Therapeutic patient education (TPE) programs are psycho-educational treatments suggested for all chronic diseases. For several years, these programs have been developing for people living with bipolar disorder. However, to date, only few qualitative studies have explored the experience of caregivers. We wanted to explore the experience of caregivers working in psychiatry as facilitators of a therapeutic education program for people living with bipolar disorder.A single-center qualitative study was carried out. We conducted an inductive exploration, examining the content of the discourse produced in a focus group of eight caregivers in therapeutic education. The corpus was transcribed manually and a thematic analysis was conducted by two authors in a blinded fashion before combining.Four dimensions and twenty themes were identified: i) facilitators' pleasant experiences of the TPE sessions with a secure climate and a sense of belonging to a group, ii) being a TPE facilitator with a new horizontal and collaborative posture valuing the experiential knowledge, iii) the role of the TPE sessions with knowledge provision, empowerment and destigmatization, and iv) perceived changes in patients with an appeasement, the awareness of a shared experience, openness to others, a phenomenon of identification to peers and a new commitment.The observations noted overlap with the elements of the personal recovery well known CHIME framework . Therapeutic education is a developing form of psychosocial rehabilitation care: through the mobilization of a new attitude of caring, the facilitation of TPE programs could be a lever for changing the posture of caregivers in favor of supporting the personal recovery of people with bipolar disorder. These results would need to be confirmed by further studies. The caregivers interviewed who lead therapeutic education groups described a change in their caregiving posture, which was more horizontal and collaborative. Therapeutic education thus fostered empowerment and destigmatization, promoting patients appeasement and openness. The observations overlap with personal recovery levers. Facilitation of therapeutic education could help caregivers move towards a more recovery-oriented care posture.The World Health Organization considers bipolar disorder (BD) to be one of the ten most disabling chronic pathologies , and it Quantitative studies have indicated that psychoeducation has a beneficial impact on BD by reducing the rate of relapse, increasing the time between episodes of decompensation, decreasing the number and length of hospitalizations –12, and "aims to help patients acquire or maintain the skills they need to manage their lives with a chronic disease" ["educational diagnosis" evaluation. This degree of personalization in TPE differs from that in psychoeducation programs. The regulatory framework recommends the co-construction and co-facilitation of TPE programs with people concerned about the specific disease.In France, the “Hospital, Patients, Health and Territories” Act of 2009 included therapeutic patient education (TPE) in the Public Health Code  and therdisease"  and mustOnly a few studies have explored the experience of caregivers as facilitators in TPE. In the field of psychiatry, there are no articles to our knowledge that have explored the experiences of the facilitators of these programs. A recent study was interested in the representations of caregivers concerning the practice of TPE, and highlighted the great reluctance to use this care tool, which would conflict with a traditional model more paternalistic than collaborative . The aimThe studied TPE program was dedicated to people living with BD and was developed by the research team in 2016; the team developed the program according to the national recommendations in force . The program has since been facilitated by the professionals of the Psychosocial Rehabilitation Center (PSR): nurses, peer helpers, and psychiatric physicians. It had been running on a regular basis for 5 years when the study was conducted.The program was co-facilitated by two to three health professionals and peer helpers trained in TPE. Each TPE group included 10 patients. It was conducted following four stages: i) an individual assessment interview, leading to an “educational diagnosis”; ii) nine weekly group sessions lasting two hours ; iii) a final individual interview to evaluate the skills developed by the participants and their satisfaction with the program; and iv) a group consolidation session three months after the ninth session.Each session began with an "ice-breaker", followed by a debriefing on the previous session using participatory animation tools. A theme was addressed during the first hour; after a short break, a second theme was addressed, and the session ended with a period for synthesis and a mood self-assessment. An individual time could be proposed to participants who felt the need. The team created a booklet that followed the themes of the program that was given to the participants so that they could write down information throughout the sessions.Table Our study was based on an inductive and monocentric qualitative exploratory methodology. For this purpose, we conducted one focus group (FG) of health professionals  and peer helpers facilitating a TPE program for bipolar disorders in a psychosocial rehabilitation center located in a Psychiatry and Mental Health Department. This FG was conducted in January 2021. The framework of the FG was developed by a public health intern and a psychiatric physician who facilitated the FG and were not involved in the care. The themes that were addressed following a semidirective guide were i) the facilitators' motivation to facilitate a TPE program; ii) representations of the role of the TPE facilitators; iii) caregivers' experiences; iv) changes observed in the participants by the facilitators; and v) dimensions associated with the observed changes.Our sample targeted the study population of health professionals and expert patients running the "Bipolar Disorders" TPE program. The inclusion criteria for this study were i) to have facilitated at least one session of the bipolar disorders TPE program studied in the past year; ii) to have received 40 h of academic training in the facilitation of TPE programs; and iii) to be available for the duration of the FG.After receiving the agreement of the head of the PSR center, we presented our study project to the health care team in charge of running the "Bipolar Disorders" TPE program. At the time of the study, two sessions of the program were taking place in parallel, with each program having its own team of facilitators. We offered all the TPE program facilitators the opportunity to participate in the FG, and all agreed. A single FG was convened with all facilitators from the ongoing programs. The FG, which lasted one and a half hours, was facilitated by two health professionals, a public health intern trained in FG facilitation and a psychiatric physician; the latter were not involved in facilitating the TPE program. Two observers were also present: a public health intern not involved in the program, and an advanced practice nurse who was familiar with the program from having previously co-facilitated it. The observers wrote down the participants' reactions and responses. With the participants' consent, an audio recording was made and stored on a password-protected audio file. Transcription was performed manually without software support. The recordings were deleted once they were transcribed. The sociodemographic data of the sample were also collected during the FG.The FG corpus was transcribed manually by the first author. To process the data, we relied on the method of thematic analysis  which coThis method made it possible to understand and interpret the data while remaining faithful to what the participants said. The reading of the FG transcript and its analysis were carried out by an advanced practice nurse and a psychiatric physician in a blinded fashion. Neither of these two individuals had been involved in the facilitation of this program under review, but they had previous experience in facilitating it. A consultation between these two authors took place at the end of the coding process to compare the themes identified by each and to create links between the categories. All themes were identified by both researchers, and agreement between them on the organization of the categories was reached.Each participant was given an oral presentation of the study design, and signed informed consent was obtained. The protocol was validated by the ethics committee  on 23 July 2020. To avoid the identification of any participant, the data collected in this study were processed in an entirely anonymous manner. Anonymity was ensured by a numerical code accessible only by the researchers.In this study, our sample consisted of eight facilitators from the TPE program studied.N = 6).The average age of the participants was 40.5 years; the minimum age was 29 years, and the maximum age was 66 years. Half of the participants were between 33 and 49 years of age, 3 were between 18 and 33 years of age, and 1 was over 50 years of age. The standard deviation of ages was 11.32, and the median age was 37.5 years. The majority of the participants were women , two were state-registered nurses (Ns), two were volunteer peer helpers (VPHs) , one was a psychiatric intern (PI), and one was a hospital-employed peer health mediator (EPH). All had experience working in a psychosocial rehabilitation department.N = 1) to more than 30 sessions facilitated (N = 1). More than half of the facilitators had facilitated at least eleven TPE sessions (N = 6). Two-thirds of the co-facilitators (N = 6) had participated in the facilitation of at least four different sessions of the studied TPE program; two of these facilitators had co-facilitated the program four times, two six times, one seven times and one eight times. The other two had co-facilitated the TPE program one and twice.Experience in facilitating TPE sessions ranged from less than 5 sessions facilitated  facilitators' experiences of the TPE sessions, ii) being a TPE facilitator, iii) the role of the TPE sessions, and iv) perceived changes in patients.For each dimension, themes and subthemes emerged. A summary of the results is presented in Table "It is my desire to facilitate a climate of authenticity and listening in the group" .This dimension was associated with four themes: a climate of safety, belonging to a group, sharing experiences and the pleasure of facilitation. The theme of safety was associated with three subthemes: feeling confident, allowing oneself to be authentic, and the notion of caring. One of the main elements in providing a safe climate was the desire to create a space of trust:"It reminds me of what a patient said at one point, as if it was very surprising. He said, 'It's incredible here they listen to us,' as if in a psychiatric hospital, you can't be listened to. He couldn't believe it. It was quite spectacular to hear this come from his own mouth" .One of the facilitators noted what a patient said about being listened to:"To have an identity that is my own, that can be different from others" . One facilitator mentioned the desire to "create this space where (…) he feeds both the feeling of freedom and the need for relationship" .The notion of authenticity was taken up and explained in these terms:"A good atmosphere and to make sure that there is a link between people, that there is exchange, and that people can have moments of listening with their peers that they don't necessarily have outside the sessions, of support in fact from others, to develop a feeling of belonging, to live better with it afterward" .This intention for relationships and connection was taken up again by another participant:"which is quite present in TPE and which is good for the group and good for ourselves" .Creating this space of security was reinforced by the notion of benevolence."There is something benevolent in the group in general, which makes me feel good" .This benevolence created a climate of security for the participants and the facilitators:N = 4) mentioned the feeling of belonging to a group shared with the users:"It is first of all that we are in a group, that the patients I meet in another context than the crisis" ; "to be part of this adventure, which is something I believe in, which is everything that is mutual aid groups" .Half of the facilitators interviewed (N = 7) verbalized the feeling of belonging with colleagues and associated it with a notion of pleasure:"One of my motivations for participating is already to find people from the service; being able to lead the groups is always a pleasure for me" .The majority of the facilitators .For one of the facilitators, the fact that the program was run in a group setting encouraged the sharing of experiences:"There is this sharing between peers, which is very important. It is very interesting because it leaves room for knowledge through experience" .This point was supported by other participants:"these TPE groups allow for an exchange between participants and an awareness of certain symptoms or disorders"  and adding that "there is also the fact that exchanging between peers allows some people to get out of the denial in which they are to varying degrees" .Others mentioned the effects of this sharing, stating that"It feels good in general. After a TPE session, I feel good" .All the participants in the FG expressed their pleasure in leading these TPE sessions:This dimension highlighted the following themes: the place of peer helpers, having an expert role, taking an educational posture, taking a listening posture, having a horizontal relationship and being the guarantor of the framework. The place of peer helpers was associated with being."a reference point. That's what I felt when I had a peer helper as a facilitator, that he was a pillar of recovery" ."a witnessing role (…) of a patient with bipolar disorder in recovery (…) that exists, that you can see" meant being a bearer of hope toward a recovery process.For this facilitator, embodying."When I am in the TPEs, it is to validate certain questions (asked by the participants in the TPE program) with my experience, my experimentation. It gives legitimacy to a whole bunch of sometimes quite delirious things that we may have experienced but that exist" .The lived experience of the illness was also associated with an expert role. One of the peer-helper facilitators described his role as follows:"delivering medical information. I feel like I'm taking on a bit of a posture (…); like the doctor who is a guest on a TV show, ‘So doctor, tell us’ (laughter). At the same time, I feel that sometimes, there are questions that need to be answered and that we have some answers, and I want to pass on knowledge and information, and it can be nice to have this medical hat on" .This function of expert of experience was contrasted with the role of medical expertise. One of the participating doctors showed his discomfort with."When I am a facilitator, I feel that I am leaving my medical and caregiving posture to be more an educator. I have that feeling. I am trying to create a climate conducive to learning by transmitting information" .One of the psychiatrists involved in TPE mentioned that the expert posture could give way to an educational posture:"During the TPE groups, I spend a lot of time in a listening position. Everyone around the table, I feel like I am listening to them" .Another facilitator emphasized being in a listening posture:"What we aim for in TPE is horizontality" ;"It's about being on the same level in fact" .Most of the facilitators had perceived a tendency to be in a horizontal posture of collaborative partnership in interaction with their co-facilitators and with patients:"the notion of a framework, the organization of the session, paying attention to time, sharing the word (…) The framework and the flexibility in the framework" .Finally, one of the psychiatrists mentioned the importance of being a guarantor by ensuring."I am almost in the position of the one who is also learning, who is learning, who is growing at the same time as the group" . Another added "… it taught me a lot of things in fact. I think it improves my daily practice and the support I can offer my patients" .The following three themes were used to clarify this dimension: knowledge provision, empowerment, self-normativity and destigmatization. The TPE facilitators mentioned the contribution of knowledge both for themselves and for the patients through exchanges:"being able to accompany, encourage, transmit knowledge"  and "to bring clarity to people concerned by psychological disorders, on the disorders themselves" .Others underscored the pleasure of."To create this space where we tell them that there is another possible way than the one of dependence on care, to find their own resources, to better understand themselves" .Associated with this theme was the promotion of empowerment:"We can explain things, but it won't have the same impact as someone who has experienced the same disorders or who has gone through certain things or who has taken certain treatments, who has realized that with certain treatments, it was effective or not" .This notion of empowerment could also be promoted through experiential sharing:"I like this image of the toolbox, that they can leave at the end with a toolbox of the TPE session, that they can choose the tools they prefer to work with" .The notion of empowerment could also be promoted through the provision of tools to develop autonomy:"to really find their own standards within themselves by trying to get away from the injunctions of the outside world, of society, to really build their recovery on who they are, on their needs" .For some participants, the role of TPE sessions was to promote self-normativity by helping them."the illness, in general, which is quite stigmatized. For personal reasons, I really want to be able to put words to it, to have things said, to be able to put words to it" .For others, the role of TPE sessions was to promote destigmatization by talking about."It's about appeasement. The fact of being able to verbalize in the group. The fact that it can be heard by others, that it is not judged, accepted, validated because we have gone through the same things" .This dimension included seven themes: relief, awareness of a shared experience, openness, identification, quality of life, a first stage of re-engagement, and grief. The notion of appeasement was the first change identified in patients; this change emerged through the destigmatization of words and experiences:"the awareness that there is a common experience of the disorder" .Another change observed was awareness, which is an internal process of transformation that changes representations of the self and the world. One caregiver observed among patients:"of one's real limitations, that's something that can seem negative in TPE; patients are all at different stages of their disease, not necessarily all the same" .This awareness may also have had a negative effect. As one participant described, the awareness."the different phases of grief; in any process there is grief. What's funny is that when you're in this TPE, they're all addressed together. There are some who are in acceptance, recovery (…). A patient was quite in denial at the beginning and all that. It progresses; it progresses, and finally, all the phases of mourning are approached. Depending on where each person is at, they have the possibility of moving on to the next phase; there is a process that takes place" .This TPE facilitator verbalized that she observed a grieving process among the patients, understood here as a cognitive and affective process that accompanies the loss of someone or something:"People identify with the person who has a pathology and who has recovered. They say to themselves "why not me?" False shame disappears; for example, when you start talking about your delusions, "he too", this necessarily breaks down barriers. The peer identifies with the participants who are also there. Double movement. It is because there is a double identification that complex exchanges take place and everyone identifies" .However, the phenomenon of identification with peers, and in particular with the peer helper, could make it possible to overcome this negative effect:"As the sessions progress, participants will allow themselves to say things that they have experienced or gone through because they know that it will be heard and validated, because it will be experienced or in any case welcomed without being stigmatized" ; "at the end of the TPE, there is often a group created on WhatsApp® to keep in touch; they have become aware that it is a key to recovery to be supported by peers" .The FG participants also perceived a change in openness on the part of the patients. This openness was first described toward their peers:"(…) Taboos that disintegrate. There are people who say 'if he or she talks about it, I can talk about it too'. Under certain conditions of prudence, it can be an opportunity to talk about it with those close to them. It frees up speech" .For one participant, one of the effects of openness was the destigmatization:"In the session with the loved ones, accepting that what you do as work is shared with the most intimate people and that it succeeds like the ones we have been able to live that pffff, (sic.)… it mobilizes a lot of things" .This transition toward openness toward loved ones was also highlighted by another participant:"a kind of destigmatization of psychiatrists (…) they are also there to help people" .Another participant identified an openness toward psychiatrists via.“individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”. :"With  as."Participating in the TPE group is a first step to get back into action, to take care of oneself again" .The notion of commitment was mentioned:"A participant was able to build her own information booklet based on her skills and transmit them to the whole group, and that was very important for her and useful for the other participants" .This empowerment was underlined through this example:This action reinforced the participant’s feeling of personal efficiency in managing her disease in her daily life.Our study examined the experiences of caregiver facilitators of TPE groups in the specific area of bipolar disorder in psychiatry. The facilitators emphasized that their particular posture in the TPE program involved horizontality, a feeling of belonging to a common group with the participating patients, the sharing of experiences and even self-disclosure. They also said that they observed the effects of these programs on the participants; in addition to mutual knowledge, they insisted on the notions of empowerment and destigmatization. Mutual identification with peer helpers seemed to favor identity reconstruction, or at least a form of appeasement.“a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles… a way of living a satisfying, hopeful and contributing life even with the limitations caused by illness” .Personal recovery from psychiatric disorders is a journey toward a satisfying and hopeful life despite the possible persistence of symptoms. It is described as.The CHIME framework was developed based on a literature review conducted by Leamy and her colleagues , who ide"renouncing the omnipotence linked to one's knowledge in front of the patient, who was previously considered incompetent to manage his or her illness".The data from our study highlighted the importance of the posture of the TPE facilitator, which seems to involve continuous oscillation between being an expert  and engaging in collaborative partnership aiming at horizontality. This notion of horizontality is taken up in numerous works. According to Lang , facilit"must be based on exchanges, trust and the absence of hierarchy" to move toward a partnership .To move toward a partnership, it is necessary to build a framework of security and benevolence, as confirmed by Le Rhun . Viard sThe recognition of the patient as a full person was discussed during our FG; according to Petré, this recognition fosters a sense of equality between the patient and the health professional as well as a more horizontal and less patriarchal relationship , 30. FinTo confirm this hypothesis, it would be important to carry out quantitative studies specifically focused on the effectiveness of TPE programs for people with bipolar disorder on their personal recovery.Our exploratory, single-center qualitative study was conducted using an FG. This method has limitations regarding the ability of each participant to express himself or herself in a group, to express his or her own opinions and to ignore the hierarchical functional relationships between the participants, which may have led to normative responses. In particular, we noted that during this focus group, we did not hear any expression of a negative experience of this group facilitation. The choice of sampling represents another limitation: in our study, a convenience sample was used. Additionally, the FG participants belonged to the same care unit and shared the same philosophy of care. Therefore, the results may not be representative of all TPE facilitators. It would be desirable to carry out further work exploring the experiences of facilitators in a larger number of different centers; this was not easily achievable at the beginning of our study, as very few centers had implemented similar programs. To strengthen these results, it would be interesting to use qualitative methods to reach data saturation and to combine the experience of facilitators and patients. The modalities of FG facilitation could have potentially guided the participants' responses. Our study does not specify the perceived effects on participants by characteristics such as severity or duration of the disorder, or by demographic characteristics. Studies exploring quantitative or qualitative variables on these subpopulations could contribute to our knowledge.The results of our study allow us to formulate the hypothesis that the facilitation of TPE programs could allow for a change in caregiver posture and peer-to-peer exchanges that would promote the personal recovery of people living with bipolar disorder. To confirm this hypothesis, it would also be important to carry out quantitative studies specifically focused on the effectiveness of TPE programs for the personal recovery of people with bipolar disorder. Such studies specific to TPE programs in bipolar disorder have not been published to date. There are several prerequisites for such studies, especially the choice of a relevant outcome and a suitable design. Indeed, it would be necessary to be able to precisely measure personal recovery in individuals living with bipolar disorder, as well as its determinants, to better understand how participation in the TPE program could sustain recovery. The implementation of a randomized controlled trial poses other problems in regard to psychotherapeutic actions, particularly concerning the question of the composition of the control group.The objective of our study was to explore the TPE experience from the perspective of the caregiver-facilitators. We were able to show that the posture sought by the facilitators corresponded to the national recommendations and allowed for the establishment of a particular horizontalized relationship of collaborative partnership between the facilitators and the program participants. With regards to the changes observed in the program participants by the facilitators, it appeared that they corresponded to almost all the dimensions of the CHIME recovery model, since the study found the dimensions of Connectedness, Hope, Identity and Empowerment. Further qualitative and quantitative studies would be needed to strengthen these findings.


Despite the potential for businesses, our understanding of lovemark brands and their consequences is limited. Numerous psychological and brand-related consequences are linked to lovemarks, but the role of influential underlining mechanisms is not fully understood. Inspired by the norms of reciprocity theory, the current study investigates the underlining role of customer advocacy in the relationship between perceived lovemarks and brand loyalty of customers in the automobile industry.By adopting the survey method, a sample of 478 was drawn from Pakistani automobile customers. Structural equation modelling was used for the analysis. We conceptualised lovemarks and brand loyalty as reflective higher-order constructs that we analysed through a two-stage disjoint analysis.Our results support the conceptualization of lovemarks and brand loyalty as higher-order constructs. The influence of lovemarks and customer advocacy on brand loyalty was statistically significant when we controlled for age, gender, and income. Our findings also reveal that customer advocacy, seen as a company’s positive interactions, mediates and play a key role in influencing the relationship between lovemarks and brand loyalty.This is among the first studies to examine the role of customer advocacy in the lovemarks-brand loyalty relationship. We examined these relationships in the automobile sector of Pakistan, which offers several theoretical and managerial implications for academia and practitioners. The implications are proposed and outlined in this study. Since the global car market has grown fiercely competitive, it has also affected Pakistan’s automobile industry. There are now more than a dozen new firms in the Pakistani automotive industry, which was formerly dominated by three Japanese automakers. Businesses have struggled to come up with innovative ways to serve their clients via informational exchanges that are rich in value, especially when we consider the significance of consumer empowerment in a highly connected society . CustomeIn today’s market, differentiating brands, products, and services on emotional value (such as relationships) is becoming highly important ,5. A priHowever, not all companies can build robust, long-lasting relations with their target audiences. Roberts  defined A recent but significant development of the organisation-customer relationship lies in the understanding of customer advocacy. A recent study  suggestsThere is a plethora of studies debating consumer loyalty, however, little is known about the antecedents and consequences of customer advocacy. To fill this gap, our research focuses on the critical examination of customer advocacy and its consequences. Customer advocacy in this sense can be seen as the act of organisations, working on behalf of their clients, advocating for them internally, and defending their best interests to enhance customer’s confidence and loyalty, and to secure positive repurchase intentions . CustomeBrand loyalty is widely debated among researchers, yet there is little agreement on its causes and determinants. Particularly, little empirical evidence is available to explain how perceived lovemark brands interact with customer advocacy to influence brand loyalty in emerging countries ,16. The Our study thus contributes to the knowledge about customer advocacy as a mediator of perceived lovemark brands and customer loyalty associations in the automobile sector of Pakistan. Drawing on the norms of reciprocity (NOR) that emphasise on the tit-for-tat behaviour and respond with benefits for benefits, the current study seeks an empirical validation of a mediation model where customer advocacy is conceptualised as a mediating variable (a reciprocating customer’s behaviour) between perceived lovemarks and brand loyalty (reciprocating action) in Pakistan’s automobile sector.In terms of growth, the automobile sector in Pakistan has expanded exponentially, which is evident from a growth rate of 171% for the period 2014–2018 and still growing . FurtherAccording to Roberts , the twoThe concept of lovemarks strongly resonates with branding theory and with the significance of customer-brand associations. As organisations and their products become lovemarks, they focus on fostering and deepening their emotional connections with customers . A produBrand love can be seen as a deep emotional connection that a customer feels for a specific trade name . Brand lProducts must gain the respect of customers in addition to their affection to become lovemark brands. Based on the assessment of a brand’s performance, customers’ favourable view of a brand is expressed via brand respect . FurtherCustomer advocacy aims to create and maintain valuable connections by gaining the confidence of customers via open dialogue and collaborative efforts with them . It has Developing and maintaining customer advocacy continues to be a crucial strategy for businesses to gain a competitive edge, particularly when it comes to establishing client trust . AccordiThere is relatively little agreement among academics about the causes and effects of brand loyalty as region-specific factors including culture, industry, and other factors also affect consumer behaviour . CustomeBrand loyalty is a good predictor of future buying intention and creates favourable customer opinions that spread good word-of-mouth about the company . Brand lOliver  presenteAccording to the NOR theory, individuals tend to reciprocate in kind for the favours they have received . It may While the NOR theory specifically argues about the interaction between people where reciprocity takes place, we investigated the NOR theory by examining the company/product interaction with customers to examine the process of reciprocity. We thus argue that a positive perception of a company and its product (lovemark brands) along with customer-oriented actions and supportive interactions with customers (customer advocacy) is seen as a benefit and holds value for the customers. In return, customers attempt to pay this benefit by participating in reciprocal behaviours such as brand loyalty.Perceived lovemarks are anticipated to be incredibly satisfying for consumers and can produce unquestionable brand loyalty ,9. The lBrand loyalty refers to the customer’s intent for remaining loyal to the brand, to recommend it to others, and to prefer the brand over competing brands . Since cBrand loyalty positively regresses on perceived lovemarks.H1: Customer advocacy positively predicts brand loyalty.H2: Lovemark brand improves the bond between customers and a brand, which consists of brand love and respect . The proPerceived lovemarks positively predict customer advocacy.H3: Satisfaction, trust, and commitment are said to be indicators of enhanced relationship quality . Brand lCustomer advocacy mediates the perceived lovemarks and brand loyalty association.H4: To summarise, we present The research ethics committee at the Institute of Business Studies and Leadership, Abdul Wali Khan University has approved the consent procedure of the current study. The data was gathered from adult respondents through online surveys as we have explained in the data collection section of our study. Participants were asked to read the consent form and provide written consent before participating in the study. Through the consent form, the participants were informed about the purpose of the study, and we confirmed that all responses will be used for academic purposes only. The current study also ensured the participants that their identities will be kept anonymous so that the data cannot be traced back to them in the published article.An online survey of Pakistani automobile owners was conducted to collect the data for our study. The survey was hosted on Google Forms and sent out through email. The data was collected between January 15 to February 22, 2022. Identifying minimum sample size for multivariate analysis via structural equation modelling, a recent study recommends the use of power analysis . We usedAll constructs were measured using the established scales from prior research studies. A recent study presented a third-order lovemark construct . GiovaniWe measured brand loyalty  with its three lower-order constructs  as conceptualised in a recent study . We adapWe measured customer advocacy with a 4-items scale adapted from . A five-To determine the psychometric characteristics of each concept, we followed the recommended procedure for model analysis using SmartPLS 4 ,46. We uWe started the analysis procedure by first examining the psychometric characteristics of the six first-order constructs using reflective indicators. The range of factor loading was between 0.701 to 0.914. The composite reliability was recorded between 0.894 to 0.936, which falls in the acceptable range i.e., between 0.70–0.95 . Each laUsing the heterotrait-monotrait (HTMT) ratio, method of analysis for establishing discriminant validity, we followed the procedure explained in prior studies . The HTMThe latent variable scores of brand respect, brand love, cognitive loyalty, conative loyalty, and affective loyalty were saved to the original data file to measure the reflective second order lovemarks variable.Consistent with the process used for measuring first-order reflective variables, we achieved acceptable results for the perceived lovemarks variable using PLS consistent approach . The facThe lovemarks and brand loyalty constructs also produced acceptable levels of CR and AVE values that are recommended for establishing reliability and convergent validity for latent variables . FurtherWe collected data from a single source through a survey, therefore common method variance (CMV) might be problematic . To loweThe structural model analysis  was cond2 demonstrates a variance explained for customer advocacy and brand loyalty were 53.4% and 80.2% respectively, thus displaying medium to large explanatory power. The influence of lovemarks and customer advocacy on brand loyalty also has a moderate to large effect size (f2). Finally, we checked for predictive power using PLS Predict available in SmartPLS. The results from PLS Predict depict a medium to the strong predictive power of our model.The diagnostic metrics of the model see  were deeThe hypotheses test results presented in Table 4 show a positive direct effect of perceived lovemarks on brand loyalty  thus lending support to H1. The results show that customer advocacy  had positive direct effects on brand loyalty that we hypothesised (H2) in this study. Also, H3 came out statistically significant where we hypothesised that customer advocacy is positively predicted by perceived lovemark brands . During hypothesis testing, we considered the influence of age, Income, and gender by controlling its effects. Being categorical variables, we used the category of “below 30 years” for age and the category of “less than 40,000” for income as reference categories to test the significance of age and income. As evident from The guidelines provided by Nitzl et al.  for testThe current study investigates the significance of customer advocacy in the relationship between perceived brand love and brand loyalty, where the findings of our study have significance for the marketing of automobiles in the Pakistani context. Customer actions represent our collective sense of being where advocacy behaviour becomes highly significant in protecting the welfare of the customers. Pakistanis place a significant emphasis on collectivism and cultural embeddedness that emphasise deriving life’s meaning from one’s social interactions with others, maintaining in-group cohesion and traditional order ,56. ThesOur key theoretical contribution lies in the exploration of perceived lovemarks and brand loyalty association, and the mediating role of customer advocacy through the lens of NOR theory. Our findings highlight the importance of being a lovemark brand and customer advocacy in constructing brand loyalty. We argue that when customers perceive companies and their products as lovemark brands, along with the organisational effort to interact and listen to customer feedback (customer advocacy), it holds value for customers in such company-initiated social interactions. Being beneficial and valuable to the customers, lovemarks coupled with customer-oriented organisational effort (customer advocacy) trigger the norms of reciprocity among customers. In other words, customers value the effort and benefits offered by the firm are reciprocated by becoming loyal to the brands  . It becaOur findings also suggest that in the automobile sector, where customer advocacy is present, perceived lovemarks become quite important. In competitive markets, developing lovemark brands will allow an automotive business to create unique competencies that are hard to duplicate, thus giving the company a competitive edge . Our resFrom a practical implication perspective, automobile manufacturers should emphasise customer advocacy, which further complements lovemarks in establishing loyalty among the customers of the automobile industry. This is important for automakers that may seek to enhance brand loyalty and gain additional resources. We argue that perceived lovemarks may also be employed as a strategy for improving one’s reputation to encourage favourable reciprocal behaviours, for instance enhancing favourable word-of-mouth about the organisations. While advocating for customers, organisations can place a strong emphasis on creating lovemark brands by giving customers fair, honest, and transparent advice. This makes it possible for businesses to gain the trust of their clients and motivates them for advocating their brand resulting in a reciprocal advantage . Additionally, it instils a sense of pride and exclusivity in the consumers, igniting their enthusiasm for the lovemark brands and fostering a favourable perception of the companies, which strengthens brand loyalty and encourages desirable behaviours. Through cognitive, emotional, and conative loyalty, it establishes a favourable affinity for the firm. As a result, the automobile industry should acknowledge that lovemarks and customer advocacy may be able to help their brand co-creation strategies.Some limitations can be attributed to our study. First, we used survey data that restricts statistical power and generalisability issues as to how broadly the results can be applied to the broader population. The scope of our study is further constrained since the information was mainly gathered from Pakistan’s large cities, which reflects a highly cosmopolitan view. Future research should broaden its geographic span to include new regions and countries. Subsequent research studies can expand into service sectors and other manufacturing industries. Lovemarks literature is dominated by examining its antecedents and limited outcome variables. It will be interesting to examine how the perception of lovemark brands interacts with other social behaviours and perceptions, for instance, brand image and brand equity. One could also think of exploring the influence of perceived lovemarks in an eco-friendly and sustainable environment and their association with the green practices of the firms.The study’s main objective was to evaluate how perceived lovemarks influenced brand loyalty. To enhance the link between brand loyalty and customer advocacy, the current study analysed this relationship through the lens of customer advocacy as its key mediator. It thus attempts to present interconnectedness among key theoretical constructs that result in achieving superior brand loyalty and gaining much-needed competitive advantage in the ever-growing cutthroat competition. We used structural equation modelling as a mode of analysis to attain the set objectives of our study. The result of the current study confirms that perceived lovemarks can be seen as a key construct for building brand loyalty where the relationship is further enhanced in the presence of an effective customer advocacy strategy.The results of our research add to the body of knowledge on brand loyalty and lovemarks. To the best of our knowledge, this is the first model concentrating on how brand loyalty in the automobile industry is influenced by perceived lovemarks and customer advocacy and validating their higher-order formations. By revealing the important role of customer advocacy as a mediator between perceived lovemarks and brand loyalty, this research expands our knowledge of lovemarks.S1 Data(XLSX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.


Mantente REAL (keepin’it REAL) program was culturally adapted to the Spanish context, implemented, and evaluated in six public middle schools in two regions of Spain. Participating teachers (N = 15), students (N = 354), and research team members (N = 6) reported on the feasibility, acceptability, and utility of the program implemented with first grade secondary school students. Qualitative and quantitative data about the program, its curriculum, and the implementation process were collected through teachers’ focus groups, students’ surveys, and observation forms completed by members of the research team. Mantente REAL was perceived to be a prevention program that was feasible for implementation in Spanish middle schools, although some logistics related to school structural constraints should be addressed in future implementations. The topics and activities in the curriculum were highly accepted by teachers and students, and they reported that the program was useful in teaching resistance strategies to cope with substance use and other risky situations. The findings support the social validity of the culturally adapted Mantente REAL program for early adolescents in Spain, and highlight how feedback from stakeholders involved in the implementation can improve the dissemination of effective prevention approaches.Studies focusing on the relevance or impact of a program, not just on its efficacy or effectiveness, can make important contributions to prevention science. This article documents the social validity  of a universal substance use prevention program for early adolescents in Spain. The  The aim of designing and evaluating evidence-based prevention programs is to assure that youth have access to quality, efficient and effective interventions that can prevent or delay their use of alcohol and other drugs and increase the wellbeing and overall health of communities  established quality standards to guarantee effective and efficacious drug abuse prevention. The principles encompass the entire prevention process, from assessment of needs and resources to the final evaluation and dissemination of efficacious interventions . The evidence considered by the database focuses on efficacy. However, previous research has indicated that universal school-based drug prevention interventions usually show low levels of efficacy  feasible to be implemented (in the specific context with the target population and the available resources), (2) acceptable regarding contents and activities, and understandable, and/or (3) useful to gain knowledge and impact participants’ lives.keepin’ it REAL, a program originally designed for a multicultural population of middle school students in the US, was demonstrated efficacious in multiple studies in the United States  to test the feasibility and acceptability of the Mexico-based Mantente REAL version in Spain .Phase two consisted of a cultural adaptation study conducted in Seville (2017–2018). Students and teachers from two middle public schools in Seville participated in the adaptation process. The study focused on the adaptation of the materials of the program  to the Spanish context. The adaptation of the content of the videos involved 32 students between 11 and 12 years old participating in four focus groups, who worked on script development for the five videos. More than 60 students from the same two schools participated in producing the videos, with the support and technical assistance of a professional videographer. Based on the feedback received from teachers, students and observers, researchers from the binational team and 5 external experts revised the manuals. Once the culturally adapted curriculum was finished and revised, a new study was conducted to assess its efficacy.Mantente REAL intervention, relative to treatment-as-usual controls  study (2018–2019) to test the efficacy of the adapted version of the program in the two sites involved in the adaptation process, Seville and Santiago de Compostela. The study was conducted in 12 public secondary schools of medium socio-economic level (6 from each site). The total sample included 755 first grade secondary school students . The results suggest the program was efficacious in curbing the increase in excessive alcohol consumption and intoxication episodes among students who received the Mantente REAL in the Spanish context, examining factors that contribute to the quality, impact and sustainability of this evidence-based and culturally adapted prevention intervention. This study aimed to analyze the feasibility, acceptability, and utility of the Mantente REAL program in the first grade of Secondary Compulsory Education in Spain, equivalent to 7th grade in the United States. Because Mantente REAL was developed by youth and for youth, we hypothesized, from a social validity perspective, that the culturally adapted version of the intervention for Spain would be evaluated as feasible, acceptable and useful by the participants and facilitators. To provide the perspectives of different informants involved in the implementation of Mantente REAL, from the two different regions, we analyzed data evaluating the intervention from the perspective of participating students, teachers , and the research teams’ observations of fidelity during the implementation process.After finding preliminary evidence of its efficacy in the small RCT study, the present study assessed the social validity of Mantente REAL in Spain. The 12 selected state schools from Seville and Santiago de Compostela were randomized into two conditions: Mantente REAL (schools implementing the program) or control . Schools in both sites, Seville and Santiago, were assigned to control and intervention conditions (3 schools per site and per condition). All students enrolled in the first grade of the selected schools were invited to participate and 80.1% of that target population participated in the study  and teachers implementing the program (N = 15), as well as members of the field research teams serving as observers (N = 6).The sample of this study came from the small cluster randomized trial testing the efficacy of the culturally adapted Mage = 12.3; SD = 0.59). The teachers implementing Mantente REAL were 53.3% female, aged 24 to 50 , and had an average of 12 years teaching experience. Members on the research teams from the two participating universities included the field coordinators of the project and graduate students who performed roles as liaisons to the schools and observers of implementation fidelity.Participating students were enrolled in the initial grade of secondary school  in their classrooms during school hours. Before starting the curriculum’s lessons, all 1st grade (7th grade in the US) tutors received practical training over a two-day long session to learn how to deliver the Ethical research review committees for the Spain and US research teams approved the study’s research design and all qualitative and quantitative data collection procedures. Information about feasibility, acceptability, and utility was collected through focus groups with teachers, students’ surveys, and the research team’s observations of fidelity during the implementation process.Teachers focus groups. All teachers (N = 15) from the six schools that implemented Mantente REAL were invited to participate in focus groups about a month after finishing the program implementation. All of them accepted the invitation and gave their assent to participate in about a one-hour focus group. In each site, focus groups were conducted with teachers in each school  to get information about the implementation process and opinions about the Mantente REAL curriculum. All the focus groups were recorded and transcribed in Spanish .Student post-test surveys. Students (N = 354) enrolled in the initial grade level of the six secondary schools assigned to the intervention condition completed a post-test survey about a month after finishing the program implementation. Parents provided informed consent for their child to participate in the survey, and students gave their assent before completing the survey. Qualified members of the research teams informed students that completing the survey was voluntary and answers would remain confidential, and provided proper instructions to answer the self-reported survey in a 50-minute classroom session. Questions assessing different aspects of Mantente REAL and students’ opinions about the program were included at the end of the post-test survey.Fidelity observations. Qualified members of the research teams visited the classrooms of each implementing teacher at sessions 1, 3, and 7 to rate fidelity to the manual, classroom management, and student participation. The observers completed standardized forms with closed-ended ratings of various aspects of fidelity and participants’ involvement, and open-ended comments about implementation issues and feedback provided to teachers.The degree to which the program was viable to be implemented was explored through the following measures that directly affect program implementation  Intervention fit: perception of the program as relevant to address the prioritized goals (substance use) and appropriate to the target population (1st grade secondary school students). (2) Implementation characteristics: complexity of the delivery of the curriculum, helpfulness of the manual, and time adequacy (or time concerns) to implement the program. (3) Practicality: engagement in delivery by teachers and participation by students.Quantitative measures from students’ post-test surveys. 1) Practicality: students reported on the post-test survey how many videos they watched (0–5) and how much they participated in the program .Quantitative measures from researchers’ observation forms. (1) Practicality: observers rated three closed-ended items to assess student involvement with the curriculum . (2) Fidelity: observers informed about fidelity using multiple measures. One was whether the teacher completed each of 8 or 10 curriculum items that were specific to the observed lesson . Two of the three sessions observed have an 8-item curriculum checklist; the other session has a 10-item checklist. These were combined into an index counting the number completed, from 0 to 10. Additionally, single items assessed how well the teacher was prepared for the lesson, informed about its content, followed the lesson plan, gave clear instructions, and motivated students to participate . Another two items rated the teacher’s class management of the group processes in the curriculum  and whether the pace of instruction was appropriate . One more item assessed whether the teacher added content not included in the manual .The degree to which the participants accepted the program was explored through the following measures  Satisfaction: overall satisfaction with the program . (2) Comfort with topics and activities: grade in which participants and/or facilitators liked topics and activities in the curriculum . (3) Understanding of content: grade in which participants and/or facilitators understood (or have problems understanding) concepts and activities in the curriculum . (4) Willingness to use the intervention in the future: expressed willingness to continue implementing the intervention in schools.Quantitative measures from students’ post-test surveys. (1) Satisfaction: students responded to four items on the post-test survey asking about how much they liked Mantente REAL, including its various components  and the program overall . (2) Comfort with topics and activities: students reported in four post-test questions whether the program was interesting, fun, easy to pay attention to, or boring .The degree to which the program is perceived as useful in producing individual and social change  Knowledge: information acquired and perception that contents are useful. (2) Applicability: similarity with participants’ life; authenticity of content. (3) Impact: changes in the lives of participants; changes in the work of facilitators and routine of services.Quantitative measures from students’ post-test surveys. (1) Knowledge: students reported on the post-test survey whether the program gave them useful information (0 = strongly disagree to 3 = strongly agree), and how much they learned from it . (2) Applicability: students assessed the authenticity of content in three post-test items, whether it was “like my life”, “like youths I know”, and like situations that they know other students get into. Two additional items assessed whether situations in the curriculum and characters in the video appeared “real” (0 = strongly disagree to 3 = strongly agree). (3) Impact: students reported whether they talked about the program with various people in their social network: parents, siblings, cousins, other family members, friends, and others. These were assessed separately  and as a count of the number of different categories of people they talked with (0 to 6).Mantente REAL program and to effectively organize and interpret the data. Thematic analysis was conducting following Braun and Clarke’s (b to d of Braun & Clarke’s recommendations) were used as a reference during the data analysis process to increase consistency in coding and decrease misrepresentation of the data: e.g., creating codes that are analytical and theoretical and not merely descriptive; organizing codes hierarchically and comparing codes . The codes were generated from keywords that define feasibility, acceptability, and utility after the agreement of three researchers based on the literature reviewed. Focus group data were transcribed verbatim in Spanish by the local team responsible for data collection in each site and two independent researchers utilized these Spanish-language transcripts to conduct the thematic analysis.Qualitative analysis was conducted following a thematic and framework approach to identify codes and analyze patterns (themes) among the teachers’ experiences with, and beliefs about, the Clarke’s  recommenClarke’s  and RabiClarke’s  recomment-tests to assess differences in teachers’ implementation and students’ perceptions of Mantente REAL between the two sites . Differences between sites on the evaluations of the program can be an indicator of the cultural appropriateness of the program after the cultural adaptation. Because it was adapted in Seville, the program might be viewed as more socially valid in that site.Quantitative analysis was conducted with SPSS 25 to analyze frequencies, other descriptive statistics , and Mantente REAL program is displayed in Table A summary of qualitative results regarding the teachers’ opinions and experiences with the Mantente REAL, perceiving it to be a feasible program for implementation in Spain and to be a well-designed program to address substance use and peer pressure at the beginning of adolescence.Teachers provided overall positive feedback about Es importantísima la prevención, en esta edad tan pequeña casi ningún programa [se aplica] . . para mí debería ser obligatorio” . “Desde un principio nos pareció muy interesante este programa y creemos que es muy necesario empezar a tratar la presión de grupo en los primeros años de la secundaria” . . . for me it should be mandatory” . “From the beginning we found this program very interesting and we believe that it is very necessary to start dealing with peer pressure in the early years of middle school” .]“Mantente REAL should have prior expertise in prevention. Teachers felt comfortable implementing the sessions due to the detailed guidelines presented in the manuals. This contributed to the high perceived practicality of the program, as teachers expressed their involvement in delivering the curriculum and noted positive student participation.One of the characteristics of the program that teachers liked the most was the manualization of the intervention. It helped increase the teachers’ confidence in their ability to deliver effective program results, and reduce concerns that facilitators of Estructurado, eso es fundamental, eso es lo que más me ha gustado el hecho que todo estuviera tan estructurado”, “Yo he estado a gusto y también he tenido respuesta por parte del alumnado” . “Está todo muy explicado en los manuales y eso es una ayuda cuando no sabes del tema”, “Mostraron mucho interés en las tareas y actividades que se llevaron a cabo” . “Teachers mentioned some issues that affect feasibility, specifically regarding time concerns and the complexities of implementing the program given the certain constraints in the schools. For example, the 12-week long timeline (one lesson per week) or the large classroom size posed challenges. Teachers usually implemented the program during homeroom hours, so they had to manage the time to also address overlapping school activities and other activities inside and outside school. Therefore, teachers expressed some challenges completing all the activities in the curriculum on time and felt they needed more time to implement the program (or for the lessons to be shorter). They also mentioned that it would be better to implement the program in small groups. Teachers did not mention additional cost or resource implications  of the program so the cost-effectiveness of the program was perceived as high.Había temas en el aula que no podíamos tratar en la hora de tutoría, entonces estaban bien las 12 sesiones, pero a lo mejor cada 3 sesiones, un hueco” . “Nosotros tenemos tutorías de casi 30 alumnos y se hace muy difícil manejar la clase con tantos niños” . “Mantente REAL as a prevention program for early adolescents in Spain. Teachers expressed their satisfaction with the implementation experience and with the curriculum of the program.On the other hand, teachers confirmed the acceptability of El programa en sí está fantástico” . “La experiencia fue muy buena” . [“The program itself is fantastic” . “The experience was very good” .]“Teachers noted the students liked the activities very much, especially the interactive activities and the videos. Although some teachers pointed out that early adolescents may have difficulty participating in activities that require greater capacity for abstraction , teachers generally reported a high degree of comfort with topics and activities included in the curriculum, for themselves and their students.Para mí son los dos grandes éxitos: prácticas y vídeos” . “[Los estudiantes] Prefieren hablar y compartir experiencias de forma dinámica. Creemos que es un material muy bueno”, “Los vídeos, por ejemplo, les encantaron” . [“For me the role-playings and the videos are the two great successes of the program” . “[Students] prefer to talk and share experiences in group. We think it’s very good material”, “They loved the videos, for example” .]“Mantente REAL are acceptable for use with older students and can serve as a reinforcement of previous learning.Ultimately, teachers reported high willingness to use the intervention in the future with new students starting middle school, but also in later grades as they thought the topics and activities of Las cuatro habilidades están geniales y no solo para este curso, me gustaría seguir usándolas” . “Mantente REAL as a highly applicable prevention program for Spanish early adolescents. They mentioned specifically the utility of learning behavioral skills (the REAL strategies) to deal with substance use situations. The REAL strategies were also considered useful while dealing with other risky situations.Teachers viewed Las estrategias que han aprendido luego le servirán para el consumo y para otra cosa” . “Mantente REAL es una forma interactiva de aprender ciertas habilidades que pueden ser útiles a los niños más allá del consumo de drogas” . [“The strategies they have learned will serve them later for [substance] use, and for other things” . “Mantente REAL is an interactive way to learn certain skills that can be useful to children beyond drug use” .]“Teachers from both sites commented that materials overall were applicable to the students’ daily life, although teachers from Seville sometimes perceived the videos, language and the situations as more similar to their students’ lives because the materials were developed and adapted in their city.La cosa buena [de los vídeos] es que, al estar rodado aquí en Sevilla por chicos de aquí, le sonaban muy cercanos” . “Comentaron en más de una ocasión que les gustaría que reflejasen más el contexto gallego. Muchas veces no se entendía lo que decían” . [“The good thing [about the videos] is that, being shot here in Seville by youth from here, they sounded very close to the students’ [way of speaking]” . “They commented on more than one occasion that they would like them to reflect more of the Galician context. Many times, they did not understand what they were saying [in the videos]” .]“Mantente REAL impacted how they work at school.The impact of the knowledge acquired, that is, the changes in students’ lives because of the program implementation, was reported more specifically in connection to the resistance strategies. Teachers themselves also expressed that Saben perfectamente lo que es REAL”, “Es un programa que me ha ayudado mucho, a trabajar, a conectar con los niños, a presentarles herramientas” . [“[The students] know perfectly what REAL is”, “It is a program that has helped me a lot, to work, to connect with the children, to present them with tools” .]“[Los estudiantes] Mantente REAL curriculum . There were no differences by city in measures such as level of participation in the curriculum activities, how much students liked the program overall, whether it was boring, whether the program was like their lives, whether they knew youth who get into situations like those presented in the videos, and whether they talked to others about the program.On most indicators, students from Seville reported more positive evaluations of Table Mantente REAL program in the first grade of Secondary Compulsory Education in Spain. Mantente REAL is a culturally adapted program that showed preliminary evidence of efficacy in preventing drug use in a small RCT study .The objective of this study was to analyze the feasibility, acceptability, and utility of the The high level of substance use among European and Spanish populations, and young adolescents in particular, highlights the need for interventions focused on early universal prevention. Establishing the scientific and social validity of interventions is needed in order to change actual substance using behaviors by teenagers. These findings support the premise that a reduction in risky behaviors among adolescents can happen by implementing programs that are not only evidence-based . Students and teachers recognized that these skills were made accessible through effective curriculum and video messaging, and the participatory teaching and learning style. From the eco-evolutive perspective  was viewed as: feasible for implementation, although with challenges related to school structural constraints; acceptable in terms of satisfying and comfortable content; and of utility in prompting desired individual change.The high prevalence of substance use and abuse in Spain, among youths and adults, highlights the need to disseminate effective prevention approaches and conduct systematic research to improve the quality, reach, and social validity of prevention programs. Teachers and students provided strong and notably consistent evidence that the culturally adapted version of Mantente REAL, we recommend that certain elements need to be incorporated into the design and testing of prevention programs: (1) systematic data collection to establish an evidence base, (2) rigorous cultural adaptation through a process of co-design with the different actors involved in the intervention, (3) an understanding of the context and cultural specificity on the part of the program facilitators, (4) appropriate training of the facilitators to deliver the program with fidelity, and (5) engage the active participation of the target population. The adaptation, implementation and testing of Mantente REAL in Spain followed these steps, which produced a very promising end result.Based on these findings demonstrating the social validity of


According to the Institute of Medicine, immediate steps must be taken across the United States to educate and train the healthcare workforce to work collaboratively to address the needs of the growing older adult population. The Geriatric Practice Leadership Institute (GPLI) was designed to support professional teams working in acute and post-acute care in transforming their organization into a designated Age-Friendly Health System. The program was built around the Institute for Healthcare Improvement’s Age-Friendly Health Systems 4Ms framework. This framework focuses on What Matters, Medication, Mentation, and Mobility (the 4Ms) in supporting care for older adults. The GPLI program is an online, seven-month team-based program with four to seven participants from one organization per team. Additionally, each team selected, developed, and completed a quality improvement project based on Age-Friendly Health Systems 4Ms. The curriculum also includes organizational culture, leadership, and interprofessional team-building modules. Using a post-completion survey, the experiences of 41 participants in the GPLI program were assessed. All respondents found the information in the program ‘very’ or ‘extremely’ valuable, and their executive sponsor ‘very’ or ‘extremely’ valuable in supporting their team’s involvement and project. The GPLI program has trained over 200 healthcare professionals and teams that have successfully implemented projects across their organizations. By 2030, the number of adults aged 65 years and over will double to 24% of the United States (U.S.) population ,2. The TGiven the increase in the older adult population and the complexity of care, older adults are at a higher risk of healthcare-related harm due to increased healthcare utilization. The focus on healthy aging has received national and global attention in recent years and has been integrated into academia and healthcare delivery, including the United Nation’s Decade of Healthy Aging: Plan of Action 2021–2039 . AccordiThe increased demand for primary care is most prominently seen by general/family medicine and general internal medicine practitioners. Moreover, based on the latest projections of the Health Resource Service Administration (HRSA), the national demand for primary care physicians is projected to increase from 224,780 in 2013 to 263,100 in 2025, a 17% increase . UnfortuThese factors have resulted in healthcare systems needing help to provide evidence-based practice to every older adult at every point of contact in the healthcare system. In addition, as the U.S. population ages, our healthcare system must be better prepared to care for older adults. The Age-Friendly Health System 4Ms framework, developed by the John A. Hartford Foundation, refers to the effort to use evidence-based elements of high-quality care for older adults ,17. In tThe team-based GPLI program is a tuition-free program formed from a shared vision initiated in 2013 by geriatric clinicians from the University of North Texas Health Science Center (UNTHSC) and executive education leaders from the Texas Christian University (TCU) Neeley School of Business to inspire and promote transformational team-based solutions that optimize outcomes for older adults. The program has been funded by the HRSA since 2013, and has been offered to over 200 participants from acute and post-acute organizations. The GPLI program aims to provide participants with a solid foundation to begin their organizational journey to becoming recognized as a Level 1 Age-Friendly Health System or continue their age-friendly journey to Level 2 if Level 1 designation has already been achieved. The program prepares early- and mid-career professionals working in teams to become clinical leaders in their organizations. In addition, the GPLI program provides participants with skills and knowledge to improve patient care for older adults by incorporating the Age-Friendly Health Systems 4Ms framework. The GPLI shifted to be based entirely on the Age-Friendly Health System 4Ms framework three years ago, and has now graduated from two cohorts of teams from an age-friendly program. Two years of graduates from this age-friendly program were asked to complete a survey to assess the program’s success at program completion. The survey consisted of two open-ended questions and six closed-ended five-point Likert scale questions, where one equaled ‘Not at all valuable’ and five equaled ‘Extremely valuable’. The teams comprised four to seven participants and could be pre-existing or assembled for the GPLI program. Individuals from various disciplines participated. Previous teams included nurses, physicians, social workers, pharmacists, rehabilitation therapists, administrators, regional managers, C-suite executives, and social service providers. Each team was assigned a coach with expertise in healthcare delivery and business leadership, who worked with the team for the duration of the program, offering professional support and guidance throughout the project development and implementation process. Coaches who had previously implemented the age-friendly model were available to assist teams with concerns about integrating the model into their quality improvement projects. Coaches regularly met with teams to provide support based on the participants’ learning needs and GPLI team members’ priorities. Additionally, each team had an executive sponsor to help with project sustainability, potential funding needs, navigating organizational culture, and cultivating changes in the organization’s ecosystem. The projects covered topics ranging from fall prevention and behavioral management to nonpharmacologic interventions in nursing homes. The participants completed five online, self-paced sessions and associated individual and team writing assignments, as outlined in A total of 41 participants, consisting of nine project teams over two years, participated in the study, with a response rate of 73%. The program participants ranged in age from 20 to 60, were mostly female (76%), and had a range of backgrounds in internal medicine, clinical social work, nursing, emergency medical services, pharmacy, electronic medical record administration, healthcare administration, and academia. In the post-completion survey see , all resIt was evident from the open-ended queries that participants became agents of change within the health system while also increasing their knowledge of Age-Friendly Health Systems. The participants were instructed by their team coach on how highly effective teams function and how to set and achieve team objectives, which are crucial when caring for older adults. In addition, the GPLI program helped participants improve their use of effective strategies to incorporate evidence-based practices into their existing care. The program raised awareness of how enhancing patient-centered geriatric care, patient safety, and workflows can positively affect older individuals’ health outcomes and quality of life. This newfound awareness empowered participants and teams to spearhead their organizations’ preparations for Age-Friendly Health System certification. Two organizations have already earned this distinction, and two others have pending applications.In 2021, MedStar, a local government agency that provides a wide range of services, including acute emergency medical response, flu vaccinations, and a mobile integrated health (MIH) program, teamed up with the Alzheimer’s Association and UNTHSC SaferCare Texas, supported by a team coach from the TCU Neeley School of Business. Their GPLI project involved finding effective ways to integrate the 4Ms framework into the emergency medical services (EMS) system through emergent responses and MIH services. This initiative was built upon a prior MedStar MIH GPLI team initiative to integrate fall risk assessment and intervention into the current in-home comorbidity management for high-utilization callers. In addition, the emergency responder team sought to provide what matters, medication, mentation, and mobility interventions to the MedStar 911 calls. In addressing what matters, the question ‘What matters to you today?’ with guided categories including family, health, and religion/spirituality was added to the electronic medical record (EMR) algorithm for paramedics. Additionally, 911 staff members were coached to ask the patients to determine the course of action. Considering the complexities of treating older adults, addressing what matters in an emergency could avoid unwanted emergency room visits or hospitalizations and focus instead on quality-of-life goals. Regarding medications, as older patients are commonly on at least one prescription drug, addressing medications in an emergency could avoid drug mismanagement or adverse drug events. To address medication, any reported medications on the Beers’ list, an established list of potentially inappropriate medications for older adults, were automatically set to flag in the EMR . This geAs for mobility, falls as a significant contributor to emergency calls, screening, and addressing fall risk factors could significantly reduce subsequent calls or medical care and associated morbidity and mortality from fall-related injuries. To address mobility, an inquiry using the Centers for Disease Control and Prevention (CDC) Stopping Elderly Accidents, Deaths & Injuries (STEADI) Stay Independent Investigation was also embedded into the EMR . AnswersDementia, depression, and delirium negatively impact the management of health conditions and lead to a higher fall risk. Screening mentation provides earlier awareness and interventions to remediate or control negative health outcomes. The 911 responders were asked four questions to screen for dementia. Some patients were enrolled in the MIH program as a follow-up to the EMS visit. This program expanded the use of the 4Ms framework to further assess and act on areas needed to manage health conditions, decrease fall risk, and provide targeted care intervention, often serving as a liaison between the patient and the required providers and community services. In expanding on what matters, paramedics addressed subjects related to advance care directives, patient goals, and what matters most to support their quality of life. Moreover, during in-home MIH visits, managing what matters provides an opportunity to align care with the patient’s priorities. Further education and discussion with the patient, caregivers, and their medical providers helped address the high-risk medications flagged in the EMR. Regarding mentation, screening tools, including the Montreal Cognitive Assessment (MoCA), Ascertain Dementia (AD8), Patient Health Questionnaire (PHQ-9), and Geriatric Depression Scale (GDS), were used to screen for dementia and depression, thus guiding appropriate community services and support ,24,25,26MedStar still uses the 4Ms framework to identify factors impacting health management and emergent needs and aligns findings with patient-centered and targeted needs by coordinating care with physicians and community services. As of January 2023, MedStar continues to use what matters in its EMR. In September 2021, an in-person what matters continuing education session took place with the entire MedStar staff, emphasizing the idea and its implication in the care of older adults. Another in-person training was conducted, which focused on communication with the emergency department staff. For medication, MedStar 911 and MIH paramedics continue to flag Beers’ list of medications in their EMR when obtaining patients’ medical histories. Additionally, paramedics verify the potential risks and develop care plans based on the medications taken. Through these actions, MedStar demonstrated efficient and effective execution of the 4Ms framework. In 2022, the 911 team screened 25,912 older adults for risk factors affecting falls and health management. A total of 775 referrals from 911 calls received follow-up care from the MIH team.Several organizations participating in the GPLI program have already been designated as Age-Friendly Health Systems. For example, the Family Medicine Clinic at the UNTHSC included a physician’s assistant, clinic director, licensed social worker, and medical assistant on the GPLI team. The UNTHSC Family Medicine Clinic has a large population of older adults with Medicare or dual eligibility that requires additional attention to ensure excellent care. The clinic sought to become a designated Age-Friendly Health System to meet the needs of this population and better serve older patients by connecting them to appropriate resources. The clinic focused on integrating 4Ms into the clinical workflow for annual wellness visits. The team added additional eligibility criteria to the electronic check-in flow and created a template for the annual wellness visit that included the 4Ms. As a result, the team increased their patients’ annual wellness visits by 84% over the two years.The results of the post-completion survey among GPLI program participants demonstrated the program’s positive impact on healthcare providers working with older adults. The GPLI program successfully equipped participants with the knowledge and skills of the Age-Friendly Health Systems 4Ms framework needed to care for the growing older adult population, effectively addressing the diverse needs of this population. In addition, the Age-Friendly Health System 4Ms framework has played a pivotal role in enhancing the care provided to older adults by focusing on patients’ overall well-being rather than solely on their disease states.The collaborative team-based approach of the GPLI program has fostered an environment in which professionals from various disciplines work together to improve care for older adults. This approach has resulted in the development of highly effective teams to set and achieve the objectives crucial for caring for older adults. Moreover, the program has facilitated the integration of evidence-based practices into existing care systems, leading to improvements in patient-centered geriatric care, patient safety, and enhanced workflows.The GPLI program empowered healthcare providers to spearhead their organizations’ preparations for Age-Friendly Health System certification and contributed to the successful designation of several participating organizations as Age-Friendly Health Systems. The example of the UNTHSC Family Medicine Clinic demonstrates how implementing the 4Ms framework can lead to significant improvements in patient care, such as increasing annual wellness visits by 84% over two years.One key aspect of the GPLI program that has contributed to its success is the inclusion of executive sponsors and coaches in the program structure. Executive sponsors provide essential support for navigating the organizational culture, securing funding, and promoting sustainability. In addition, coaches with expertise in healthcare delivery and business leadership guided the teams throughout the project development and implementation process. This support system facilitated the integration of the Age-Friendly Health System 4Ms framework into the daily practices of healthcare providers and promoted lasting changes within their organizations. Based on feedback from the team coaches, program faculty, and participants in the program, the following lessons learned have been identified.The teams most successful in achieving change in their organizations had representatives from all levels and disciplines where the quality project was implemented. Additionally, as highlighted by the post-completion survey, executive sponsor support is critical to individuals’ success, teamwork, and development. Feedback from all patient-facing team members was crucial for implementing and, more importantly, sustaining age-friendly changes. Recognizing that care for older adults involves many healthcare providers with various backgrounds and formal training is critical to creating an age-friendly environment within medical practice.Quality improvement is important. While quality improvement tools can seem complicated at first glance, they become simple to execute when individuals are trained on how to use them. Change management, however, is a more complex part of the transition to providing age-friendly care that requires consistent, intentional effort. Finding local champions and early adopters, especially physicians or other leaders, is critical to seeing participation in and commitment to the program. Finding barriers in small tests of change was good, and teams that adopted this mindset were successful. Changing a culture takes time, anywhere from three to five years, to create a long-lasting positive change that will support all the elements of an Age-Friendly Health System. Education is essential to age-friendly culture change but is not always immediately successful. It takes time and a trusting relationship to help team members and patients understand the importance of an Age-Friendly Health System and the 4Ms. As exemplified by the MedStar team, continued training and education are important to effectively employ the 4Ms framework.Staffing has been challenging for teams across settings and has been exacerbated during the COVID-19 pandemic. Setting reasonable expectations that hold teams accountable while allowing flexibility helps them deal with changing work demands. The most successful teams selected something small that was obtainable to help build momentum. Additionally, resilience when facing challenges is essential for leaders working to change their culture.Despite the success of the GPLI program, some limitations should be considered. First, the impact of the program may be limited by the small number of participants and the focus on a specific geographical region. Expanding the program to include more participants and healthcare providers from various regions would allow for a broader understanding of the program’s effectiveness in diverse settings. Second, the survey assessing the program’s success may not capture the full range of outcomes and challenges that participants face while implementing the 4Ms framework. Third, the age-friendly curriculum has only been part of the program for two years, so the conclusions are based on a short time span. Future research could explore the long-term impact of the GPLI program on healthcare providers, organizations, and patient outcomes through a more comprehensive evaluation methodology, including qualitative interviews and longitudinal follow-ups. In addition, as the growing older population and the associated challenges in healthcare are a worldwide problem, with the world’s population aged 60 years and older expected to increase by 1.4 billion by 2030, future directions should consider a roll-out of similar training in other countries as well .The GPLI program effectively provided healthcare providers with geriatric training focused on the Age-Friendly Health System 4Ms framework. As the older adult population grows, it is crucial to equip healthcare providers with appropriate knowledge and skills to ensure better patient outcomes. The success of the GPLI program highlights the importance of team-based collaborative approaches in managing complex chronic diseases and improving the quality of life of older adults. Furthermore, including executive sponsors and coaches in the program structure emphasizes the value of organizational support in promoting lasting changes in healthcare systems. As the demand for primary care physicians and healthcare providers skilled in geriatric care continues to rise, programs such as the GPLI will become increasingly essential for addressing the complex healthcare needs of the aging population.