Community-based exercise programs integrating a healthcare-community partnership (CBEP-HCP) can facilitate lifelong exercise participation for people post-stroke. Understanding the process of implementation from multiple perspectives can inform strategies to promote program sustainability.To explore stakeholders' experiences with undertaking first-time implementation of a group, task-oriented CBEP-HCP for people post-stroke and describe associated personnel and travel costs.We conducted a descriptive qualitative study within a pilot randomized controlled trial. In three cities, trained fitness instructors delivered a 12-week CBEP-HCP targeting balance and mobility limitations to people post-stroke at a recreation centre with support from a healthcare partner. Healthcare and recreation managers and personnel at each site participated in semi-structured interviews or focus groups by telephone post-intervention. Interviews and data analysis were guided by the Consolidated Framework of Implementation Research and Theoretical Domains Framework, for managers and program providers, respectively. We estimated personnel and travel costs associated with implementing the program.Twenty individuals from three sites  participated. We identified two themes related to the decision to partner and implement the program: (1) Program quality and packaging, and cost-benefit comparisons influenced managers' decisions to partner and implement the CBEP-HCP, and (2) Previous experiences and beliefs about program benefits influenced staff decisions to become instructors. We identified two additional themes related to experiences with training and program delivery: (1) Program staff with previous experience and training faced initial role-based challenges that resolved with program delivery, and (2) Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Participants identified recommendations related to partnership formation, staff/volunteer selection, training, and delivery of program activities. Costs (in CAD) for first-time program implementation were: healthcare partner ($680); fitness coordinators and instructors ; and participant transportation .During first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations.Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017—Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03122626 Continuing to exercise through CBEPs after rehabilition can help people post-stroke maintain their functional independence, feel better, and reduce the need for caregiver assistance (Community-based exercise programs (CBEPs) adapted for people with stroke are emerging worldwide –7. Availsistance , 7–9.One novel program model is a community exercise program that incorporates a healthcare-community partnership (CBEP-HCP) . ProgramDespite the documented benefits of exercise programs adapted for people post-stroke, these programs are not widely available in community settings , 17. ThiThe use of theoretical frameworks to guide the investigations of implementation experiences is recommended as such frameworks provide a standard terminology and comprehensive overview of factors affecting the implementation process –21. The Few studies have evaluated experiences of program providers with implementation of CBEPs post-stroke , 26–29. Current guidelines  recommenWe conducted a 2-group pilot randomized controlled trial to evaluate a CBEP-HCP called the Together in Movement and Exercise (TIME™) program at three urban sites in Ontario, Canada . TIME™ iAs part of the trial, we conducted a planned qualitative study to explore stakeholders' experiences with implementing the 12-week TIME™ program for people post-stroke for the first time. The implementation process included the decision to partner, training, coordination, and delivery of the first program. A secondary aim was to outline potential personnel and travel costs for program providers, healthcare providers, and exercise participants associated with first-time program implementation.A qualitative descriptive study involving semi-structured telephone interviews and focus groups was undertaken as part of pilot randomized controlled trial . The triThe TIME™ program offers two one-hour exercise classes per week for 12 weeks. Group classes include a seated warm-up, repetitive and progressive practice of functionally relevant balance and mobility tasks organized in a 3-station circuit, and a seated cool-down. An instructor-to-participant ratio of 1-to-4 is required to optimize supervision and safety; volunteers can be used to supplement instructors to attain this ratio. Healthcare partners visited the first two classes and three additional classes interspersed across the remaining 22 classes .In the trial, community centres first signed the TIME™ license, and then received an electronic toolkit with materials  required to implement the program. Fitness instructors, healthcare partners, and volunteers completed training which involved a combination of e-modules, and in-person and virtual sessions .We conducted interviews with managers, and focus groups, consisting of two to three participants, with fitness instructors or volunteers. A Toronto-based, female, interviewer with six years of experience with conducting qualitative research obtained informed consent and conducted focus groups and interviews. Interview or focus group guides were tailored to each stakeholder group. We selected the CFIR to inform interview guides for managers as this framework incorporates factors at the organizational level relevant to managers’ experiences and decision-making. We selected the TDF to inform the interview and focus group guides tailored for program providers as this framework emphasizes factors relevant to individual experiences and decision-making. Across sites, interviews and focus groups were held up to 8 months post-intervention and lasted 45–60 min. The interviewer used probing questions to obtain greater detail or explanation. Sessions were conducted by telephone to allow for flexibility given geographical distance. Sessions were audio recorded and professionally transcribed.To inform the description of costs, we documented the time required to complete the activities involved with training and delivery of the first program. We also documented the hourly wages of the staff involved in program delivery and the cost of the equipment that was purchased for the sites. We requested fitness instructors to document the travel modes used by participants to attend the class using a standardized form, while healthcare partners were requested to document the time spent on class visits.A directed content analysis that incorporated the CFIR and TDF was undertaken. We developed a codebook composed of CFIR and TDF domains. Two researchers (NMS and KB) used an inductive and deductive approach to independently open-code one transcript per stakeholder group . Researchers then met to compare and contrast codes to ensure consistency and to revise the coding scheme before KB proceeded to independently code the remaining transcripts using NVivo 10 software. Subsequently, for each CFIR and TDF domain, KB reviewed coded text from all stakeholder groups first within each site and then compared and contrasted coded text across sites. NMS, GA, and KB met and reviewed within-site node summaries to identify emerging categories as they related to facilitators, barriers, and recommendations for the process of first-time implementation of the exercise program. After recognizing that experiences were similar across sites, KB combined site-specific data to develop summaries of facilitators and barriers within each CFIR and TDF domain, and recommendations, with supporting quotes. Through a series of meetings, NMS, GA, and KB met and refined summaries of the facilitators and barriers to ensure alignment with CFIR and TDF domains. An inductive approach was then used to identify overarching themes across the data through discussion and consensus. Similarly, the recommendations and supporting quotes were reviewed and classified by the activity within the implementation process. To maintain records and encourage reflexivity about data collection procedures, an audit trail was used. The interviewer took reflexive notes after completing each session related to similarities across interviews and focus groups and new ideas arising from the data. Preliminary results were presented and discussed with the interdisciplinary research team to consider alternative interpretations of the data. Throughout the analysis, discrepancies around emerging ideas, codes, and themes were resolved by discussion and through reference to the original transcripts to ensure authors were in agreement. Lastly, we presented findings with direct quotations from the participants as exemplary anecdotes that support the findings of the study.We developed a sample budget that presents personnel and travel costs for the healthcare partner, recreation partner and the participant to run a 12-week TIME™ program. For healthcare and recreation partners, we distinguished costs for planning and implementation activities. We took the mid-point value of pay rates observed across the three sites during the study to generate cost estimates; otherwise we used and indicated an alternate source.Twenty individuals from three study sites participated in focus groups or interviews. Participants included 4 recreation managers, 3 healthcare managers, 7 fitness instructors, 3 healthcare partners and 3 volunteers. Fitness instructors had between 8 and 30 years of experience in their position. Healthcare partners were physical therapists with between 16 and 30 years of clinical experience. Each healthcare partner completed five planned class visits.In site A, a municipal for-profit recreation centre partnered with a local hospital. In site B, a hotel-based for-profit fitness centre partnered with a local hospital and in site C, a non-profit recreation centre partnered with a local hospital.The experiences of managers and program staff could be grouped into the following two categories based on the phase of program implementation: (1) experiences with the decision to partner and implement the program; and (2) experiences with training and program delivery.Within each category two main themes emerged. 3.1.3.1.1.3.1.1.1.When making a decision to partner with a novel program, healthcare and recreation managers strongly considered the quality of the program as reflected by the reputation of the organization that developed it, presence of scientific evidence, and evidence of its successful implementation. These factors influenced managers' opinions of the value of implementing the program.Recreation managers also confirmed the positive impact of the method of program introduction. Involving a knowledgeable individual to introduce and highlight the advantages of the program was critical to ensure interest and support, as was the presence of all organizational decision-makers and managers during the meeting.[The lead investigator] did all of her homework … approached the program director and then was invited for an information session. And during the information session, she made sure that all the right players were at the table—the manager who would be involved, and the program directors … So when she did the presentation and provided all of the information … Because she was very thorough, it was a no-brainer that this is something that as an organization we should be supporting. 3.1.1.2.Managers reported that the potential benefits of the program for their clients and their organization were important in their decision to adopt the program. Recreation managers recognized that their staff involved in the program would acquire new skills and knowledge to support people with mobility issues, and that the model offered novel opportunities to partner with reputable research and healthcare organizations. They also valued the opportunity to positively impact the lives of marginalized seniors residing in their communities in addition to establishing their presence in the rehabilitation sector.Hospital managers viewed their involvement with a novel community program as supporting their organizational mandates to be leaders in stroke care. They viewed the TIME™ program as serving their outgoing patients by enabling them to continue advancing their recovery in the community setting. Recreation and hospital managers perceived the compatibility of the program and organizational values and goals as another facilitator of their decision to adopt the program.Managers also identified cost and resource requirements of the program as critical factors to consider. Hospital managers weighed the amount of time needed from the physiotherapist for initial training and program visits. They were concerned about the ability of the physiotherapist to manage their role as a healthcare partner along with their clinical responsibilities. Recreation managers viewed the recommendation to schedule the program during non-peak hours as advantageous as staff and resources could be made available. Recreation and hospital managers acknowledged that the provision of funding to support the ongoing involvement and training of their staff was crucial to their wilingness to partner with and implement the CBEP-HCP.So what is this going to cost? There aren’t any extra dollars available within the healthcare system and within our organization. So had there been a major cost to this then we would have to weigh the benefit to the patient and the cost associated to that to see whether or not it could be made a priority for us. 3.1.2.Program delivery staff described feeling excited about taking part in the TIME™ program and viewed their participation as an opportunity to gain experience working with clients who have mobility issues, and advocate for the benefits of exercise. They associated their interest in becoming TIME™ program instructors with their previous experience prescribing exercise for and working with people with stroke or cognitive or motor impairment. Healthcare partners saw their involvement as an opportunity to learn about a novel program so they could not only educate their patients and refer them to the program, but also influence how the program is run.I think it's just great to see the potential for a community program for the stroke patients. So that we're aware of what's being offered out there… I love being with the patients. And it is an opportunity to educate them—the fitness instructors as well. I try to give a little bit of information where I can. I mean it benefits everybody. 3.2.3.2.1.Fitness instructors, who had experience working with people with mobility issues, and healthcare partners, found the TIME™ program training, toolkit and online support videos comprehensive and useful. However, as first-time instructors for the TIME™ program, they reported initial challenges with understanding the impact of stroke-related deficits and grouping participants based on their ability levels. They also described feelings of nervousness in managing individuals with mobility issues in a group format and raised concerns about their abilities to manage larger groups with varying ability levels in the future. Some of this uncertaintly was attributed to the lack of confidence in managing individuals who may need additional support while not being a healthcare professional. As one instructor explained:So I was a little nervous about it. Like having these people sort of under my wing, like being responsible for… Like when you're not a physiotherapist or you're not a doctor or a nurse or a healthcare provider but just as an instructor, like a yoga instructor, I just felt like I was a little bit out of my element maybe. Only because of the responsibility part. I feel like it was a pretty big responsibility to be able to guide these people. Other instructors commented that additional training and material may be required for fitness instructors with minimal exposure to individuals with mobility issues. Although centres were provided with information on mobility aids and medications used by participants in advance of the program, instructors expressed a desire for information about mobility aid use and falls risk before the first class so they could understand the diverse ability levels of participants.Some instructors reported difficulty in recalling all the exercises and levels within the circuits and used cue cards as aids. Other challenges related to the availability of resources. At one site, instructors reported not having access to optimal ballet bars or chairs for handholds, or not having enough volunteers to assist participants with low ability levels.Intructors noted, however, that they gained confidence and grew more comfortable over time with the experience of delivering more classes; a change also reported by healthcare partners. The healthcare partners confirmed observing these changes in the instructors and ascribed it to the instructors gaining an understanding how stroke deficits may affect a person' ability to do different exercises, and getting more comfortable with the circuits and running a group class.And so I think the first couple of sessions when they start working with stroke patients, that’s when they start to click and think, “Oh, okay, so that’s what they mean.” It’s just they don't have the background, right. Fitness instructors and healthcare partners reflected on their professional roles and highlighted the importance of being able to work with people, troubleshoot and empower each other. They noted the need to work as a team where the healthcare partners, instructors and volunteers support each other to be able to work with participants with different abilities and challenges; which in turn would allow them to support and empower their participants.[Healthcare partners have] to be comfortable dealing with people, and feel comfortable troubleshooting. You definitely can't have an ego and say that yeah, I'm the physio … here it's all about empowerment—empowering the patient, empowering the instructors to make sure they can be a partner in helping the patient help themselves, and empower the volunteers so they can feel a part of this program. Program providers also expressed the need for improved clarity in their roles. Healthcare partners discussed the need to recaliberate their professional role and identity from a hands-on, clinical role to more of an observer or supervisory role. At one site, the healthcare partner noted they felt instructors viewed them as a supervisor during class visits, and the healthcare partner was not comfortable in this role. One healthcare partner reported that inadequate guidance was provided on the responsibilities of the instructors and the healthcare partner to group registrants for the exercise stations during the first class. Fitness instructors reported the need to guide the volunteers on what to do during the class, and questioned if this was a part of their role as an instructor and pointed to the need for more information during volunteer training.3.2.2.All managers identified availability of adequate financial, human, and space resources as factors to consider for program maintenance and continuity. Recreation managers emphasized the need to have more than two instructors available to ensure that classes would not be cancelled due to illness. Although fitness instructors with experience working with people with mobility issues in a group setting were desired, some fitness instructors only had experience working with individuals with mobility issues one-on-one.One of the factors was availability of instructors. So you never want to run a program just with one or two. Just that if there's any sickness or anything comes up … our goal is never to cancel a class … And then space is obviously a major consideration. Hospital managers reported concerns related to the time and the cost commitment required from the hospital for the healthcare partner to perform their duties . The managers highlighted the potential impact of redirecting manpower from the hospital and its impact on the professional commitments at the hospital. One hospital manager reflected on the need to identify a suitable individual for the role.We had to take into account how much time was going to be needed from the physiotherapist at our organization …And so the training up front, the cost of the training, the cost for her time was a big piece. And then even aside from the cost, it was do we even have the manpower?… It's often difficult to recruit physiotherapists. So we wanted to make sure that we actually had the person that could give up time to do this. Findings highlighted important considerations made by stakeholders during the decision to partner and implement the TIME™ program and during training and program delivery. Program quality and packaging strongly influenced the perceived value of the program among managers who also weighed program costs and required resources with expected benefits for staff, clients, and and their organization. Positive experiences during training and program delivery were facilitated by engaging fitness instructors who had experience working with people with disability and the comprehensiveness of the program training procedures and materials. Nevertheless, program staff faced personal challenges with taking on a new role that diminished as they gained experience delivering the program. Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Findings yielded cost estimates and recommendations from multiple stakeholders that will help to optimize the process of first-time implementation.Recreation and healthcare managers reported similar priorities and organizational considerations that influenced their decision to implement the program. The reputation of program developers, scientific evidence, successful implementation in other centres, interaction with program experts, and alignment with organizational mandates, were influential. This suggests that even when implementing an evidence-based program such as the TIME™ program, management places importance on how it is implemented, who is involved with the implementation, and program compatibility with the characteristics of the organization and the community. Determining who presents the program is important as someone with comprehensive knowledge of the program can highlight key advantages of the program and address any concerns. When organizational leaders have confidence in the program and display a readiness for change, it is reflected in the program staff's attitudes and involvement  which inRecreation and hospital managers confirmed that organizational capacity to bear program costs, a commonly reported barrier to program implementation , 36, 37,Community organizations can establish cost-recovery mechanisms to offset the cost of implementing and delivering the program. This includes program fees, membership fees, donations or applying for and obtaining funding to support program activities , 15, 29.In this study, healthcare and recreation managers placed value on inner setting variables such as organizational readiness to implement the program, and the potential growth in organizational impact on the community brought on by program implementation. Since the program could be scheduled during “off-peak times”, it was not challenging for the recreation manager to allocate space, equipment, and instructors to the program. Interestingly, despite their mandate to include accessible programming for all community residents, it was the implementation of the TIME™ program that allowed the recreation organization to serve residents who experience balance and mobility limitations resulting from a stroke. This intersects with hospital managers' identified need for programs in the community that support people with stroke as they transition from the hospital to home. The partnerships created through the process of implementation were nurtured through the complementary mandates and a shared culture that values innovation and inclusivity. While some of these factors have been identified in previous studies on the implementation of CBEP-HCPs , 16, thiProgram staff were aware of the influence of their skills, knowledge, and beliefs on the delivery and impact of the program. In the absence of previous experience working with individuals with disabilities, program staff described a lack of confidence in managing people of varying abilities. At the same time, their beliefs about the positive consequences of participating in the program for themselves (obtaining/expanding skills) and the participants  motivated them to remain involved. Recommendations to improve support included adapting the training material to cater to inexperienced instructors and discussing specific challenges, such as lack of resources, participant safety, and delivering a class for people with varied ability levels. Importantly, program providers recognized having previous experience working with individuals with disabilities and the eagerness to work with them as important attributes in a TIME™ fitness instructor.Study findings reinforce the role of the manager in identifying staff who fit the profile of a suitable instructor. This would include someone with experience and eagerness in working with individuals with mobility issues, ability to troubleshoot and innovate on-the-go, or the willingness to learn these skills. To assist instructors with program delivery, the healthcare partner role would require an individual who is able to empower and work with the instructor to adapt the program to the needs and abilities of the participants. When program staff can internalize the benefits of associating with the program and feel supported through the challenges, turnover may decline . This isThe factors identified as facilitators and barriers to first-time program implementation in the current study also impact program continuity and sustainability. In a study examining factors influencing sustainability of CBEP-HCPs , CBEP-HCDuring first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations. Stakeholders identified recommendations that can be used to improve first-time implementation with people post-stroke. Personnel and transportation cost estimates can help inform decisions to implement the CBEP-HCP model with people post-stroke and highlight the need to identify low-cost transportation options for exercise participants in financial need.


Smartphones have become increasingly essential in people’s daily lives. Studying the enablers that influence students’ smartphone buying intentions can inform technology-enhanced learning development, whereas research on brand loyalty and experience is important for marketing strategies. While prior research has acknowledged the importance of brand experience and customer loyalty, little literature has investigated the specific dimensions of brand loyalty and their connection to brand love and trust. This study investigates the effects of brand attributes on loyalty and word-of-mouth engagement in choosing smartphones in China, including the mediating role of brand trust and brand love between brand experience and loyalty. The study adopted a research framework based on the previous literature and tested it empirically. The study adopted a cross-sectional survey method, collecting 369 questionnaires from Chinese students in mainland China. The collected data were analyzed with the help of structural equation modelling by applying AMOS software version 26. The results showed that brand experience had a significant influence on brand trust, brand love, attitudinal loyalty, and word-of-mouth, except for behavioral loyalty. Likewise, the link between brand trust and attitudinal loyalty, behavioral loyalty, and brand love was found to be significant. The effect of brand love on attitudinal loyalty and behavioral loyalty became significant. Additionally, the study confirmed that behavioral trust and brand love significantly mediates the relationship between brand experience–attitudinal loyalty, and brand experience–behavioral loyalty, respectively. The study results provide numerous theoretical and managerial implications to help academicians and practitioners provide better customer and brand relationship management. In the current competitive business environment, building and maintaining strong relationships between brands and customers is crucial for business success. Cultivating and retaining a devoted clientele is considered to be the primary factor that drives a corporation’s long-term success, as it reduces marketing costs, enhances competitiveness, boosts market share, generates positive word-of-mouth, and creates more opportunities for expansion . To achiSmartphones have become an integral part of daily life, as most individuals carry one with them wherever they go . The purThe smartphone industry in China has become a major player in the global market, with several of the world’s largest smartphone manufacturers, including Huawei, Xiaomi, Oppo, and Vivo, establishing themselves as significant competitors to established brands like Apple and Samsung . With ovIn order to build the consumer–brand relationship and improve performance outcomes, unique and memorable brand experiences have been increasingly important in branding literature during the past ten years ,11. ReseDespite the importance of brand experience and consumer loyalty, relatively little marketing literature has investigated the elements that connect these two facets of the industry. This research addresses this issue by focusing on two important brand love and trusts mediators on the linkages between brand experience and brand loyalty. Therefore, in comparison to other studies, this one provides a more accurate process model on how and to what extent customers develop brand loyalty . AdditioThus, this study diverges from other research and examines the particular dimensions of brand loyalty, namely, the behavioral and attitudinal dimensions. As a result, compared to earlier research, this study provides a more thorough analysis of the brand loyalty aspects. This study proposes a model that is motivated by brand experience, influenced by brand love and brand trust, and culminates in the outcome of word-of-mouth and brand loyalty. This study tackles these significant but under-researched research concerns. This study focuses, especially, on examining two different issues:(1) Is there a difference in the effects that brand love, brand trust, and brand experience  have on brand loyalty ?(2) Do the connections between having a positive experience with a brand and being loyal to that brand act as a moderating force between brand love and brand trust?The present study will contribute to the literature, exploring new relationships such as brand experience and attitudinal aspects, behavioral loyalty and word-of-mouth. The manufacturers of smartphones will benefit by understanding young students’ brand loyalty and the related predictors.The remaining parts of this paper are structured as shown below. After conducting a thorough analysis of the pertinent research, the author next presents the fundamental theory, which is known as the brand resonance model. After that, the method, findings, and conclusions are presented, followed by the study model and the assumptions. In the final section, we discuss the implications for theory and management, we discuss some limitations, and then draw some conclusions about where future research should go.Using “sensations, feelings, cognitions, and behavioural responses triggered by brand-related stimuli that are part of a brand’s design and identity, packaging, communications, and environments,” Brakus et al.  defined According to Hirschman and Holbrook , the ideExperience, on the other hand, is not an example of an emotional bond and cannot be used to define one. One example of this is brand attachment, which may be regarded as a powerful emotional connection between the customer and the brand . InternaAccording to another definition, brand experience is “the perception of the consumers, at every moment of contact they have with the brand, whether it be in the brand images projected in advertising, during the first personal contact, or the level of quality regarding the personal treatment they receive” The brand resonance model measures brand strength based on consumer perceptions, assumptions, and attitudes. Marketing managers must choose what and how consumers should learn about the brand, what its differences and associations are, the desired reactions, and the reasons why consumers should be brand loyalists , as wellAccording to the brand resonance concept, it is possible to achieve brand resonance, such as brand loyalty, using both logical and emotional approaches . The ratCustomers have a variety of expectations when they buy a branded product . CustomeH1: BE significantly affects BT.Customers have specific expectations when they buy branded goods. Users of the brand will like their interactions if the supplied value exceeds their expectations. Additionally, Khan and Rahman,  and FullH2: BE significantly affects BL.As separate from services as products are from services, experiences are a unique economic offering. The experience is a real offering, just like any other service, good, or commodity; it is not some abstract concept. An experience occurs when a business purposefully uses services as the props to draw certain customers, in a way that produces an unforgettable event . HoweverBrand experience, according to certain earlier studies ,57,58, hH3: BE significantly affects AL.H4: BE significantly affects BHL.The second result on brand experience that this research identified is a person’s propensity to share favorable brand messages through word-of-mouth. “Informal, person-to-person communication between a perceived non-commercial communicator and a receiver regarding a brand, a product, an organisation, or a service”, is how Harrison-Walker  describeAccording to Iglesias et al. , brands H5: BE significantly affects WM.A brand’s ability to anticipate or explain its customers’ behavior and provide high levels of satisfaction can be directly tied to its ability to meet their emotional demands, as stated by Ahuvia and Ahuvia , who argTrust in a brand can be influenced by consumers’ emotional responses to that brand, according to a study by Song et al. . Brand tH6: BT significantly affects BL.Customers do not decide what to buy at random. Instead, they are influenced over time by a number of internal factors. Customers will be psychologically connected to a brand, in addition to their recurring buying habits. This means that brand loyalty not only draws in new customers, but also keeps them coming back for more in a cutthroat market. The majority of empirical studies suggest that in order to accurately measure brand loyalty, both attitude and behavior must be taken into account, i.e., behavioral loyalty and attitudinal loyalty ,81,82,83H7: BL is significantly linked to AL.H8: BL is significantly linked to BHL.Customers’ judgments on a brand’s dependability and/or responsibility for their welfare are what is meant by brand trust, which is why it contains a cognitive component . From a H9: BT is significantly linked to AL.Behavioral loyalty refers to the extent to which consumers repeatedly make purchases from a brand over an extended period . Brand tH10: BT is significantly linked to BHL.This study adheres to the brand resonance model’s rationales, stating that brand loyalty might be attained by starting with brand salience  and, then, going along both the emotional and rational paths of brand love and trust . AdditioLikewise, brand experience and behavioral loyal were found to be linked in many earlier studies ,61. CustH11: BT mediates the association between BE and AL.H12: BT mediates the association between BE and BHL.Furthermore, brand love is a strong emotional connection that customers feel toward a brand, and it is closely related to attitudinal loyalty . When cuSimilarly, brand love creates a strong emotional connection with customers, and it motivates them to engage in behaviors that are beneficial to the brand . CustomeH13: BL mediates the association between BE and AL.H14: BL mediate the association between BE and BHLThe present research is a quantitative study conducted in China. An empirical survey was conducted to accomplish the objective of the current research. Some methodological issues are discussed in detail in the following sections.The present study employed the cross-sectional survey method to gather data using a questionnaire survey method from Chinese Universities. The sample frame was university students in China. The duration of the survey was for 2 months from March to April 2022. Smartphone brands such as Huawei, Apple, Xiaomi, Vivo, OPPO, Samsung, and OnePlus were chosen for this study, as those brands are popular in the Chinese market .2 = 0.15 for effect size, = 0.05 for error type one, and = 0.20 for error type two). A good rule of thumb for sampling, according to Barclay et al. [This research used the a priori test created by the G*power software to determine an appropriate sample size. As per Cohen’s proposal , the recy et al. , is to mThe study utilized a back-translation technique to ensure the accuracy of the survey. Here is how it was carried out: Firstly, the research questionnaires were thoroughly reviewed by three academicians. Secondly, we sought assistance from proficient research experts who were fluent in both English and Chinese to translate the questionnaire into Chinese. Thirdly, two professional translators who spoke both English and Chinese independently translated the Chinese questionnaire back into English. Fourthly, the quality of the translation was evaluated by comparing the two versions. In instances where discrepancies were found, the researchers and translators collaborated to resolve them. Finally, the questionnaire underwent a pre-test to determine its accuracy, and any necessary modifications were made and confirmed. The Cronbach alpha of the constructs was higher than 0.750, along with each factor loading which was above 0.5. Therefore, the study was found to have the appropriate reliability and validity.All items were adopted or adapted from previously validated questionnaires to measure the instruments. Brand experience and brand love were adapted from the scales developed by Kazmi . The meaBased on the suggested guidelines by Harman , in thisOverall, a larger part of the respondents were male (53.21%); as expected, respondents between 20–25 years of age (68.66%) were the significant contributors to this research. Graduate students were the larger portion of the total respondents (58.48), while the next group was under-graduate students (47.52) .Internal consistency and construct validity were estimated through the evaluation of the measurement model. The AVE (average variance extracted) and composite reliability tests were used to investigate the construct validity. Convergent validity (AVE > 0.5) may be inferred for all constructs in The results were satisfactory in terms of normality, with no significant deviation from normality. Both skewness and kurtosis were under 3 and 10, respectively  Table 3Table 3. High CR values above 0.7 are indicative of a reliable model and are generally accepted in the preliminary stages of research . Since t2) of the endogenous variable. According to Falk and Miller’s [2 value for the endogenous variable should be 0.10. Cohen [2 of 0.26 for endogenous constructs is considerable, an R2 of 0.13 is moderate, and an R2 of 0.02 is weak. 2 values higher than the minimum required by Falk and Miller [Santosa et al.  suggesteMiller’s  calculat0. Cohen  suggested Miller , indicatConfirmatory factor analysis was used to evaluate the reliability of the measurement model’s factor confirmation (CFA). 2/df = 1.738) (= 1.738) . The rooThe results  show brap < 0.05), and BE and BHL  significantly. It is clear that BE and AL , and BE and BHL  are significant. Therefore, we accept hypotheses 11 to 14.As proposed by , the cur2 value for attitudinal loyalty, word-of-mouth, and brand trust were 0.57, 0.59, and 0.54, respectively, while behavioral loyalty and brand love were 0.24 and 0.47, respectively. These results showed that the proposed model is generally comprehensive, adequate, accurate, and functional for understanding brand loyalty and word-of-mouth.The study attempted to integrate brand attributes, such as brand trust, brand experience and brand love, and tested the relationship with loyalty  and word-of-mouth engagement. The proposed framework contained 14 hypotheses, where 13 were accepted. With this, the explanatory power was moderate to high as the RA brand experience is a sort of experiential marketing that includes a comprehensive set of circumstances developed by a business to affect the perception a customer has of a specific product or brand name. Companies try to establish a broad atmosphere of goodwill, dependability, or trust through a mix of the many channels consumers use to interact with a brand, in order to establish a connection between the brand and a certain need or emotion. Hypothesis 1 assumed that BE is related to BT. The result of this study confirmed the hypothesis in line with the past study by Huaman-Ramirez and Merunka . This siSurprisingly, hypothesis 4 did not support the assumption that BE is positively linked with BHL. This is opposite to past studies , which fAs expected, the relationship between BT and AL is proven as significant in this investigation (H6). The past result by Huang  also supThe understanding could be that BT brings BL into the consumer’s mind. Additionally, we assumed that brand love positively influences the AL and BHL of consumers toward the brand (H9 and H10). Both the hypotheses were proven to be true in this regard and also in supporting the past literature by Huang . People Customers are able to develop certain feelings toward a good brand, such as happiness, amazement, anger, disappointment, or other feelings, when they are confident that their chosen brand can satisfy both their needs and wants. When customers have faith in a brand, this condition can also ignite customer loyalty in the form of attitudes and behaviors.To better understand consumer behavior, many studies have looked into brand loyalty. It can assist businesses in boosting their earnings and market share. Since the 1990s , BT reseRegarding the mediation relationships, the current study found all four mediating factors significant. Hypothesis H11 postulated that BT mediates the relationship between BE and AL. The result confirms that the indirect relationship of BT is partially significant. This means that brand experience also predicts AL via brand trust in product buying choice. Likewise, brand love, which was found to have a direct relationship with AL and BHL earlier, was also found to have a moderating role between BE and both loyalties. This helps estimate that enhanced BL could assist in predicting the association between product BE and brand loyalties indirectly as well (H13 and H14). However, BT and BL as mediator constructs in the association between BE–BHL are evident in the full relationship.The purpose of the study was to identify the effects of brand attributes on loyalty and word-of-mouth engagement in choosing smartphones among Chinese students in mainland China. The study also investigated the mediating effect of BT and BL between BE and loyalty. The results showed that BE had a significant influence on BT, BL, AL, and WM, except for BHL on the same. Likewise, the link between BT and AL, BHL and BL was found to be significant. Also, the effect of BL on AL and BHL became significant. Furthermore, the study found that BT mediates the relationship between brand experience and AL and BHL, indicating that the positive impact of brand experience on these two aspects of consumer behavior is partially explained by the influence of BT. This highlights the importance of building brand trust and credibility in order to influence consumer attitudes and behaviors. However, these findings highlight the importance of creating positive brand experiences to improve consumer behavior and increase word-of-mouth for smartphone companies. Overall, the study contributes to our understanding of consumer behavior and provides valuable insights for marketers looking to enhance brand experiences and leverage them for better outcomes. The following are the details on the implications, limitations, and future research directions:Customers can develop enduring relationships with brands when they have favorable impressions of those brands. This connection increases consumer affection, trust, and loyalty to the brand. This study’s findings, which show the value of brand management in the context of service-led reasoning, show that the various types of brand relationships have variable effects on brand loyalty and brand trust. This demonstrates that brand trust and brand love models should be included to increase brand loyalty in addition to enabling customers to develop an intimate psychological relationship with the brand in order to enable them to form a long-lasting emotional connection with it. Generally speaking, our analysis results of this study in the context of smartphone usage offers empirical support for the conceptual framework proposed in this study.Zhang et al.  conducteBT and BL have been discussed in the literature , but theMost earlier studies’ theoretical frameworks for brand qualities and relationships relied on interpersonal theories with a Western focus. On the other hand, interpersonal theories that are applicable to China are distinct from those that are applicable in Western countries. It is important for brands, which are tools for developing relationships, to conform to the society in which they operate. It has been discovered that the Chinese are more likely to be influenced by preexisting relationships, whereas Western studies have primarily concentrated on the dynamics between brands. On the basis of these findings, our research constructs a brand attribute model that is founded on indigenous ways of thinking. It also underlines the necessity to concentrate on brand attributes and brand loyalty, both of which are extremely important. The findings from this research not only provide a deeper level of explanation, but also offer practical advice for addressing one of the more challenging aspects of relationship marketing, namely the process of creating brand loyalty in customers.Given these findings, marketers should employ the finest brand architecture and brand portfolio approach to create the greatest brand. The brand’s quality varies depending on the product and the target market. The brand should be created by the seller with the targeted market in mind. If a brand deviates from what consumers anticipated, this will cause them to see it as having inferior quality.Increasing a customer’s love for a brand can improve their flexibility and positive awareness toward the brand, which in turn increases the customer’s level of pleasure from the brand. Businesses not only need to keep a trustworthy and communicative relationship with their consumers in order to enhance their repurchase rate, but they also need to improve their customers’ brand loyalty in order to keep their existing customers and attract new ones.Customers who trust a brand are the ones who control their opinions of it, whether they are positive or negative. Additionally, when consumers have faith in a brand, their psychological process, which includes their commitment to and preference for the brand, is altered, and this is reflected in how they feel about the brand. These findings could be applied by marketers to build consumer trust in their brand by providing a solid guarantee, an accessible company and product line, a sustainable service, dependable items, the best value for customers, consistency, and many other factors.In order to ensure customer loyalty, whether in the form of attitudinal or behavioral loyalty, the brand’s quality should also be maintained and improved by developing a long-term plan for quality improvement, talking and sharing ideas with customers about improving the quality of products and services, comparing products with competitors, giving supreme priority to quality in all plans and procedures, creating a qualified quality assurance team, and many other things.The current study is not beyond having limitations. First, this study is regarded as cross-sectional because the data was acquired through the use of a standardized questionnaire; hence, no longitudinal or experimental data were accumulated regarding the customers’ loyalty to smartphones. In light of this, researchers are strongly encouraged to investigate scenarios in which customers react to various brand relationships and to take into account topics relating to love for a brand, trust in a brand, and loyalty to a brand from both qualitative and quantitative perspectives to the extent that data resources allow for such an investigation. Second, we discussed brand trust, brand love and loyalty based on the brand resonance model. Future studies could be conducted from other perspectives, applying other theories to add value to the research. Third, we found no relationship between brand experience and behavioral loyalty, and we found the presence of an indirect relationship with brand trust as a probable reason for this insignificance. However, other factors such as external influences such as peer influence, and self-efficacy variables can be integrated in advanced studies. Fourth, the moderation constructs are ignored in this study, where future studies could come up with such variables to enrich the literature on brand loyalty, or so. Finally, this study relied on a student sample and the findings may not generalize to other populations, such as non-student adults or children. This can limit the external validity of the study’s findings and make it difficult to apply the results to real-world contexts. Future research could focus on collecting data from a more diverse range of participants, including individuals from different age groups, ethnicities, and socioeconomic backgrounds, to cover such limitations.


We introduce a culture-centered indigenous program called the Family Listening Program (FLP), which was developed through a long-standing community-based participatory research (CBPR) partnership involving tribal research teams (TRTs) from three American Indian communities  with the University of New Mexico’s Center for Participatory Research (UNM-CPR). This paper provides background information on the TRT/UNM-CPR multi-generational FLP intervention funded by the National Institute on Drug Abuse and how it is poised to take the next steps of dissemination and implementation (D&I). In preparing for the next steps, the TRT/UNM-CPR team piloted two FLP dissemination activities, first at the state-level and then nationally; this paper describes these activities. Based on the learnings from the pilot dissemination, the TRT/UNM-CPR team developed an innovative D&I model by integrating a community-based participatory research culture-centered science (CBPR-CCS) approach with the Interactive Systems Framework (ISF) to examine the uptake, cultural acceptance, and sustainability of the FLP as an evidence-based indigenous family program. Embracing community-based participatory research (CBPR) principles  and cultThe Pueblo of Jemez, traditionally known as Hemish of Walatowa, is located in north central New Mexico, has ~3400 members, and is the only Towa-speaking community, with language fluency surveyed in 2006 at 80–85%. With community members now concerned about a decline in the Towa language, language preservation (with Head Start immersion), and Hemish ways of life are tribal priorities, with the belief that cultural preservation enhances health and educational attainment . Since 1The Ramah Band of Navajo, with ~3000 members, is located in western New Mexico and is one of three noncontiguous reservations from the main Navajo Nation. Ramah Navajo was the first New Mexico tribe to exercise self-determination for education in the 1970s, with oversight from the Ramah Navajo School Board, Inc. (RNSB). In 1978, RNSB expanded its role to oversee health and social services. Since 2000, Ramah Navajo has partnered with UNM-CPR in multiple research studies; their FLP was created and piloted with NARCH III (2005–2009) funding .The Mescalero Apache Tribe has over 5000 enrolled members in south-central New Mexico, with three sub-bands, Mescalero, Chiricahua, and Lipan Apache, speaking Southern Athabaskan, though with much language loss. Mescalero has been a leader in native sovereignty, including business and water rights. With healthcare delivery under the Indian Health Services, their FLP was the first tribal-directed prevention research program, working with UNM-CPR with NARCH V (2009–2014) funding .Based on the success of piloting three culture-centered family curricula, the three TRTs agreed to collaborate in the rigorous testing of each program and to aggregate child and parent data to build an evidence base of the FLP through current NIH-National Institute on Drug Abuse (NIDA) funding (2014–2021). Though still in effectiveness trial, other southwest tribal communities have expressed an interest in learning more about the FLP, and with promising preliminary data from the effectiveness trial, the UNM-TRT team began to actively plan and disseminate information about the program, including the processes of building a tribal team and using a CBPR approach to culturally re-center and implement the family program with new tribal communities. This paper will describe the pilot dissemination efforts by the TRT/UNM-CPR partnership and their experience in conducting a state-level and national dissemination workshop.1.1.The FLP is a two-hour dinner program with 12 sessions that uses cultural connectedness, empowerment, and a positive youth development model that is led in each tribe’s language or bilingually with a focus on communication skills, New Mexico health education standards, and drug/alcohol prevention messages with reinforced cultural traditions and indigenous knowledge. Research has found evidence that the connection to history, land, language, traditional food, and culture can have a positive impact on indigenous health . There aWelcoming Dinner—emphasizing cultural foods and eating together as a family; My Family—relationships, core values, and cultural roles of families; Our Tribal History—communities’ ancestral lineage of the people; Our Tribal Way of Life—phases of life, cultural roles, and responsibilities; and Community Vision—strengths and visions for each community. The next seven sessions focus on cognitive-behavioral exercises: Community Challenges—challenges and solutions needed; Communication and Help Seeking—cultural norms and behaviors of extended support systems; Recognizing/Managing Types of Anger—approaching anger from traditional ways; Problem Solving Strategies/Being Different—exploring discrimination while highlighting beauty in differences; and Positive Relationships of respect and support. By session six, the families start their Community Action Projects (CAPs) supporting empowerment efforts. Sessions end with Building Social Support and Making a Commitment—with a sharing of CAPs. All sessions are based on a cyclical reflection process, based on Brazilian Educator Paulo Freire’s emancipatory educational methodology, which embodies deep listening to each other, engaging in dialogue across generations, and supporting the families to engage in actions for change, which then repeats in subsequent sessions of re-listening, dialogue, action, and reflection , we have recruited parent–child dyads from our three tribal communities, resulting in over 560 participants [program (n = 295) and comparison (n = 265)]. Measures for children included assessment of depression, anxiety, problem-solving skills, cultural participation, alcohol and drug use, and other factors. Adult measures included parenting skill, coping strategies, community support, and engagement in traditional and cultural activities.1.2.Dissemination and implementation (D&I) science has become increasingly important as health interventions are developed, tested, and found to be effective in improving health outcomes in a specific setting, only to fail to be integrated into larger practice . ImplemeThe concept of culture-centeredness deepens an approach to culture beyond a set of beliefs or superficial images. We mean by culture-centeredness the integration of people’s agency, voice, and power to direct community change through indigenous knowledge and ownership . Researc1.3.Nationally, tribal oversight in research has grown in the past decades to counter historic abuses of “helicopter” research, stereotyping, and disregard for community knowledge. Tribes now demand the benefits of research studies, i.e., data ownership and authority over publications . In the CBPR has become a valued research approach between tribes and academic institutions as a counter to the history of research abuse and in recognition of the increasing evidence of CBPR effectiveness in reducing inequities . Tribal Prevention Science of large-scale NIH-funded intervention trials, based on CBPR practices, for AI/AN communities has led to an upsurge of interest in the next step of D&I of interventions that are proving to be effective -based mini-dissemination conference and, second, a pre-conference workshop for the 2019 National Indian Child Welfare Association (NICWA) conference. The goal of these events were to translate the research process into a program implementation process in establishing a FLP program with tribal communities who had shown an interest in re-centering and implementing their own FLP to be housed in their own health, education, or prevention departments.The NM mini-conference came about through extensive planning by the TRT/UNM-CPR team who defined the conference structure, developed a recruitment plan, and scheduled a conference date. In the planning process, there was consensus that the sessions needed to have both interactive activities so that the participants could experience the FLP and information on the CBPR partnership between the TRTs and UNM-CPR to highlight the research development and implementation of the FLP in each community. Administration and program logistics were also key suggestions for the mini-conference based on the fact that each of the three TRTs had experienced important learnings within their own tribal administrative processes.Participant recruitment to the NM mini-conference began in mid-summer 2018 with the posting of flyers in emails to tribal networks in New Mexico and to those who had previously indicated an interest in the FLP. The TRT/UNM-CPR team purposely chose to cover travel expenses  of three individuals from six different tribal communities so that attendance by tribal members outside of Albuquerque did not become a burden for participating. The conference objectives were as follows: (1) to experience and gain knowledge about the family listening curriculum and determine feasibility for their community and (2) to gain an understanding of community-based participatory research processes for adapting and re-centering the program to their own tribal history, practices, knowledge, and values.Based on the learnings and success of the NM mini-conference, the TRT/UNM-CRT team had a unique opportunity to share their dissemination experience through a pre-conference workshop prior to the National Indian Child Welfare Association (NICWA) conference that was to be held in Albuquerque in the spring of 2019. The TRT/UNM-CRT team reflected on their mini-conference experience and adjusted the agenda from a day-and-a-half conference to a successful six-hour workshop. These two dissemination experiences prompted the team to continue to work together and to develop an innovative framework that brings together the CBPR model, the Interactive Systems Framework.1.4.To create a D&I framework that would be appropriate for the multifaceted structure of tribal systems, the UNM research team identified the Interactive Systems Framework ISF; . The ISFTo strengthen the science of community engagement, our UNM research team, with national partners, has had three stages of NIH funding since 2006. We first developed and tested a CBPR conceptual model with four domains important in community–academy collaborations, which include the following: context; partnering processes and practices; processes and outputs of community-engaged research designs/interventions; and intermediate capacity and policy and longer-term health and health equity outcomes . In the For our FLP D&I approach, we combined our CBPR conceptual model, which includes a culture-centered approach to intervention development, with the ISF  to creat2.Welcoming (learning our Indian names and clans) and Family and Community Values; (2) Our Family Tree; (3) Being Different; and (4) Our Tribal Histony. In the breakout sessions, digital stories were shared that were produced by each TRT based on their own program, and in a discussion about the curriculum, a TRT facilitator stated, “The curriculum was developed by the community for the community, that’s why the program has been working for so long.”The NM mini-dissemination conference was held on 6–7 September 2018 with 28 participants from six southwestern tribal communities, 10 more participants than anticipated with total attendance at 46, which included the TRT/UNM-CPR team. The participants were from the following communities: To’hajilee (the Cañoncito Band of Navajo), Taos Pueblo, Tesuque Pueblo, Kewa Pueblo, Zia Pueblo, and Navajo members of the San Juan Collaborative. The conference participants represented staff from education, behavioral health, language, prevention programs, and tribal leadership. Through breakout sessions, the TRT facilitators from Jemez Pueblo, Mescalero Apache, and Ramah Navajo led conference participants through four of the twelve sessions: (1) While explaining the logistics about the program, a Mescalero Apache TRT member talked about the challenges and benefits of having support: “We were very fortunate to have research funding that helped us have transportation. We needed it because we had to pick up families and take them back after the program sessions.” Another important discussion focused on recruiting families and a Ramah Navajo TRT member shared, “we talk to the families and explain to them the program. We  go to the schools and talk to principals.” A Jemez Pueblo TRT member also added, “We have a newsletter that goes out monthly and explains how families can be recruited.” Lastly, in the creating your own family program session, the discussion centered on the importance of building a team and moving towards sustainability of the FLP program; a question was raised about procedures to start a program, and a Ramah Navajo TRT member responded that they identified another tribal department with similar goals, and this was helpful in the success of their FLP.3.Family Values, Being Different, and Tribal History, as well as panels on community action projects, administration, and logistics for implementing the FLP. The challenge was modifying a day-and-a-half mini-conference into a six-hour workshop. Despite the shorter timeframe, the workshop successfully shared the FLP and garnered interest from several communities. One participant stated, “I will be talking with Tribal Council about applying or using this program.” Another participant shared that “I plan to relay this program to our Director. I will share the information I’ve gained to coworkers and I plan to use some of the concepts and icebreakers within our community.”Based on the success of the NM mini-conference, the TRT/ UNM-CPR team actively sought out the opportunity to host a pre-conference workshop at the 39th Annual NICWA, which was held in Albuquerque, NM, in March 2019. The workshop had 35 participants from across the U.S. and Canada who expressed interest in adopting the FLP. Based on the learnings from the NM mini-conference, the TRTs led participants through the same experiential hands-on FLP curriculum sessions focused on synthesis and translation system, refines the evidence-based innovation into practice-based user-friendly processes, and CBPR-CCS incorporates contextual and cultural processes that enhance community readiness and capacity, based on the context domain of the CBPR model. The second ISF stage, support system, strengthens structural/functional factors  and people power  to ensure sufficient bi-directional knowledge for innovative uptake that leads to an improvement of the quality of the implementation. CBPR-CCS reinforces the support system with skilled-TRT members who will provide trainings and mentorship of the new tribal CABs through collaborative partnerships, relationship building, and navigation of complex tribal oversight and approvals that support tribal community-driven efforts. The third stage, the ISF delivery system, focuses on how the translated practice-based culture-centered intervention and research, the third domain of the CBPR model, will be implemented and evaluated for quality implementation to enable enhanced feasibility, cultural acceptance, with uptake and sustainment of new capacities and program outcomes as the final goal.After experiencing these two dissemination conference/workshops, the TRT/UNM-CPR team turned these learnings into a NIH D&I grant proposal with the development of an innovative framework that brings together the CBPR-CCS model with the ISF . The ISFSurrounding this model are steps of implementation from the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework , helpingAfter this integrated model was created, we adapted tools for evaluating how the FLP will be disseminated and implemented in other tribal communities. We integrated multiple qualitative and quantitative tools to assess implementation steps with the ISF coaching system  to incre4.In this paper, we describe the process of culturally centering the FLP and opportunities to improve D&I science through integrating a CBPR approach. The NM mini-dissemination conference and the NICWA pre-conference workshop were successful events that engaged participants from numerous tribal communities in deep and powerful discussions on the need for a tribally centered family intervention/program that could be re-centered in their own communities. Some highlights of the events, as expressed by the participants, were the presence and presentation by the different tribal communities  and that the conference utilized positive experiential approaches and provided solutions (via the FLP program) to address community problems . The participants commended the TRTs for their commitment to the creation and now sustainability of their FLPs in their communities and the long-term partnership between the TRTs and UNM-CPR. One of the participants praised the entire FLP team stating, “This work is not just bringing people together, but it is also making them aware about the issues to be addressed and why culture and language are important to be looked at.” Overall, the participants valued most the following topics: the process of curriculum re-creation, the involvement of language teachers, the role of facilitators and trainings, the administrative processes to run their own FLP, and the sharing of digital stories. Lastly, the participants not only learned about the FLP program, but were also able to network with plans to continue the dialogue about expanding the program to other tribal communities.As a result of these two pilot D&I activities, we have strengthened our integrated D&I system, combining our CBPR- CCS model with ISF importance of providing tools and coaching for continued support to new tribal communities interested in the FLP. We also recognized the importance of capacity building of new FLP tribal teams, which will require ongoing consultation and coaching, especially in navigating support from tribal leadership and re-creating and re-centering the curriculum to their own culture, practices, history, and ways of knowing.5.In this paper, we shared the pilot dissemination efforts of the culture-centered FLP, an intergenerational indigenous family program based on a long-standing CBPR partnership between three research teams from three American Indian communities and UNM-CPR. The findings from the pilot dissemination activities moved the TRT/UNM-CPR team to developed an innovative D&I model, which integrated CBPR-CCS with the ISF; this process will strengthen D&I science by testing the implementation of our indigenous-focused FLP with implications for indigenous global health. Future research should continue to examine appropriate D&I strategies among indigenous communities to improve health disparities.


The number of people with chronic diseases has increased globally, as has the number of chronic diseases per person. Faced with this reality, the term “complex patient” is current and actual.The healthcare costs associated with these patients are high and are expected to increase since most healthcare systems are not yet ready to provide integrated long-term care. In Portugal, several health institutions have made efforts to provide integrated care: case management models have been implemented to complex patients follow-up. However, studies related to cost of these programs are still limited. Therefore, a qualitative investigation was conducted, approaching the design criteria of a case study research, to design a case management program for complex patients and determine its direct costs, following the Time-Driven Activity-Based Costing methodology, in Local Health Unit setting.The direct costs of providing care to a complex patient involved in a case management program were determined, using the Time-Driven Activity-Based Costing methodology.A map of the complex patient was drawn, considering a standard flow in the program. Times and costs were allocated to the activities on the map, following Portuguese and international practices of case management models.A total of 684,45€/year is spent for each new patient in the case management program, of which 452,65€ corresponds to cost of remuneration of professionals involved; and 663,85€/year, for each patient who is in the case management program (over 1 year), where 432,05€ corresponds to cost of the remuneration of the professionals involved.Follow-up is the most costly phase (80.82%) and where more time is spent (85.62%).The time spent by professionals and resources involved and the costs associated with each patient were obtained. The economic impact of the analysed activities was not studied, however, according to international authors, when well applied and selected, integrated care models lead to cost reduction and improved health outcomes.The online version contains supplementary material available at 10.1186/s12913-023-09729-5. Globally, greater longevity and population growth are observed . Those fPatients can have an indication for certain medications, but if they have kidney disease or other conditions, these medications may be contraindicated” [.Multiple chronic conditions can coexist in a person's health and, thus, influence the complete cycle of healthcare that the person must receive. This type of patients are known as complex patients , 2. Accodicated” .Complex patients have a greater number of potentially preventable health complications, reduced quality of life, and greater consumption of healthcare resources, leading to higher healthcare costs , 2.Healthcare costs, particularly hospital costs, continue to rise . DespiteAccording to the literature, a costing system in the health sector is fundamental to the knowledge of the costs incurred in the provision for financer-provider contracts , cost ofIn Portugal, with the aim of increasing the coordination of provision between the primary, secondary and tertiary healthcare levels, on the scope of the National Health Service, in 1999, Local Health Units (LHU) began to be created .LHU are public entities, with business nature and legal personality and administrative, financial, and patrimonial autonomy. Funding is carried out on a per capita risk-adjusted basis to reflect differences in supply and demand from the target population. Data on their costing methods are not available , 10.The high level of care performance of this type of organization is achieved by strengthening the role of primary care center (PCC) as patient and case managers . LHU conA successful Portuguese example of healthcare integration is the Alentejo Coast Local Health Unit, with its “Case Management” programme, which is focused on the needs of patients and their families. It faces the conventional model of response to acute illness, in an episodic, reactive way and not focused on chronic conditions. The pillar of this Case Management is the coordination between hospital healthcare and the PCC, based on a multidisciplinary team made up of healthcare professionals. It encourages accessibility and morbidity reduction, creating a single point of contact between the patient and healthcare institutions – the case manager . The casFor Alentejo Coast Local Health Unit, the results have been clear, including a reduction in the decompensation of chronic patients, and consequently, a 66,6% to 77,1% decrease in visits to the emergency department, a 52,4% reduction in hospital admissions and a lower consumption of consultations , 14. TheAs in the previous example, Matosinhos LHU also operates its services through a case manager with its “Support team for complex chronic patients” program. The program had positive results too in this institution, with: a reduction of 55,6% in the number of hospitalizations for urgent episodes if we consider the same period of the previous year or 63% if we consider the period immediately before the integration of the program; 42,3% reduction in the number of hospitalization episodes if we consider the same period of the previous year or 65,4% if we consider the period immediately before the integration of the program .There is still little research on the determination of costs in LHU. In Portugal, there is no legal framework for costing in of vertical integration healthcare context, as in hospitals example that has the Analytical Accounting Plans for Hospitals of ministry of health . AccordiTime-Driven Activity-Based Costing (TDABC) methodology, recommended for integrated care models, calculates the cost per care activity, pathology and time, enabling the determination of precise estimations of the cost of each activity throughout the entire provision cycle to produce a certain result in health , 9, 16.Thus, this investigation proposes the design of a case management program for complex patients and the determination of its direct costs, following the TDABC methodology, in LHU setting.To respond the defined objectives of this study, the methods followed the steps of TDABC methodology .To design the flow map of a case management program for complex patients, the following procedures were carried out:i - Identification of all key activities carried out throughout the entire cycle of standard care of a complex patient, for one year;ii - Identification of direct resources involved in providing care;iii - Flow map obtention - Fig. 1In order to determine the direct costs per complex patient in the case management program, applying the TDABC methodology, the following procedures were carried out:i - Obtaining time estimations for each activity and resources used, based on a research article, You E. C. et al. , and an ii - Estimation of the cost of all direct resources involved in the provision of care, using Portuguese Government documents as a reference, allocated according to the time of each activity and resource involved.iii - Calculation of the total cost of providing care.Microsoft® Excel® for Microsoft 365 MSO  64-bit was used.The perspective of this investigation is the Portuguese National Health Service, more specifically the health care provider LHU.1 - Complex patient flow-map, in a case management program in a LHU and identification of key activities carried out throughout the care cycleFor confirmation of the data and better knowledge of the context, experts from an LHU were consulted.The flow map is about the standard course of a complex patient in a case management program, in a LHU. That is, due to the heterogeneity of care provided through the heterogeneity of the complex patient's needs, only the standard course to which all selected complex patients are submitted was considered.Tortajada S. et al. [2 - Human resources involved and time allocatedThe map was built based on adaptations of the model used in a LHU, described in “Case Management Program” , and the. et al.  study. TFor standardization purposes, were always considered 35 work hours per week and 140 work hours per month as the basis for all professionals involved, public sector workers.For the implementation of the program, various professional groups were considered: Physicians , Nurses , Social Worker and Operational Assistant.The choice of these professionals was based on what is being done in an LHU Case Management Program, reported in its technical sheet . As the Tortajada S. et al. [You E. C. et al. [3. Time allocated to the different flow map phasesSupplementary material . et al. , resourc. et al.  and detaYou E. C. et al. [For purposes of time and cost allocation, according to the article . et al. , two addYou E. C. et al. [4. Time allocated by human resources to flow map different phasesTo obtain times allocated to each phase in the case management program, the article . et al.  was usedAt each phase, the professionals involved were identified, as shown in Supplementary material From the previous steps, it is known the time that each phase spends in the program. And, the time allocation of each professional to the program is also known. From here, the time allocation of each professional to each phase was determined by crossing the data.5. Human resources costsTo 100% of “Time allocated to different flow map phases” , 40 min 6. Other resources involved in the flow-map phasesThe costs of professionals involved were based on the 2022 Portuguese Public Administration Remuneration System [At all phases, it was considered that information system (IS), technological infrastructure and other necessary infrastructure resources were available within health units, where they are already implemented and used by teams at different care levels. Thus, these resources were disregarded in the mappings when the milestone took place within the facilities of health units.Since follow-up phase is the only that involves the work of professionals outside health units, it was also the only phase where “Other resources involved” were associated, as shown in Table For limited-use devices, it was assumed that their lifetimes are 3 years and their use divided among 35For the transport subsidy, journeys of 100 kilometers were considered;7. Times and costs allocated, by the resources involved, in different flow map phasesAt this stage of investigation, all previously presented elements were crossed. To achieve a summary table, formulas were applied to obtain conclusive data that were easy to interpret—presented at Supplementary material You E. C. et al. [The article used as a basis for calculating the time allocated in each phase  does noResults of this investigation were calculated using Microsoft® Excel® for Microsoft 365 MSO (version 2205 Build 16.0.15225.20172) 64-bit.1 - Complex patient flow map, in a case management program in a LHU and identification of key activities carried out throughout the care cycleEach step reported in the Methods represents the calculations performed and Results obtained.2 - Human resources involved and time allocatedThe results were based on the standard complex patient flow map described in Fig. 3. Time allocated to the different flow map phasesThe choice of these professionals was based on what is being done in a LHU case management program, reported in its technical sheet  and presYou E. C. et al. [4. Time allocated by human resources to flow map different phasesThe time and costs obtained in this investigation, resulting from compilation of . et al. , LHU tec. et al.  and the Knowing the time allocation of professionals and of each phase, per month in the program, it was possible to determine the allocation of each professional involved in each phase—Supplementary material 5. Human resources costsIn line with what was saw in calculations made in “Human resources involved” and “Time allocated to different flow map phases”, nurses case managers and hospital nurses, in phases in which they participate, are the ones who dedicate most time by program phase, among other professionals, thus validating the central role of nurses in building a case management program.6. Other resources involved in flow map phasesAll professionals’ remunerations considered, presented at Table Follow-up phase was the only one to have “Other resources involved” associated. As described in Table For home visits dislocation, the transport subsidy considered was 0,36€/Km , and forAlso, the mobile monitoring kit was estimated 3 years of useful life. Each unit costs 959,40€ , leadingA laptop with VPN  is also necessary. With 3 years of useful life, it costs 0,79€ per use.7. Times and costs allocated, by the resources involved, in different flow map phasesThis calculation step is the intersection of all the steps performed previously. It is the compilation of all the information of the resources considered in this investigation.The sum of time spent by all professionals, per year, per patient entering the program is 40,49 h; and 39,31 h/year per patient that is in the program over 1 year.For each patient entering a case management program is spent 684,45€/year, of which 452,65€ corresponds to costs of salaries of professionals involved; and 663,85€/year, for each patient who is in a case management program (over 1 year), in which 432,05€ corresponds to costs of salaries of professionals involved.Follow-up is the costliest phase  and where most time is spent , as shown in Table The direct costs and calculated times are only related to standard flow of all complex patients, regardless of their chronic conditions and specific health care in the program.TDABC applications studies have been reporting that indirect costs represent around 26% to 38% and human resources salary 51% to 73% of total costs , 24. In To make Results of this investigation comparable, costs obtained were extrapolated and interpreted as being 51% of the actual cost of the program:Extrapolated cost for each patient entering a case management program:   = 1.342,06€Extrapolated cost for each patient who is in a case management program (over 1 year):  =1.301,66€The increase in life expectancy has been a global reality, which increases people's exposure to risk factors that trigger chronic diseases . ChronicStudies have revealed that more than 67% of people over the age of 65 have more than one chronic disease , 3. SpecHealthcare costs in Europe for chronic diseases are estimated at 700 billion euros per year . It is eAs presented in this investigation, some studies also support that human resources are the biggest cost part of a case management program. Integrated care models aiming home disease management reduce the costs of these programs .In the present investigation, where the model was oriented to diseases self-management and patient empowerment, the extrapolated annual cost of it was 1,301.66€ per patient involved in the program. The extrapolated cost obtained per patient is 2,1 times lower than the base price of hospitalization per DRG costing method  . AlthougOn 2021, one Local Health Unit (Alentejo Coast), with 103,197 registered patients , obtaineWithin the scope of providing care in an integrated manner, the signed agreements between the financier and the Portuguese health institutions include the integrated financing of programs for specific conditions, such as obesity, diabetes, and chronic obstructive pulmonary disease ; which aIn Surgical Obesity Treatment Program, the funding is defined from 750,67€ to 754,67€/year of follow-up (plus surgery), per patient ;In Treatment of Patients with Continuous Subcutaneous Insulin Infusion Devices Program , 1.547€/year is paid, by the financier, for each new patient in the program and 1.092€/yearIn Telemonitoring Program for Chronic Obstructive Pulmonary Disease, the funding per patient is 2.156€/yearIt is important to emphasize that the above-mentioned funding programs are directed to only one chronic condition and, therefore, do not consider the therapeutic complexity and costs associated with patients with the coexistence of two or more chronic conditions.To compare the results of this investigation with fundings presented above, the costs obtained were extrapolated and presented in Fig. Desmedt M. et al. [n = 22) reported positive economic impacts after a short time.Although initially integrated care programs could mean extraordinary investments compared to the conventional care approach, the cost reduction per patient and year in the short term and the health gains for those involved are worth it . Desmedt. et al.  confirmeAlentejo Coast LHU reported that with the application of its case management program, it reduced by 57% the number of hospitalizations and 73% of the number of visits to the basic emergency service, of program integrated patients :For every 100 hospitalizations, the State (financier) saved 157.263€   saved 3.066€   . This was not conducted in the present investigation for reasons of lack of available data to proceed the methodology and get the quantitative results.To the entities responsible for Health in Portugal are recommended to implement more flexible accounting rules that keep up with the versatility of health care for current populations. TDABC costing method would be an added value to the reality of providers, accompanied by a single IS that would facilitate registration of the process and all necessary information to calculate costs. Otherwise, with complex needs growing, how else can provision, costing and correct financing of healthcare be fully studied? How else can we have registered all the costs incurred in maintaining health of populations?It is believed that the incidence of chronic diseases, and consequently complex patients, will continue to increase in upcoming years, at a higher rate than population growth. The increase in health costs associated with these patients and the management of multimorbidity are current and future issues that introduce a new paradigm of integrated healthcare.Although in Portugal, some care integration strategies are already implemented, namely case management, the cost knowledge of these programs are limited. In this investigation, the standard flow of a complex patient was designed in a case management program and direct costs were calculated using TDABC. For each patient in a case management program, an extrapolated cost of 1.301,66€/year was obtained. This amount is lower than Portuguese funding of some chronic disease care programs described in financier-provider contracts. These stated financing programs are directed only to one chronic disease and, therefore, do not consider the heterogeneity of care, thus reinforcing the premise of cost reduction with implementation of integrated care. There is the need to create funding programs dedicated to complex patient, and not just to single chronic diseases.Effectiveness of interventions and their economic impact were not studied. However, according to several authors, when well applied , integrated care programs, namely case management models, generate gains in health and cost reduction, thus being cost-effective in comparison to fragmented conventional care offered by current health systems.Additional file 1: Supplementary material 1. Resources involved in a complex patient case management program, in a LHU [in a LHU , 14, 15.Additional file 2:Supplementary material 2. Time and cost allocated, per the resources involved, in the different phases. Calculations performed in a Microsoft® Excel®.Additional file 3: Supplementary material 3. Costs included in the program of this investigation. Direct costs were included.