ensuring that countries have access to affordable and accurate RDTs to respond to future outbreaks of ZIKV and other arboviral infections. Field studies to determine the feasibility of using these RDTs for arbovirus case detection and surveillance, including prenatal care settings, are ongoing. This mechanism can serve as a template for epidemic preparedness for other diseases of epidemic potential.RWP and DB designed the evaluation in collaboration with all the other authors who conducted the evaluations and analysed their site-specific data. RWP, CTD and DB collated all the site-specific data and performed the analysis for review by all authors. All authors have access to the data and the results of the analyses. RP and DB took the decision to submit the manuscript for publication. All authors contributed to the writing and finalisation of the manuscript.We declare that we have no conflicts of interest.Requests for data sharing should be submitted to the corresponding author.


The COVID-19 pandemic has highlighted the importance of technology for communication and social interactions. Especially for children in low-income families—a vulnerable population suffering from health and digital disparities—the situation worsened during the pandemic. Earlier studies in times of COVID-19 suggested that the children in Korea who usually do homework and dine at community childcare centers  need to learn more about how to eat healthily and how to interact with others using digital technology. Therefore, to reduce these children’s health and digital inequalities, an interactive live and online cooking program was developed and provided to 313 children and 95 staff members at the 29 CCCCs located in the southern provinces in South Korea. The aim of the current study was to explore the experiences of children and staff with the program. After surveying their experiences, a high degree of satisfaction was found . Aspects that needed improvement in the program were related to (in)experience in online technology, the frequency and timing of the cooking classes, and the communication between the centers and (online) chefs. In addition, in a word cloud analysis, terms such as ‘fun’, ‘delicious’, and ‘want’ were highlighted for children, and terms such as ‘participating’ and ‘preparation’ dominantly appeared for the staff. In the analysis of negative experiences, terms related to environmental factors such as ‘sound’, ‘hear’, and ‘voice’ were highlighted. This novel but preliminary approach for children from low-income families, by integrating cooking with digital technology, indicates that with enough digital support, the CCCCs are a promising platform to promote healthy eating and digital literacy. Optimizing and disseminating these strategies during this pandemic period, and future pandemics, could be beneficial to keep children in their communities healthy, and ultimately reduce socioeconomic health disparities. The coronavirus disease 2019 (COVID-19) pandemic has affected many families in many ways. For example, people experienced fear, depression, and stress more often , and chaThese health problems resulting from the pandemic related lifestyle changes have been more often reported in low income households. For example, these households have a high tendency to allocate their reduced income or disaster relief funds to medicine expenses or housing rent first, and consequently purchase cheaper junk food or instant food with the remaining money ,9,10. MoIn the 1950s, after the Korean War that brought the country extreme poverty and led to mass production of orphanages, a facility called ‘study room’ was created by non-government organizations (NGO) and religious groups in local communities and towns. These study rooms helped poor children across the country, resulting in the current community childcare centers (CCCCs). In 2004, the Korean government amended the ‘Child Welfare Act’ to legislate these CCCCs. They are the recognized child’s welfare institutions in South Korea, which do not only provide after-school care for vulnerable children, but also comprehensive services, including meal services, health care, learning assistance, and counselling ,22,23,24The COVID-19 outbreak and associated social distancing and lockdowns at schools, workplaces, and markets have brought about many challenges in the ‘social connection’ in our daily life . For exaSo far, limited research has focused on non-face-to-face improvement of eating habits for children from low-income families in Korea, except for the study by Lee et al. , which eThe objectives of the current study were (1) to examine the satisfaction level and experiences of children and staff at CCCCs with the interactive live and online cooking program, and (2) to receive their potential suggestions for program improvement.This study is a preliminary pilot study that uses an interactive live and online cooking program and describes the program experiences of children (aged 5–16 years) and staff at CCCCs. This study provides implications for the implementation and dissemination of the interactive live and online cooking program suitable for the COVID-19 pandemic era.As this investigation adopted community-based participatory research (CBPR) framework which community stakeholders and researchers engage as equal partners, two public health centers were responsible to recruit participants and operate the program. The research team analyzed the data and summarized the points for improvement. In the recruitment process, the public health center confirmed their attendance at the center, and all children who wanted to participate in the program did attend. In two communities, 313 children and 95 staff members from 29 CCCCs participated in this interactive live and online cooking program in August 2021. Zoom was used to teach skills and deliver information to the remote target population . In thisThe motto of this cooking class was “Make Your Own Healthy Meal Using New Information & Communication Technologies (ICT)”. Considering children’s food preferences, Irani sushi with beef topping as the main meal and a strawberry milk drink as the dessert were chosen for the menu ,37. ThreThe program consisted of a one-hour live and online cooking program. The cooking classes were held simultaneously at the studio, with a chef and operational staff, and at the centers for children; at least one center and a maximum of four centers participated in the program at the same time. In the studio, one chef and two operational staff members were involved. One staff member assisted the chef in the cooking process, and the other assisted with the technical aspects, such as the Zoom connection and video shooting. At the center, one operational staff member of the research team visited the center an hour before the class started and ascertained the preparation status of the food ingredients, the technical aspects of digital readiness, and the Zoom connection status with the studio. The children were divided into four teams of three children, while all the staff at the centers participated in the cooking class together. In case the center had a large TV monitor, the image was transmitted through the monitor; in other cases, a communication device, such as a laptop or mobile phone, was used instead. The program started with the preparation of the Irani sushi with beef topping, followed by preparing the strawberry milk drink. Because active communication and interaction with the chef on the screen during class was deemed very important, the chef asked the children for physical signals, such as drawing a circle by hand, to make sure that all participants could follow the program at the same speed. In addition, the chef explained the importance of making and eating dishes using healthy ingredients, such as vegetables and fruits. After the cooking class, the children and staff filled out a questionnaire. The time taken for the questionnaire was approximately 10 min. In addition, due to the COVID-19 pandemic regulations in South Korea, eating the food inside the center was forbidden. Therefore, each child made his/her own lunch box with the prepared food and took it home.The questionnaire used in this study included items to measure the participants’ general characteristics, program satisfaction, and program experiences.The questionnaire was developed based on the main components proposed by Larsen et al. (1979)  for the Participants were asked if they had participated in online cooking classes in the past and were also asked about the need for a program to prepare their own food and the need for a program using online technology.The ethics review board of the researcher’s institution approved this study (IRB No. 2022-02-015), and all procedures complied with the institution’s ethics policy. The children and staff who participated in the program filled out the questionnaire immediately after the cooking program ended. The assistant of the research team provided the participants with the questionnaire and asked them to answer honestly about their feelings on participating in the program. This study is a preliminary study that was performed to understand the participants’ experiences, including program satisfaction and suggestions, of the cooking program. To solve the research questions systematically, the data of the survey were quantitatively analyzed, and simultaneously, the opinions of the participants from the survey were analyzed qualitatively. For the quantitative approach, descriptive statistics, including the mean and standard deviation and percentage, were applied to analyze the data, using the Statistical Package for the Social Sciences (SPSS) version 21.0. In addition, qualitative data from a total of 202 participants  who had described their participation experiences via open-ended responses were analyzed. First, descriptions by the respondents were translated from Korean to English, incorporating a conversational style as much as possible to vividly convey their experiences. The translated data were then uploaded onto NVivo 12, a qualitative analysis software, and analyzed and expressed with word clouds. It can be quite challenging for researchers to utilize computer-assisted qualitative data analysis software (CAQDAS), including NVivo 12. However, these programs increase the efficiency of data management and transparency in analysis. In particular, the ‘word clouds technique’ utilized in this study helps to create a comprehensive description of the phenomenon through the visualization of research results . The overall program satisfaction score was 3.62 (±0.46) (out of 4) points for the children and 3.64 (±0.45) points for the staff, showing generally high satisfaction see . Both thIn response to the question that asks about the reasons for being satisfied with the cooking class, 45.1% of the children and 62.0% of the staff answered that ‘It was fun to cook together using the zoom program’. In addition, 23.6% of the children and 31.5% of the staff answered that ‘The program was convenient because it was an online program that doesn’t require any travel away from the center’. Moreover, 29.0% of the children and 21.7% of the staff responded that ‘It was such a novel program that I have never experienced before’. It should also be noted that the statement ‘Seeing other people having a lot of fun while cooking’ was also listed as a reason for program satisfaction by 12.8% of the children and 40.2% of the staff. Finally, 36.4% of the children and 34.8% of the staff answered that ‘I was able to learn how to make simple and healthy food through this program’.Among the very few participants who expressed dissatisfaction with the program, some participants selected ‘I am not familiar with using online technology ’ (two children and one staff member) and ‘The cooking space was too small’ (three children and two staff members) as reasons for their dissatisfaction. In addition, eight children responded that their dissatisfaction was related to their preference and taste of the food.Suggestions made by the program participants are shown in Lastly, as displayed in the word clouds, ‘Fun’ stands out as the major keyword in the experiences of the children, as well as the staff. The children responded, for example, with the following statements: “It was helpful to learn how to cook. It was a big joy and interesting to make food with my friends.”, “Given the COVID-19 situation, I liked how we did an interactive-live online class without meeting people face-to-face. I would like to do it again.” The staff’s responses included the following statements: “I think it gave the kids a good experience of cooking in an innovative way.”, “Due to the limited space, it was difficult for many children to participate in the cooking class. No matter how good the content of interactive live and online cooking program is, it is difficult to proceed with the class smoothly if the class is not thoroughly prepared due to lack of manpower and lack of time. Since it was the first time for us to have an interactive live and online class, we were not ready enough for the class. Nevertheless, the children were able to happily participate and thank to the program staff”.To summarize the narrative responses, the participants ‘enjoyed making food together and wished for this kind of opportunity again because the food was great’. The staff reacted positively about the children ‘having fun and participating actively’, but emphasized the need for more preparation by both CCCCs and program operators in terms of cooking supplies, tools, online education equipment, etc. They also pointed out the program was difficult because it was their first time engaging with an online educational program and that the low volume and poor audio quality need to be improved see .As the COVID-19 pandemic progressed, the socioeconomic health disparities among children became larger and were accelerated. Therefore, the development of digital technology-based health promotion strategies that can be adapted to the circumstances during the COVID-19 pandemic also needed to be accelerated. As a result of this interactive live and online cooking program using Zoom at CCCCs for children from vulnerable families during the COVID-19 pandemic, a high level of satisfaction for the program was reported; however, several elements need to be improved, as the participants’ experiences revealed. Cooking and nutrition programs for children are effective for cultivating healthy eating behaviors in children and the related social determinants, including knowledge and self-efficacy regarding cooking ,41. HoweDespite the high satisfaction with the program, there were several points for improvement; A few children answered that they had not been satisfied when cooking foods that they did not like before, while the staff stated that lack of skills for the digital programs and poor preparation of food ingredients made them not satisfied. In relation to the children’s negative responses to unfamiliar food, a previous study about a community meal program for the elderly in Korea suggests that it is also difficult for the elderly to understand the recipes of unfamiliar foods and that familiar ingredients and recipes reduce the resistance of program participants ,44,45. PDuring this pandemic era, the online learning became a main educational way between teachers and children, however, it was mostly implemented in a unidirectional manner that did not fully allow children to communicate in real time. It is well known that effective learning is optimized by using two-way communication ,49,50. HThe younger generation is likely to form healthy eating habits as they have more opportunities to cook for themselves . During This study is a first attempt to examine user satisfaction and improvement points of an interactive live and online cooking program that enrolled 408 participants in CCCCs in Korea. The CCCCs involved in this study included 29 centers located in 2 cities in the southern part of Korea. Therefore, expectations about the effectiveness of the program were preliminary. A well-designed experimental field-study with a comparison group is recommended to verify the effectiveness of the program, not only in terms of lifestyle changes , but also in terms of physiological indicators . Additionally, future studies should examine the influence of other factors, such as current cooking behaviors, family income, age, and regional distributions, to better inform governmental decision making.Many program participants in this study responded that in addition to improving their digital literacy, the expertise of the program operators should be improved. In this study, one operational staff member monitored the technical aspects of the digital apparatus before the program, and at least one or two assistants supported the participants during the entire period of the program. To ensure the service quality, we measured their satisfaction with the questionnaire item ‘Service provided by Staff’ in Lastly, the centers used to directly ‘provide’ children with meals and snacks rather than ‘shape’ life-long eating behaviors, including teaching the children how to cook, and how to eat in a healthy manner, etc. As result of the simple provision of foods and without behavioral intervention, the children at the CCCCs became just eaters and had no chance to improve their eating habits. As the COVID-19 pandemic has changed this world to adapt digitally convergent lifestyle, it is the right time to reform the environment of CCCCs in that way. In addition, the CCCCs has now faced to change their classical role as a place for foods for the vulnerable children to digital platform for healthy nutrition.Most of the participants expressed very high satisfaction with the interactive live and online cooking program, which can be attributed to program elements such as direct participation in making the food, live interaction with multiple people and the convenience of the Zoom program. Notwithstanding these positive elements, it was found that digital education/experience programs for CCCCs should not be implemented as a one-time event, but must be planned, improved, and implemented regularly to achieve a greater impact.In conclusion, CCCCs are a significant place  for children with vulnerable backgrounds in South Korea, but careful attention is needed at the community and policy level to ensure that CCCCs can continuously expand their role as a digital learning platform that can provide children with experiential dietary education, shifting away from the role of simply ‘providing’ care and meals to children from low-income families.


In today’s world, the higher education system represents a means of developing the national and global economy by providing individual and collective benefits. Student loyalty is a critical measure in the success of higher education institutions that aim at retaining students until graduation and then attracting them back. As they fuel the knowledge economy, universities create a more educated labor market, providing employment and higher salaries. Having this major significance, it is vital to study the key determinants that persuade stakeholders to form long-term relationships with universities, revealing high loyalty. Aiming to stay competitive and survive the drastic, ongoing changes, successful universities thrive on building loyalty among all stakeholder groups, especially students. Despite the importance of the higher education institutions (HEIs), little research has been conducted on student loyalty. Therefore, the main objectives of this study are to empirically examine the key factors influencing student loyalty by testing two models, namely perceived quality, brand associations, satisfaction, trust, and commitment, and to test the relationships among them. To analyze the data, a confirmatory factor analysis was applied where it explored the associations between items and constructs and, then, utilized a structural equation model (SEM) to investigate the relationships existing between constructs with the application of the STATA program. A structured questionnaire comprising of 66 questions was developed, using a five Likert scale. A total of 682 students from the Bucharest University of Economic Studies filled in the questionnaire. In both cases, the findings reveal that commitment has the most significant direct impact on loyalty. The other factors have an indirect effect, satisfaction having the most significant total effect, followed by trust and commitment. Therefore, universities must focus on improving service quality to develop positive brand associations, student satisfaction, trust, and commitment in developing student loyalty. Loyalty is one of the most important character traits everyone should have. In all areas of life, whether personal or professional, loyalty is priceless and a top priority in every kind of relationship.In today’s globalized world, the higher education system has to be seen as a service industry and universities as service providers. Therefore, universities should focus on the needs and wants of all stakeholder groups, especially on those of students. Moreover, to be successful, the higher education system must be directly linked to the increasingly complex requirements of profit . AdditioApplying marketing concepts to higher education is shared, from academic branding, ,18,19,20The purpose of the present study involves the empirical testing of a conceptual model of student loyalty. As in other industries, higher education studies on student loyalty focus mainly on developing conceptual frameworks that integrate the antecedents and mediators of loyalty. For instance, Chandra et al.  revealedMoreover, Carvalho and Mota  demonstrThe main objectives of the present study are to empirically test and identify the key factors affecting student loyalty based on two models with structural equations, developed based on research conducted by Rojas-Méndez et al. Figure 1Figure 1.perceived quality ≥ satisfaction ≥ trust ≥ commitment to the brand ≥ brand loyalty;brand associations ≥ satisfaction ≥ trust ≥ commitment to brand ≥ loyalty to brand.Based on the above model, two models have been tested in this paper, namely:The paper brings its contributions to the literature in several ways. In the first way, the determinants of student loyalty have been studied before, but the majority of the studies have covered just main determinants of loyalty such as student satisfaction and ignored perceived quality and brand associations. This study has been conducted to fill these knowledge gaps and propose a comprehensive model depicting elaborate relationships of all important antecedents of student loyalty. Thus, starting from Rojas-Méndez et al.’s  model, tThe paper is structured as follows. The second section is dedicated to a literature review and hypotheses development, while the third section is dedicated to research design and methodology. The next two sections are dedicated to empirical results and discussions, and the paper ends with the conclusions, main limitations, and future direction of research.Recognizing the importance of loyalty in the marketing literature, practitioners and researchers started to study this concept a long time ago , trying a deeply held commitment to rebuy or re-patronize a preferred product or service consistently in the future, despite situational influences and marketing efforts having the potential to cause switching behavior.” Jacoby and Chestnut [The study and approach of customer brand loyalty should always start with a coherent and comprehensive definition and a thoroughly developed measure. Brand loyalty has had a long and dynamic past. Copeland  was the Chestnut  suggesteChestnut , p. 39),Chestnut .Student loyalty refers to students’ loyalty to the university expressed after the educational experience ,59,60. IPerceived quality can be defined as the customer’s perception of the overall quality or superiority of a product or service concerning the proposed purpose and existing alternatives ,61. The Brand associations are closely related to the information held by the customer about the brand, whether positive or negative . These aSatisfaction is the extent to which a consumer experiences a pleasurable level of consumer satisfaction. It develops as a result of various interactions with the brand  and as aTrust refers to the ability and openness of an organization to honor its promises and fulfill its customer relationship obligations, being indispensable in forming and maintaining stable and collaborative relationships with customers ,74. SirdFor the whole period 2009–2019, there was a trend of strengthening of “institutional trust” for Romania and Eastern Europe. The institutional trust as a concept explored in the relationship between students and the Bucharest University of Economic Studies is clearly part of the institutional trust in Romania. There are some measures of social trust under the Legatum Prosperity Index (LPI) or also under the World Values Survey. The LPI measures “institutional trust”, “interpersonal trust”, and “social networks” along with two other elements of “social capital”, while the WVS measures, among others, the general level of trust together with the level of trust in universities. The social capital pillar measures the strength of personal and social relationships, institutional trust, social norms, and civic participation in a country. In 2009, Romania ranked position 122 on the pillar of social capital, indicating a weak rank; in 2019, Romania advanced to position 116, indicating a small improvement . AddAccording to the 7th wave of the World Values Survey (2017–2021) , which rDeveloping and maintaining long-term partnerships is the primary goal of relationship marketing. Commitment is essential in building a successful long-term relationship. It is defined as a belief that a relationship between partners must be maintained and continued with maximum effort  or as a What are the key factors influencing student loyalty?What are the cause-and-effect relationships among the key factors influencing student loyalty?Given the empirical results mentioned in the introduction, the next two research questions can be addressed:H1: brand associations have a significant positive effect on student satisfaction.H2: perceived quality has a significant positive effect on student satisfaction.H3: student satisfaction has a significant positive effect on student trust.H4: student trust has a significant positive effect on student commitment.H5: student commitment has a significant positive effect on student loyalty.Starting from the questions above, the following research hypotheses were formulated:The present research is quantitative, non-experimental, cross-sectional research, and the method we used is the survey. The research is much broader, including specific themes related to the marketing mix and brand equity, but this paper presents aspects related to the loyalty of students at a business university in Romania and its determinants. The instrument used in conducting this research is the questionnaire, which comprises a set of standardized and formalized questions. The population of this research is represented by all the students from ASE. In 2020, ASE will number 24,234 students, master’s and doctoral students , using as sampling layers the student gender distribution, age group distribution, and distribution of the main faculty followed by the student.The sample included a total of 712 respondents, of which, after thorough checks of the questionnaires and the elimination of those with incomplete answers, 682 students remained. Thus, at a 95% confidence level, the margin of error is 4%. This research was conducted from January to March 2021, and the questionnaire was applied online through the Google Forms platform. There is very little research focusing on the effects of COVID-19 on student loyalty. To address this gap, we need to conduct studies during such a crisis to conclude if COVID-19 can influence student trust.To achieve the research objectives, a questionnaire was developed based on two key marketing constructs, namely marketing mix and brand equity. The questionnaire in this paper consists of three main sections. The first section deals with the components of the marketing mix in the service industry, proposed by Booms and Bitner , namely The third section contains personal data, including gender, age, occupational status, academic program, year of study, major, form of funding, obtaining scholarships and what type of scholarships, plans for the future, interest in the field of study, and self-assessment of academic performance. The mentioned variables are structured as follows:Gender: a dummy variable in which 1—female and 2—male.Age: is a continuous variable quantifying the age of the respondent.Occupational status: a polychotomous variable with the following variables 1—I work full time, 2—I work part time, 3—I’m not working, but I’m looking for a job, 4—I’m not working, and 5—I’m not looking for a job.Academic program: a polychotomous variable with the following variables 1—bachelor program, 2—master’s program, and 3—doctoral program.Year of study: a polychotomous variable with the following variables for the bachelor program 1—first year, 2—second year, and 3—third year; for the master program 1—first year, and 2—second year; for the doctoral program 1—first year, 2—second year, 3—third year, and 4—other years.Major: a polychotomous variable with the following variables for the bachelor program 1—The Faculty of Business Administration (in Foreign Languages), 2—The Faculty of Administration and Public Management, 3—Bucharest Business School, 4—The Faculty of Business and Tourism, 5—The Faculty of Economic Cybernetics, Statistics and Informatics, 6—Faculty of Accounting and Management Information Systems, 7—Faculty of Law, 8—The Faculty of Agrifood and Environmental Economics, 9—The Faculty of Theoretical and Applied Economics, 10—The Faculty of Finance and Banking, 11—The Faculty of Management, 12—The Faculty of Marketing, 13—The Faculty of International Business and Economics; for the master program 1—The Faculty of Business Administration (in Foreign Languages), 2—The Faculty of Administration and Public Management, 3—Bucharest Business School, 4—The Faculty of Business and Tourism, 5—The Faculty of Economic Cybernetics, Statistics and Informatics, 6—Faculty of Accounting and Management Information Systems, 7—The Faculty of Agrifood and Environmental Economics, 8—The Faculty of Theoretical and Applied Economics, 9—The Faculty of Finance and Banking, 10—The Faculty of Management, 11—The Faculty of Marketing, 12—The Faculty of International Business and Economics; for the doctoral programs 1—Business Administration, 2—Economic Cybernetics and Statistics, 3—Accounting, 4—Economics, Economics and International Business, 5—Finance, 6—Economic Informatics, 7—Management, 8—Marketing, and 9—Law.Form of funding: a polychotomous variable with the following variables 1—financing from the budget, with scholarship, 2—budget funding, no scholarship, 3—tax, and 4—other answers.Obtaining scholarships: a dummy variable in which 1—yes and 2—no.Type of scholarships: a polychotomous variable with the following variables 1—scholarships of excellence, 2—performance scholarships, 3—merit scholarships, 4—social scholarship, and 5—other answers.Plans for the future: a polychotomous variable with the following variables 1—to get hired by state institutions, 2—to get hired by a private company, 3—to pursue an academic career, 4—to start my own business, and 5—other answers.Interest in the field of study: a polychotomous variable with the following variables 1—to a very small extent, 2—to a small extent, 3—to some extent, 4—to a large extent, and 5—to a very large extent.Self-assessment of academic performance: a polychotomous variable with the following variables 1—poor, 2—fair, 3—Satisfying, 4—good, and 5—very good.The questionnaire is detailed in As research methodology, within the analysis there have been developed two structural equation models (SEM) as follows: associations ≥ satisfaction ≥ trust ≥ commitment ≥ loyalty as well as perceived quality ≥ satisfaction ≥ trust ≥ commitment ≥ loyalty.To investigate the degree of correlation within the set of items, Cronbach’s Alpha  was determined, which is the most common estimate of the internal consistency of items in a model. Thus, when the correlation is high, then it can be said that indicators can be used to build a composite indicator. An acceptable reliability threshold is 0.7 . HoweverTo evaluate the models and select the optimal model, the model accuracy was evaluated, including the statistical significance of the parameters, the value of the chi-square test that evaluates the model compared to the saturated model, root mean square error of approximation (RMSEA), residual standardized square mean root (SRMR), comparative fit index (CFI), Tucker–Lewis index (TLI) and coefficient of determination (CD) values, Akaike information criteria (AIC) values and Schwarz (SBC) .p-value must be 1. The RMSEA is the value of the square root approximation error, and the p-close is the probability that the RMSEA value is less than 0.05. The probability must be much closer to 1 in an optimal model. AIC and SBC criteria are used to compare models, with lower values indicating a better model. CFI and TLI are two indices whose values close to 1 indicate a good match. A value of 0 for SRMR indicates a perfect fit quality, while a value of less than 0.08 indicates a good fit. A value of the coefficient of determination close to 1 indicates a good quality of adjustment.The chi-square test evaluated the performance of the model compared to the saturated model, which fits perfectly with the covariances. To accept that the model fits, as well as the saturated model, the From the total of 683 Romanian students interviewed, 23% are males, 77% are females, and the majority of them (60.6%) are between 20–22 years old. Almost 74% of the respondent students are enrolled in the bachelor’s program, 21% in the master’s program, and only 5% in doctoral programs at the Bucharest University of Economic Studies. The number of students enrolled in undergraduate programs is the highest, of which 35.84% are in year II, 33.66% are in year III, and 30.50% are in the first year. Regarding master’s programs, 54.17% of the responding students are in the first year, and 45.83% are in the second year. In the doctoral programs, 41.18% of the responding students are in the first year, 23.53% are in the second year, 20.59% are in the third year, and 14.71% are in the additional years.Regarding the bachelor’s programs, there are no answers from students enrolled in the faculties of Accounting and Management Information Systems, the Faculty of Law, and the Bucharest Business School, and also none from students enrolled in master’s programs within the faculties of Accounting and Management Informatics and the Bucharest Business School. The distribution of students according to the specializations within the faculties of ASE is presented in Regarding the scholarships offered by ASE, the majority of responding students (61.64%) do not receive any scholarship, while 38.36% of students receive different types of scholarships, as follows: merit scholarship (70.99%), performance scholarship (21.37%), social scholarship (4.20%), and excellence scholarship (3.44%).The occupational status of the students reveals the fact that most students (39.09%) are not currently working but are looking for a job, while 25.62% are not working and are not looking for a job. Moreover, 23.13% of the responding students work full time, and 8.64% are employed full time, while a small percentage, namely 3.51%, have their own business.Regarding the career plan after graduation, 42.38% of the respondent students want to work in a private company, 29.18% intend to open their own business, 18.77% plan to work in various state institutions, and fewer than 9.68% of students want to pursue an academic career.The descriptive statistics of all items included in the analysis are displayed in The results were first examined using a correlation matrix  between Two structural equation models (SEM) that reveal the relationships among the latent variables were used to test for the validity of the measurements and to evaluate the usefulness of the models. For both models, confirmatory factor analysis (CFA) revealed an acceptable fit indices with all factor loadings ranging from 0.75 to 1 for the perceived quality model, and from 0.79 to 0.1 for the associations model. Reliability Cronbach’s alpha coefficients were above the minimum threshold of 0.70 recommended by Nunnally : associaThe first structural model tested involves the relationships between perceived quality ≥ satisfaction ≥ trust ≥ commitment ≥ loyalty; the empirical results are presented in Therefore, the empirical results validate hypotheses H2, H3, H4, and H5 in their entirety, meaning that there is a significant positive relationship between perceived quality, satisfaction, trust, commitment, and loyalty.The empirical results of the first structural model analyzing the relationships between perceived quality ≥ satisfaction ≥ trust ≥ commitment ≥ loyalty revealed that, based on standardized path coefficients, satisfaction has the largest total effect on loyalty (0.92), followed by trust (0.84) and commitment (0.84), of which commitment shows a direct effect, while the other variables have only an indirect effect on loyalty. Satisfaction (0.92) and trust (0.84) show the strongest indirect effect on loyalty, while commitment (0.84) shows the strongest direct effect on loyalty. Together, perceived quality, satisfaction, trust, and commitment explain 92.4% of student loyalty, as derived from the CD of the structural equation model.Regarding the testing of the hypotheses related to the first model, the results are shown in The empirical results of the second structural model examining the relationships between the associations of brand ≥ satisfaction ≥ trust ≥ commitment ≥ loyalty are shown in As can be seen, satisfaction retains the largest indirect effect on loyalty (0.92), followed by trust (0.84) and brand associations (0.84). In contrast, commitment (0.84) shows the strongest direct effect on loyalty. Thus, of all these dimensions, only commitment has a direct effect on loyalty, while brand associations, satisfaction, and trust have an indirect effect on loyalty. Together, brand associations, satisfaction, trust, and commitment explain 95.2% of student loyalty, as shown by the CD of the structural equation model. Regarding the testing of the hypotheses formulated based on the second model, the results are shown in Therefore, the empirical results validate the hypotheses H1, H3, H4, and H5 in their entirety, meaning that there is a significant positive relationship between brand associations, satisfaction, trust, commitment, and loyalty.The GFI and AGFI are above 0.95 and the RMSEA is under 0.05, indicating a good fit of the models to the data. The comparative fit index (CFI) and Tucker–Lewis index (TLI) are well above 0.90 registering 0.929 and 0.92 for the associations model, respectively, and 0.926 and 0.916 for the perceived quality model, respectively, indicating a good fit of the model to the data. Similarly, the other indices of comparative fit and parsimonious fit are above their recommended thresholds. The Hoelter’s (1983) critical N (which relates the adequacy of the sample size to the model) is well above 200, indicating that the samples are large enough to allow for an adequate fit to the model.The purpose of testing these two models was to explain student loyalty in higher education institutions by examining the key factors that influence loyalty. Perceived quality, brand associations, satisfaction, trust, commitment, and loyalty were reviewed in two models, which are comprehensive enough to explain loyalty. The empirical results showed that satisfaction has the greatest total effect on loyalty, followed by trust and commitment in both models. Commitment has the most significant direct impact on loyalty, mainly due to its direct and strong relationship with loyalty. The other factors have only indirect effects on loyalty and direct relationships in the following sequence: perceived quality to satisfaction, brand associations to satisfaction, satisfaction to trust, and trust to commitment. Therefore, in developing loyalty to the academic brand, university management must emphasize improving the quality of educational services, developing positive brand associations, and improving student satisfaction, trust, and commitment.In many ways, these results are similar to those reported by Mazhar and Masood , who conTherefore, in generating student brand loyalty, university management must first and foremost facilitate student satisfaction, which improves long-term relationships between them and the university. Enhancing student brand loyalty requires a deep understanding of the factors that influence satisfaction, the lack of which has negative consequences for both the university and the students ,100,101.In short, managers should increase student satisfaction towards the educational services to enhance students’ loyalty, which in turn maintains the survival rate of the university. Loyal students will always recommend the university to others and will keep future relational activities, such as returning when seeking future degrees. This stringent necessity of strengthening service quality and customer satisfaction is nowadays of paramount importance in such a competitive environment because students’ loyalty enhances higher education institutions’ sustainability and survival rate.New research could explore service quality in the higher education system and particularly in the Bucharest University of Economic Studies. Likewise, service quality could be measured for each and every faculty in the university, comparing them with each other. Moreover, student loyalty could be measured in various contexts. For example, in specific careers and social groups. Other studies should focus on the loyalty of other stakeholders’ categories to the university, especially that of teachers and employers. The aim is to have more useful information and knowledge for the proper application of loyalty programs and strategies.Student brand loyalty has become an essential strategic topic for higher educational institutions’ planning. The present results suggest no difference between students and consumers of other services because, over time, students have adopted client positions when interacting with the university . In thisIn our view, to inspire more loyalty among students, any university should establish a strong relationship, which involves obligations and accountability, by behaving reasonably and keeping promises towards the students. To be respected, institutions need to treat students with fairness and respect. Moreover, institutions have to build a brand and project an identity that resonates with students’ wishes, interests, and expectations. Consequently, a university brand should strive to be positive, unique, and interactive. In building an effective academic brand, universities must first identify their target audience, know their needs, and then manage their mission, vision, and organizational culture accordingly. Being a brand that respects its audience shows a great understanding of them, which is what customer loyalty implies.The research results indicate the importance of a strategic approach to brand and customer loyalty. Moreover, the results indicate that university management needs to focus on loyalty programs that correctly generate loyalty among the important stakeholder group: students. In such a competitive market as the education market, with different perceptions of the quality of educational services, loyalty, being a complex tool, can be an optimal way to achieve institutional goals and build solid and lasting relationships. This paper serves as a diagnostic tool for evaluating and improving loyalty among students with focused marketing efforts. The Bucharest University of Economic Studies could benefit from this research, integrating the approach into a new marketing strategy or improving the current marketing strategy by improving educational quality.With regards to the main limitations of the study, first of all the present study extracted the sample from a single university in Romania. The final sample was indeed representative of the Bucharest University of Economic Studies student population, and the statistical modeling was robust. Still, future research should aim at reproducing the results using other student populations, for example, from other economic faculties in Romania, to have more conclusive and relevant results.Secondly, the sample was extracted only from an economic university in Romania, representing only the student population within the Bucharest University of Economic Studies. Therefore, future research could take samples from several universities with different profiles in Romania to conduct comparative studies.Finally, the present study is cross-sectional, which means that the results were recorded only once. A longitudinal study, in which research continues for a more extended period, using the same sample at each stage, would provide a much more concrete estimate of the measurement and performance of brand loyalty in higher education.


Data were collected before and after the program implementation through online questionnaires for: a. attitude, intention, subjective norms, and PBC toward healthy eating; b. knowledge about healthy eating; c. exercise behavior and attitude toward the DIEX program; and d. satisfaction with the DIEX program (only post-program). The results showed that there were significant differences among the pre- and post-measures of students’ knowledge and behavior about healthy diet, as well as attitudes and satisfaction toward the program’s application. The results show that the DIEX program may have improved nutrition behavior variables. Conclusively, a theory-based behavioral intervention with skills training may result in positive behavioral changes for young students during health education in school settings with the assistance of new technologies.The present study examined the effectiveness of a school-based health education program promoting healthy diet and exercise, named DIEX, implemented on adolescents. The program is based on the Theory of Planned Behavior (TPB) and is supported by life skills training. The recipients of the program were high school students ( The Global Nutrition Report  highlighAdolescent health is overlooked in global public health because this age group is regarded as healthy . HealthyReviews have demonstrated that the most efficient health interventions will be those that include a behavioral theory framework ,17,18. TAccording to research, participation in regular exercise is highly recommended to prevent nutrition-related health problems . For exaA multicomponent approach is needed to apply an effective intervention that aims to prevent childhood obesity, targeting the modification of exercise, lifestyle, and dietary behavior . Thus, tRelevant reviews have stressed that school-based programs covering a variety of strategies can be effective in promoting healthy diet among youth . SteinmeSchool-based educational interventions guided by TPB have exhibited a post-intervention positive change in participants’ intentions and dietary behaviors, and they have also been found to improve children’s and adolescents’ behaviors toward healthy diet, increased fruit and vegetable consumption, and decreased junk food consumption ,38,39, aIn a recent review, Salam et al.  suggesteSchool health education programs integrate educational components, which aim to improve students’ well-being ,47. In mUnhealthy diet in coexistence with low levels of exercise has been shown to have high impact on obesity in youth . InterveMcIntosh et al.  reviewedTo the best of our knowledge, only a few studies have tested the effectiveness of a TPB intervention targeting only exercise behavior among youth during leisure time ,59. The Although there are numerous interventions to promote PA among youth , the resDanish defined life skills as “… those skills that enable individuals to succeed in the different environments in which they live” . Life skAs several studies highlight that TPB is a well-documented framework for promoting healthy dietary behaviors  and PA , the strThe participants were 367 students  from 14 secondary schools across Greece that voluntarily participated in the DIEX program. In an attempt to recruit a representative sample, we promoted the DIEX program through advertisements on social media and emails. Participants were recruited using the snowball sampling method (SSM). Fourteen teachers enrolled voluntarily in the program by fulfilling a form of participation, indicating their willingness to participate, and used the program’s materials in class according to the researcher’s guidance. Teachers informed students about the program. The inclusion criteria were being a high school student, 13–17 years old, willing to participate in the study, having parents’ consent, and being able to read and complete the questionnaires on their own. The exclusion criteria were a lack of participation in the program and an incomplete questionnaire.The following scales were used for the assessment of the DIEX health education program:Attitudes toward healthy eating. Five items were used to assess attitudes toward healthy eating . The answers were provided on a 7-point bipolar Likert scale with opposing words .Intention toward healthy eating. This was assessed with two questions . Answers were offered on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).Subjective norm. Two items incorporated the assessment of the subjective norm, e.g., “Important people to me believe that I will take care of my diet”. Participants’ responses were provided on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).Perceived behavioral control. Two items assessed students’ ability and capacity to control themselves regarding taking care of their nutrition, e.g., “It depends on me If I take care of my diet”. Answers were provided on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).Attitudes toward the application of the program. Students answered one phrase “For me, the program is …” and provided their responses on a 7-point Likert scale with opposing words .Satisfaction with the program. This was assessed by the responses to six items  upon the completion of the intervention and the answers were provided on a 7-point Likert scale from 1  to 7 .Knowledge about healthy eating. A questionnaire was created to assess general knowledge of nutrition and diet based on previous studies by Hassandra et al. [Junk foods are highly processed and high in calories” or “Poor diet and lack of exercise are linked to cardiovascular disease”) and was delivered before and after the implementation of the educational program. Students provided their responses on a 3-point Likert scale , and the final score ranged from 0 to 60.a et al.  and Koloa et al. . It consExercise behavior. Participation in regular exercise was assessed using a single item . The answers were provided on a 7-point Likert scale from 0 (never) to 6 (every day) [ery day) . This itery day) .All measures were completed by the students before (pre-) and/or after (post-) the implementation of the DIEX health education program. Most of the instruments used in the present study were based on the TPB ,84. Theshttp://research.pe.uth.gr/nutrition/ (accessed on 28 March 2019). The distribution of the health education material through the program’s official website enabled a large sample of participants from all over Greece. Initially, teachers, who were interested in implementing the program completed a form indicating their interest in taking part in the program. In total, 14 teachers and their secondary schools from different parts of Greece responded to this call. Students and their parents also provided informed consent before participating in the program. Teachers received usernames for each student to log in and answer the pre-intervention questionnaire. The prerequisite for gaining access to the material of each program was completing the pre-intervention questionnaires. After they gained access to the educational material of the program, teachers started to implement it. The program consisted of 10 sessions of one hour each. All material was downloadable, containing application instructions, a relevant bibliography, data from research on healthy diets and PA, PowerPoint presentations, tasks, ideas for experiential activities, games, appropriate teaching strategies and techniques and guidance for practicing them, topics for project work, relevant websites, and more. Upon the completion of the program, students reused their usernames and reevaluated the programs by responding to the post-intervention questionnaires. A certificate of attendance was provided to the teachers who implemented all of the sessions and motivated their students to complete the post-intervention measurement, along with the results of the evaluation. During the implementation of the sessions, teachers were fully supported by the research team through e-mails and telephone communication.The present study examined the implementation of a school-based health education program promoting healthy diet and regular exercise in Greek secondary school students. The education program is based on the behavioral change theory, TPB, life skills education, and the use of digital elements aiming to affect the process of educating and enhancing adolescents’ lifestyles (exercise and dietary choices). The program’s sessions included behavior-modification techniques, goal setting, stress management, problem-solving, and cognitive restructuring. Teachers had online access to the educational material of the program and implemented it through class sessions. Each student completed a pre-intervention and post-intervention online questionnaire on the website of the DIEX program. Participants were recruited by social media advertisements related to the health education program. The website of the program is t-tests with Cohen’s d effect sizes were used in order to examine possible differences in the dependent variables  pre- and post-intervention programs. All statistical analyses were conducted with IBM SPSS Statistics for Windows, version 26.0 . The p-value was set at 0.05.In each intervention, descriptive statistics (means and standard deviations) and the reliability index (Cronbach’s α) were calculated for both measurements. Then, separate paired-samples p < 0.05, d = 0.10), knowledge , and behavior toward a healthy diet  between the pre-and post-intervention measures. Students reported higher scores for their attitudes toward the program’s application, knowledge about healthy eating, and behavior toward healthy eating after the application of the DIEX health education program compared with their pre-intervention measures (p = 0.134), intention toward healthy eating , subjective norm , PBC , and exercise behavior .The results of the descriptive statistics, reliability index, and significant differences between pre and post-intervention measurements on the DIEX health education program are presented in measures , Table 2The purpose of the present study was to examine the effectiveness of a school-based educational program named DIEX in promoting healthy diet and exercise to secondary school students. In general, the application of the program was satisfactory. The results indicated that the strongest effect of the program was the students’ improved knowledge (d = 0.34) about healthy eating followed by their satisfaction with the program implementation (d = 0.10). It seems that knowledge remains an easy goal to achieve by implementing such programs. Health education programs have a great impact on improving students’ knowledge, which is in accordance with previous findings . The eduOn the contrary, no significant differences were found in attitudes toward healthy eating. One potential explanation of this finding may be that attitudes toward the above behavior were already positive at the pretest. Furthermore, this could reveal the difficulties in forming personal attitudes and beliefs through a short-term intervention. Similar conclusions were reached by previous research . Upon fuFurthermore, their behavior toward healthy eating resulted in significantly higher post-test scores (d = 0.17). By comparing the results from Harrington et al.  and ArriA limitation of the present study was that students’ behaviors were assessed by self-reported questionnaires. Thus, their answers might be affected by recall bias. In future studies, the assessment could be based on teachers’ or parents’ proxy self-reporting instruments, if possible, as parental involvement is suggested for more effective healthy diet educational interventions . It is aConsidering the results of this study, the most prominent evidence from the application of this educational school program is the knowledge factor. Furthermore, it was successful in changing attitudes toward the program and behavior toward a healthy diet, but not for subjective norms, perceived behavioral control, and intentions. In addition, students reported high scores in satisfaction with the program’s application. These findings have great implications for healthy diet promotion interventions among young people, especially in Greek schools. A theory-driven and skill-improvement educational intervention was effective among adolescents.


Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is characterized by balance impairment and mobility limitations, which both increase the risk of falling. The objective of this study was to explore the effects of a rehabilitation program aimed at increasing trunk and lower limb motor control on balance and walking abilities, and accomplishment of activities of daily living. In this exploratory study, a group-supervised rehabilitation program was performed three times a week for 8 weeks (two sessions at a rehabilitation gym and one pool session). Outcome measures included the Ottawa Sitting Scale, Berg Balance Scale, modified Activities-specific Balance Confidence Scale, 30-Second Chair Stand Test, 10-Meter Walk Test, Barthel Index, and Scale for the Assessment and Rating of Ataxia. Significant improvements in balance, trunk control, maximal and self-selected walking speed difference, ataxia severity and accomplishment of specific activities of daily living were noted for the whole group at the end of the program. At the individual level, all participants improved beyond the standard error of measurement in at least two outcome measures. Also, most participants reported many perceived improvements related to balance, posture and functional mobility. This study provides encouraging results on the effects of a rehabilitation program for ambulatory people with ARSACS. Group intervention could have a positive impact on their daily lives and improve the health care service offered to this population. Future studies with larger sample sizes including control groups and other forms of ataxia are necessary to validate our results to generalize them. Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is a progressive ataxic disorder  caused bTo date, there is no cure and only one documented exercise program for ARSACS. The latter was an exploratory study with the objective to improve physical condition using an individualized multimodal program including sports and upper and lower strength training. No effect was observed for physical condition but significant improvement was observed for balance and mobility . In otheThe objective of this study was to explore the effects of a rehabilitation program aiming to increase trunk and lower limb motor control and at improving walking abilities, balance and accomplishment of daily living activities (ADLs) in people with ARSACS.An exploratory study.Groupe de recherche interdisciplinaire sur les maladies neuromusculaires, Québec, Canada  approved the study and written informed consent was obtained. The protocol was registered at clinicaltrials.gov (NCT05479656).Ten participants were recruited in April 2019 among a subset of 52 people with ARSACS who have participated in a previous longitudinal study led by the e 1–2013 ; phase 3Participants were divided into two groups of five for safety considerations. Two well-trained and experienced physiotherapists (PT) delivered the group rehabilitation program. It involved three training sessions per week  over 8 weeks, for a total of 24 training sessions. The rehabilitation program focused on the following three domains: 1) postural control, 2) balance, trunk-limbs and multi-joints control and coordination and 3) functional mobility . Each domain contained a standardized list of exercises with one or more component(s). For each exercise component, different difficulty levels were suggested and standardized. The initial level of difficulty for each exercise was determined by the PT based on individual results of the pre-intervention assessment (T0) related to each domain. To ensure individualized progression throughout the rehabilitation program, the PT ensured high balance challenge for each exercise component based on the participant’s performance, fatigue level and safety . A modality interventions log, including participant adherence, each exercise component with the level of difficulty performed, the number of sets and repetitions (dosage), and the participant’s perceived difficulty, was compiled by the PT at each session for each participant. In the first weeks, the PT taught participants the importance of slowing movement and using good methods of transfers from sitting to standing , among other things.Hôpital de Jonquière of the Centre intégré universitaire de santé et de services sociaux du Saguenay–Lac-St-Jean . Outcome measures were administered following standard operating procedures (SOP) to ensure the reliability of the results between the two raters and the three assessments. The physiotherapists did not assess the same patient at each measurement time point to decrease recall bias. At T0, a sociodemographic questionnaire was administered to document age, sex, height and weight. The type of walking aid used for indoor mobility was also documented at the beginning (T0) and the end (T2) of the project. The genotype of participants was retrieved from their medical records. Using an open-ended question, participants were asked to indicate the main changes they perceived at the end of the program. The adherence rate is based on the number of sessions executed divided by the total number of sessions planned throughout the study.Participants were assessed by the two physiotherapists before the rehabilitation program (T0), after 4 weeks (T1) and after 8 weeks (T2) during a 3-hour session at the Sitting balance and trunk control were assessed with the Ottawa Sitting Scale (OSS) . It inclThe Berg Balance Scale (BBS) was used to assess balance and risk of falling . It inclShort-distance walking speed was assessed using the 10-Meter Walk Test (10mWT) at the self-selected and maximal speed. One trial was performed and the speed in meter/second was used for analyses. The 10mWT has shown to be valid in the ARSACS population and has excellent interrater reliability (ICC = 0.992) . The abiThe Barthel Index (BI)  was admiThe severity of cerebellar ataxia was assessed using the Scale for the Assessment and Rating of Ataxia (SARA), which includes eight items: evaluation of gait, stance, sitting, speech, and four tests assessing dynamic limb function for a total score ranging from 0 (no ataxia) to 40 (most severe ataxia). The inter-rater reliability (ICC = 0.98), test-retest reliability (ICC = 0.90) and internal consistency  are all excellent in ataxia populations including ARSACS , 17.Given the design (exploratory study), the sample size was based on recommendations for pilot studies .T0*√(1-ICC) [To be included in the statistical analysis, each participant needed to have an adherence rate of at least 80% (at least 17 sessions out of 24) , 20. Des√(1-ICC) . The fol√(1-ICC) , BBS (3.√(1-ICC) , 10mWT (√(1-ICC) , SARA (1√(1-ICC) , 30s-CST√(1-ICC)  and m-AB√(1-ICC) . As used√(1-ICC) –28 p-val√(1-ICC) . Data weAll participants completed the program and had a mean adherence rate of 95% (83–100%). The mean age was 36.6 years old and 60% were women. For the whole group, significant improvements in balance (BBS) (p = 0.067) and sitting balance (OSS) (p = 0.002) were observed between T0 and T2 and in addition for OSS between T1-T2. The change between T0 and T2 is observed in the delta of the walking speed (p = 0.061). The SARA demonstrated a change for two measurement times (T0-T2 and T1-T2) (p = 0.085). A significant change was present for the BI as well for two measurement times (T0-T1 and T0-T2) (p = 0.069). All participants showed improvement beyond the SEM in at least two outcome measures see . The selThis exploratory study suggests the positive effects of an 8-week rehabilitation program aiming to increase trunk and lower limb motor control on walking abilities, balance and accomplishment of daily living activities in ambulatory people with ARSACS.Significant improvements in balance, trunk control, ataxia severity and accomplishment of specific activities of daily living were noted at end of the program. In addition to the individual improvements outside of SEM observed for many outcome measures, most participants perceived positive effects and reported mainly changes in balance, trunk control, various activities related to mobility and activities of daily living. A recent study showed that an 8-week training program including physical activities, strength power and aerobic training for people with ARSACS (mean age: 28.1 years) has significant benefits on functional mobility activities such as walking (endurance and speed), transfer from sitting to stand, upper and lower limb muscle strength . The resParticipants’ results at T0 illustrated the high level of impairments, activity limitations and ataxia severity, which most likely had an impact on the group effects of the rehabilitation program. Only three participants walked without a walking aid inside their home at T0. Two participants used a wheelchair to get around their home, despite being able to walk, due to fear of falling and the need for supervision. The mean age of the participants was 36.6 years, which is close to the age at which walking abilities are lost in this population (38.9 years) . A revieThe improvements obtained on the SARA scale for ataxia severity were between T0-T2 and T1-T2, which means that they occurred between five and eight weeks after the start of the rehabilitation program. These results are consistent with the review, which suggests that improvements in ataxia minimally occur after four weeks of intervention .All participants were at high risk of falling at T0 with a BBS score lower than 45  and resuThe most significant improvement following the training program is related to trunk control and seated balance with the OSS. A significant improvement was found between T0-T2 and T1-T2, suggesting that improvements in sitting and standing balance require rehabilitation longer than 4 weeks. The results observed in our study are not in agreement with the review on hereditary ataxia which noted that balance improvement could occur after only three weeks of rehabilitation . At T0, Decreased trunk control makes it hard to execute sit-to-stand transfers. The performance in mobility activities at each time shows that participants had a lot of difficulties performing the sit-to-stand transfer without using their upper limbs. In fact, their results are similar to those obtained by healthy people over 95 years old . The majAs for the 30s-CST performance, we hypothesize that the lack of significant improvement in the self-selected walking speed was due to the caution exercised by participants, who are very aware of the risk of falling as well as of the importance to have a good walking pattern. Regarding the maximal walking speed, although the change between T0 and T2 is not significant, there is an increase in the maximal average walking speed of the whole group. Additionally, 50% of participants improved their maximal walking speed beyond the SEM. Since the average of the self-selected walking speed did not change, the difference between the maximal and the self-selected walking speed significantly increased between T0 and T2 for the whole group. In other degenerative diseases, such as myotonic dystrophy type 1, this difference between the maximum and self-selected walking speed is a factor that significantly influences the frequency of falls . More prSignificant improvement in the performance of activities of daily living assessed using the BI was noted between T0-T1 and T0-T2. We hypothesize that the improvements that occurred between T0 and T1 were mainly the result of learning good execution techniques rather than real improvements in functions. As the BI assesses performance in only six basic activities of daily living, it would be interesting for a future study to assess the impact on the performance of a more complete portrait of activities of daily living.At the end of the training program, deterioration outside the SEM was observed for some participants, mainly in the functional tasks of walking  and sit-to-stand transfer (n = 1). People with ARSACS tend to execute their movements very quickly, which impairs the execution quality. In the first weeks of the program, the physiotherapist taught the importance of slowing down the movement speed to increase the execution quality, such as walking and sit-to-stand transfer, to promote good motor learning. It is therefore not surprising that some participants obtained lower scores on tasks that primarily assessed the execution speed, such as the walking speed and the sit-to-stand transfer task. Unfortunately, none of the outcome measures selected were able to validate an improvement in the quality of movement execution in the task. In a future study, it would be interesting to evaluate changes in gait using a layer pressure-sensitive walkway such as the GAITRite.The most important limitation of this study is the small sample size. To properly document the impact of our rehabilitation program, it would be essential to conduct a study with a larger sample size, including a control group. However, the results of this pilot study help to establish the choice of a primary outcome, as well as the sample size required in future larger studies. In addition, the results of this study and the adherence of the participants support the feasibility and acceptability of rehabilitation programs with this population. As the majority of improvements occurred after the fourth week of intervention, it would be interesting to see the impact of a 12-week program. We also only focused on ambulatory patients and further studies are needed to examine whether people with ARSACS with more severe impairments would also benefit from rehabilitation programs. We also did not evaluate the persistence of gains from this intervention by a follow-up assessment.The study’s findings provide encouraging results on the effects of a rehabilitation program for ambulatory people with ARSACS. The main findings of this study are the significant improvements in trunk control, balance, and the change in walking aids needed for ambulation. Group rehabilitation programs could have a positive impact on the health care services offered to individuals with ARSACS.S1 Checklist(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.