College of Wilmington Marketing a Services as Opposed to Product Paper

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Attached are the 5 journal/research articles that pertain to marketing a service (as opposed to a product) . Please look at the attached documents and write a 3-5 page report (excluding cover page, abstract, and references) synthesizing those 5 articles in APA format and include the references. The document should consist of the following:

Key Term: authentic leadership

Notes: A report is not rehashing what was already stated in the article, but the opportunity for you to add value by sharing your experiences, thoughts and opinions. This is the most important part of the assignment. REFERENCES: All references must be listed at the bottom of the submission--in APA format. Be sure to use the headers in your submission.

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Hijazi et al. BMC Health Services Research (2020) 20:386 https://doi.org/10.1186/s12913-020-05258-7 RESEARCH ARTICLE Open Access Role of community pharmacists in weight management: results of a national study in Lebanon Mohamad Ali Hijazi1, Hibeh Shatila2, Abdalla El-Lakany1, Hiba Al Rifai2, Maha Aboul-Ela1 and Farah Naja2* Abstract Background: Ideally situated within the community, pharmacists can be involved in a broad range of health promotion campaigns including prevention of obesity. Limited evidence is available regarding their involvement in weight management in Lebanon, a country with escalating prevalence rate of obesity. Objective: To examine the role of community pharmacists in weight management in Lebanon, specifically studying their beliefs, current practices, services, and knowledge. Methods: Using a stratified random sampling approach, a cross sectional national survey of community pharmacists was conducted (n = 341, response rate 89%). At the pharmacy, and through a face-to-face interview, pharmacists completed a multi-component questionnaire that addressed, in addition to socio-demographic and work characteristics, their beliefs, practices, knowledge in relation to weight management. Frequencies and proportions were used to describe the data. Simple and multiple linear regression analyses were used to examine the determinants of knowledge in the study population. Results: Over 80% of study participants agreed that they have an important role to play in weight management. However, 50% of pharmacists did not agree that weight loss products are well regulated and 81.1% thought that companies marketing weight loss products are making false promises. The majority of pharmacists always/often sold weight loss products (84.7%) and counseled their patients for diet (86.3%) and physical activity (91.7%). Despite taking weight and height measurements, 50% of pharmacists rarely/never calculated BMI. Among the pharmacists who reported side effects of weight loss products (46.5%), the majority (91.3%) did so to the pharmaceutical company. The knowledge of pharmacists was better for the use of weight loss products as opposed to their side effects and interactions. Significant predictors of knowledge were holding a Masters/ PhD degree in Pharmacy, graduating from a university inside Lebanon, obtaining weight management training within the academic degree, and receiving inquiries about weight management in the pharmacy more than once daily. Conclusions: The results of the study provided important insights on the beliefs, practices and knowledge of community pharmacists in weight management in Lebanon. These findings could be used to inform the development of future evidence-based community pharmacists led weight management service provision nationally and internationally. Keywords: Weight management, Obesity, Community pharmacy, Lebanon * Correspondence: fn14@aub.edu.lb 2 Nutrition and Food Sciences Department, Faculty of Agriculture and Food Sciences American, University of Beirut, Beirut, Lebanon Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hijazi et al. BMC Health Services Research (2020) 20:386 Background Over the past 30 years, the prevalence of obesity has been increasing at an alarming rate worldwide. It is described as a global pandemic with currently more than 1.9 billion adults being overweight of which more than 650 million are obese [1]. Obesity is associated with increased morbidity and mortality and is a major risk factor in the etiology of many non-communicable diseases including type 2 diabetes, stroke, coronary artery disease, dyslipidemia, hypertension, pulmonary disease and cancers [2]. In addition to its physical consequences, obesity has also been linked to an increased risk for many psychiatric disorders, such as depression, impaired body image, low self-esteem, eating disorders, stress and poor quality of life [3]. The continuous rise in obesity is hence considered a global public health challenge and is threatening health improvements in many countries. Therefore, there is an eminent need to control the escalating burden of obesity through the implementation of evidence-based interventions for weight management [4]. Although physician recommendations have consistently been shown to exert a powerful influence on weight management, time constraints, limited access to resources for lifestyle changes, and low reimbursement are barriers between patient and provider [5]. Accumulating evidence suggested that a multidisciplinary approach that utilizes a broad range of health care expertise with proven synergy is most likely to be effective [6]. Among these health care expertise, community pharmacists are often considered the first contact point between patient and the health care system, perceived as accessible and trustworthy and have frequent contact with patients due to prescription dispensing schedules [7]. Ideally situated within the community, they can be involved in a broad range of health promotion campaigns and services, including prevention of chronic diseases such as hyperlipidemia, hypercholesterolemia, diabetes, osteoporosis, as well as obesity and weight management [8–13]. In fact, the American Society of HealthSystem Pharmacists recommends that pharmacists work with obese patients to manage lifestyle modifications [14]. A significant component of the pharmacists’ academic education covers etiology of obesity, its risk factors, management and treatment which qualifies as a strong foundation for providing lifestyle management counseling [15]. A recent scoping review of studies addressing the role of pharmacists in weight management counseling concluded that weight and obesity management interventions delivered by community pharmacies resulted in some weight loss, which, despite being modest, can be clinically significant as it improves surrogate markers of cardiovascular disease [16]. The majority of studies included in this scoping review were however conducted in developed countries [17–19] with limited evidence in many developing counties, including those in the Eastern Mediterranean Region (EMR), Page 2 of 12 where the prevalence of obesity is escalating at an alarming rate [10, 20]. Lebanon, similar to neighboring countries in the EMR, is also witnessing a sharp increase in obesity prevalence with rates doubling between years 1997 and 2009. In 2009, among adults, obesity prevalence was 28.2% compared to 17.4% in 1997 [21]. This increase in obesity prevalence was also seen among children [21, 22]. The increase in obesity prevalence in Lebanon necessitates the inclusion of a multi-disciplinary team for a proper obesity management [23] among which pharmacists in Lebanon are highly trusted and recognized as having expertise in the health field [24]. In fact, a previous survey of community pharmacists in Lebanon investigating their role in managing hypertension showed that the majority advised and counseled patients on lifestyle habits and behaviors, addressing smoking, alcohol abuse, and healthy eating choices [24]. Furthermore, a recent study by our group examining the role of community pharmacists in Complementary and Alternative Medicine (CAM) showed that 80% of the surveyed pharmacists believed that providing information to customers about CAM products is a pharmacist’s professional responsibility, and 64.5% of pharmacists were always or often advising patients on safe use of CAM products and ask for their feedback after use [25]. These positive attitudes and practices of Lebanese pharmacists, in addition to their convenient and affordable accessibility, represent a potential opportunity to explore their role in weight management services. Therefore, the aim of this study is to examine the involvement of community pharmacists in Lebanon in overweight and obesity prevention and treatment, specifically studying their beliefs towards their role in weight management, current practices, services, and knowledge. In addition, the study aims to investigate the barriers to deliver optimal weight management services among community pharmacists in the country. Methods In this study, a national cross-sectional survey of pharmacists in Lebanon was conducted between August 2018 and January 2019. The target population was pharmacists practicing in community pharmacies in Lebanon, while the study population included pharmacists recruited from a nationally representative sample of community pharmacies in the country. The sampling unit for this study was the pharmacy. A comprehensive list of community pharmacies in various governorates of Lebanon was obtained from the Order of Pharmacists in Lebanon (OPL). Pharmacies were chosen from this list using a stratified random sampling. The stratification was at the level of the six Lebanese governorates. Within each stratum (governorate), random samples of pharmacies were selected whereby numbers of pharmacies selected from each stratum was proportional Hijazi et al. BMC Health Services Research (2020) 20:386 to the total number of pharmacies in that particular stratum. In a few pharmacies, more than one pharmacists were present at the time of the conducting the survey, in which case one pharmacist was selected at random, using the Kish method [26]. Sample size calculations showed that a minimum of 342 pharmacists need to be recruited in order to detect an expected outcome at a prevalence of 50% with a 95% confidence interval (CI) and a margin of error of 5%. The calculations for sample size were conducted using Raosoft sample size calculator [27]. The study protocol was approved by the Institutional Review Board at the Beirut Arab University under the protocol number 2019H-0059-P-R-0300. The study protocol involved conducting a survey among community pharmacists in the selected pharmacies. Data collection was carried out by field workers who were trained extensively on interviewing techniques and administration of the questionnaire. Prior to starting the survey, field workers introduced the study and assured the pharmacist of the confidentiality of data collected and that he/she has the right not to answer any of the questions in the questionnaire and to withdraw at any point during the survey. Interested pharmacists signed a written consent. Completing the survey lasted 20–25 min. The development of the questionnaire used in the data collection for this study was designed by a detailed review of relevant past literature [15, 28–37]. The questionnaire was further reviewed by an expert panel of a community pharmacist, a professor of pharmacy, a nutrition epidemiologist, and a clinical nutritionist. The main aim of this review was to ensure content validity, clarity, as well as relevance to the Lebanese context. The questionnaire was written in English, translated to Arabic and then back translated to English to ensure parallel form reliability. The developed questionnaire was administered for pilot testing to 16 community pharmacists in various governorates in Lebanon. The pharmacies for the pilot test phase were conveniently selected. Results of the pilot test were not included in this study. The main changes that were introduced to the questionnaire, because of the pilot testing, were in relation to the technical translation of certain terms, in order to enhance the cultural and context specificity of the questionnaire. A copy of the English version of the questionnaire is found in Additional file 1. The final version of the questionnaire consisted of five sections: the first section addressed demographic characteristic of the pharmacist (age and gender), education information (level of education (Bachelors, Masters, Pharm D or PhD), location of the university he/she graduated from (inside or outside Lebanon), receiving education/training related to weight management during his/her university education years or post-graduation), employment (employment status, number of years of experience as Page 3 of 12 community pharmacist), characteristic of the pharmacy (number of pharmacists in the pharmacy, duration for which the pharmacy open for) and frequency of queries/ day the pharmacists receive about weight management products. The second section of the questionnaire focused on participants’ beliefs of a few issues related to weight management such as the role of the pharmacists in weight management, the exclusivity of sale of weight management product in pharmacies, whether or not they believe weight management should be addressed through a multidisciplinary team approach and whether other healthcare professions are more suited than pharmacists to deal with weight management and the need for continuous education for pharmacists in weight management. In addition, this section included the pharmacists’ perception regarding the regulatory framework of weight management products in Lebanon, the use/ abuse of weight management products by consumers, and the role the companies and media play in orienting the consumers’ behavior. The third section of the questionnaire included questions assessing the pharmacist’s practices in weight management, such as selling, advising patient on safe use, reporting of adverse effects, checking for drug or food interactions, counseling patients on (behaviors related to weight management such as low calorie diets, physical activity, pharmacotherapy, etc.), the provision of weight related measurements (weight, height, waist circumference, Body Mass Index (BMI) calculations, blood glucose, body fat, blood pressure measurements), referrals of customers to dieticians and follow up on possible side effects of weight management. The fourth section of the questionnaire assessed pharmacist’s perceived barriers in providing weight management service such as time, staff, space, equipment, the need for additional payment, the lack of knowledge and interest. For sections 2, 3 and 4, responses were measured on a 5-point Likert scale (1-strongly agree, 2agree, 3-neutral, 4-disgaree and 5-stronglt disagree). The last section of the questionnaire addressed the pharmacist’s knowledge toward weight management. Ten questions were selected to address general knowledge in overweight and obesity as well as the uses, side effects and drug interactions of commonly sold weight management products [15, 28–36]. The weight management products used in the questionnaire included herbal (green tea), laxative and orlistat; and were selected based on consultation with a panel of pharmacists who suggested that these products were the most commonly used products in the market for weight management in the Lebanese market. This panel of pharmacists consisted of the President of OPL, the chief executive officer of the largest wholesaler in Lebanon, and a sale manager from a pharmaceutical company. This panel, based on their experience and their sales data, suggested a list of Hijazi et al. BMC Health Services Research (2020) 20:386 commonly sold products. This list was further vetted by five community pharmacists, one from each of the Lebanese governorate, in order to select the three most commonly sold products for weight management in the country. A copy of the questionnaire used in data collection is provided as supplementary file to this manuscript. Statistical analysis Data collected were entered into the Statistical Package for Social Sciences (SPSS, version 25). Accuracy of the collected data was evaluated by visual inspection and examination of ranges and logic checks. Frequencies and proportions were used to summarize the subjects’ characteristics, as well as the beliefs, practices, barriers and knowledge of study participants. For knowledge, in addition to the aforementioned descriptive statistics, a knowledge score corresponding to the sum of points a pharmacist obtains for all the knowledge questions, whereby he/she is given one point for a question that they answered correctly and ‘0’ point if their answer was either wrong or ‘I don’t know’ answer’. Therefore, the knowledge score ranged between ‘0’ and ‘10’, with higher values of the score reflecting more correct answers and hence better knowledge. In order to determine the correlated of knowledge, simple and multiple linear regression analyses were conducted. In these regression analyses, the knowledge score was considered as the outcome variable while the socio demographic factors were entered as independent variables. Of the socio-demographic characteristics, variables that were found significantly associated with knowledge score in the simple regression were entered in the multiple regression. Regression diagnostics were examined to ensure that the assumptions for the MLR were met, including linearity between the independent and the dependent variables, homoscedasticity, and multicollinearity. The results of the diagnostics are presented in Additional file 2. A p-value < 0.05 was considered statistically significant. Results Three hundred and eighty three pharmacists were approached, 341 of whom agreed to participate in the study (89% response rate). The distribution of the pharmacies in Lebanon and the study sample, across the 6 Lebanese governorates are shown in Table 1. The study sample showed similar proportions of pharmacies among the various governorates. The characteristics of the study population are presented in Table 2.The pharmacists were of varied age groups, with most of them aged 40 and below (66.4%). The proportion of males (51.9%) and females (48.1%) were comparable. The study sample included pharmacists who were employed in the selected pharmacies (41.8%) or owners of these pharmacies (58.2%). As for the education level, more than half of the study Page 4 of 12 Table 1 Distribution of pharmacies across governorates in this study in comparison to national distribution of pharmacies n = 341 Pharmacies in the study n(%) Pharmacies in Lebanon n(%) Beirut 27(7.9) 238(7.8) South 40(11.7) 353(11.6) North 50(14.7) 436(14.3) Mount Lebanon 147(43.1) 1311(43.1) Beqaa 51(15.0) 482(15.8) Nabatieh 26(7.6) 223(7.3) Total 341 3043 population were holders of a Bachelor’s degree (57.5%), while 42.6% had attained higher degrees: 22.3% a Pharm D degree and 20.2% a Masters or PhD degree. Sixty-four percent of the pharmacists attained their university education in Lebanon. Only 35.3% of the pharmacists reported receiving weight management training during their university education and a lower proportion (21.5%) underwent a post-graduation training in weight management. Forty-four percent of the pharmacists had more than 10 years of work experience, followed by 32.1% having 4–10 years of experience and 24.1% having 1-3 years of experience. Most of the pharmacists work in a pharmacy that has been open for more than three years (81.1%). Almost half of the pharmacists (47.5%) reported receiving more than 1 query a day about weight management products. The majority of pharmacists (87.9%) were strongly agreeing or agreeing that obesity is a growing problem in Lebanon. Overall, the study participants strongly agreed or agreed that pharmacists have a role to play in the field of weight management (84.8%), that providing information about weight management products is a pharmacist’s professional responsibility as extension of their role as health professional (83.1%) and that weight management products should be sold only in pharmacies (83.8%) (Table 3). A total of 82.7% of participants strongly agreed or agreed that a multidisciplinary team approach to weight management will work best (82.7%). Eighty-two percent strongly agreed or agreed that continuous education of pharmacist should include weight management and training. In general, the participant showed negative beliefs toward the market by strongly agreeing or agreeing that customers are abusing weight management drugs (76.9%) and companies are abusing customers by making false promises (81.1%). In addition, more than half (54.9%) disagreed or strongly disagreed that that weight loss products are well regulated. The majority of the pharmacists (84.7%) participating in this study reported that they always/often sell weight loss products in their pharmacy and 88.7% reported always/often being asked for weight loss products Hijazi et al. BMC Health Services Research (2020) 20:386 Page 5 of 12 Table 2 Characteristics of study sample. (n = 341) Frequency Percentage Age range < 30 years 114 33.5 31–40 years 112 32.9 ≥ 41 years 114 33.5 Gender Male 177 51.9 Female 164 48.1 Employments status Employed 142 41.8 Pharmacy owner 198 58.2 Bachelors 196 57.5 Pharm D 76 22.3 Masters/PhD 69 20.2 Highest educational level attained University you graduated from Outside Lebanon 123 36.3 In Lebanon 216 63.7 During your university education, did you receive any weight management training? Yes 120 35.3 No 220 64.7 Did you receive any postgraduate education/ training on weight management? Yes 73 21.5 No 266 78.5 Years of work experience 1–3 years 82 24.1 4–10 years 109 32.1 Above 10 years 149 43.8 263 77.4 How many pharmacists work in this pharmacy? 1–2 pharmacist 3–5 pharmacist More than 5 pharmacist 74 21.8 3 0.9 How long has this pharmacy been opened for? 1–3 years 64 18.9 4–10 years 117 34.5 Above 10 years 158 46.6 How many times per day do you get queries about weight management products at your pharmacy? Once daily or less 179 52.5 More than once daily 162 47.5 (Table 4). Eighty-six percent reported always/often counselling customers who request to buy products for weigh management on the safe and effective use of the product and 77.6% always/often check for drug or food interaction while dispensing weight loss products. The majority were always/often advising the patients to eat low calorie diet (86.3%), increase physical activity (91.7%), and increase consumption of soluble fibers (80.9%). In addition, participated pharmacists reported that they always/often provide weight and height measurement for their patients (80 and 60%, respectively). However, the majority (81.7%) were rarely/never providing waist circumference measurements for patients. Most participants answered always/often provide blood glucose and blood pressure measurements (83.7 and 89.0%, respectively) at their pharmacy, but only 15.3% of them provided body fat measurement. Around 66% of the surveyed pharmacists reported referring patients to dieticians, on as needed basis. Most of the pharmacists (73.6%) reported that they always/often ask customers for any side effects or undesirable reactions after taking weight loss products; however, 53.5% of the pharmacists rarely/never reported any toxicity or adverse reaction of weight loss products. Among those who reported the incidence of toxicity or adverse reactions, 91.3% of pharmacists were reporting to the pharmaceutical companies and only 1.9% reported to the OPL, whereas the remaining reported to physician (3.9%) and MOPH (2.9%) (Table 5). Over 30% strongly agreed/agreed to the following barriers to weight management services; I don’t have time (30.4%), I don’t have enough staff (36.5%), I don’t have enough space to have private consultation area (37%), I don’t have the relevant equipment (39.8%), I would need additional payment (31.8%). On the other hand, fewer pharmacists strongly agreed or agreed that adequate knowledge (21.5%) or interest in the weight management (18.6%) were barriers for them to provide weight management services (Table 6). Table 7 displayed the results of self-knowledge assessment of community pharmacists with regards to weight management. The assessment included 10 questions addressing general knowledge about overweight and obesity as well as the uses, side effects and interactions of commonly sold weight management products in Lebanon, namely green tea, herbal laxative and orlistat. While 71.1% of pharmacists answered correctly the question related to BMI cutoff for obesity, only 25% knew about weight loss targets and 51% realized the importance of weight maintenance, after reaching the target weight. The percentage of pharmacists answered correctly the side effects and interactions of laxatives was greater than those for green tea and olistat (83.4 and 79.2% for laxatives as compared to 45.2 and 17.3% for green tea and 67.1 and 54.6% for olistat). Hijazi et al. BMC Health Services Research (2020) 20:386 Page 6 of 12 Table 3 Community pharmacists’ beliefs towards their role in weight management*. (n = 341) Strongly agree Do you think obesity is a growing problem in Lebanon Agree Neutral Disagree Strongly disagree 221(66.8) 70(21.1) 27(8.2) 9(2.7) Do you believe that pharmacists have a role to play in the field of weight management 198(58.1) 91(26.7) 24(7.0) 17(5.0) Providing information about diet products is a pharmacist’s professional responsibility as extension of their role as health professional 166(49.4) 114(33.7) 35(10.4) 14(4.1) 17(5.0) 4(1.2) 11(3.2) 9(2.7) Do you think that weight loss products should be sold only in pharmacies 235(69.3) 49(14.5) 22(6.5) 16(4.7) Do you feel other healthcare professionals are more appropriately suited to be involved in this area 135(40.1) 105(31.2) 60(17.8) 26(7.7) 11(3.3) Do you think that multidisciplinary team approach to weight management will work the best 196(58.8) 80(23.9) 9(2.7) 34(10.1) 16(4.8) Continuous education of the pharmacist should include weight management and training 180(53.3) 97(28.7) 40(11.8) 12(3.6) 9(2.7) Do you think that customers are abusing weight loss products 163(48.8) 94(28.1) 46(13.8) 24(7.2) 7(2.1) Do you think that companies marketing weight loss products are making false promises? 174(52.3) 96(28.8) 32(9.6) 12(3.6) Do you believe that herbal weight loss products are well regulated? 37(10.9) 53(15.6) 63(18.6) 79(23.3) 107(31.6) Do you think that media and advertisements are playing a positive role in educating customers towards weight loss products and weight management 112(33.0) 54(15.9) 43(12.7) 52(15.3) 78(23.0) 19(5.7) Values in this table represent n (%) * For the overall score of knowledge, results of the multiple linear regression revealed few factors that were associated with a higher score, indicated by a significantly positive value for ß. The magnitude of the latter indicated the difference in knowledge score between the categories compared. These factors included: Holding a Masters or PhD degree in Pharmacy as compared to Bachelor’s degree (ß =0.79, 95%CI: 0.37–1.21), graduating with a pharmacy degree from a university in Lebanon as opposed to abroad (ß =0.88, 95%CI: 0.5–1.26), obtaining weight management training within the academic degree (ß = 0.42, 95%CI: 0.08–0.75), and receiving inquiries about weight management in the pharmacy more than once daily (ß =0.41, 95%CI: 0.1–0.73) (Table 8). Table 4 Current practice towards weight management services among community pharmacists in Lebanon*. (n = 341) Always Often Sometimes Rarely No Do you dispense weight loss products at your pharmacy 188(55.5) 99(29.2) 32(9.4) 14(4.1) 6(1.8) Do your patients ask you for weight loss products 212(62.7) 88(26.0) 21(6.2) 8(2.4) 9(2.7) Do you counsel customer who request to buy products for weight management on the safe and effective use of the product 224(66.9) 65(19.4) 26(7.8) 10(3.0) 10(3.0) Do you check for drug or food interaction while dispensing weight loss product 193(57.8) 66(19.8) 35(10.5) 22(6.6) 18(5.4) Do you advice the patients to eat low calorie diet 235(69.7) 56(16.6) 30(8.9) 8(2.4) 8(2.4) Do you advice the patients to increase physical activity 262(78.0) 46(13.7) 14(4.2) 8(2.4) 6(1.8) Do you advice the patients to increase consumption of soluble fiber 214(63.9) 57(17.0) 35(10.4) 19(5.7) 10(3.0) Do you provide weight measurements for patients 222(66.1) 46(13.7) 22(6.5) 14(4.2) 32(9.5) Do you provide height measurements for patients 150(44.6) 45(13.4) 18(5.4) 23(6.8) 100(29.8) Do you provide waist circumference measurements for patients 21(6.3) 15(4.5) 25(7.5) 34(10.1) 240(71.6) Do you provide BMI calculation for your patients 101(30.0) 33(9.8) 38(11.3) 28(8.3) 137(40.7) Do you provide blood glucose measurement at your pharmacy 243(71.9) 40(11.8) 16(4.7) 10(3.0) 29(8.6) Do you provide blood pressure measurement at your pharmacy 253(75.1) 47(13.9) 13(3.9) 3(0.9) 21(6.2) Do you provide body fat measurement at your pharmacy 39(11.5) 13(3.8) 21(6.2) 15(4.4) 250(74.0) Do you refer your patient to dieticians when needed 156(46.3) 69(20.5) 58(17.2) 17(5.0) 37(11.0) Do you ask customers for any side effect or undesirable reaction after taking weight loss products 186(55.2) 62(18.4) 44(13.1) 11(33.3) 34(10.1) Do you report any toxicity or adverse reaction of weight loss products? 89(26.5) 31(9.2) 36(10.7) 27(8.0) 153(45.5) Values in this table represent n (%) * Hijazi et al. BMC Health Services Research (2020) 20:386 Page 7 of 12 Table 5 To whom do you report any toxic or undesirable effect that occurred with patients using weight loss products?? n = 103 % Manufacturing company 94 91.3 Ministry of Public Health (MoPH) 3 2.9 Order of Pharmacy in Lebanon (OPL) 2 1.9 Physician 4 3.9 Discussion This is the first national study to examine the role of pharmacists in weight management in Lebanon and to shed light on their beliefs, practices and knowledge regarding weight management and weight loss products. Overall, the study findings highlighted a general positive belief among pharmacists regarding their role in weight management while acknowledging the role of other health care professionals in managing overweight and obesity. Pharmacists participating in this study, however, expressed reservations towards the regulatory framework governing the market of weight loss products in the country. With regards to practices, despite engaging in counseling for weight management as well as dispensing weight loss products, a sizeable proportion of pharmacists were rarely carrying out important diagnostic measures, such as BMI calculations or waist circumference measurements. In addition, even though 73% of pharmacists in this study inquired about products’ side effects, only 35% reported such effects with the majority doing so to the company selling the products or to its medical representative. This study revealed important gaps in the knowledge of pharmacists, most importantly with regards to the side effects of certain weight loss products and their interaction with other medications. In this study, factors significantly associated with better knowledge were higher education (Masters or PhD), earning the pharmacy degree from a university in Lebanon, obtaining formal education in weight management, and receiving frequent inquiries about weight management from patients/customers. In this study, the majority of pharmacists believed that their role is important in weight management and that dispensing diet and weight loss products ought to be the pharmacist responsibility solely. More specifically, the findings indicated that while pharmacist perceived that they have a role to play in the area of weight management, they also believed in the importance and effectiveness of a multidisciplinary team and that other health care professionals may be better suited to take lead on that front. These findings are in line with previous research, whereby a survey of 128 community pharmacists in Scotland showed positive attitudes to the provision of healthy weight management services [38]. Furthermore, a qualitative study in Australia investigating the pharmacists’ opinion about provision of weight management services indicated that participants clearly perceived an important role for pharmacists in weight management, as part of a multi-disciplinary team [17]. Also in Australia, a more recent study conducted among pharmacy students and early career pharmacists showed that participants were positive about their perceived role in providing weight management services [39]. These positive beliefs of pharmacists towards their role in weight management were contrasted with the doubts that many surveyed pharmacists casted on the regulations governing the market for CAM products including those for weight loss. Such doubts were also reported by other studies [25, 40–42]. In fact, since only few of the hundreds products sold in pharmacies for weight loss are licensed medicines, they are not subject to the strict control required for medicines, in terms of efficacy, safety, quality or provision of a standardized patient information leaflet [43]. In Lebanon, several weight loss products were promoted and sold for many years before Table 6 Barriers in providing weight management services among community pharmacists in Lebanon.* (n = 341) n(%) I don’t have enough time to provide weight management services Strongly agree Agree Neutral Disagree Strongly disagree 55(16.2) 48(14.2) 59(17.4) 64(18.9) 113(33.1) I don’t have enough staff to provide weight management services 70(20.6) 54(15.9) 51(15.0) 66(19.5) 98(28.9) I don’t have enough space to have a private consultation area to provide weight management services 74(21.9) 51(15.1) 39(11.5) 59(17.5) 115(34.0) I don’t have the relevant equipment (e.g. weighing scale,etc) to provide weight management services 78(23.0) 57(16.8) 41(12.1) 56(16.5) 107(31.6) I would need additional payment to provide weight management services 69(20.4) 38(11.2) 40(11.8) 43(12.7) 148(43.8) I don’t have the enough knowledge to provide weight management services 36(10.6) 37(10.9) 47(13.9) 72(21.2) 147(43.4) I don’t have the interest to provide weight management services 36(10.6) 27(8.0) 48(14.2) 76(22.4) 152(44.8) Values in this table represent n (%) * Hijazi et al. BMC Health Services Research (2020) 20:386 Page 8 of 12 Table 7 Evaluation of self-knowledge towards weight management among community pharmacists in Lebanon. (n = 341) The cut off for body mass index (BMI) to indicate obesity is > 29.9 kg/m2. True/ False % answered correctly % answered incorrect % answered I don’t know T15 239(71.1) 41(12.2) 56(16.7) 82(24.3) 175(51.9) 80(23.7) 27,28,36 An initial weight loss goal should be to lose more than 10% of current body weight in 6 months F Once a weight loss goal is achieved it is okay to discontinue treatment.a F29 172(51.0) 146(43.3) 19(5.6) Laxatives are considered very useful method to lose weight in obese persons. F 30 262(77.5) 66(19.5) 10(3.0) Herbal Laxative (like senna, cascara, etc) are recommended for pregnant or breast feeding women F31 282(83.4) 42(12.4) 14(4.1) High consumption of green tea may exert toxicity to liver cells. T32 152(45.2) 71(21.1) 113(33.6) Orlistat use is associated with a higher incidence of gastrointestinal adverse events compared with placebo. T 33 226(67.1) 71(21.1) 40(11.9) The chronic use laxatives may potentiate the effects of diuretics which may lead to significant losses of fluid and electrolytes, including sodium, potassium, magnesium and zinc. T34 267(79.2) 41(12.2) 29(8.6) Concomitant use of large quantities of green tea may increase the effectiveness of anticoagulation drugs (warfarin). F 58(17.3) 143(42.7) 134(40.0) Orlistat is contraindicated in patients with cardiovascular diseases. F33 184(54.6) 109(32.3) 44(13.1) a 30,31,35 Interviewers were trained to indicate that ‘treatment’ in this question referred to ‘dietary changes’ the Ministry of Public Health (MoPH) withdrew them from the market and prevented their uses because of contamination, presence of unauthorized ingredients, or counterfeits [44]. In this study, the positive belief of the surveyed pharmacists regarding their role in weight management was also reflected in their practices, whereby the majority of pharmacists always/often dispensed weight loss products and counseled patients on healthy lifestyle habits, including diet and physical activity. A few studies reported more elaborate interventions for weight loss as part of the pharmacist’s role such as patient-centered weight loss programs [45, 46] and conducting slimming courses [47]. However, and in support of the study findings, the supply of medication and counseling for weight loss remain the two most common pillars of the pharmacist role in weight management [17]. Alarmingly, in this study, a few practices that were reported by the surveyed participants jeopardized the efficacy and safety of their role in weight management. For instance, although the pharmacists reported taking height and weight measurements, only a few calculated the BMI or provided assessments for waist circumference and body fat, raising questions regarding the sensitivity of their diagnosis of obesity and consequently the relevance of their consultation. It is indisputable that weight and height measurements alone are poor indicators of obesity, if not used to calculate BMI. In fact, most of the scientific reports call for other anthropometric measurements (in addition to height and weight) such as waist circumference and body fat to classify obesity [48]. Another disconcerting finding in this study is related to the practices of dispensing weight loss medications. First, over 40% of surveyed pharmacists did not discuss with their patients the side effects or undesirable reactions of these medications. Certain drugs advertised for weight loss could pose significant adverse effects, for example Garcinia cambogia extract and hepatic failure [49] and low dose Human Chorionic Gonadotrophin injections and increased thrombosis risk [50]. According to the American Pharmacists Association, a patientcentered discussion on safe and effective medication use is among the main medication-related responsibilities of pharmacists as it is directly linked to improving patient safety [51]. Therefore, it is important for the pharmacist to heighten the patients’ awareness of potential health implications while dispensing weight loss medication. Second, over 50% of surveyed pharmacists indicated that they do not report toxicity or adverse effects of drugs when encountered. Moreover, of the few pharmacists who reported these adverse effects, the vast majority did so to the manufacturing/distributing company. Similar practices were also observed among community pharmacists in Lebanon in the case of complementary and alternative products [25]. These practices threaten public health safety, since many of the adverse effects remain not reported and could lead to serious health implications. Furthermore, communicating these adverse effects to the manufacturing/distributing company, whose main objective is financial gain from drug sales, raises a serious ethical question over such practices. Alternatively, it could be argued that such a practice stemmed from the fact that a large proportion of pharmacists reported little trust in the regulatory bodies of the market in Lebanon. In both cases, these findings call upon the MoPH to Hijazi et al. BMC Health Services Research (2020) 20:386 Table 8 Predictors knowledge score (related to weight management products) among community pharmacists in Lebanon. n = 341 B, 95% CI Adjusted B, 95% CI Ref Age range < 30 years Ref 31–40 years −0.32(−0.72, 0.09) 0.05 (−0.44,0.54) ≥ 41 years −0.73(−1.13, − 0.32) −0.10(− 0.75,0.56) Gender Male Ref Ref Female 0.37 (0.04,0.71) 0.17 (−0.17,0.51) Employed Ref – Pharmacy owner 0.18(−0.17, 0.52) – Bachelors Ref Ref Pharm D 0.26(−0.16,0.68) 0.13(−0.27,0.53) Masters /PhD 0.61 (0.19,1.04) 0.79(0.37,1.21) Outside Lebanon Ref Ref In Lebanon 0.88(0.55,1.22) 0.88(0.50,1.26) No Ref Ref Yes 0.45(0.10, 0.80) 0.42(0.08,0.75) No Ref – Yes 0.14(−0.27,0.55) – 1–3 years Ref Ref 4–10 years −0.16(− 0.62,0.29) −0.15(− 0.63,0.34) Above 10 years −0.52(− 0.94,-0.10) −0.16(− 0.80,0.48) 1–2 pharmacist Ref – 3–5 pharmacist 0.12(−0.30, 0.53) – More than 5 pharmacist −0.71(−2.88, 1.46) – Employments status Highest educational level attained Which university did you graduate from During your university education, did you receive any weight management training? Did you receive any postgraduate education/ training on weight management? Years of work experience How many pharmacists work in this pharmacy? How long has this pharmacy been opened for? 1–3 years Ref – 4–10 years −0.25 (− 0.74, 0.23) – Above 10 years − 0.46(− 0.93,0.02) – Once daily or less Ref Ref More than once daily 0.42(0.09, 0.76) 0.41(0.10, 0.73) How many times do you get queries about weight management products at your pharmacy? Page 9 of 12 upscale the health care system and implement a proper reporting system for the pharmacists and other healthcare provider as well. In this study, the beliefs and practices of pharmacists with regards to weight management were contrasted by significant knowledge gaps in this domain. More specifically, over 50% of participants in this study missed critical concepts such as the recommended percent weight to be lost over a certain period of time and the need to maintain healthy dietary habits after the target weight is reached. Furthermore, despite the fact that the majority of pharmacists in this study were involved in dispensing weight loss products, a sizeable proportion answered incorrectly the questions related to side effects and interactions of these products. Such knowledge gaps were also identified in previous studies, whereby pharmacists indicated the need for trainings in weight loss consultations, overweight and obesity diagnosis and uses of weight loss products (including side effects and interactions with other drugs) [38, 39]. An important factor was found to be associated with better knowledge, was receiving formal education in weight management. In Lebanon, although the academic curricula of pharmacy education have been evolving to match the shift in pharmacy profession from solely dispensing medicine towards a more patient centered delivery of healthcare services, more focus on weight management services is still needed. In fact, many authorities in the field of pharmacy education, including the International Pharmaceutical Federation (FIP), and the Accreditation Council for Pharmacy Education (ACPE), called for reforms in pharmacy education to include courses on nutrition and lifestyle counselling. The implementation of these reforms was shown to improve knowledge about many aspects of weight management [52–54]. Related to pharmacy education, the results of this study showed that attaining a Masters or PhD of pharmacy was found to positively influence knowledge of weight management. This finding further underscored the role of formal education in enhancing the foundational knowledge in health and wellness. Another factor found to be associated with knowledge was obtaining the degree of pharmacy from a university inside Lebanon. A potential explanation of this association is that pharmacists studying in the country may be more literate in the health and social constructs of the society than those who studied abroad. Examining the barriers that pharmacists faced in providing weight management services was essential to provide a more comprehensive situation analysis. The results of this study showed that considerable proportions (more than 30%) of surveyed pharmacists agreed that resources in terms of time, space, staff, remuneration, and relevant equipment were all common barriers to providing weight management services. The majority of these barriers were also cited in previous studies [10, 15, 17, 38]. A recent Hijazi et al. BMC Health Services Research (2020) 20:386 study showed that the pharmacy profession in Lebanon has been facing multiple challenges relating to the practicing of the profession and the protection of the professional status of pharmacists. More specifically pharmacists in Lebanon were found to be dissatisfied with multiple issues including the distribution of pharmacies, drug prices, profit margin, low income, workload, policies governing the profession, prescribing ethics, sale of counterfeit drugs and political intervention [55]. Recommendations proposed to overcome the ‘time’ barrier included (in addition to proper staff) the formation of multi-disciplinary practice models, within which pharmacists and other health care team members work together [15] and increasing the involvement of technicians and students/residents in the dispensing role, hence freeing the pharmacist for counseling [56]. Regarding space limitations, it is argued that the physical space in the majority of pharmacies is designed to support the drug dispensing role of the pharmacist with little room for counseling. For the latter, space is needed not only to provide the physical setting but also to ensure confidentiality of personal information often shared during weight management counseling. In Lebanon, such a barrier still existed despite that, according to OPL Decree No. 2622 issued in 1992, a section in the pharmacy should be dedicated to reception and counseling of patients. In fact, this decree specified that a minimum of 32 m2 is required to register a pharmacy which should be divided into four sections:1-reception of customers, 2-department of medicine cabinets, 3-laboratory dedicated to the preparation of prescriptions, 4 -warehouse of goods and medicines [57]. A few studies attempted at altering the lay out of the pharmacy placing the pharmacist in front of the counter, rather than behind. The results of these studies showed promising results in allowing a more prominent counseling role of the pharmacist [58, 59]. This is the first study to examine the role of pharmacists in weight management in Lebanon. The strengths of this study included the recruitment of a nationally representative sample of community pharmacies. The high response rate further enhances the external validity of the study findings. To achieve such a response rate, the field workers were trained to present the objectives of the research in a manner to illicit the interest of the pharmacist and hence increase his/her chance of participation. Despite this high response rate, 42 pharmacists who were approached did not agree to participate in this study. Therefore, a non-respondent bias could have affected our results. However, the likelihood that pharmacists who were less interested in weight management were more likely to decline participation, further underscores the implications of this study’s findings. In addition, by addressing various aspects such as beliefs, practices, knowledge and barriers, the study provided a comprehensive assessment allowing for the development of evidence based Page 10 of 12 interventions to enhance the role of pharmacists in weight management. The data collection was conducted using an interview-based survey technique, therefore limiting reporting errors and decreasing missing answers. It is important to note, however, that the results of the study ought to be considered in light of a few limitations. First, the cross sectional design of the survey prevented any inference about causality. The direct association observed between the frequency of queries regarding weight management and knowledge could be an example of reverse causality precipitated by the design of the survey. Second, although field workers were extensively trained on maintaining a neutral attitude and on non-judgmental reaction, the possibility of a social desirability bias could not be ruled out and the results of the study could have been skewed in a manner to satisfy the person administering the questionnaire. That said, it is important to note that despite this potential bias, certain mal practices were observed at high rates. Alternative methods to conducting the survey, such as mailing or emailing the questionnaires, were not possible in the context of the study, given that not all pharmacists possess a mailing address or have access to emails. Conclusions The results of this study showed that community pharmacists in Lebanon have a general positive belief regarding their role in weight management and are engaged in counseling for weight loss and dispensing weight loss products. In addition, the study findings highlighted important gaps in current practices of the pharmacists (such as failing to report side effects of drugs) as well as in their knowledge, specifically with regards to side effects of certain products and their interaction with other medications. In this study, higher education (Masters or PhD), earning the pharmacy degree from a university in Lebanon, obtaining formal education in weight management, and receiving frequent inquiries about weight management from patients/customers were all significant predictors of better knowledge. In addition, time, space, staff, remuneration, and relevant equipment were all common barriers to providing weight management services among community pharmacists in Lebanon. In conclusion, the findings of the study provided important insights on the beliefs, practices and knowledge of community pharmacists in weight management in Lebanon. Concerted efforts of multiple stakeholders including the Ministry of Public Health, Ministry of Education together with the OPL, are needed to promote the active role of community pharmacists in order to better address the escalating rates of obesity in the country. The findings of this study could be used to inform the development and provision of future evidence based community pharmacists led weight management service nationally and internationally. Hijazi et al. BMC Health Services Research (2020) 20:386 Supplementary information Page 11 of 12 6. Supplementary information accompanies this paper at https://doi.org/10. 1186/s12913-020-05258-7. 7. Additional file 1. Additional file 2. Abbreviations BMI: Body Mass Index; OPL: Order of Pharmacists in Lebanon; CI: Confidence interval; FIP: International Pharmaceutical Federation; ACPE: Accreditation Council for Pharmacy Education Acknowledgements N/A Authors’ contributions FN, MAH, designed the data collection form and the methodology. MAH managed the data collection. MAH, FN and HS wrote the first draft of the manuscript. HS performed the statistical analysis. HAR assisted in the development of the questionnaire and conducted data entry. AEL and MAE critically reviewed the manuscript. All authors have read and approved the final manuscript. 8. 9. 10. 11. 12. 13. 14. Funding No financial support. 15. Availability of data and materials The survey questionnaire is included as Additional file. The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. 16. Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board at the Beirut Arab University under the protocol number 2019H-0059-P-R-0300. The informed consent obtained was written and all respondents have agreed to take part in the research and signed a free informed consent form. 18. 17. 19. 20. Consent for publication Not applicable. 21. Competing interests The authors declare that they have no competing interests. 22. Author details Faculty of Pharmacy, Department of Pharmaceutical Sciences, Beirut Arab University, Beirut, Lebanon, P.O. Box: 11 5020, Beirut, Lebanon. 2Nutrition and Food Sciences Department, Faculty of Agriculture and Food Sciences American, University of Beirut, Beirut, Lebanon. 1 23. 24. 25. Received: 5 August 2019 Accepted: 28 April 2020 References 1. World Health Organization. Obesity and overweigh fact sheet. 2018. https:// www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight. Accessed 7 May 2019. 2. Malnick SD, Knobler H. The medical complications of obesity. J Assoc Physicians. 2006;99(9):565–79. 3. Chu D-T, Nguyet NTM, Nga VT, Lien NVT, Vo DD, Lien N, et al. An update on obesity: mental consequences and psychological interventions. Diabetes Metab Syndr. 2018;13(1)155-160. 4. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. 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Effectiveness of a community pharmacy weight management programme. Int J Clin Pharm. 2014;36(4):800–6. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. BioMed Central publishes under the Creative Commons Attribution License (CCAL). Under the CCAL, authors retain copyright to the article but users are allowed to download, reprint, distribute and /or copy articles in BioMed Central journals, as long as the original work is properly cited. J. of the Acad. Mark. Sci. (2018) 46:317–337 DOI 10.1007/s11747-016-0508-3 ORIGINAL EMPIRICAL RESEARCH Hey big spender! A golden (color) atmospheric effect on tipping behavior Na Young Lee 1 & Stephanie M. Noble 2 & Dipayan Biswas 3 Received: 2 November 2015 / Accepted: 3 November 2016 / Published online: 15 November 2016 # Academy of Marketing Science 2016 Abstract This research examines how gold-related color in atmospherics might influence customer tipping behavior at restaurants. A series of five studies shows that the color gold (as opposed to other colors) in a service atmosphere positively influences consumer tipping. First, a field experiment (Study 1) demonstrates that customers presented with a gold-colored (vs. black-colored) service prop (i.e., bill folder) leave larger tips. Study 2 further confirms this effect of the color gold by validating the findings of Study 1 with a different service prop (i.e., tablecloth). Process evidence demonstrates the underlying mechanism of this effect, whereby a gold-colored service prop increases tipping by influencing status perceptions about the restaurant and the self (Study 3). Additional studies further confirm this by ruling out novelty of the color in this mechanism (Study 4) and by highlighting the effect of status on tipping through status priming (Study 5). The findings of this research have implications for strategic use of color in servicescape design and atmospherics in general. Kelly Haws served as Area Editor for this article * Stephanie M. Noble snoble4@utk.edu Na Young Lee nlee15@utk.edu Dipayan Biswas dbiswas@usf.edu 1 University of Tennessee, 305 Stokely Management Center, Knoxville, TN 37996-0530, USA 2 University of Tennessee, 310 Stokely Management Center, Knoxville, TN 37996-0530, USA 3 University of South Florida, BSN 3218, Department of Marketing, 4202 E. Fowler Avenue, Tampa, FL 33620, USA Keywords Color . Gold . Payment behavior and tipping . Servicescape . Service props . Sensory cues . Atmospherics . Retail ambience . Frontline employee . Retail strategy Marketers are extensively using colors to create corporate images, build brand personalities, attract consumers, and shape consumer perceptions (Abril et al. 2009; Labrecque and Milne 2012; Madden et al. 2000). Recent industry trends point to an even greater interest in the use of color as a marketing tool to influence consumer behavior. Apple is incorporating the color gold in their design narratives for strategic purposes to associate their brand with luxury (Strange 2015), and GE provides a wide range of color choices to ensure their refrigerators resonate with consumers (Barry 2015). Hyatt has used the color gold in their BGold Passport^ loyalty program to convey the notions of exclusive benefits and higher status to customers who join the program (Henderson et al. 2011). Across industries, a wide range of color options are available for mobile phones, laptops, and even home appliances (Labrecque et al. 2013). In accordance with these industry trends, academic researchers have recognized the role of color and have provided empirical support for its importance in marketing, including the impact of color on branding (Labrecque and Milne 2012), purchase intention, choice likelihood (Biswas et al. 2014a), and shopping behavior (Babin et al. 2003; Bellizzi and Hite 1992). Despite these agreements on the importance of color as a marketing tool (Geboy 1996), our understanding of the effects of color remains limited (Crowley 1993; Labrecque and Milne 2012). Most color-related studies in the relevant marketing literature have investigated color effects by using an arousalevaluation framework and they provide a limited perspective in terms of understanding the complex nature of the color phenomenon (Labrecque et al. 2013). For example, an 318 arousal-evaluation framework posits that consumers respond to color in two ways: arousal or evaluation (Crowley 1993). Consumers respond to red (vs. blue) by being more active or stimulated (i.e., arousal), but they respond to blue (vs. red) by showing pleasant or relaxed responses (i.e., evaluative) (Crowley 1993). This stream of literature has focused on the dichotomized color hue in the investigation of color effects: red/warm vs. blue/cold. Since color hues are dichotomized based on wavelength, the meaning of color as assessed by consumers (Madden et al. 2000) and colors that are hard to place on the spectrum of red/blue or warm/cold have gained little attention in this stream of literature. To overcome this, some recent works have examined the effects of color on brand personality by using an embodied-referential meaning framework (Labrecque and Milne 2012; Zeltner 1975). More attention, however, is needed to understand the ways in which color influences consumers’ behavior when color has associated meanings, whereby consumers associate words or meaning with particular colors (Labrecque et al. 2013) (e.g., white might indicate cleanliness to some, such as in white bedding sheets (Berry et al. 2006)). In addition, extant color research has examined the effects of color by focusing on consumer behavior in retailing, branding, or advertising settings (Babin et al. 2003; Bellizzi and Hite 1992; Lohse and Rosen 2001). However, questions about how colors might influence consumer tipping behavior, which is a pervasive activity in restaurant settings, remain unanswered. Our study extends prior literature by investigating how gold-colored service props influence consumers’ tipping. Service props are the objects used in service delivery and help create the overall atmospherics in a service setting (Fisk et al. 2008). Tip amount is an important variable behind the viability of many businesses. To understand the ways in which goldcolored service props influence consumers, we employ a referential meaning of color framework. Anecdotal evidence and research studies suggest that the color gold is associated with status perception (Drèze and Nunes 2009). Building on the referential meaning of color framework, we posit that consumers activate gold–status (color–meaning) associations when they encounter the color gold. Thus, we incorporate consumers’ assessment of color–meaning in our investigation. The color gold is widely used in marketing practices (e.g., The Hunger Games gold-colored special edition book cover), but has gained little attention in the marketing literature. By investigating an understudied but important color, the present research enriches the color marketing literature. Additionally, the present study contributes to service literature. Although their importance in the creation of service atmospherics and service delivery is widely accepted (Berry et al. 2006; Fisk et al. 2008), there is little empirical support in the literature for the strategic use of service props. Moreover, the results of our study could have significant managerial implications for the service industry given the J. of the Acad. Mark. Sci. (2018) 46:317–337 economic importance of tipping; consumers spend $27 billion every year on tipping in US restaurants (Azar 2007a). A series of five studies shows that gold-colored service props (vs. other-colored service props) enhance consumers’ tip amount through consumers’ status perceptions. The first two studies (Studies 1 and 2) demonstrate the positive effects of gold-colored service props on tipping, the last three studies (Studies 3–5) examine the underlying mechanism of the gold effect. More specifically, in Study 1, a field experiment conducted at a restaurant, we demonstrate that a gold-colored (vs. black-colored) service prop (i.e., bill folder) leads to higher tip amounts (in terms of percentages). In Study 2, we validate this effect of the color gold in a more controlled lab environment. Moreover, we use a different service prop in Study 2 (i.e., tablecloth) to enhance the generalizability of the findings. Delving into the process of the gold effect, we unveil status perception as a mediation mechanism in Study 3 and further confirm this by ruling out a potential explanatory variable related to the novelty of the color in Study 4. In Study 5, we provide further evidence of status as the underlying mechanism by examining the effects of priming status. The remaining sections are organized as follows. We first review the literature on color, atmospherics, and tipping. Building on the theoretical framework in the color literature, we link these literature streams to propose our hypotheses. We then test our hypotheses with the help of five studies. Finally, we present our conclusions by outlining our contributions and limitations, in addition to providing suggestions for future research. Theoretical background Color A significant body of research in marketing literature has examined the role of color in the context of two key research questions: (1) BWhich colors influence consumers?^ and (2) BWhat effects do colors have on consumers and what are the associated implications for businesses?^ (Crowley 1993). A stream of literature has addressed the first question based on three dimensions of color: hue, chroma, and value (Gorn et al. 1997, 2004). Hue refers to the pigment of a color such as blue, yellow, and green. Chroma refers to the amount of pigment in color, for example, low chroma colors are dull and high chroma colors are rich and deep. Value is the degree of lightness of a color on a scale ranging from low (black) to high (white) (Gorn et al. 1997). Among the three dimensions of color, hue has been the main focus of color-related studies, especially in the marketing literature. Although marketers use a wide array of color hues in marketing contexts, most researchers have studied dichotomized color hues such as warm versus cool (or red vs. blue) and J. of the Acad. Mark. Sci. (2018) 46:317–337 examined consumers’ reactions to them. A wide range of studies has shown the effects of color on different aspects of consumer behavior and the associated marketing implications (Madden et al. 2000). For example, consumers’ purchase intentions were higher for merchandise displayed on a bluecolored background (Babin et al. 2003), and consumers rated a blue-colored shopping environment as more pleasant (Crowley 1993). Although these studies provide meaningful insights, color hues other than red and blue also need to be studied given the variety of colors used by marketers. Our study intends to contribute to the literature by exploring a less-studied color hue, that is, the color gold. In investigating the second question (i.e., BWhat effects do colors have on consumers? and what are the associated implications for businesses?^), researchers have focused on the effects of color mostly in the contexts of retailing, advertising, and branding (Bellizzi and Hite 1992; Labrecque et al. 2013; Lohse and Rosen 2001). Psychology literature has noted that the effects of color could be context dependent, for example, red clothing motivates approach behavior at a dinner party but the same color motivates avoidance behavior in a street sign (Elliot and Maier 2014). In sum, the present research extends the extant color marketing literature in two ways. First, we expand the color hue spectrum in the marketing literature beyond red/blue or warm/ cold to a different color (gold). Second, we extend the study context of the color effects to tipping in a service setting, which is a novel setting and has been under-explored thus far. Table 1 presents a summary of the key color studies in greater detail as well as highlights our contribution. In the next section, we build the theoretical foundation for our hypotheses. Referential meaning of color Earlier studies in the marketing literature have supported a two-dimensional framework, the arousal-evaluation dimension, in explaining color effects (Crowley 1993; Labrecque and Milne 2012). Recent studies have turned their attention to embodied and referential meaning frameworks (Labrecque and Milne 2012; Labrecque et al. 2013), focusing to a greater extent on the effects of the meanings associated with a given color. This theory originated in aesthetics philosophy literature, where Zeltner (1975) originally conceptualized referential and embodied meanings to explain how aesthetics-related stimuli influence people’s perceptions. Drawing from this theory, Zhu and Meyers-Levy (2005) used the referential and embodied meanings of music to explain how music influences customers’ perceptions (i.e., how music conveys a meaningful message to customers). Labrecque and Milne (2012) applied this theory to color, calling it the referential meaning of color, and used the resulting conceptual framework to explain the effect of color on brand personality. The embodied part of the theory refers to the meanings intrinsic to stimuli that evoke hedonic or valenced feelings 319 (Labrecque and Milne 2012; Meyers-Levy and Zhu 2010). For example, the embodied meaning conveyed through red evokes arousal, and blue elicits feelings related to happiness (Bagchi and Cheema 2013; Hemphill 1996). Although the referential meaning framework was not a dominant conceptual framework in early color marketing literature, color associations have been studied as a topic in color psychology literature (Elliot and Maier 2014; Whitfield and Wiltshire 1990) and a few earlier studies in color marketing literature have investigated color–meaning associations. For example, consumers’ color preference for certain logos or brands have been found to vary across cultures because of dissimilarities in the meanings of the color activated by color–meaning associations (Block and Kramer 2009; Madden et al. 2000). In this study, we explore the effect of the color gold, which is associated with status perception (discussed in greater detail below); thus, we apply the referential meaning of color as the theoretical framework for our hypotheses. In the next section, we review works on color–meaning associations to identify the meaning associated with the color gold in order to develop our hypotheses from a referential meaning perspective. Color–meaning associations Color possesses not only aesthetic value but also informative value that conveys a specific meaning (Elliot et al. 2007). Repeated pairings of colors and particular concepts or messages create a strong or implicit learned color association over time. As a result, even the mere presence of color in a particular situation activates color associations (Elliot et al. 2007; Elliot and Maier 2014). The color gold is often associated with status concepts (Drèze and Nunes 2009). Status is defined as an individual’s position or ranking in society and is associated with entitlement, prestige, exclusivity, admiration, and respect from others (Anderson et al. 2015; Drèze and Nunes 2009).1 Consistent with this concept, it is customary to award golden trophies or gold medals for the first place in competitions, as is done for example, in the Olympics (Drèze and Nunes 2009). Words that begin with Bgolden^ are considered the first or the best (e.g., golden age, golden voice). Consumers are likely to develop a gold–status association through repeated pairings in marketing practices as well. For example, gold is one of the most widely used color hues to convey the meaning of wealth and status in marketing practices. Specific examples include gold labels being widely used in companies’ loyalty programs to symbolize high status and exclusive benefits for their loyal customers (e.g., American Airlines’ gold membership card). 1 Power is conceptually different from status. Unlike status, which is determined by Bthe eyes of others,^ power is defined as the ability to influence others through control over resources or through the capacity to punish them (Anderson et al. 2015; Emerson 1962; Fiske 1993; Magee and Galinsky 2008). Full color vs. black (hue) Red vs. blue (Hue) Retail: interior color of furniture store Advertising Advertising Online auction, background color Crowley (1993), Marketing letters Gorn et al. (1997), Mgt. Science Lohse and Rosen (2001), JA Bagchi and Cheema (2013), JCR Branding Labrecque and Milne (2012), JAMS Hue, saturation and value Color warmth Online shopping (warm vs. cold color) (visual elements and saturation of online shopping) Kaltcheva and Weitz (2006), JM Hue, chorma and value Online, screen color Gorn et al. (2004), JMR Chroma, value and hue (red vs. blue) Red, yellow, green, blue (Hue) Cool vs. warm color: red, yellow, green, blue and white (Hue) Retailers’ interior color Bellizzi et al. (1983), JR Orange vs. blue (Hue) Red vs. blue (Hue) Retail wall color Babin et al. (2003), JBR What color (IV) Bellizzi and Hite (1992), Shopping Psychology environment and Marketing (background color of merchandise) Context Summary of key studies on the effects of color in marketing Study Table 1 Affective and cognitive evaluations Arousal and affective dimension of color Embodied-referential meaning of color Arousal Purchase intention and pleasantness of shopping environment Brand personality, purchase intention Feelings of relaxation Auction bidding ($) Arousal Arousal and hedonic state Arousal-evaluation Approach Evaluation orientation (Physical attraction) Shopping time Behavioral Theoretical framework Perceived download quickness, attitude toward and likelihood to recommend website Attitude toward and advertiser and ad. Willingness to pay Feelings and attitude toward ad and brand Arousal and evaluation of environment and merchandise. Perceived store environment and product and price fairness Pleasure, dominance, arousal, purchase intention Purchase intentions Attitudinal What effect (DV) Color and light together affected perceived price fairness and purchase intentions through affective and cognitive responses. Blue (vs. red) shopping environment leads to more positive customer outcomes including more simulated purchases, fewer purchase postponement and stronger intentions to shop and browse. Affective perception of color rather than arousal dimension of color may be responsible for this outcome. Warm colors (vs. cool colors) physically attract, however, it produced less positive responses (vs. cool colors) in evaluation factor such as relaxed or favorable. Evaluative effects are most positive (more pleasant) in cool colors, whereas warm colors are more arousing. Two dimensions of color (arousal-evaluation) are suggested as theoretical framework for color effects. High saturation increases likability through feelings of excitement. High value increases likability through feelings of relaxation. Color can signal product quality and credibility of printed ads. Red backgrounds increase bidding price in online auction, whereas it decreases price offer in negotiation, because red induces aggressiveness through arousal. All three color dimensions of background screen color influence perceived download quickness through feelings of relaxation, which would in turn influences attitude toward website and likelihood of recommendation of the website to others. Consumers’ motivational orientation moderates the effect of arousal produced by a store environment (color) on the pleasantness of the environment. High arousal has a positive effect on pleasantness for recreationaloriented consumers, but for those who have a task-orientated motivational orientation, it decreases pleasantness. Hue, saturation and value influenced brand personality, logo shape and likability. Package color and brand personality needs to be aligned to increase purchase intention. Main findings 320 J. of the Acad. Mark. Sci. (2018) 46:317–337 321 Note: JA = Journal of Advertising, JAMS = Journal of the Academy of Marketing Science, JBR = Journal of Business Research, JCR = Journal of Consumer Research, JM = Journal of Marketing, JMR = Journal of Marketing Research, JR = Journal of Retailing, Mgt. Science = Management Science Referential meaning of color Tipping ($) Gold Service, restaurant atmospherics This study Liking of the color, logo color preferences, color meanings Hue, blue, green, white, black, red, orange, yellow, brown, purple, green Branding Madden et al. (2000), Journal of International Marketing Attitudinal What color (IV) Context Study Table 1 (continued) What effect (DV) Behavioral Theoretical framework Color-meaning association Main findings There are cross-cultural patterns of both similarity and dissimilarity in color preferences and color meaning associations. Color-meaning associations are dependent on cultural background, therefore culture needs to be considered to manage brand and corporate image across international markets. Gold in restaurant atmospherics increases customer’s tipping through activation of referential meaning, status perception. J. of the Acad. Mark. Sci. (2018) 46:317–337 These prevalent practices help reinforce perceptions related to color–status associations. Research shows that customers in gold and silver tiers perceive themselves as top-tier customers who hold higher status than others, whereas those in blue and yellow tiers do not, implying that the color gold conveys the notion of hierarchy and status (Drèze and Nunes 2009). In sum, it can be posited that consumers associate the color gold with status. Drawing from the referential meaning of color, we hypothesize that this gold–status association is activated when consumers encounter the color gold in a service landscape, which influences their subsequent behavior. Atmospherics and service props The influence of atmospheric elements (e.g., color, light, music, and scent) on consumer behavior is well documented in the literature (Bitner 1992; Biswas et al. 2016; Singh 2006). For example, Madzharov et al. (2015) found that semantic associations of a warm (vs. cool) scent in retail atmospherics influence customers’ spatial perceptions, which, in turn, increases power restoration motivation and subsequently enhances the purchase of premium brands. More recently, Biswas et al. (2017) examined the role of light in atmospherics and found that changing the ambient light influences restaurant patrons’ alertness levels and their tendency to order healthy versus unhealthy foods. These studies suggest that subtle cues in atmospherics impact customers’ behaviors by influencing their perceptions toward the environment and self. In a similar vein, service literature has recognized the importance of subtle atmospheric elements in service environments because such elements contribute to the creation of customer experiences and shape customers’ perceptions of the service provider (Baker and Cameron 1996; Berry et al. 2006; Bolton et al. 2014). Service props are a subtle, but important, aspect of atmospheric elements in service settings (Fisk et al. 2008). Using the analogy of props in the stage of a service performance, Fisk et al. (2008) referred to the objects in a service delivery process as service props (e.g., restaurant booth, airline seat, or hotel bedding) and proposed that they can contribute to and shape consumers’ perceptions of the overall service atmosphere and experience (Bolton et al. 2014; Fisk et al. 2008; Haeckel et al. 2003). Thus, we posit that the colors of service props can shape consumers’ perceptions of the service experience. In sum, these literature streams support the notion that gold–status associations activated by the color of service props should influence consumers’ perceptions of the service atmosphere and experience. These perceptions 322 about the service atmosphere and experience should in turn influence tip amounts. Tipping Tipping is a prevalent consumer behavior that allows customers to set the price of a portion of a service offering (Lynn et al. 1993). Consistent with prior research, we conceptualize tipping in percentage terms in all our studies. Although tipping is widely accepted as a voluntary payment behavior that demonstrates consumers’ appreciation and gratitude toward service providers, surprisingly, prior research has documented that tip amount has a weak relationship with server’s efforts, restaurant’s food, or even service quality (Azar 2007a; Kwortnik et al. 2009; Lynn and Grassman 1990; Lynn and Latane 1984; Lynn et al. 1993). Several empirical studies have instead identified several drivers of tipping behavior that are extraneous to the specific service or meal quality. For example, prior research has documented the relationships between tip amount and weather conditions or even specific characteristics of the servers (such as servers’ gender, body shape, hair color, amount of cosmetics, and customer touching behavior) (Guéguen 2012; Jacob et al. 2010; May 1980; Rind and Bordia 1996; Stephen and Zweigenhaft 1986). Although color has not gained much attention as a research topic in this literature stream, a few recent works have tested color as a manipulation stimulus that improves servers’ physical attractiveness (e.g., lipstick, clothing, or hair color) (Guéguen 2012; Guéguen and Jacob 2012, 2014; Lynn et al. 2016). Another stream of research on the motivations for tipping has suggested that tipping is a largely norm-driven behavior (Azar 2007b; Lynn et al. 1993). For example, it has been found that customers leave a tip to adhere to social norms and to avoid feeling guilty for not leaving one (Lynn and McCall 2000; Lynn 1997; Lynn et al. 1993). In relation to the social norm perspectives, different tipping customs across countries suggest that consumers use tipping, in part, as a tool for status display (Azar 2007b; Lynn 1997). For instance, tipping was found to be more prevalent in countries where achievement or status is highly valued (Lynn et al. 1993). Consistent with this, historical accounts suggest that tipping could be related to an individual’s motivation toward status. Historically, tipping has been used as a tool to display an individual’s status, as the custom of tipping allows wealthy consumers to demonstrate their socioeconomic status to themselves, their guests, or their servers (Lynn 1997; Shamir 1984). Although there are differing views as to whether tipping started in 16th century Europe or whether it was prevalent in the Roman era, scholars agree that tipping originated as a socioeconomic status feature (Azar 2004), whereby individuals of economically higher status (i.e., wealthy) gave tips to people of economically lower status. In essence, tip amount is, therefore, likely to be influenced by the tipper’s desire for J. of the Acad. Mark. Sci. (2018) 46:317–337 status and status display (Azar 2007b; Conlin et al. 2003; Lynn 1997; Lynn and Grassman 1990; Lynn and Sturman 2003; Lynn et al. 1993). The idea that tipping is, in part, driven by a desire for status display (Lynn 1997; Shamir 1984) suggests that customers are likely to leave a generous tip when their status perception becomes salient. Applying this to a referential meaning perspective, it can be hypothesized that gold-colored service props will activate consumers’ gold–status associations, which would, in turn, make their status perceptions salient. This will lead consumers to leave larger tips since they are likely to display their status perception activated by the goldcolored service props through tipping. More formally, H1: Consumers presented with a gold-colored service prop will leave a larger tip (%) than consumers presented with a non-gold-colored (e.g., black or white) service prop. Underlying process for effects of gold color on tipping behavior In her seminal piece on servicescape, Bitner (1992) suggested that atmospherics usually affect individuals’ perceptions of the environment itself first, which would, in turn, generate individuals’ internal responses and subsequent behaviors. Multiple studies have supported this conceptual framework by showing that atmospherics influence customers’ perceptions of a service provider. For example, customers attribute service failure to service organizations more frequently when they see that service environments are disorganized (vs. wellorganized) (Bitner 1990). In a similar vein, it has also been proposed that atmospherics in a servicescape can be an extrinsic cue for customers to infer the quality of service and that of the service provider (Baker et al. 1994; Bitner 1992; Zeithaml 1988). Customers infer restaurant service quality from facility aesthetics, including interior design and décor (Heung and Gu 2012). Along the same line, it has been suggested that service props influence customers’ perceptions of the serviceproviding organization because they create the overall atmosphere (Berry et al. 2006; Fisk et al. 2008). These perceptions of the environment itself could influence self-perception in service contexts such as restaurant settings, because being in a restaurant and consuming its services could be regarded as possession of the restaurant’s services, whereby they become part of the extended self, similar to possessed objects (Belk 1988). Building on this relationship among service props, overall perceptions of atmospherics, and their influence on self-perception, we propose that gold-colored service props influence consumers’ perceptions of the restaurant itself, which would, in turn, affect consumers’ self-perception, leading to the generation of subsequent behavior. Applying this to the referential J. of the Acad. Mark. Sci. (2018) 46:317–337 meaning of color framework, we propose a serial mediation mechanism of the effect of gold, such that encountering goldcolored service props activates consumers’ status perceptions of a restaurant, which, in turn, elevates individuals’ self-status perception, subsequently increasing the amount they leave as tip. Formally, H2: The effect of a gold-colored service prop on tipping amount will be serially mediated by status perception such that: a gold colored (vs. non-gold colored) service prop → increased restaurant status perceptions → increased self-status perception → tip amount (%). Across five studies, we test our hypotheses using a bill folder (Studies 1, 3, 4, and 5) and tablecloth (Study 2) to manipulate the color of service props. We use these service props as manipulation instruments for two main reasons: First, both of them are managerially relevant because they are relatively easy and inexpensive to change on short notice (as compared to the color of interior décor). Second, bill folders and tablecloths are the service props that customers encounter with a high physical proximity in a dining situation, and thus their colors have greater exposure for customers and can also be more salient. Study 1: the effect of the color gold on tipping Design, participants, and procedure Study 1, a field experiment, tested H1 that encountering a gold-colored service prop (a bill folder in this study) increases tipping. We tested gold-colored bill folders against blackcolored folders because black ones are commonly used in restaurants. We conducted a two-week field experiment at an independently owned (i.e., non-chain) restaurant during lunch hours. During these two weeks, a total of 252 customers had lunch at the restaurant, and these customers’ payment amounts were recorded. Across all studies, anyone tipping above and below three standard deviations of the mean were removed, consistent with the approach of prior studies (Mandel and Johnson 2002; Rucker et al. 2011). In Study 1, this resulted in 17 participants being removed, yielding 235 participants for analysis. Two participants were excluded from Study 2 based on the same criterion. In Studies 3, 4, and 5, tipping did not fall outside this range; hence, no respondents were removed from those studies based on this criterion. During the first week of the field experiment (Monday through Saturday), only gold bill folders were presented to 119 customers. In the second week, only black bill folders were presented to 116 customers. This method ensured that the day of the week was not an influencing factor. It should also be noted that there were no special events or holidays 323 during these two weeks. To rule out the possibility of design differences such as size and texture of the bill folder, we made certain that both folders were identical except for their color (see Fig. 1). We collected data from the merchant copy of each customer’s receipt, including the price of the meal, tip amount in dollars, payment method (credit card or cash), and server name.2 The restaurant did not suggest pre-calculated tips on the receipts, nor did they add any automatic tip to the check for parties greater than a certain size. Results and discussion To test H1, we conducted an ANCOVA. Tip percentage (tip amount divided by meal price including tax) was the dependent measure, and color of the bill folder (gold vs. black) was the independent variable. Based on the tipping literature, we included several factors that might influence tipping as covariates: server, payment method, and day of the week (Lynn et al. 1993). Consistent with H1, the results of the ANCOVA analysis revealed the effect of the bill folder color. Specifically, customers presented with the gold-colored bill folder left higher tip amounts than those presented with the black-colored bill folder (Mgold = 21.5% vs. Mblack = 18.9%; F(1226) = 4.76, p < .05). Additionally, we explored whether there were any interactions between color and payment mechanism (cash vs. credit card), server, server gender, and day of the week on tipping behaviors. No significant interactions were found (all p-values > .20). In sum, the first study—a field experiment—revealed that encountering a gold-colored service prop increased consumers’ tipping amount. Although this study provided support for the existence of our hypothesized gold effect, it has limitations in terms of the limited controls and measures of extraneous variables (e.g., individual customers’ mood or involvement in tipping) that might influence tip amounts. We address these concerns in the following studies. Study 2: robustness of the gold effect Study 1 showed that customers who encounter gold-colored (vs. black-colored) bill folders leave larger tips. Although this gold effect supports H1, it is limited to one service prop, the bill folder. Moreover, one might have concerns about double money-priming effects. That is, the gold-colored bill folder might prime money thoughts twice because a bill folder may be associated with a payment check and the color gold can also be associated with money. Thus, a gold-colored bill folder might heighten the accessibility of the idea of money twice 2 Since individual’s identifiable information could not be collected, returning customers were not captured. When customers left a tip in cash, wait staff noted the tip amount on the merchant copy of the receipt. 324 Fig. 1 Bill folders used across studies J. of the Acad. Mark. Sci. (2018) 46:317–337 Black (Vohs 2006). This double money-priming effect can potentially influence our results because even a subtle reminder of money can change subsequent consumer behavior (Vohs 2006; Vohs et al. 2008). Study 2 attempted to address this concern by investigating a different service prop—the tablecloth. Therefore, the purpose of Study 2 was twofold: (1) to extend the gold color effect beyond the bill folder context by examining the effects of the color gold in tablecloths and (2) to rule out alternative explanations related to the double moneypriming effect because tablecloths are not related to money/ tipping as are bill folders. Design, participants, and procedure Study 2 involved two manipulated conditions—gold- vs. white-colored tablecloths. White was used as the control/ comparison color because white tablecloths are used commonly in fine...
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Running head: MARKETING REPORT

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Marketing Report

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MARKETING REPORT

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Marketing Report
Marketing a Services as Opposed to Product
With high levels of competition in the market place, it is important for business to
understand various strategies that can be used in order to attain competitive advantages. This
is by first understanding the needs of the consumers and also identifying the best approaches
that need to be applied while dealing with them. Two of the major strategies when it comes to
marketing are product marketing and service marketing. Most companies use either of these
strategies in order to differentiate themselves with the competitors. But then the big question
is whether marketing of services is of great benefit and importance as opposed to marketing
products (Woodside & Sood 2017). How effective does it turn out when it comes to
attracting customers? In breaking this down, it is first important to understand what service
marketing and product marketing means in the first place.
Product marketing is the process of producing a product which is on demand. The
demand of these products enhances promotion and selling. Identification of demand in this
form of marketing is essential in order to come up with products that would benefit the
consumers. The major focus in product marketing is to ensure the products provided to the
consumers are relevant and other factors such as prices less matter. On the...


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