Nuevo Amanecer or NA) to be generalizable to rural, low literacy Spanish-speaking Latinas with breast cancer survivors at all phases of survivorship.Adapt a cognitive-behavioral stress management program (Nuevo Amanecer or NA-II), design a randomized controlled trial for community settings, identify recruiters and interventionists, and recruit participants into the trial.Apply the Transcreation Framework, a community-engaged translational model, to develop the adapted program  were randomized to the intervention or a wait-list control group. The sample was vulnerable: 69% had < high school education, more than half had only Medicaid or no insurance, 91% was foreign born, and 48% reported financial hardship in the past year.Adaptations included expanding the program from eight to ten weeks, simplifying materials, and increasing skills practice. We added stress management videos, healthy lifestyles information, and survivorship information. Interventionists were trained Latina breast cancer survivors. All core components of Applying the Transcreation Framework to engage stakeholders in designing community-based RCTs enhanced congruence with community contexts and recruitment of this vulnerable population. Rural cancer survivors represent a vulnerable and understudied population. Rural cancer patients across the U.S. face challenges receiving cancer care due to poverty and limited access to cancer treatments, cancer support providers, and transportation . Rural rTwo systematic reviews found that rural breast cancer survivors have a greater desire for information about their cancer and less access to psychosocial supportive resources than their urban counterparts , 7. BarrCognitive-behavioral stress management (CBSM) interventions are evidence-based cancer supportive services that can improve health-related quality of life, reduce stress and anxiety –20, and However, only one study of supportive services delivered in rural settings to cancer patients and no studies among rural Latina breast cancer survivors  were fouCBSM programs for cancer patients have been delivered primarily by mental health professionals in large cancer centers. Widespread adoption of these programs could be enhanced if they were translated for delivery in community settings by trained peers, and tailored to meet the needs of more vulnerable, ethnically diverse groups. Utilizing peer cancer survivors for program delivery is a promising avenue for increasing access to stress management services in community settings, , 24 espeNuevo Amanecer-A New Dawn, hereafter referred to as NA) for recently diagnosed, urban, Spanish-speaking Latina breast cancer survivors [NA program is a culturally tailored, peer-delivered intervention that teaches cognitive-behavioral coping skills to survivors, to manage stress and emotions. The RCT results indicated that women who received the NA program improved in several health-related quality of life domains and decreased breast cancer concerns and depressive and bodily symptoms over a six month period, compared to a wait-list control group [Utilizing this strategy in a prior study, a community-based participatory randomized controlled trial (RCT) was conducted to develop and test a CBSM intervention . As part of this research program to translate evidence-based interventions into community settings to reach vulnerable populations, we published a novel community-engaged translational model called the “Transcreation Framework” [Having demonstrated program efficacy for amework” . It descNA to be appropriate for rural, low literacy Spanish-speaking Latina breast cancer survivors throughout survivorship. Also, we describe methods for working with community partners to design a RCT to test the new program Nuevo Amanecer-II (NA-II), and enrollment results.The purpose of this paper is to describe the process employed, using the Transcreation Framework , to adapNA-II and design and implement the RCT in three rural communities, seven steps were followed from the Transcreation Framework [To develop ramework . These aIn this section, the results of the seven steps are described. For step 7, we report on recruitment results, and describe the sample and methods for monitoring implementation.The purpose of Step 1 is to identify settings with sufficient infrastructure and relevant experience to deliver the intervention, and potentially sustain it. The project was jointly directed by an academic (PI) and community-based investigator (Co-PI). The academic PI was a Mexican-American behavioral epidemiologist and Professor at the University of California San Francisco (at the time the study was implemented). The community Co-PI was a Puerto Rican clinical psychologist, breast cancer survivor, and Executive Director of Círculo de Vida Cancer Support and Resource Center. The academic PI had primary responsibility for the scientific aspects of the project and the community Co-PI oversaw training and community interventionists.During the planning phase, county-level cancer registry data were used and U.S. Census data and maps to identify geographically-defined counties of California that could be study sites. The criteria included: 1) rural (defined as counties whose economy is heavily based on agriculture); 2) large Latino immigrant populations; and 3) sufficient numbers of new breast cancer cases among Latinas. Fifteen counties that met these criteria were identified. Within these 15 counties, online searches for organizations that provided cancer supportive services in Spanish were conducted. Eight counties with a community organization that provided cancer supportive services in Spanish were identified. These eight agencies were called and screened for sufficient infrastructure to deliver and potentially sustain the program, experience providing cancer services to the target population, and established relationships with health care providers who could refer potential participants. After screening the organizations, the organizations were offered the possibility of collaborating on the grant proposal and study (if funded) to three organizations that agreed and participated for the duration of the study. The final organizations (and county in which organization is located) were Cancer Resource Center of the Desert , WomenCARE/Entre Nostras (Santa Cruz county), and Kaweah Delta Health Care District (Tulare county). Cancer Resource Center of the Desert is the only local non-profit community-based organization in the Imperial Valley providing comprehensive cancer and patient navigation to Spanish-speaking clients. WomenCARE is a cancer support program of the Family Service Agency of the Central Coast  and Entre Nosotras is the Spanish-language arm of WomenCARE. Kaweah Delta Health Care District is the only local hospital in Visalia that offers comprehensive health care services and it employs community health workers who conduct health education and prevention services in the community. These partners were interested in partnering on the study to obtain training on evidence-based cancer support services, to generate evidence on the effectiveness of community-based services, and to add the program to their repertoire of services offered.NA, Social Cognitive Theory [NA-II. All sessions incorporated key Social Cognitive Theory components of self-efficacy , outcome expectations , self-regulation , and interventionists modeling behaviors .Step 2 is to select a theoretical framework that fit the health priority and context, working with the coalition identified in Step 1 . As in Ne Theory , 34 was NA [NA for a new setting and population. We describe the three inputs: 1) the original NA program, 2) debriefing interviews conducted with NA participants and interventionists, and 3) new formative research conducted in the new study settings.Step 3 in the framework includes reviewing evidence-based interventions, systematic reviews, evidence-based guidelines, and other evidence  to inform the intervention. This comprehensive level of review was conducted to develop NA , 32. ForNA-II was the NA program designed for Latina breast cancer survivors living in urban settings [NA emphasized cognitive-behavioral coping skills training, coaching, and modeling to actively manage stress and emotions. Interventionists were trained peers  who delivered the intervention and provided social support. Core program components included stress management skills training , cognitive reframing (turning unhelpful thoughts into helpful thoughts), effective communication , setting goals, and self-regulation to achieve goals. During program sessions, compañeras modeled these skills, had the participant practice them, and provided positive reinforcement.The foundation for settings , 30. NA NA RCT was completed, debriefing interviews were conducted with two compañeras (trained breast cancer survivors who delivered the program) and 10 randomly selected program participants (breast cancer patients). Participant surveys and semi-structured interviews were used to assess perceived benefits, quality, ease of use, usefulness of components, and suggested improvements. Debriefing interview results are described in detail elsewhere [After the lsewhere . BrieflyNA program manual was given to informants to review prior to the interviews. Interviews were conducted by the academic PI, community Co-PI, or Project Director. An open-ended interview guide queried informants on suggestions for improvements, how to simplify activities and program delivery, and how to maximize attendance. Informants were asked specific questions about the program manual and activities . Interviews were audiotaped and transcribed in English or Spanish.New formative research aimed to identify cultural, practical, organizational, and contextual factors in the new settings, to inform program adaptations. Key informant interviews were conducted with two Latina breast cancer survivors, seven cancer supportive services providers , and two clinicians in the three rural settings to identify local needs. Key informants were identified by community partners as having experience with the target population. A copy of the Informants suggested expanding the program from eight to 10 sessions for more time to practice cognitive and behavioral skills and provide healthy lifestyles information and survivorship care. Informants also suggested flexibility to deliver the intervention individually, in a group, or combination. Other suggestions were to add audiovisual versions (not just text) of the relaxation exercises  and breast cancer treatment information, simplify medical terminology, supplement text with diagrams, simplify activity sheets and goal setting for low-literacy participants, and include the participants’ families.Participant Program Manual. It included assuring fit to the new rural community setting and population by tailoring specific program components.Intervention design involved working with the community partners to synthesize and integrate inputs (identified in Step 3) into a new NA to meet the needs of rural Latina breast cancer survivors, be appropriate for women throughout survivorship (not just in the first year after diagnosis), and improve suitability for low-literacy women. The team consisted of the academic PI, community Co-PI, project director and new community partners. Each aspect of the program was discussed by the team, starting with the original NA program and integrating the debriefing and key informant interview results and experience with NA. Two experienced bilingual-bicultural researchers, the academic PI and project director, consolidated all responses and annotated applicable program manual pages and/or activities with suggested adaptations.The aim was to modify NA-II program and specific modifications are described here.Once initial program adaptations were made, iterative consultations with community partners from the three rural areas informed further program modifications. The compañeras, who were all breast cancer survivors , also reviewed and provided feedback on the program and manual. Final modifications were made based on feedback received during the compañera training. The NA-II consists of 10 weekly 90-minute sessions, conducted in-person by a compañera. This format and structure are similar to NA. Each weekly session (except the first one) begins with a deep breathing exercise, a session overview, and a brief review of the prior week. A Participant Program Manual is provided at the first session and used during subsequent sessions. Referring to the manual, the compañera explains the educational content for that week. Each session includes 2–3 activities to reinforce a new stress management technique or skill. The compañera and participant work together on activity sheets, skills practice, role-playing, and discussion of content. Each session ends with a recap and weekly assignment to practice specific skills.NA-II weekly sessions and information on how each session was modified from NA if applicable. Sessions cover a range of topics including managing the impact of cancer, breast cancer and survivorship, finding cancer information, getting support, managing thoughts and mood, stress management techniques, managing activities that affect mood, healthy lifestyle, and goal-setting.Modifications involved improving stress management and cognitive reframing practice and training. The goal setting was simplified to focus on concrete, realistic activities. “Weekly homework” was renamed as “weekly goal” to be less intimidating. Written materials were supplemented with new stress management videos and videos explaining breast cancer and its treatments in lay terms in Spanish and English. All participants are provided a DVD with all videos. These videos are also accessible on YouTube for those who have access to the internet, if they preferred.Participant Program Manual is organized by the 10 weekly sessions and designed to be referred to during each session and to be used independently. It contains information, visual images, and activities developed for lower literacy individuals, written at approximately a sixth-grade reading level. Also included is a DVD (see above). All materials were rigorously translated into Spanish by four bilingual-bicultural research staff, using standard translation methods with team reconciliation.Delivery of the intervention was standardized through compañera and participant program manuals. The Compañera Program Manual corresponds to the participant manual but contains additional instructions on how to explain the content, and prompts for the compañera to ask certain questions to aid participant self-reflection. Compañeras are given tablets preloaded with the same audiovisual materials provided to participants. Compañeras use the tablet during sessions to demonstrate program videos of the skills and exercises, such as meditation with guided imagery. Instructions for delivery of NA-II are expanded to allow for individual or group format. Nevertheless, all partnering sites decided to deliver the program individually face-to-face, primarily in participants’ homes.The Step 5 focuses on specialized methodological strategies for evaluating the intervention when the study is being conducted in community settings (as opposed to academic settings) where optimal control of study conditions is not possible.NA-II in improving breast cancer-specific quality of life (BrQoL) dimensions [NA-II intervention to a wait-list control group. [With the community partners, a six-month RCT was designed to assess the effectiveness of mensions –38. Thisl group. The Institutional Review Boards (IRB) at the University of California San Francisco (UCSF) and the Kaweah Delta Health Care District approved the protocol. UCSF was the IRB of record for the other two sites. Written informed consent was obtained from all participants.The study population consisted of Spanish-speaking Latinas with non-metastatic breast cancer residing in the selected rural counties. By design, inclusion criteria were broad because this was an effectiveness trial conducted in real-world settings. Further, it was aimed to increase generalizability to women throughout survivorship. Thus, inclusion criteria were: 1) diagnosis of Stage 0 to IIIC primary breast cancer, 2) lives in Imperial, Tulare, or Santa Cruz/Monterey counties, 3) speaks primarily Spanish, and 4) self-identifies as Latina. Exclusion criteria were: 1) terminal illness, 2) Stage IV breast cancer (distant metastasis), or 3) plans to move out of the area within 6 months.Two sites, Cancer Resource Center of the Desert and WomenCARE/Entre Nosotras, had well-established relationships with local oncology clinics and hospitals. Recruiters identified potentially eligible women face-to-face or on the phone as they performed their normal outreach and cancer education duties. Recruiters verified eligibility of potential participants through medical records review or medical staff confirmation  at the clinical sites. The third site, Kaweah Delta Health Care District, was a public hospital and utilized medical records to draw a sample of outpatients who might be eligible. Kaweah Delta Health Care District mailed potential participants an initial contact letter, a study information sheet, and a prepaid refusal postcard to return to the District. The letter and information sheet were in English and Spanish and written at a 6th grade level. If no refusal postcard was received within two weeks, the recruiter initiated contact with the potential participant.During the initial contact, recruiters used a bilingual script to confirm the woman’s diagnosis, stage at diagnosis, self-reported ethnicity, and absence of terminal illness. When the contact was by phone, if the woman expressed interest in the study and was eligible, an appointment was scheduled at a convenient time and location. At that appointment, the recruiter described the study and answered questions. If the woman agreed, written informed consent and a breast cancer medical records release form were completed. The baseline interview was conducted, followed by randomization. When the initial contact was in-person, recruiters used the same procedures except that women had the option of completing the interview at that time or scheduling an appointment.The individual was the unit of randomization with 1:1 allocation to experimental groups. Randomization was stratified by recruitment site. Prior to initiating recruitment, stratum-specific sequential identification numbers were generated and randomly pre-assigned within blocks of random sizes. After the baseline assessment, the recruiter handed each participant a sealed, opaque envelope preprinted with the next sequential identification number from her stratum that revealed her group assignment. Women were randomized to either the intervention group or wait-list control group. Wait-list control group participants were offered the intervention after the six-month assessment.Primary and secondary outcomes were assessed at baseline, three months, and six months. All assessments were completed in Spanish. Participants were compensated $30 per assessment, and $10 at the end of the intervention for completing a brief telephone survey about the program. The baseline assessment was conducted in-person; 3- and 6-month assessments occurred by telephone for practical reasons.Primary outcomes were the Functional Assessment of Cancer Therapy—Breast (FACT-B)  subscaleNA-II, we used the Measure of Current Status Part A (MOCS-A) [We measured women’s ability to practice four of the self-management skills taught in (MOCS-A) . We usedd = .45).Our target of 140 women was based on a power analyses that assumed 80% power; two-tailed α = .05; 90% retention; Functional Assessment of Cancer Therapy—Breast (FACT-B)  subscaleBuilding capacity focuses on enhancing the community infrastructure identified in Step 1. The methods for building capacity of the participating organizations in order to deliver the program are highlighted here.The project was funded through the California Breast Cancer Research Program Translational Research Award mechanism. Although the academic partner was awarded the grant, roughly half of the funding was provided to the community Co-PI’s agency (Círculo de Vida) via a subcontract. The community Co-PI’s agency, in turn, managed and disbursed the funds for program implementation to the community agencies. Each partner site received an organizational fee of $45,000 from the community Co-PI to offset agency costs to pay site recruiters, compañeras, and overhead. It gave them ownership of their own budget, thus enabling each site to identify what worked best within their organization. Each site decided on the pay rate of their recruiters and compañeras. In some cases, recruiters were paid on an hourly basis, and in other cases, the funds were used to pay part of their salary as this project was added to their job description. The Co-PI’s organization reimbursed recruiters and compañeras for mileage ($0.50 per mile) incurred to enroll or meet with participants for program delivery.To build organizational capacity, through monthly conference calls, all partners were involved in most aspects of the research, including developing the grant proposal, adapting the intervention, designing recruitment materials and strategies, and study implementation and evaluation. Conference calls were an important forum for reviewing recruitment results, brainstorming ways to improve recruitment and outreach, sharing rewards and challenges, and discussing program sustainability and dissemination. Calls continued on a monthly basis until the final assessments were completed, after which they continued on a quarterly basis for the remainder of the study.Each partner site identified a recruiter applicant pool. Recruiters had to be bilingual and have prior health education or outreach experience and access to Latina breast cancer patients through their community activities or contacts. The academic PI and project director screened candidates using a structured interview protocol that assessed their interpersonal communication skills, relevant experience, and outreach skills.A four-hour training session conducted by the academic PI and project director prepared recruiters to recruit, enroll, randomize, and conduct baseline assessments. The training included a PowerPoint presentation on the study, review of enrollment and tracking forms, review of the baseline survey, and role modeling of interview skills and study procedures. Each recruiter was provided with a recruiter manual that included information on the study protocol, recruiter and compañera roles, and detailed procedures for tracking, identifying, screening for eligibility, obtaining informed consent, conducting the baseline interviews, and randomization. Two recruiters completed training in each site.Community recruiters also completed human subjects protection training, either on the Collaborative Institutional Training Initiative website or through in-person training by the academic PI and project director using the Community Involvement in Research Training (CIRTification)  developeNA, peers delivered the intervention. Compañeras were breast cancer survivors and served as role models to inspire hope. The community partners identified potential candidates. Compañera requirements were being bilingual or Spanish-monolingual, a Latina breast cancer survivor, and at least three years post diagnosis with no recurrence. The community-based Co-PI  interviewed potential candidates using a structured interview protocol. Compañeras needed to display warmth and compassion to create a strong sense of familismo  and confianza (trust). Sensitivity to spirituality was important as Latinas often use faith as a source of support and acceptance. Women had to demonstrate having processed their experiences being diagnosed with breast cancer and effective coping and communication skills.As in Compañera Training Manual in addition to the Compañera Program Manual. The training started with a PowerPoint presentation that covered psychosocial issues among Latinas with breast cancer living in rural communities, theoretical basis of the program, results of the NA study, protocol, randomization, role of recruiters and compañeras, overview of compañera manual, logistics of program delivery, and how to collect process evaluation and fidelity indicators. The training continued with detailed hands-on review of the Compañera Program Manual, role playing, skills demonstration and practice. The manual included step-by-step instructions  and materials  for the 10 weekly sessions. Compañeras were compensated for attending training and they received a certificate of completion.Compañeras participated in three eight-hour training sessions conducted in Spanish by the academic PI, project director, community Co-PI, and the community Co-PI’s clinical director. The training included didactic presentations, hands-on review of the program manuals, and active practice of the skills training and other activities, with feedback from trainers. Training materials include a Compañeras were trained to follow the manual, but encouraged to make it client-centered such that they could reinforce sections when the client verbalized or demonstrated a need for more practice, or omit sections that were not relevant . They were instructed to follow the manual content, but make the session conversational. The community Co-PI accompanied the compañeras on their initial intervention sessions until she was satisfied that they were delivering the intervention as intended; the Co-PI also conducted two additional in-person observations with each of the compañeras to determine the extent to which the program was presented as intended. These encounters were audio-recorded and the Co-PI rated the quality of delivery of the program using a structured form. The audio-recordings of the encounters were also rated independently by the Project Director using the structured form. In addition, the Co-PI provided on-going supervision via telephone.Step 7 involves implementing the intervention and monitoring implementation processes. A description of the first part of this step–recruitment results and the sample characteristics are provided, as well as our methods for monitoring implementation.The study recruitment period was from September 2016 through March 2018. The enrollment goal of 140 women was exceeded. In total, 231 women were approached, 153 enrolled and were randomized, 24 were ineligible due to language , and 54 refused, with an overall recruitment rate of 66% (153/231). Of those that refused, 28 were not interested, 19 were too busy/no time, and 7 were moving out of the study area.One hundred fifty-three Spanish-speaking Latina breast cancer survivors were enrolled . The meain situ, 76% with invasive breast cancer, 10% with inflammatory breast cancer, and 4% had missing information or medical records could not be obtained. Regarding surgery type, 50% had a lumpectomy, 47% had a mastectomy, 1% had no surgery, and 3% were missing. Regarding treatment, 60% received both radiation and chemotherapy, 18% had radiation only, 14% had chemotherapy only, 7% had no treatment, and 1% was missing.Of 153 women randomized, years since most recent diagnosis was 2.5 years ; eight were recurrences. Of these, 10% were diagnosed with ductal carcinoma To assess participant adherence to the program, compañeras completed a structured program tracking form after each of 10 sessions. Data included: logistics , whether the participant had completed the homework for that week (yes or no), whether the participant reported difficulty in doing the homework (yes or no) and if so, the type of difficulty (open-ended). For sessions 2–10, the compañera assessed whether the participant was able to demonstrate the skill covered in the prior session (yes or no). The tracking form was also used to document reasons why women dropped out at any point. This information was collected for women in the intervention group and those in the control group who elected to receive the program after the wait period. Program adherence was defined as having completed at least 7 of the 10 sessions.To assess fidelity, two intervention sessions for each compañera were selected for observation based on convenience. The observer was either the community Co-PI or the community Co-PI’s clinical director. Using structured rating scales  the observer rated compañera's compliance with six program components: the extent to which they followed the manual for that session, explained concepts in language the participant understood, checked that the participant understood the material, spoke in a caring/supportive way, modeled the skills, and provided feedback to participants for efforts to practice the skills. Seven additional questions rated the extent to which the compañera encouraged participants to practice seven skills . Sessions were audiotaped and reviewed independently by two people .For this project, the Transcreation Framework  was applNA program, the content and delivery format were refined based on input from survivors, clinicians, and advocates. Major modifications included adding sessions on healthy lifestyles and further practice of cognitive reframing skills. Audiovisual materials were developed to supplement text information, further simplified medical terminology and activity sheets, and added instructions for delivering the program in a group format. Finally, content relevant for longer term survivors was added, e.g., survivorship care plans and symptom management. Without the involvement of community experts, the need for many of these adaptations might have been missed [In this second iteration of the n missed .NA materials into their support groups. As a result of the NA projects, Círculo de Vida Cancer Support and Resource Center was awarded a grant from The Foundation for Hope & Grace to extend the program to three additional rural communities where twenty-one Latina breast cancer survivors were trained and provided the 10-week program to 120 Latinas living with breast cancer.A fundamental feature of the Transcreation Framework is community capacity building to deliver behavioral interventions. In this study, partners increased their capacity to deliver evidence-based cancer supportive services and participate in rigorous behavioral research, including RCTs. As a result of their involvement in this study, two of the community organizations have indicated that they are working now with other academic or public entities on planning of future studies and adaptation of the program for other conditions. One of the organizations has incorporated The three community sites in the study varied in nature, indicating that a variety of types of community organizations can successfully engage in research to improve psychosocial services for vulnerable cancer populations. In this study, one was a public health care system, one was a community-based mental health services provider, and one was a community-based cancer supportive care provider. Thus, researchers can consider a broad spectrum of community organizations and service providers as potential partners when undertaking community-engaged research.There were study limitations. First, the majority of the sample was of Mexican origin and may not reflect experiences of Spanish-speaking Latinas of other national origin groups. Second, the sample was limited to Latinas living in rural California and may not be generalizable to the Latina cancer survivors living in other regions.Two promising directions for future research are to address the roles of caregivers and family members and how variations in intervention intensity and delivery modes affect outcomes. In the formative research in both urban and rural settings, key informants suggested that family members be included in the intervention. Although there were insufficient resources to extend the program to family members, a handout was designed for family members that described the content of the program, what changes they might notice in their family member, and how to support her through the program. Development and testing of family-centered and dyadic interventions are future directions for research. Related to program intensity and delivery mode, the only other stress management intervention in the literature that targeted rural cancer patients (not Latinas and not breast cancer-specific) found that women who participated in a 4-week group-based videoconference program felt disconnected from others and desired a longer program . AdditioThe utility of the Transcreation Framework stems from engaging the community throughout, building community capacity, and conducting a rigorous evaluation of the behavioral intervention in community settings. These implementation and translation strategies could be powerful tools for testing the transportability of effective behavioral interventions among underserved vulnerable populations . Increas


In 2015, the Department of Veterans Affairs (VA) nationally implemented a transgender e-consultation (e-consult) program with expert clinical guidance for providers.This mixed-methods project aimed to describe providers’ program experiences, reasons for nonuse of the program, and ways to improve the program use.From January to May 2017, 15 urban and rural VA providers who submitted at least one e-consult in the last year participated in semistructured interviews about their program experiences, which were analyzed using content analysis. From November to December 2017, 53 providers who encountered transgender patients but did not utilize the program participated in a brief online survey on the reasons for nonuse of the program and the facilitators encouraging use.Qualitative analysis showed that providers learned of the program through email; colleagues; the electronic health record (EHR) system; and participation in the VA Lesbian, Gay, Bisexual, and Transgender committees or educational trainings. Providers used the program to establish care plans, hormone therapy recommendations, sexual and reproductive health education, surgical treatment education, patient-provider communication guidance, and second opinions. The facilitators of program use included understandable recommendations, ease of use through the EHR system, and status as the only transgender resource for rural providers. Barriers to use included time constraints, communication-related problems with the e-consult, impractical recommendations for underresourced sites, and misunderstanding of the e-consult purpose. Suggestions for improvement included addition of concise or sectioned responses, expansion of program awareness among providers or patients, designation of a follow-up contact person, and increase in provider education about transgender veterans and related care. Quantitative analysis showed that the common reasons for nonuse of the program were no knowledge of the program (54%), no need of the program (32%), and receipt of help from a colleague outside of e-consult (24%). Common suggestions to improve the program use in quantitative analyses included provision of more information about where to find e-consult in the chart, guidance on talking with patients about the program, and e-mail announcements to improve provider awareness of the program. Post hoc exploratory analyses showed no differences between urban and rural providers.The VA transgender e-consult program is useful for providers, but there are several barriers to implementing recommendations, some of which are especially challenging for rural providers. Addressing the identified barriers and enhancing the facilitators may improve program use and quality care for transgender veterans. Transgender is an umbrella term that encompasses individuals with gender identities  that conflict with societal prescriptions of masculinity and femininity associated with sex assigned at birth. Transgender individuals experience numerous health disparities  includinAchieving equity in health and health care, irrespective of gender, is a specific objective for the Department of Veterans Affairs (VA) . The VA Generally, e-consults provide a technology-based platform through which teams of providers with expertise in a specific medical condition or process of care can assist providers in medical centers where experts may not exist locally . The VA Since the e-consult is a relatively new resource for VA providers, there is a critical need for formative evaluation that can guide future implementation research  to, for All qualitative activities were conducted as part of a quality-improvement initiative by the directors of VA’s LGBT Health Program in the Office of Patient Care Services; therefore, no subject approval or informed consent to participate was required. The quantitative analyses were approved by the Institutional Review Board of the VA Pittsburgh Healthcare System.We received the LGBT Health Program’s list of unique VA providers who used the VA transgender e-consult program, from the program’s national launch in April 2015 through December 2016. We categorized the provider roster by urban and rural sites based on urban-rural definitions of the VA Office of Rural Health . SubsequWith guidance from personnel who direct and administer the e-consult program, we developed a semistructured interview guide based on the most-germane needs identified. The initial set of guiding questions were as follows: How did providers learn about the availability of e-consultation? How useful was the e-consultation response? How did the treatment plan change as a result of the consultation? Were there provider-perceived changes in patient outcomes as a result of the consultation? What were the challenges or limitations of the e-consultation program? From the guiding questions, the project team developed and finalized an interview guide with open-ended questions and additional probes to direct in-depth inquiry. From January to May 2017, a trained interviewer conducted interviews, which were audio-recorded and transcribed for analysis.Microsoft Word 2016  was used to transcribe the audio recordings verbatim to identify categories across interviews. The interviews were analyzed using conventional qualitative content analysis . Using iWe performed quality control and bias mitigation in several ways. First, an experienced qualitative researcher reviewed the codebook prior to completion of the coding process. Second, the same researcher reviewed 20% (4 transcripts) of the samples of coded transcripts to ensure transparency and comprehensibility in the application of codes. The results were subsequently reviewed and discussed by three of the authors before their finalization.For the survey portion of our project, VA’s administrative data were extracted from April 1, 2015, through April 1, 2017, for all inpatient and outpatient visits in which a transgender-related International Classification of Diseases (ICD)-9 or ICD-10 diagnosis code was noted for the visit . For each visit, the names of all unique providers who noted the diagnosis code were extracted to create a census of providers who encountered a transgender patient during the study period. The list of providers who had used the transgender e-consult program during the study period was cross-referenced with the total list of providers who encountered a transgender patient, and the providers who used the e-consult were removed. The remaining providers represented the eligible sample of providers who had encountered transgender patients during the study period, but did not utilize the e-consult program . Of the eligible providers, a random sample of 300 providers was selected, regardless of the provider type . Email addresses of all providers were manually collected from the VA’s global contact list, and addresses of 279 providers  were available, which comprised the analytical sample for this project. Providers received a recruitment email on November 13, 2017, which explained the purpose of the research project and provided a link to a brief 9-item survey on VA’s internal network via REDCap . Two weeks later (November 27), a second recruitment email was sent to all providers who had not completed the survey.In the brief online survey, VA providers were asked to identify their discipline from social work, psychology, psychiatry, primary care, primary care nursing, endocrinology, speech therapy, nursing, and other. Providers indicating “other” were asked to elaborate on their answer. Before beginning the project with the VA, providers were asked if they ever received any training on providing health care to transgender patients; response options were yes, >1 hour; yes, >1 to <3 hours; yes, ≥3 hours; and no. Using the same response options, participants were asked if they ever received training when working for the VA. In addition, providers indicated the number of transgender patients they had cared for in the last 12 months. Finally, providers were asked, “Based on your own perception of the VA facility in which you do most of your work, how would you classify your VA facility?” The response options were urban, rural, or highly rural.Three questions focused on the transgender e-consult program. First, providers indicated if they had ever used the program. For individuals who indicated “yes,” they were thanked for their participation, and the survey ended. Individuals who indicated that they had not used the e-consult program received two additional questions. The first queried the providers about the issues that prevented them from using the program, and the response options included the following: I did not know about it, I do not know how to access it, I have not needed to use it yet, I am comfortable with my level of knowledge with transgender care, my patient(s) told me they did not want me to use it, I have a colleague I can call on for help, template takes too long to complete, and other. The second item queried providers about the factors that would encourage them to use the program. Response options included the following: provision of more information about where to find e-consult in the chart, allotment of more time to complete an e-consult, encountering more transgender patients, VA-wide email announcements about the program, guidance on how to talk with patients about the program, and other. For both items, providers could choose more than one option, and persons indicating “other” were asked to elaborate on their answer.t-tests were used to examine categorical and mean differences, respectively. All quantitative analyses were conducted using Stata or SE, version 14.2 . Values of P<.05 were considered statistically significant.Univariate statistics were used to describe the sample. Chi-square tests of independence and Of the 15 interview participants included, most were primary care providers (12/15), practiced at VA for >10 years (7/15), categorized their current VA facility as rural (9/15), had no transgender-specific training (9/15), encountered 1 transgender patient in the last year (6/15), and reported that the program was 90%-100% useful for their specific needs (7/15) . In addiFourteen VA health care providers participated in a telephone-based interview, of which 1 participant sent written responses via email because they could not schedule an interview. The longest interview lasted for 30 minutes 19 seconds, and the shortest was of 7 minutes 36 seconds; the mean interview time was 18 minutes 9 seconds. Six major areas were identified: how providers learned about the e-consult program, reasons for using the program, results of using the program, facilitators for using the program, barriers to using the program, and suggestions for improving the program. Providers commonly received information about the program through an email from the VA’s LGBT Health Program. Local providers or colleagues such as pharmacists, mental health providers , and gynecologists also educated interviewees before the e-consult as well as when another provider asked for assistance or advice through “word of mouth.” In addition, providers learned about the program by seeing “Transgender E-Consultation” as an option in the VA electronic health record (EHR). Some providers saw this option when entering an e-consult request in a different specialty area, whereas others saw it while going through orders. Other providers learned about the program through participation in local VA LGBT-specific activities or educational lectures for providers about transgender care.Providers used the program to create individual patient-care plans, particularly providers with “extremely limited” transgender care experience. Some examples focused on gender-affirming medical care, including determining whether the patient was a good candidate for medical transition and the type of monitoring necessary during the transition process. Others sought recommendations about hormone therapies. Although there were “general medication questions,” most asked specific questions about appropriate medication doses and adjustments to optimize therapeutic outcomes and address safety concerns . Furthermore, providers used the consult for education about sexual and reproductive health to help make care decisions such as those regarding standard preventative health-screening tests  and gynecology for transgender men. Others desired education about available surgical treatment options . Moreover, providers sought guidance for communication with transgender patients on, for example, information about hormone therapy they should provide their patients and the responses they should expect. E-consults also provided a second opinion when providers were uncertain about a health care decision, especially in complex cases or cases involving high risk. The consults were found to be especially helpful when they confirmed what the provider already informed the patient or helped bolster provider decisions that were made against patient preferences.Providers sometimes modified care plans for their transgender patients after obtaining an e-consult response, including a formal diagnosis. Modifications included addition of recommended gender dysphoria evaluations, health screenings, medication monitoring, and meeting standard time frames for follow-up care. Most treatment plan changes were related to dosage of hormone therapy and addition of specialist referrals. Providers who used the program became more comfortable and confident in their assessments and in relaying testing and treatment decisions for transgender patients. Some providers felt confident in their judgment before the e-consult, but a second opinion confirmed what they discussed and decided with the patient. E-consults helped improve patient-provider relationships by placing those interactions and care provision in line with the gender  of their patients. In addition, the e-consults provided patients added motivation to follow recommendations because experienced providers were involved. Moreover, communication during clinic interactions improved because the e-consult request requires providers to answer a number of questions about the patient, which encouraged them to collect additional relevant information from the patient during their visit. Discussing recommendations with their patients allowed them to engage in informed, shared decision making about their care.E-consult responses contained “timely and up-to date-information” that was useful and easily understood because it did not contain jargon. They appreciated the fact that the e-consult was reviewed by an expert multidisciplinary team in transgender care and saw them as “coaches.” The recommendations reportedly provided a clear “road map” for where to start and how to proceed with care. The program was said to be “easy to access” and use through the VA EHR system, which also made it “easier for continuity of care” because information such as test and treatment results can be added, accessed together, reviewed, and incorporated into a patient’s care plan.Providers who used e-consults received responses in a “timely manner,” ranging from 2 days to 2 weeks, depending on the question, which was much shorter than the time for other types of consultations they requested in the past. The program made providers aware of other existing health care services and resources . Some rural providers said they used the e-consult program because they believed it was their only available resource for patient-specific transgender health. In particular, providers at rural sites said there were no on-site providers or resources they could consult about care for transgender patients.The providers reported that entering the required information to submit an e-consult and reading the responses could be time consuming. For example, providers had to enter extensive patient information, some of which was not directly relevant to their question . Some providers thought the template contained repetitive questions. Others said the responses were too long  and not user friendly, including templated information and irrelevant information that they would not use. One provider was frustrated when the response did not address her question and suggested unrealistic and broad changes in her practice.Communication-related issues were noted with receipt of the response and follow-up questions, some of which related to the technology central to e-consults. For example, in a situation with multiple e-consults for different questions about the same patient over time, it was unclear whether providers should add a new e-consult or add comments to their previous e-consult. Providers were also unable to follow recommendations because they found them impractical or unfeasible . Some providers at rural facilities could not follow recommendations because they lacked the necessary local resources, and the e-consult did not help them access the required resources. A few providers misunderstood the e-consult purpose, which led them to misuse the e-consult and question why their request was not met. For example, some providers thought a referral request would result in other providers taking over their patient’s care. Some providers did not use e-consult due to a lack of understanding about transgender patients, including dimensions of gender  and transgender-specific health care needs.Providers suggested streamlining responses into sections to make them easier to read and understand. Redundant or templated sections could be moved to a common share point on the VA intranet. Additionally, providers suggested increasing provider and patient awareness of the program; for example, “Getting information out that, if the veteran has concerns, they can go to their primary care clinics and get the process started, so they don’t have to go outside the VA.” Providers also suggested designating a point-person after an e-consult is completed, so that providers can follow-up and discuss the issue, and not just receive a one-sided, one-time response. Further, they suggested provision of additional provider education about transgender-specific health care needs through the e-consult and the VA Specialty Care Access Network-Extension for Community Healthcare Outcomes program. Creation of new programs would help educate providers about transgender veterans, including dimensions of gender and transgender-specific health care. Providers suggested that additional information and clarification be given to providers about the e-consult program’s operational processes and timeline for e-consults, including the estimated time required to enter an e-consult request and average wait time for a response.P=.36), number of visits (P=.48), and number of patients (P=.31) (data not shown). Of the 279 eligible providers, 53 responded to the survey (19% response rate). Providers were evenly distributed across disciplines . On an average, the practitioners worked in the VA for 6.9 years . A total of 35 respondents (66%) viewed their VA facility as urban; 15 (28%), as rural; and 3 (6%), as highly rural.Over half (53%) of the sample had no training in providing transgender health care before working in the VA. Among those who had prior training, 11% had 1 hour, 21% had >1 to <3 hours, and 15% had >3 hours of training. In addition, half of the sample (50%) indicated that while they were working for the VA, they received some form of training on providing care for transgender patients.Nearly one-third (32%) of the providers encountered only 1 transgender patient in the previous 12 months, and 5 providers (9%) did not encounter any transgender patients in the last 12 months. The majority of the providers (87%) had encountered 1-9 transgender patients over the last 12 months, and 2 providers encountered >10 transgender patients.The most-common reasons for nonuse of the e-consult were as follows: no knowledge about it, no need for it, and receipt of help from a colleague . The mosPost hoc exploratory analyses were conducted on the basis of the self-reported locale of the providers. Rural and highly rural respondents were combined in one category because of the small number of providers in highly rural facilities. We found no overall differences between urban and rural providers .Increase of provider knowledge about transgender patients’ needs can reduce misconceptions and stigma and facilitate high-quality care provision ,15. The Because formal transgender health care is relatively new to the VA, it is crucial to understand health care providers’ experiences with a program designed to enhance their practice. Lessons learned can guide improvement and inform other health care organizations that may want to develop or replicate such a program. Some large health care organizations have implemented e-consult programs for several system needs, mainly those facilitating low-cost connections with specialists and continuity of care within the system -18. The Because the VA operates the single-largest health care system in the United States, we were able to specifically examine the experiences of providers at rural sites. Qualitative data showed that rural providers who have used e-consult faced unique challenges in providing quality care to transgender veterans. In particular, they did not have on-site providers with knowledge of and experience in transgender-specific care, who they could consult about the veteran. At times, they were unable to follow the e-consult recommendations they received for a specific patient, because the recommendations were not feasible at their location. Thus, the e-consult program did not provide local resources needed to follow providers’ advice. These themes highlight a conundrum that required more directed inquiry, such as exploring how providers in rural areas can deliver the same quality of care as their urban peers, consolidating e-consult responses to rural providers in order to develop tailored guidelines for providing transgender care in underresourced areas, or convening system-focused consensus meetings to bring together providers and administrators from both urban and rural settings to discuss creative quality-improvement strategies.Although our quantitative analyses showed no statistically significant differentiation between urban and rural providers, the results suggested that rural respondents may be less likely than their urban peers to indicate that they have colleagues who can be informally called for help, reiterating that rural areas generally have limitations to health care infrastructure and availability of providers -21, whicOur results are consistent with existing research findings that highlight ongoing barriers to provision of quality transgender- specific care in VA and nonVA settings -28. AlthWe noted several limitations to our study. The qualitative analyses relied on self-reported data from interviews with providers who used the VA transgender e-consult program, which may not replicate direct observational data. Although our relatively small and homogeneous sample was suitable for qualitative analysis, we may not have captured the full range of provider experiences with the VA transgender e-consult program. Notably, the majority of the sample had only used the e-consult program once and one person had used it 7 times; perceptions of the program could vary based on familiarity. In addition, due to the qualitative nature of the study, our results may not be representative or generalizable; this limitation should be considered when interpreting the results before applying our conclusions to other providers and settings.For the quantitative survey, we identified providers who encountered transgender patients , which is a proxy method of identifying transgender patients; therefore, the sampling may have resulted in a conservative estimate of providers. The quantitative response rate was low, limiting the statistical power of analyses and generalizability of findings. Moreover, because we did not have data on the disciplines for the 14,502 providers in the pool that was sampled, we could not ascertain if providers from certain disciplines were more inclined to respond to the survey, which may have introduced response bias. Future studies with more-frequent and varied follow-up strategies to increase the response rate could alleviate issues of generalizability and response bias. Furthermore, as a pilot study, the survey was limited in scope and did not collect additional information about providers .This mixed-methods study offers insight into provider experiences with the VA transgender e-consult program and conveys lessons of implementation that can guide other health care organizations to create similar programs . Our results suggest that the program is useful for providers, but there are several barriers to its use among providers. Additionally, rural providers face unique challenges in care provision for transgender patients, including the lack of access to necessary resources.Future studies with a larger, more-diverse sample of urban and rural health care providers as well transgender veterans who were involved in the e-consult program (patients must consent for their providers to submit an e-consult) are warranted. The present study included only the providers who asked for e-consults and not the providers who answered the e-consults. Further research, probably via a dyadic approach, could better investigate the entire course of e-consult use. Additionally, a global study of VA e-consults would allow comparisons across consult content  to discern challenges that may be universal to the e-consult format in contrast to challenges that may be unique based on the health care need. Examining transgender e-consults from the patient’s perspective would allow the health system and its providers to learn how consumer experience  may be influenced by the use of e-consults .In summary, an e-consult is a relatively low-cost system improvement that health care organizations can implement to support providers in caring for transgender patients. As examples of best-practice suggestions for transgender health accumulate -39, feas


Loyalty is one of the greatest intangible assets that any organization can possess and improving client loyalty is a primary marketing goal that can have a significant financial impact on any business. This quantitative study examined the mediating role of communication on the relationship between satisfaction and loyalty  in veterinary clinics, along with the moderating roles of trust, commitment, perceived value, and relational characteristics. Responses collected from 351 pet-owners through social media were analyzed using descriptive and inferential statistics. The results show that attitudinal loyalty (AL) has a strong positive relationship with communication at multiple points in a veterinary clinic, whereas the relationship with behavioral loyalty (BL) was not as clear. Additional findings suggest that AL, which is influenced by trust in the veterinarian, communication from staff members and commitment, has a strong positive relationship with behavioral intentions, increases the number of products and services that a pet-owner consumes at his or her primary veterinary clinic, and attenuates the role of cost in receiving veterinary care. These findings can help veterinary clinic owners and managers in developing and implementing relationship strategies that improve pet-owner loyalty. The following article is a synopsis of the author’s dissertation . VeterinPet-owner loyalty is not guaranteed. Pet-owners, like any other consumer will change service providers in the pursuit of higher service quality and better value . Often, Loyalty is one of the best intangible assets that an organization can have , thus dePet-owners may become aware of and choose a veterinary practice for any number of reasons; location, referral and price are the most common reasons cited . Pet-ownAttitudinal loyalty (AL) has affective and possibly emotive components that are lacking in cognitive loyalty . As suchBehavioral loyalty (BL) is a function of purchase activity over time . BL can Achieving loyalty is a primary marketing goal that can have a significant financial impact on any business . It has Pet-owner satisfaction with veterinarians is consistently very high, and in some cases it is above 90% , yet onlCommunication has been studied in human medicine for decades , and satThe current cross-sectional study is exploratory and investigated whether pet-owners’ satisfaction with the communication that they received at a veterinary clinic had a relationship with both AL and BL to the veterinary clinic. The importance of this study is to better understand what pet-owners want, how they think, how their preferences can be turned into perceived value by the pet-owner, and ultimately to improve loyalty towards veterinary practices. The findings from this research serve as a baseline of pet-owner loyalty.The target population for the survey was broadly defined as pet-owners who participate in one of two social media sites on which the survey was administered. A convenience sample of participants was gathered using a snowball methodology , wherebyThe questionnaire consisted of four main sections in addition to demographics. The first section asked pet-owners to cite the frequency with which he or she observed customer service and communication behaviors from veterinary clinic staff members. This section was subdivided to include the front desk staff, veterinary technicians, veterinarians, and check-out staff. A four-point Likert scale was used with choices of rarely, sometimes, often, and always. Questions were selected from a client satisfaction survey from AAHA  for the After the survey instrument was developed, it was sent to 12 industry experts for evaluation of content validity. Three of the experts provided feedback and each agreed that the instrument was valid for measuring communication, trust, value and loyalty. Minor changes were made to the wording of several of the questions based on the feedback that was provided. The final survey instrument was created using an online survey tool and was tested for reliability by the researcher. It was designed to collect primarily quantitative data. A four-point scale was chosen to eliminate the midpoint choice and to minimize central tendency bias after determining that a four-point scale would not adversely affect the reliability of the findings . Opportut-tests were conducted to test the differences between various groups of pet-owners. All statistical analyses were overseen by a faculty statistician at Wilmington University.Descriptive and inferential statistics were used to analyze the data using Statistical Package for the Social Science (SPSS) version 25 . Answers to the qualitative questions were compiled and categorized by the author. A Spearman’s rho correlation was run to assess the relationship between pet-owner satisfaction with communication and the individual communication points, as well as with the higher-order constructs of trust, loyalty, commitment, and perception of value. To better understand the relationships, linear regressions were run on the higher order constructs. A logistic binomial regression was run for behavioral loyalty since it is a dichotomous construct. One-way analysis of variance (ANOVA) and independent sample This research received ethical approval from the Wilmington University Human Subjects Review Committee (HSRC). Participants were presented with a privacy disclosure and were required to agree to the terms in order to access the survey instrument. No data were collected to identify individual participants.n = 295, 84.0%) was 1.78, for cat owners  was 1.47; some respondents reported owning both dogs and cats . Pet-owners consider their pets to be members of the family (85.4%). This figure is higher than the 63.2% previously reported [n = 115, 33.24%). Some pet-owners reported that he or she takes pets to the veterinarian only when the pet is sick  or when the pet needs a vaccination . This is consistent with 10% of pet-owners completely agreeing that they only take a pet to the veterinarian when the pet is sick or needs a vaccination [A total of 435 individuals began the survey, and 351 (80.7%) of these individuals completed the survey. Partially completed surveys were omitted from the results. Because the survey was anonymous, it was not possible to determine the reasons for survey abandonment. The gender makeup of the population shows that 284 (80.1%) were female and 54 (15.4%) were male and 13 (4.5%) declined to self-identify. Completed surveys were received from 39 states and one Canadian province. The mean age of the population was 45.6. Respondents have patronized their current veterinarian for an average of 7.7 years. The mean number of pets for dog owners , followed by a perception of poor care . It is doubtful that lay pet-owners can accurately assess the quality of care that is provided by a veterinarian [A total of 140 respondents (40.6%) reported having stopped patronizing a veterinary clinic at some point and provided reasons for leaving. Cost of care was the most commonly reported reason for leaving  and from veterinary clinic staff . Satisfaction was compared to the communication point constructs to verify whether the constructs were measuring satisfaction with communication at each separate communication point. A Spearman’s rho correlation was run to assess the relationship between pet-owner satisfaction with communication and the individual communication points  = 124.835, p < 0.001). It was found that the customer service and communication skills of veterinary technicians significantly predicted trust in the veterinarian , as did satisfaction with communication from the veterinarian , and customer service and communication skills from the checkout staff . Additionally, there is a strong positive relationship (R = 0.720) between trust and the model predictors. The linear regression model is statistically significant (p < 0.001).A linear regression was run to better understand the predictors of pet-owner trust in the veterinarian. Trust has been identified as an antecedent of both commitment and loyalty . TherefoNumerous studies in a variety of industries have concluded that a relationship exists between satisfaction and loyalty ,27,32. T2 = 0.812, F = 498.105, p < 0.001). It was found that trust in the veterinarian predicted AL , as did satisfaction with communication from the staff , and commitment to return to the practice . There is a strong positive relationship (R = 0.901) between AL and the model predictors. The linear regression model is statistically significant (p < 0.001). There was no evidence of multicollinearity as evidenced by a variance inflation factor (VIF) of less than five for each variable. The significance of the potential impact of commitment on this model reflects its strong relationship with AL that was found in To better understand the nature of the relationships above, a linear regression was conducted to investigate the predictors of AL. Results of the regression indicated that three predictors explained 81% of the variance in AL  = 149.295, p < 0.001). It was found that trust in the veterinarian predicted pet-owner commitment , as did satisfaction with communication from the veterinarian , satisfaction with communication from the staff , the perception of cost and value of services , and satisfaction with the checkout process . There is a strong positive relationship (R = 0.827) between commitment and the model predictors. The linear regression model is statistically significant (p < 0.001). Commitment to conduct future business is a key moderator of loyalty and can be thought of as a cognitive intention towards future BL. As such, it is important to understand the factors that can influence commitment. A linear regression was performed with two models. The first model investigated commitment in the absence of AL. In this model, the regression indicated that five predictors explained 69% of the variance in pet-owners’ commitment to return to the practice , p < 0.001). It was found that satisfaction with communication from the veterinarian significantly predicted pet-owner commitment , as did AL . Additionally, there is a strong positive relationship (R = 0.904) between commitment and the model predictors. The linear regression model is statistically significant (p < 0.001).Model two introduced AL to the commitment linear regression model. It has been shown that commitment is not only a predictor of AL, but is also moderated by AL . A pet-oBL was determined to exist with a pet-owner who patronized the same veterinary clinic for a minimum of five years and consumed at least five of eight identified products or services contained in the construct Behavioral Loyalty at the pet-owner’s primary veterinary clinic. A total of 57% of pet-owners have frequented his or her current veterinary clinic for a minimum of five years. Pet-owners consume an average of 5.95 (1.79) products or services from his or her primary veterinarian, and 81.8% of pet-owners consume at least five services at his or her primary veterinary clinic. In total, 47.6% of all pet-owners were deemed to be behaviorally loyal based on the criteria presented above.2(13) = 47.086, p < 0.001, and explained 20% (Nagelkerke R2) of the variance in behavioral loyalty and correctly classified 66.8% of cases. Sensitivity was 69.0%, specificity was 64.6%, positive predictive value was 66.2% and negative predictive value was 67.4%. The positive predictive value was calculated as the percentage of correctly predicted number of pet-owners exhibiting behavioral loyalty compared to the total number of pet-owners who were predicted as having behavioral loyalty. The negative predictive value was calculated as the percentage of correctly predicted number of pet-owners who were not behaviorally loyal compared to the total number of pet-owners who were not behaviorally loyal.BL has a weak relationship with many of the higher order constructs see . To undeOf the 13 variables considered for the model, only age (pet-owner), satisfaction with the customer service and communication of the technician, and satisfaction with communication from the staff were statistically significant. One observation of note in this model is that a pet-owner who is satisfied with the communication of the staff is nearly twice as likely to be behaviorally loyal than a pet-owner who is not satisfied with the communication of the staff, Exp(B) = 1.975. A Hosmer and Lemeshow goodness-of-fit test was performed on the model. It demonstrated that the model chosen was not a poor fit but failed to determine whether the model was a good fit. p < 0.001). A Tukey post hoc analysis revealed that mean increase in satisfaction with cost and value of services was statistically significant with each of the group differences (p < 0.001) with the exception of “up to 2.0” and “2.0 to 2.9” in the group “how important are routine checkups” (p = 0.167). The cost of veterinary services was cited as the leading reason for a pet-owner leaving a veterinary clinic, it is therefore important to understand this construct further. A one-way ANOVA was conducted to determine whether there was a difference in the perception of cost and value of services between any of the demographic groups, or constructs. A number of variables had statistically significant differences between groups, including commitment to return, satisfaction with veterinarian communication, satisfied with staff communication, AL, and perceived importance of wellness exams. Prior to conducting the ANOVA, the mean score for pet-owners’ perception of cost and value was binned into three categories. A score of 1.0 to 1.9 corresponds to a response of “strongly disagree”. A score of 2.0 to 2.9 represents a response of “disagree”. A score of 3.0 to 4.0 represents a response of “agree” or “strongly agree”. Results of the ANOVA show statistically significant differences across each of the five variables in terms of satisfaction with cost and value of veterinary services  = 90.653, p < 0.001). It was found that satisfaction with customer service and communication skills of the checkout staff significantly predicted pet-owners’ perception of cost and value , as did AL , satisfaction with communication from the veterinarian , and pet-owners’ perception of the importance of wellness exams . There is a strong positive relationship (R = 0.721) between cost and value, and the model predictors. The linear regression model is statistically significant (p < 0.001).To understand the predictors of pet-owners perception of cost and value, a linear regression was conducted. The results of the regression indicated that four predictors explained 52% of the variance  = 3.339, p = 0.001; diagnostic laboratory services, M = 0.43, 95% CI , t(349) = 3.769, p < 0.001; vaccinations, M = 0.42, 95% CI , t(349) = 4.045, p < 0.001; prescription medications, M = 0.30, 95% CI , t(349) = 3.067, p = 0.002; other surgeries, M = 0.46, 95% CI , t(349) = 6.182, p < 0.001; spay or neuter surgery, M = 0.29, 95% CI , t(349) = 3.836, p < 0.001; preventive medications, M = 0.35, 95% CI , t(349) = 4.802, p < 0.001; dental procedure, M = 0.29, 95% CI , t(349) = 3.836, p < 0.001. While the t-tests confirmed statistically significant differences in AL scores between groups of pet-owners, it could not demonstrate a cause and effect relationship.Independent samples t-tests demonstrated that the differences in mean AL was statistically significantly higher for each of the eight services for pet-owners who received that product or service at their primary veterinary clinic than for those who did not. The differences were as follows: wellness exam, M = 0.52, 95% CI , t2 = 0.201, F = 22.448, p < 0.001). It was found that AL significantly predicted the number of products and services that a pet-owner consumes at his or her primary veterinary clinic , as did the pet-owners’ perception of the importance of wellness exams , and pet-owner income . There is a moderate positive relationship (R = 0.448) between the number of products and services consumed and the model contributors. The linear regression model is statistically significant (p < 0.001). A linear regression was conducted to determine which variables, if any could predict the number of services that a pet-owner consumes at his or her primary veterinary clinic. Commitment was excluded from the model since its inclusion caused the variance inflation factor (VIF) to rise above 5.0 for AL, indicating multicollinearity. The results of the regression indicated that three predictors explained 20% of the variance  agreed that the veterinary care that their pet received was good value for the money. However, nearly a third of respondents (30.1%) agreed or strongly agreed that veterinarians offer additional services just to make money. This finding suggests that the totality of care that a pet requires has not been fully explained in a way in which the pet-owner understands, or values. Pet-owners cannot be expected to understand all of the complexities of a physical exam , thus caCustomer perceived value is independent of timing and can be considered a pre- or post-purchase construct . VeterinCustomer service problems persist despite high overall pet-owner satisfaction with communication. This is highlighted by the high number of pet-owners who cited various deficiencies in customer service as reasons for defecting from a veterinary practice see . A direcImprovements in pet-owner loyalty can increase the frequency at which pet-owners visit a veterinary practice and improve adherence with recommended treatments . The preThere are several limitations noted within the study. The present study did not observe the hypothesized relationship between satisfaction with communication and behavioral loyalty. It is possible that no such relationship exists, but it is also possible that the current definition of behavioral loyalty must be refined, thus altering the findings. One factor that may have biased the findings on behavioral loyalty is that adherence data was self-reported by pet-owners. A more reliable source of adherence data could be extracted from a veterinary clinic’s database. Examining data directly from this database could address another limitation, which is a lack of veterinary clinic profitability. While an estimate can be made for the value of AL using the self-reported data, this estimate will remain speculative until further research can investigate this further. One other limitation is that pet-owners were solicited to participate in the current research through social media, and these individuals might not be reflective of the population as a whole.Females made up 80.1% of the survey population. It may be difficult to translate the findings of this research to the population as a whole. However, this demographic profile is not unusual in studies in veterinary medicine. Other surveys found female participation at 84% , and 85%The present exploratory study was able to confirm that a positive relationship does exist between satisfaction with communication and AL. This relationship also exists between trust in the veterinarian and attitudinal loyalty, as well as between the perceptions of cost and value of veterinary services, and attitudinal loyalty. The importance of AL has been demonstrated to be a predictor of a pet-owner’s perception of the cost and value of veterinary services along with the number of products or services that the pet-owner consumes at his or her primary veterinary clinic. AL was also shown to have a strong positive relationship with the behavioral intentions of commitment and willingness to refer. One of the strongest indicators of the value of AL comes in the examination of commitment.It was noted that, in the absence of AL, pet-owner commitment to return to his or her present veterinary clinic is influenced by trust in the veterinarian, satisfaction with communication from the veterinarian and staff, and satisfaction with the cost and value of services. Once AL is introduced, pet-owner commitment to return is only influenced by AL and satisfaction with veterinarian communication. Eliminating the predictors of trust, satisfaction with staff communication, and perception of cost and value implies that pet-owners who exhibit AL might indeed be inclined to forgive service failures  as well The relationship between satisfaction with communication and BL was not as clear. It was discovered that pet-owners who are satisfied with communication from staff members were nearly twice as likely to be BL, and that the likelihood of a pet-owner being behaviorally loyal improved when pet-owners see the same veterinarian and consult with the veterinarian first for healthcare questions. However, the full impact of BL on a veterinary clinic as measured for this study remains unclear.Additional factors emerged as important moderators of attitudinal loyalty and behavioral intentions of pet-owners. Those included the pet-owners’ perception of cost and value of services, whether the pet-owner sees the same veterinarian, the pet-owners’ perception of the importance of routine care, the age of the pet-owner, and whether the pet-owner consults a veterinarian or the internet first with questions about pet healthcare.Several areas for future research surfaced when evaluating this study. A better understanding of behavioral loyalty is required to fully understand the relationship between satisfaction with communication and behavioral loyalty. Gaining a better understanding could also help to determine the relationship between attitudinal loyalty and behavioral loyalty. The scope of the current research did not allow for the measurement of veterinary clinic profitability. It would be of great importance to understand the relationship between pet-owner loyalty, and practice profitability. Such a study would require the participation of one or more veterinary clinics to allow access to sensitive financial data at both a practice and pet-owner level. Using an information technology company that specializes in veterinary practices would allow for a more accurate measurement of the financial data and could serve to protect the anonymity of pet-owners.Pet-owners generally agree that the veterinary care that is provided is good value for money, yet the cost of veterinary care is the most commonly cited reason for leaving a veterinary practice. This disconnect should be explored further to expand upon the present research and the qualitative research conducted by Coe et al. . A commonly cited reason for pet-owners leaving a veterinary practice are the customer service skills of veterinarians and their staff members. Understanding what clients expect should be a priority for every veterinary practice and warrants further investigation. So too does the nature of the age differences in attitudinal loyalty that was uncovered in this research. It is necessary for veterinary clinic owners to fully understand the needs of the youngest cohort of pet-owners since they could own pets for a very long time.The availability of loyalty and referral programs had no statistically significant relationship with any of the higher-order constructs in the present study. However, these types of programs have been successful in other industries ,24. Thes