Abstract

This study investigates the role of brand equity as a strategic tool for enhancing customer retention in Zimbabwe’s medical aid sector, particularly in the context of a deteriorating economic environment. Zimbabwe’s public healthcare system faces chronic underfunding and capacity constraints, making Medical Aid Societies (MAS) critical in providing access to private healthcare services. However, ongoing economic instability, marked by hyperinflation, currency devaluation, and foreign exchange shortages, has severely disrupted MAS operations, resulting in delayed or non-payment of claims. These challenges have strained relationships with healthcare service providers and, in many cases, led to service denial for policyholders despite active coverage. Additionally, the sector has experienced increased competition from emerging, often unregulated, low-cost providers. These new entrants have attracted customers away from established MAS, despite offering inferior service quality, thereby eroding consumer trust, diminishing brand loyalty, and contributing to a decline in sector performance. In response, this study explores how brand equity can serve as a strategic asset to rebuild trust, retain customers, and restore competitiveness. Employing a phenomenological research philosophy and thematic analysis of qualitative data, the study reveals that habitual consumer behavior, declining membership, and poor service delivery are central challenges facing the industry. The findings suggest that leveraging brand equity, through consistent communication, trust-building, and visibility via both digital and traditional media, can play a crucial role in restoring consumer confidence, improving customer retention and in the process securing long-term sustainability in an increasingly volatile market.

Keywords: Medical Aid Societies; Medical Aid Society; Brand Equity; Customer retention

Abbreviations: MAS: Medical Aid Societies; PSMAS: Premier Service Medical Aid Society

Background of the Study

Medical aid societies (MAS) in Zimbabwe play a pivotal role in ensuring access to private healthcare services, especially in a context where public health systems are underfunded and overburdened. In fact, medical aid societies help to protect individuals and families from catastrophic health expenditures, promote access to essential healthcare and promotes Universal Health Coverage (https://healthtimes.co.zw/). Accordingly, these societies provide a mechanism for financial risk pooling, allowing members to access medical services through pre-paid premiums (https://psmas.co.zw/). According to the Association of Healthcare Funders of Zimbabwe (https://ahfoz.org/), Medical Aid Societies (MAS) contribute over 20 percent of the country’s total health expenditure, yet only 1.6 million Zimbabweans, which is approximately 10 percent, are enrolled in such schemes. In fact, Zimbabwe’s broader economic instability, characterized by hyperinflation, currency devaluation, and foreign exchange shortages, has posed significant operational challenges for Medical Aid Societies (MAS) in Zimbabwe. Thus, these include rising healthcare costs, sub-economic reimbursement rates, and high administrative expenditure Makurumidze & Moyo [1]. Furthermore, delayed or non-payment of claims has strained relationships between Medical Aid Societies (MAS) and service providers, often leading to service denial for policyholders despite active coverage (https://ahfoz.org/). Such operational inefficiencies have contributed to declining public confidence in the sustainability and trustworthiness of established players in Zimbabwe such as MASCA Medical Aid Society, Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, Association of Healthcare Funders of Zimbabwe, ZIMPLAZA, Medical Aid Society of Central Africa, MARS International and Northen Medical Aid Society (https://healthtimes.co.zw/, https://www.equinetafrica.org/).

A particularly disruptive trend is the emergence of new entrants, small, often unregulated players offering low-cost premiums without commensurate service quality. These entrants, while appealing due to affordability, have created market distortion by undercutting prices and failing to deliver reliable healthcare services Mookerjee & Rao [2]. As highlighted by Munyoro et al [3], these new players often operate without adequate capitalization or experienced personnel, leading to inconsistent service delivery and further erosion of trust in the sector.

This has negatively affected established providers like MASCA Medical Aid Society, Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, Association of Healthcare Funders of Zimbabwe, ZIMPLAZA, Medical Aid Society of Central Africa, MARS International and Northen Medical Aid Society (https://healthtimes.co.zw/, https://www.equinetafrica.org/), which has seen a significant decline in membership. For example, PSMAS’s membership alone has waned from 863,961 in 2020 to 847,036 in 2025 in the public sector and from 68,981 to 18,929 in the private sector (https://psmas.co.zw/). In short, these trends then underscore the urgent need for MAS players including PSMAS to reassess its brand positioning and customer engagement strategies especially in this sector where many consumers demonstrate habitual buying behavior in their selection of medical aid products, often choosing based on familiarity rather than brand loyalty Mudoi [4]. With the erosion of trust and service reliability in the medical aid sector, this is then prompting even habitual consumers to switch from established medical aid players to small, often unregulated players who are offering low-cost premiums without commensurate service quality resulting in the significant decline in membership and poor-quality service delivery and further eroding the confidence in the sector Munyoro & Madzinga-Kusena [3]. In the process, this then has affected the performance of medical aid players such as MASCA Medical Aid Society, Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, Association of Healthcare Funders of Zimbabwe, ZIMPLAZA, Medical Aid Society of Central Africa, MARS International and Northen Medical Aid Society among others and in such contexts, brand equity becomes a potentially valuable strategic asset as argued by Kotler & Keller [5,6] and Munyoro & Madzinga-Kusena [3].

In this case, Kotler and Keller [5,6] and Munyoro & Madzinga-Kusena [3], argue that strong brand equity can create a perceived differentiation, increase customer satisfaction, and drive long-term loyalty, even in commoditized or low-engagement markets even though this has not yet been tested in the medical aid industry in Zimbabwe. In addition, there is also critically limited empirical evidence focused on the role of brand equity in Zimbabwe’s medical aid sector as a whole or individual organizations such as PSMAS. In fact, Munyoro & Mapfunde [7] study was based on the role of branding on customer loyalty in the pharmaceutical industry in Zimbabwe, whilst Munyoro & Sithole [8]’s study was based on branding recognition in enhancing customer retention in the buying of tea products in addition to Munyoro et al [9], which analyzed the role of brand equity in enhancing customer retention in the buying of tea products in Zimbabwe and none of these studies critically analyzed the role of brand equity in Zimbabwe’s medical aid sector. Therefore, this study’s intention was to examine the role of brand equity as a strategic tool in enhancing customer retention in the medical aid sector through rebuilding trust and regain its venerable competitive edge. In addition, the study aimed to evaluate the effectiveness of brand equity in enhancing customer retention in the medical aid sector in Zimbabwe as well as making recommendations on strategies that can be employed to improve brand equity and customer retention in the medical aid sector in Zimbabwe.

Literature Review

Habitual buying behavior concept

Habitual buying refers to the buying behavior of customers where they make repeat purchases of a known brand quite a number of times without the process of high involvement and decision making [10, 8]. In view of that, such products where consumers can exhibit habitual buying are perceived as commodities that do not provide much difference from rivals for medical aid products. Consequently, habitual buying behavior involves customers not giving much thought on the products they will be buying, and they buy these products regularly [11, 3].

Thus, customers choose these products without thinking a lot about the brands as these products are similar with each other and hence, habits of consumers are an essential aspect of consumer buying behavior as repetition forms a strong part of daily life [12, 7]. Consequently, the understanding of habitual buying is crucial for branding and financial reasons. For that reason, habitual consumers are characterized by increased repeat purchases which is linked with increased market and customer lifetime value [13, 9]. Thus, habits form people form direct associations in memory between response and performance thereby forming perception of the product or service associated with the memory [10, 8]. It is for this reason that; contexts may activate habitual responses in memory while non-conscious perception of the context surrounding a person may automatically activate associated habitual responses in memory. Additionally, different consumers exhibit different purchasing behavior and hence can have completely different views of brand equity [14, 8]. Consequently, consumers with habitual buying behaviour, such as consumers of tea products, have low involvement and there are little significant brand differences hence brand equity is a necessity in the retention of such customers as branding alone is not sufficient [15, 3]. The research is based on tea products for which customers exhibit habitual buying behaviour hence the importance of habitual buying as explained in detail below.

The importance of habitual buying

Customers may sometimes find a product best fit for their use and then keep on buying that product over and over again without looking for an alternative product [16, 8]. However, this might not mean that there are less choices in front of customers but rather the product does not have any significant differences with other products [17, 8]. In view of that, many organizations put in a lot of effort to ensure the creation and maintenance of that habitual behaviour with efforts aimed at delivering customers’ needs, improving relations and enhancing customer loyalty Aldrich et al, 2009 [16, 8]. Hence, despite similarity of many products, people usually develop preferences for just a few brands or flavors [12, 8]. Consequently, purchase of goods of daily needs such as the purchase of bread and another level of habitual buying is when people develop preferences of a few brands or flavors despite several brands available such as in the case of tea products Aldrich et al, 2009 [16, 8]. Additionally, consumers passively receive information regarding brands through television or magazine ads rather than actively search for information about products [16, 8]. Thus, customers select a brand because it is familiar and the process Aldrich et al, 2009 [3]. In view of that, could this be the case with medical aid products? The section below gives a detailed understanding of the branding concept emphasizing on what customers can easily remember and associate with the brand.

The branding concept explained

Before defining the branding concept, it is important to understand the roots of branding. Thus, branding originates from the word marketing which is defined by the Chartered Institute of Marketing as the management process responsible for identifying, anticipating and satisfying customer requirements profitably. In fact, marketing can be explained as an on-going communications exchange with customers in a way that informs, educates and builds a relationship progressively something that is missing in the medical aid industry in Zimbabwe [18-20].

Consequently, the relationship that exists between marketing and branding is that they are all used as a means of informing, educating and building a relationship progressively through symbols, names or logos that are used to recognize as well as distinguishing products and services in the market Aaaker 1991 [21-24]. Thus, branding is key to marketing as it creates a perception of added value linked to the brand image thus steering a continuous competitive advantage [25, 22-23, 3]. Hence, marketers invest huge amounts of capital, research and development to come up with the perfect components to construct their brand as an unmatched benchmark thus leading to marketing [22-23, 26]. In fact, marketing is an assisting gadget that helps companies to create an unequalled brand strategy for their brand [22-23, 8]. Thus, the definition of a brand has no uniformity as different writers define the concept in different ways Alemu 2019 [3].

Hence, branding can be seen as a name, sign, term, design, symbol or some combination that identifies the products or services of one organization and differentiates them from competitors offering Akpan 2018 [24]. Similarly, Dar & Tariq 2020 and Munyoro & Madzinga-Kusena [3], described a brand as a name, tagline, design, logo or packaging and any other component that differentiates one brand from another. In other words, any specific constituent of a component that is not interchangeable with that of another company. Alternatively, Alemu 2019 and Munyoro & Hodzi [26], explain a brand as a promise of consistency, quality and fulfilment of customer expectations and needs. While Perepelkon & Zhang 2011 and Munyoro & Madzinga-Kusena [3] simplifies the term brand to mean a symbol that summarizes the association made with that name. Simply put, branding becomes the process that creates the distinguishing elements of a brand Dar & Tariq 2020 [26].

Today branding is recognized as the key to success in business by providing value to consumers via the buying process, hence, assumes value to the firm through customer attraction and loyalty stimulation Akpan 2018 [3]. Thus, the basic feature of a brand is that it generates loyal customers, and the most crucial feature of a strong brand is having a mass of loyal customers [24]. In fact, brands are now an indispensable asset on the economic landscape therefore, developing countries can learn from developed countries as the principles of developing a strong resilient brand are the same across different cultures [22-24, 27]. Hence, Akpan 2018, Munyoro & Hodzi [26], suggest that branding points to customer satisfaction by saving decision making time, providing peace of mind, creating differentiation, value addition, providing safety and the chance to express who we are thus giving the customer a reason to share with other potential customers. Apart from other approaches, branding can help capture and further build goodwill and reputation associated with the business thus enhancing trade revenue and strengthening competitive position on the market Alemu 2019 [3].

It is crucial to note that successful brands will only exist if the product or service offering is of good quality Dar & Tariq 2020 [3]. This is so because brands are those priceless intangible assets that allow a number of benefits to the firm and its customers hence need to be carefully managed as businesses prosper by acquiring, keeping and growing their customer base Alemu 2019 [28, 8]. In short, a brand has two important dimensions which are the psychological and physiological dimensions Akpan 2018 [8] and the customer’s perception is a cognitive relationship of the product and consumer while the perception and image give value Dar & Tariq 2020 [3]. Consequently, customers’ perception may be shaped by emotional and functional experiences therefore most favored recognition occupies the correct corner in the mind of the customer and it becomes a brand Alemu 2019 [28, 8]. Contrastingly, the physiological dimension of the brand is its symbol or logo which helps to build a long-lasting impression in the customer’s mind Dar & Tariq 2020 [26]. The most important goal of a business is to build a very strong brand which yields long term revenue and fruitfulness [29, 24]. In a hypercompetitive business environment brands are not only identifiers or symbols but also have economic function and thus, the value of a brand is its capacity to create an absolute, prominent and positive meaning in the customer’s mind Dar & Tariq 2020 [26].

Accordingly, there are many different aspects and types of branding, some of which are discussed below.

Aspects of branding

Corporate branding

It is becoming progressively important for small enterprise such as small retail pharmacies to attract attention in the current marketplace hence branding by small enterprises is an expanding area of academic interest [30, 24]. Thus, retailers should be more innovative and creative when developing store brands to ensure that they attract more customers as well as differentiate their services or products from those of competitors Abdullah et al, 2012 [26] because effective business performance in the present world market and the dynamics of customers requires skills and knowledge in marketing and branding Chepchumba 2020 [24]. In short, most contemporary retailers are highly likely to develop a store brand as it has a high potential of obtaining loyal customers Abdullah et al, 2012 [26] and strong brands seem to be a guarantee of consistency, quality and superior service delivery Chepchumba 2020 [3]. In addition, corporate branding can be defined as the process of maintaining and continuously creating a positive corporate association and reputation leveraging on the power of a brand Frazen & Moriaty 2015 [6, 8]. In other words, it is a systematically planned and executed process aimed at creating and maintaining a positive image and good reputation for the organization as a whole and hence a corporate brand serves as a representation of customers’ mind-set, their encounters, experiences and perceptions of the company Frazen & Moriaty 2015, Ajike et al, 2015 [6, 8].

Consequently, Kotler 2009, Pereira et al, [2021 and Munyoro & Madzinga-Kusena [3], define corporate brand as the verbal, visual and behavioral articulation of the company’s distinctive business model and they further explain that the corporate brand symbolizes the link between the company, its suppliers, customers and all other stake holders. Similarly, corporate branding has the strength to align a company’s resources to the development of strategic competitive advantage Frazen & Moriaty 2015 [5, 8]. Thus, the significance of corporate branding can be viewed as two dimensional. Firstly, a unique and sustainable differential advantage can be formed through successfully nurtured corporate identity and secondly, a strong corporate brand motivates, enables, and harmonises employees around the corporate brand hence result in consistent customer service interactions Jones 2010, Frazen & Moriaty 2015 [5, 8]. Hence, today’s companies are unable to control what is said about them thus necessitating corporate brand reputation management Pereira et al, 2021 [3].

Furthermore, corporate brands are more significant in the service context where employees can either break or build the brand when interacting with customers thus corporate brands that intend to deliver outstanding customer experiences have to carefully manage employee-customer interactions through addressing customer expectations and needs Jones 2010, Frazen and Moriaty 2015 [5, 24]. Hence, companies intending to nurture long term, enduring relationships with their customers should build strong corporate brands Jones 2010, Frazen & Moriaty 2015, Markovic et al, 2018 [5, 3]. Hence, Kotler 2009, Perepelkon & Zhang 2011 and Munyoro & Madzinga-Kusena [3], highlight that there is a relationship between consumer perceived corporate brand, the attitude and loyalty of the customer since a corporate brand mirrors the actions and value of the business. Consequently, brands are becoming progressively competitive hence keeping and growing relationships depends on the ability to convey a customer experience bespoke to ever changing customer needs and values coherent with the brand’s promise Akpan 2018 [8].

Hence, Kotler 2009, Methaq [31] and Munyoro & Madzinga-Kusena [3], argue that unlike product branding which is often dealt with by marketers, corporate branding processes require organization wide practices which play a part in developing corporate identity. In this case, corporate branding encompasses intangible components which are not directly related with the product, such as employee relations, social responsibility, and corporate trust Jones 2010, Frazen & Moriaty 2015 [5, 26]. In this case, it targets all stake holders for example employees, suppliers, customers, regulators, shareholders, and the community thus a corporate brand is not specific to one product but brings together the company’s services and products benefits, social values, relationships, and corporate credibility [31, 3].

Product branding

Product brands and corporate brands are identified as different entities, in fact they are occasionally considered to be equivalent since they both share the objective of bringing about differentiation from competitors Jones 2010, Frazen & Moriaty 2015 [5, 26]. In fact, the level of synergism between the product brand and corporate brand depends on the brand engineering Jones 2010, Frazen & Moriaty 2015 [32, 5, 8]. Likewise, potent corporate branding can gear up any new service or product with instant value and credibility that cannot be imitated by any other product /service focused marketing campaign Jones 2010, Frazen & Moriaty 2015 [32, 5, 8]. Therefore, it is very important for businesses that intend to build and protect a resilient company to embrace corporate branding since corporate brands give out facts about the organization and communicate the quality and attributes of services or products offered by the organization Ajike et al, 2015, Frazen & Moriaty 2015 [26]. It is also significant to note that a brand has the power to build a long-lasting belief on the customers such as brand equity which results in brand loyalty and customer retention [33-34, 24] but this study’s focus is on brand equity concept and is discussed in detail below.

The brand equity concept

The brand equity concept was produced as a way of trying to describe the relationship that exists between customers and brands Munyoro et al, 2023 [35, 36]. Thus, the concept has been debated and highlighted the reason why it is crucial to have a long-term strategic focus on the management of brands Alhaddad 2015 [3]. In other words, organizations have been trying to be more strategic in the way that brands are managed Munyoro et al, 2023 [35-36]. Thus, brand equity from a financial point of view is defined in terms of the total value of a brand as an asset Munyoro et al, 2023 [37]. Accordingly, marketing perspective to brand equity is defined as a measure of the extent to which customers are attached to a brand and the associations which customers have about the brand [38, 3]. According to Zeithaml et al, 2006 and Munyoro et al, 2023, the degree of brand loyalty determines the value of a brand as this implies guaranteed future cash flows for the organization. Thus, brand equity concept reflects a relationship between description of a brand, the strength of a brand as well as its value.

Additionally, Krizanova [39] and Munyoro & Madzinga-Kusena [3], relates brand equity to storage of profits that are going to be realized at a later date in future. Their definition follows Lizbetinova and Weberova [40] and Munyoro & Madzinga-Kusena [3], who define brand equity as the collection of all attitudes accumulated in the minds of consumers which will enhance future cash flows and profits. For example, Keller [35] and Munyoro et al 2023, propose the consumer-based view to brand equity and suggests that brand equity reflects a condition in which the consumer recalls some elements of the brand as they are familiar with it. Furthermore, Leuthesser Voyer et al, 2018, broadly defines brand equity as the behavior that a customer shows which allows the company to make profits than it could not make without the brand name. Whilst several researchers define brand equity differently, most researchers concur with the notion that brand equity is indeed a strategic issue [35-36, 3]. In this case, brand equity refers to the value of a product attributed to its brand Munyoro et al, 2023 [41]. It is, therefore, the benefits that accrue to a product through the power of its brand name Naeini et al, 2015. Consequently, brand equity enables the long-term enhancement of brand strength which is a necessity of an organization which strives to achieve competitive advantages Munyoro et al, 2023 [42]. Thus, a brand is one of an organization’s most valuable assets hence, marketing specialists are devoting their attention to the concept of brand equity [43, 3].

According to Keller [35] and Munyoro et al, 2023, there are three approaches that can be used to assess brand equity which are customer mind-set, product-market and financial-market. In this case, the customer’s mind-set, also known as customer-based brand equity refers to what customers have accumulated about the brand over time from what they heard, learnt, felt or saw about the brand. Consequently, product-market measures of brand equity are related to marketing activity that is the demand for a product and its supply [44, 3]. As a result, financial-market measures capture the future and current potential of a brand. In view of that, according to Aaker [45] and Munyoro et al, 2023, brand equity involves brand assets and liabilities which are linked to a brand’s value. Additionally, Christodoulides and De Chernatony [46] and Munyoro & Madzinga-Kusena [3], define brand equity as perceptions which customers have as well as attitudes, knowledge and behaviors that allows an organization to earn greater profits. Accordingly, Vazquez et al, 2002 and Munyoro et al, 2023, consider brand equity to be the satisfaction which customers get from using a brand. More so, Keller [35] and Munyoro & Madzinga-Kusena [3], view brand equity as a link between the marketing investments and the customers’ brand knowledge. For that reason, customers nowadays have taken a more active role as a co-curator of value than being a merely passive customer [47, 3]. Consequently, brand equity, corporate reputation and customer retention are now becoming topics of interest in understanding customers’ buying behavior [47-48, 3].

Accordingly, Wang et al, [48], argues that many firms seek to enhance brand equity by improving their CRM performance. In view of that, when the construction of brand equity is worn down, loyalty decreases and prices become the top priority [48, 47]. Thus, it is important to have an understanding of what contributes to brand equity creation Munyoro et al, 2023 [49]. It is worth noting that brand assets and liabilities add value to the brand and these include brand loyalty, recognition, perceived quality, associations and other proprietary brand assets such as patents and trademarks and accordingly, there is a substantial value of a brand when customers compare the brand to competing products with superior features [24]. In the case of tea products, where customers usually buy out of habit, could brand equity increase their loyalty and encourage them to purchase the same brand over time? In this case, Budac et al [49] and Munyoro & Madzinga-Kusena [3], argues that the core of a brand’s value to customers is brand loyalty. Several brand equity models have been developed to broaden the understanding of brand equity, and these models are discussed in detail below.

The brand equity models

Over the past decades, various perspectives to brand equity have been developed. Thus, the concept was popularized by David Aaker around 1991, and other academic contributions were developed throughout the years. Hence, the motivation behind the studies carried on brand equity were primarily financial with a view of being able to calculate the value of a brand merely for accounting purposes. Consequently, the brand equity models are discussed comprehensively below.

Aaker’s brand equity model

David Aaker developed Aaker’s brand equity model which interprets brand equity as a collection of brand awareness, brand loyalty and perceived quality, which are assets for the organization, which can increase the value of its products and provide several benefits to the customer Munyoro et al, 2023 [42]. Accordingly, Aaker views brand equity as a set of assets and liabilities which are composed of awareness, perceived quality, associations and other proprietary brand assets [45, 3].

Brand loyalty

Aaker [45] suggests that habitual buyers represent a special group which is valuable to the organization as they represent a revenue stream that can finance the organization for a long time. Thus, for those with stronger levels of loyalty their attraction rate will be lower thereby raising their value [45, 5, 3]. Accordingly, Aaker [45], Chieng & Lee [50] and Munyoro & Sithole [8] suggest that brand loyalty can be used to measure the extent to which customers support a brand. For instance, a customer who has brand loyalty to Ariston Holdings purchases tea products from Ariston Holdings only. Consequently, Aaker’s model highlights that, strong brand loyalty allows an organization to concentrate or focus on developing and retaining its loyal customers thereby giving that company competitive advantage over rivals who may fail to convince loyal customers to switch brands. Thus, brand loyalty helps accrue various benefits which include reduced marketing costs for the company [51, 3]. Hence, if customers give their loyalty to a brand, they are less likely to switch hence hanging on to a client becomes cheaper for the organization rather than trying to charm potential new customers [52, 3]. Furthermore, these loyal customers provide an organization with a stable source of revenue, and they are also free marketers for the organization as they can spread positive word of mouth and help the company gain new customers.

Brand awareness

Brand awareness has been defined by Bock et al [53] and Munyoro et al 2023 as how much a brand is known among members of the public. Thus, brand awareness considers how familiar with a brand the public is. For example, if majority of people in Harare are able to recognize Ariston Holdings’ tea products, then it means the brand is well known by the public and it means more money. In view of that, brand awareness can be used to attract more customers thus, allowing the company to attract more customers [54, 3]. Hence, customers usually consider a familiar brand to be of high quality and reliable.

(Figure 1.1) above illustrates how each element of brand equity creates value for the customer or organization in a number of ways [55]. These aspects are discussed in detail below.

Perceived quality

According to Kataria and Saini [56] and Munyoro & Gurajena [24], perceive the quality of a brand as how the public understand the company’s products. For instance, an organization selling a product or service at a higher price may have more perceived quality than another one selling the same product at a lower price. Accordingly, Kataria [56], Kodippili et al [57] and Munyoro et al 2023, suggest that perceived quality allows customers to see the organization as reliable thus, giving them a reason to buy more. Additionally, perceived quality can be measured in a number of ways such as level of differentiation, price, quality, distribution channels and number of brand extensions [58, 3].

Brand associations

Brand associations measure the connection that customers have with a brand Munyoro et al, 2023 [58]. Thus, these associations help create attitudes towards an organization which can encourage customers to or discourage them from buying its products or services [59, 3]. Hence, these associations that are triggered by a brand can be used to evaluate if a brand is able to be retrieved from the brain of the customer.

Other proprietary brand assets

According to Shen et al, 2014 and Munyoro et al, 2023, other proprietary brand assets are trademarks, patents, intellectual property rights and channel relationships which can be a source of competitive advantage. Thus, these proprietary brand assets protect brand equity of a firm from competitors who may want to imitate their name, symbol or package [60, 3]. Thus, Aaker’s model assumes ways in which brand assets create value for the firm and for customers. Additionally, loyalty is strengthened by increasing customer satisfaction Munyoro et al, 2023 [61]. In other words, brand equity enhances brand loyalty thereby preventing customers from switching from a company to its rivals Shen et al, 2014 [60, 3]. Consequently, the model helps customers to have confidence in their purchase decisions as well as confidence that the brand they last used is of quality which enhances customer satisfaction Shen et al, 2014 and Munyoro et al, 2023.

Customer-based brand equity

Kevin Lane Keller developed the customer-based brand equity (CBBE) model where he ponders brand equity from a customer’s point of view. The general idea behind the CBBE model in (figure1.2) above is that, for companies to build a strong brand, they must shape how customers feel about their product. Hence, companies should work on creating positive experiences around their brands to enable customers to have positive attitudes about their brand. In view of that, customer loyalty is enhanced and vulnerability to competitive marketing actions is reduced. Accordingly, Keller suggests a series of steps in building a strong brand and each step depends on the successful achievement of the previous step Munyoro et al, 2023 [35]. Thus, these steps include brand identity, meaning, response and relationships.

Brand identity

Brand identity involves the creation of brand salience with customers and in other words, brand identity is the way in which customers distinguish one brand from another Munyoro et al, 2023 [54]. In this case, the aim is to build a strong brand identity in the minds of customers and use it to retain customers [57]. Thus, brand associations which include brand name, logo color themes and brand symbols are created in the minds of customers at this stage.

Brand meaning

Once brand identity is achieved, customers may want to know more about the brand and be able to understand what the brand means and what it stands for Munyoro et al, 2023 [35, 57]. Accordingly, this level of Keller’s brand equity model is grouped into performance and imagery [57, 3]. Thus, brand performance refers to the tangible aspects of the brands Munyoro et al, 2023 [58]. In other words, it defines how well a company’s product meets their customers’ needs and thus, brand meaning consists of product features, product reliability, service effectiveness, style and pricing of the product or service [35, 57-58]. Furthermore, Kliestikova and Janoskova [62] and Munyoro et al, 2023, define brand imagery as how well a company’s brand meets their customer’s needs and thus, it is the intangible aspects of a brand.

Brand response

After purchasing a product, a customer builds up expectations towards the brand and the purchase and thus, this involves two categories of judgements and feelings [54, 3]. Accordingly, if the expectations match reality, the customer will be happy and satisfied and if reality exceeds expectations the customer may become a brand advocate and share with others their experience with the brand Munyoro et al, 2023 [42, 54]. More so, it is those positive experiences that generate feelings in the minds of customers and the experience which a customer has with the brand determines whether feelings or judgements are developed about the brand [35, 54, 3].

Brand resonance

Brand resonance is found at the top of Keller’s model as it is the most difficult and most desirable level to reach Munyoro et al, 2023 [51]. Hence, brand resonance reflects the nature of relationship that a consumer develops with a brand, the aim here is to establish a deep and permanent loyalty among customers [57, 3].

It is worth noting that, the whole idea of brand equity models is to encourage customer retention as a way of maintaining existing customers as discoursed below.

Customer retention

Kotler 2008 and Munyoro et al 2023, defines customer retention as a way used by companies to maintain their existing customers based on ascertaining and maintaining long-lasting relations with customers. Accordingly, Kapoor and Rani [63] and Munyoro & Madzinga-Kusena [3], notes that most marketing theory focuses on how to acquire new customers rather than finding ways to keep the existing ones. However, it is important to note that the cost of acquiring a new customer is much greater than the cost of keeping an existing one since to acquire a customer an organization incurs promotional costs such as advertising, sales promotions and others Kotler 2008, Munyoro et al, 2023. Thus, if a customer is satisfied, they support the company in its initiatives such as introduction of new products and also with repeat business Kotler 2008 [63]. Accordingly, Soni et al, 2015 and Munyoro & Madzinga-Kusena [3], points out that the importance of retaining customers in today’s challenging business world is decisive and that if a company does not give its customers some good reason to stay, the organization’s competitors will give the customer a reason to leave. Furthermore, an organization should be focused on retaining customers by delivering service that is consistent with their value proposition, developing programs to increase loyalty and decrease turnover. Additionally, the concept of customer loyalty fits well with customer retention Munyoro et al, 2023 [64].

Thus, the use of retention strategies allows loyal customers to increase their spending thus creating operating efficiencies for the organization and consequently, acquiring new customers is very costly such as there is need for new account set up, advertising and promotional expenses as compared to retaining a customer Kotler 2008 [35, 34, 3]. Hence, profitability from customers increases over time as their trust increases with each purchase Munyoro et al, 2023 [52]. Thus, loyal customers are an important asset of any organization hence, the purpose of customer retention strategies is to maintain relationships with customers who add value to the organization Kotler 2008 [35, 34, 3]. Additionally, Munyoro et al, 2023 [65], defines customer retention as the art of increasing repeat purchases from customers and being able to extract additional value from them. Thus, the goal of customer retention is to ensure that customers are highly satisfied by a company’s products and services enough to make repeat purchases [34, 65, 3].

Methodology

This study adopted phenomenology research philosophy in undertaking this study because it requires a researcher to act in capacity of a social actor [66, 67, 3]. In short, this research philosophy studies the human behavior, interaction and interpretation as is the case with this study as it looked at how brand recognition could enhance customer retention in the medical aid sector in Zimbabwe [68, 67, 66]. Thus, in this study, the researchers were given freedom to observe, see and have their own perception and understanding of reality and this is important in qualitative research [66-69]. Thus, the researcher used qualitative method because it gives a clear picture and understanding on some aspects of social life as well as generating words as compared to numbers [70, 67, 3]. Similarly, the descriptive research design was adopted for this study mainly because it was used to measure any changes in variables over time and it served time, had a better and higher external validity, was comprehensive and also easy to conduct [71-72, 67, 3].

In addition, the research design was significant for the reason that it provided the most correct and valid answers to research questions which were derived from the objectives Sekaram & Bougie 2012 [73-74, 3]. Furthermore, this study made use of the non-probability sampling technique due to limited time and restricted availability of the respondents especially customers who were hesitant in taking part in the research Zheng et al, 2015 [75, 67, 3]. For that reason, to guarantee and ensure that the sample was a representative of the population, the sampling methods that were used were judgmental sampling which was used for selecting respondents across the different sectors of the market and random sampling was used for choosing respondents within outlets Sekaran & Bougie 2012 [67, 3]. Thus, for the purpose of this study, a self-administered, closed ended and open-ended questionnaires were used for reason that they are reliable, obligatory and unblemished Mathers 2007, Oluwatayo 2012 [76-78, 67, 3].

Data Analysis

Data analysis and presentation was organized and grouped making use of thematic analysis and was also used where recurring themes emerged in the process categories of the findings were then done to distinguish critical factors as well the relationship with the data [79-80, 67, 74]. Consequently, in this research, data analysis was then done at three levels namely content, discourse and thematic and as a result new concepts were established, conceptual definitions were also formulated and the relationship among the people was examined and concluded [79-80, 67, 74]. Thus, the conceptions formulated were linked to each other in terms of sequence or opposite to give meaning to the events [79-80, 67, 3]. Additionally, similarities and glaring differences that emerged from the data of focus group discussions and interviews were also outlined [79-80, 67, 3].

Equally, qualitative data in this research or study was integrated and analyzed using qualitative data analysis whereby both questionnaire and interview data was converted into some form of justification of the respondent’s understandings on the topic under study [79-81, 67, 3]. In fact, these parts were interlinked and cyclical. As suggested by Seidel, the researcher noticed interesting things in the data and assigned ‘codes’ to them, based on the topic or theme as shown in the findings section, and these codes were in turn used to break the data into fragments. The codes were then used to act as sorting and collection devices. After that, the researcher started writing about the data and his findings. This involved writing a summary of the data and entailing some analytic ideas Gibbs 2002 [79-80, 67, 3] as shown in the appendix section. Consequently, the findings were divided into themes as stated below:

Research Findings

Themes which emerged from this study:

Economic meltdown

In the 1980s, Zimbabwe had a relatively advanced and well-performing medical aid industry which was modelled after social health insurance sector common to Latin America and Asia (https://www.worldbank.org/ext/en/home). However, at the turn of the millennium, the country suffered an economic meltdown, a number of people were rendered unemployed and thus were unable to afford the monthly premiums to medical aid resulting in a drop in contributions to the medical aid societies Krueger et al, 2000, Makina 2010, McArthur 2014, Makki 2015 (https://healthtimes.co.zw/, https://generationhealth.co.zw/). Thus, this net result of this economic meltdown contributed to the dropping of the membership in the medical aid sector leading to the inability of medical aid societies to deliver quality service to its clients (https://healthtimes.co.zw/, https://generationhealth.co.zw/). This then led to the massive termination of membership and in addition the medical aid societies did not have an alternative way to rescue the members from terminating their membership leading to the collapse of the industry at one point especially covid era (https://healthtimes.co.zw/, https://generationhealth.co.zw/, https://ahfoz.org/).

Continuous decline in the performance of medical aid sector

Sifile et al, 2016 observed that there is a continuous decline in the performance of medical aid societies in Zimbabwe which has resulted in the medical aid organizations such as CIMAS, PSMAS among others failing to meet their obligations to stakeholders as seen in the failure to pay wages, shareholders’ dividends and policy holders’ medical bills resulting in claims either being delayed or not paid something which has caused tensions between Medical Aid Societies (MAS) and service providers and policy holders frequently results in policyholders being denied services even though they are currently covered (https://ahfoz.org/). Consequently, this has eroded public's trust resulting in colossal termination of memberships leading to the continuous decline in the performance of well-known medical aid societies in Zimbabwe such as Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, MARS International, and Northen Medical Aid Society among others (www.Healthtimes.co.zw;https://www.equinetafrica.org;https://healthtimes.co.zw; https://generationhealth.co.zw; hhtps: ahfoz.org).

New entrants

The corrosion of public's trust resulted in the massive termination of memberships which has led to the incessant waning in the performance of well-known medical aid societies in Zimbabwe such as Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, MARS International, and Northen Medical Aid Society among others has led to the introduction of new entrants in medical aid sector (www.Healthtimes.co.zw, https://www.equinetafrica.org, https://healthtimes.co.zw, https://generationhealth.co.zw, hhtps:ahfoz.org). Accordingly, the emergence of new entrants, small, often unregulated players offering low-cost premiums without commensurate service quality has been found appealing by the disgruntled medical aid clients due to their affordability but unfortunately, they have created market distortion by undercutting prices through lowering of costs but at the same time failing to deliver reliable healthcare services in addition to providing inexpensive rates without matching service quality [2]. As highlighted by Munyoro et al, 2023 and Munyoro & Madzinga-Kusena [3], these new players often operate without adequate capitalization or experienced personnel, leading to inconsistent service delivery and further erosion of trust in the sector. Consequently, this has negatively affected established providers like MASCA Medical Aid Society, Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, Association of Healthcare Funders of Zimbabwe, ZIMPLAZA, Medical Aid Society of Central Africa, MARS International and Northen Medical Aid Society (www. Healthtimes.co.zw, https://www.equinetafrica.org), which has seen a significant decline in membership. For example, PSMAS’s membership alone has waned from 863,961 in 2020 to 847,036 in 2025 in the public sector and from 68,981 to 18,929 in the private sector (https://psmas.co.zw).

Habitual purchasing behavior

The study also show that a large number of consumers exhibit habitual purchasing behavior when choosing medical aid products, frequently making decisions based on familiarity rather than brand loyalty [4]. Even regular customers have shifted from large medical aid providers like MASCA Medical Aid Society, Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, Association of Healthcare Funders of Zimbabwe, ZIMPLAZA, Medical Aid Society of Central Africa, MARS International and Northen Medical Aid Society to smaller, frequently unregulated providers that offer cheap premiums without matching service quality. Consequently, the medical aid sector's deteriorating trust and service dependability, has led to a sharp drop in membership and poor-quality service deliver too [3, 82-118].

Recommendation

Need for large medical aid providers to advertise and promote their medical aid sector’s brands on both traditional and social media.

Large medical aid providers such as MASCA Medical Aid Society, Premier Service Medical Aid Society (PSMAS), CIMAS Health Group, Association of Healthcare Funders of Zimbabwe, ZIMPLAZA, Medical Aid Society of Central Africa, MARS International and Northen Medical Aid Society should advertise and promote their medical aid sector’s brands on both traditional and social media.

Build brand equity in medical aid societies

Medical aid sector should build brand equity in order to improve brand awareness, and in turn customer retention. Thus, hiring of popular brand ambassadors to advertise and popularize their brands in the market will definitely enhance their membership and financial performance. This would go a long way in enhancing brand awareness and brand association thus improving customer retention. It would also improve brand image as customers will begin to associate medical aid societies’ brands with high quality, thus improving customer satisfaction, acquisition and retention.

Employing the use of social media

Medical aid sector providers should employ the use of social media to effectively communicate with customers in medical aid sector by providing social media platforms where customers can share their comments about your medical products as well as using social media to attend to customers’ queries and complaints. Consequently, this will improve service quality and enable the building of good relationships with customers, thus facilitating the positive impact of brand equity on customer retention.

Medical aid sector should hire experienced and skilled marketing personnel

Medical aid sector should hire experienced and skilled marketing personnel whom they should equip with the knowledge and skills to design and implement effective brand equity strategies thus contributing to customer retention and financial performance through enhancing of membership.

Step up regulation of service providers

In order to prevent the emergence of new entrants, small, and frequently unregulated players who offer low-cost premiums without commensurate service quality, the medical aid sector should strengthen membership regulations before allowing medical aid providers to operate. Unfortunately, these players have created market distortion by undercutting prices through cost reductions while simultaneously failing to deliver dependable healthcare services and offering inexpensive rates without matching service quality, harming the sector's reputation.

Need for workshops and seminars in the medical aid sector

There is need for the medical aid sector to organize seminars and workshop that seek to sensitize the usefulness of brand equity in enhancing customer retention in the medical aid industry. Such workshops and seminars should also proffer suggestions on how best medical aid sector can enhance brand equity in the industry and at the same time improving customer retention.

References

1. Lippman D, Stump, M, Veazey E, Guimaraes ST, Rosenfeld R, et al. (2024) Foundations of lifestyle medicine and its evolution. Mayo Clin Proceed (1): 97-111.
2. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, et al. (2009) Healthy living is the best revenge: findings from the European Perspective Investigation into Cancer and Nutrition-Potsdam study. Arch Intern Med 169(15): 1355-1362.
3. Katz DL, Frates EP, Bonnet JP, Gupta SK, Vartiainen E, et al. (2018) Lifestyle as medicine: The case for a true health initiative. Am J Health Promot 32(6): 1452-1458.
4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL (2004) Actual causes of death in the United States, 2000. JAMA 291(10): 1238-1245.
5. World Health Organization (2022) Noncommunicable diseases country profiles 2022. Geneva: WHO.
6. Centers for Disease Control and Prevention (2022) Chronic Diseases in America. Atlanta: U.S. Department of Health and Human Services.
7. Itani O, Jike M, Watanabe N, Kaneita Y (2017) Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Med 32: 246-256.
8. Holt Lunstad J (2022) Social connection as a public health issue: The evidence and a systemic framework for prioritizing the ‘social’ in social determinants of health. Annu Rev Public Health 43: 193-213.
9. National Academies of Sciences, Engineering, and Medicine. The Social and Behavioral Sciences in K-12 Education: Past, Present, and Future. Washington, DC: The National Academies Press 2021.
10. Krist AH, Davidson KW, Ngo Metzger Q, Mills J, Kusnoor SV (2020) Primary care practice facilitation for implementation of evidence-based prevention interventions: a case study. J Gen Intern Med 35(Suppl 2): 558-564.
11. Office of Disease Prevention and Health Promotion. Healthy People 2030: Organizational Health Literacy. U.S. Department of Health and Human Services 2020.
12. Chiuve SE, Fung TT, Rimm EB, Hu FB, McCullough ML et al. (2012) Alternative dietary indices both strongly predict risk of chronic disease. J Nutr 142(6): 1009-1018.
13. Satija A, Bhupathiraju SN, Spiegelman D, Chiuve SE, Manson JE, et al. (2017) Healthful and unhealthful plant-based diets and the risk of coronary heart disease in U.S. adults. J Am Coll Cardiol 70(4): 411-422.
14. Willett WC, Rockström J, Loken B, Springmann M, Lang T, et al. (2019) Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 393(10170): 447-492.
15. Schwingshackl L, Hoffmann G, Iqbal K, Schwedhelm C, Boeing H (2017) Food groups and intermediate disease markers: a systematic review and network meta-analysis of randomized trials. Am J Clin Nutr 105(6): 1462-1473.
16. Malik VS, Popkin BM, Bray GA, Després JP, Hu FB (2010) Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care 33(11): 2477-2483.
17. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB (2011) Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 364(25): 2392-2404.
18. Orlando EA, Rebellato AP, Silva JG, Andrade GC, Pallone JA (2020) Sodium in different processed and packaged foods: Method validation and an estimative on the consumption. Food Res Int 129(2): 111-121.
19. Frates EP, Moore MA, Lopez CF, McCartney N (2021) Lifestyle medicine: a brief review of its dramatic impact on health and survival. Am J Lifestyle Med 15(5): 579-589.
20. Baur C, Prue C (2014) The CDC Clear Communication Index is a new evidence-based tool to prepare and review public communication products. Health Promot Pract 15(5): 629-637.
21. Prochaska JO, Velicer WF (1997) The Transtheoretical Model of health behavior change. Am J Health Promot 12(1): 38-48.
22. Deci EL, Ryan RM (2000) The ‘what’ and ‘why’ of goal pursuits: Human needs and the self-determination of behavior. Psychol Inq 11(4): 227-268.
23. Stableford S, Mettger W (2007) Plain language: a strategic response to the health literacy challenge. J Public Health Policy 28(1):71-93.
24. S. Department of Health and Human Services (2010) National Action Plan to Improve Health Literacy. Washington, DC: USDHHS.
25. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, et al. (2018) The Physical Activity Guidelines for Americans. JAMA 320(19): 2020-2028.
26. Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, et al. (2019) Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019(1): 1-452.
27. Ekelund U, Tarp J, Steene Johannessen J, Hansen BH, Jefferis B, et al. (2019) Dose-response associations between accelerometry measured physical activity and sedentary time and all-cause mortality: systematic review and harmonized meta-analysis. BMJ 366: l-10.
28. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, et al. (2017) Sedentary Behavior Research Network (SBRN)-Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act 14(1): 14-75.
29. Bennie JA, Pedisic Z, van Uffelen JG, Gale J, Banting LK, et al. (2016) The descriptive epidemiology of total physical activity, muscle-strengthening exercises and sedentary behavior among Australian adults results from the National Nutrition and Physical Activity Survey. BMC Public Health 16(1): 1-13.
30. Sallis JF, Owen N, Fisher EB (2008) Ecological models of health behavior. In: Glanz K, Rimer BK, Viswanath K, editors. Health Behavior: Theory, Research, and Practice. 4^th San Francisco: Jossey-Bass Pp: 465-485.
31. Ohayon MM, Wickwire EM, Hirshkowitz M, Albert SM, Avidan A, et al. (2017) National Sleep Foundation's sleep quality recommendations: first report. Sleep Health 3(1): 6-19.
32. Buysse DJ (2014) Sleep health: can we define it? Does it matter? Sleep 37(1): 9-17.
33. Watson NF, Martin JL, Wise MS, Carden KA, Curhan GC, et al. (2015) Delaying middle school and high school start times is a key factor in reducing adolescent sleep deprivation. J Clin Sleep Med 11(10): 1215-1217.
34. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, et al. (2015) National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health 1(1): 40-43.
35. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH (2015) The role of sleep hygiene in promoting public health: a review of empirical evidence. Sleep Med Rev 22: 23-36.
36. Medic G, Wille M, Hemels ME (2017) Short and long-term health consequences of sleep disruption. Nat Sci Sleep 9: 151-161.
37. Centers for Disease Control and Prevention (2017) Sleep and Sleep Disorders. Atlanta, GA: CDC.
38. Glanz K, Rimer BK, Viswanath K (2015) Health Behavior: Theory, Research, and Practice. 5^th San Francisco: Jossey-Bass Pp: 1-512.
39. Lazarus RS, Folkman S (1984) Stress, Appraisal, and Coping. New York: Springer.
40. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A (2012) The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res 36(5): 427-440.
41. Folkman S, Moskowitz JT (2004) Coping: pitfalls and promise. Annu Rev Psychol 55: 745-774.
42. Carver CS (1997) You want to measure coping but your protocol’s too long: Consider the Brief COPE. Int J Behav Med 4(1): 92-100.
43. Chida Y, Steptoe A (2008) Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med 70(7): 741-756.
44. Pressman SD, Jenkins BN, Kraft Feil TL (2014) Positive emotions and health: the role of affect as both a determinant and an outcome of physical health. In: Huppert FA, Cooper CL, eds. Wellbeing: A Complete Reference Guide. Chichester: Wiley Blackwell Pp: 1-28.
45. Aldwin CM (2007) Stress, Coping, and Development: An Integrative Perspective. 2^nd New York: Guilford Press.
46. Hyman SM, Sinha R (2009) Stress-related factors in cannabis use and misuse: implications for prevention and treatment. J Subst Abuse Treat 36(4): 400-413.
47. Berkman LF, Glass T, Brissette I, Seeman TE (2000) From social integration to health: Durkheim in the new millennium. Soc Sci Med 51(6): 843-857.
48. Umberson D, Montez JK (2010) Social relationships and health: a flashpoint for health policy. J Health Soc Behav 51(Suppl): 54-66.
49. Holt Lunstad J, Smith TB, Baker M, Harris T, Stephenson D (2015) Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci 10(2): 227-237.
50. Thoits PA (2011) Mechanisms linking social ties and support to physical and mental health. J Health Soc Behav 52(2): 145-161.
51. Brown SL, Brown RM (2015) Connecting prosocial behavior to improved physical health: contributions from the neurobiology of parenting. Neurosci Biobehav Rev 55: 1-17.
52. Lincoln KD (2000) Social support, negative social interactions, and psychological well-being. Soc Serv Rev 74(2): 231-252.
53. McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Educ Q 15(4): 351-377.
54. Centers for Disease Control and Prevention (2023) Social Connectedness and Health. Atlanta, GA: CDC.
55. Substance Abuse and Mental Health Services Administration (2019) Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health. Rockville, MD: SAMHSA.
56. National Institute on Drug Abuse (2020) Commonly Used Drugs Charts. Bethesda, MD: NIDA.
57. National Institute on Alcohol Abuse and Alcoholism (2021) Alcohol facts and statistics. Bethesda, MD: NIAAA.
58. World Health Organization (2010) The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): manual for use in primary care. Geneva: WHO.
59. Babor TF, Higgins Biddle JC, Saunders JB, Monteiro MG (2001) AUDIT: The Alcohol Use Disorders Identification Test. Guidelines for use in primary care. 2nd ed. Geneva: WHO.
60. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, et al. (2009) Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and six months later. Drug Alcohol Depend 99(1-3): 280-295.
61. Substance Abuse and Mental Health Services Administration (2019) SBIRT: Screening, Brief Intervention, and Referral to Treatment. A Comprehensive Approach to the Delivery of Early Intervention and Treatment Services. Rockville, MD: SAMHSA.