The transition from diets rich in animal products to plant-based protein foods—like pulses—is crucial, for both environmental sustainability and human health. The aim of this study was to characterize the current consumption and to describe the drivers of and barriers to pulse intake in Portugal. Using a quantitative approach, a semi-structured questionnaire was distributed online, and 1174 valid responses were obtained. The most consumed pulses were beans and peas, consumed at least once a week by 48.3% and 44.4% of the sample, respectively. When participants were asked about the possibility of replacement, even partially, of animal products for pulses, 15.0% stated they would not substitute even in a food scarcity scenario. In the qualitative study, ten individuals involved at different steps of pulses’ supply and value chain were interviewed in order to study individual behaviors and experiences linked knowledge and consumption of pulses. It was noticed that the lack of recognition of their nutritional value, the high cooking time and the effect of the anti-nutritional factors were commonly pointed out as barriers. The identification and understanding of perceived barriers for that low consumption will leverage the development of new strategies to promote this promising alternative. World population growth poses new questions as it implies an increase in food production in a lower amount of arable land. According to the United Nations Department of Economic and Social Affairs, the world population reached 7.7 billion in 2019 .This population growth brings new challenges and opportunities for a demographically modified society ,4. IncreIn 2017, the Portuguese Food Balance Sheet (PFBS) disclosed that “Meat, fish and eggs” food group had the most significant deviations from the Food Wheel (the Portuguese food guide), with an availability of 11.5% above the recommended consumption. By contrast, the pulses group had a deficient availability, accounting for only 0.6% of the total amount of recommended foods, when the recommendation is 4% .The drivers which lead to this meat consumption pattern cannot remain detached from the ecological footprint associated with livestock production ,10,11. APulses are a food group with an important role in human nutrition . These nDespite the advantages mentioned above, in most parts of the world, pulses are greatly undervalued and poorly recognized as a substitute for animal protein . Having To date, there are few studies evaluating the real predisposition to the inclusion of pulses as protein substitutes, even if partial, for meat or fish products, namely in Portugal. The aim of this study was to characterize current pulse consumption in a sample of adult Portuguese population and to describe the potential drivers and barriers to the inclusion of this source of protein in the Portuguese diet.In this research, quantitative and qualitative data were collected. Firstly, a self-administered questionnaire, with both closed and open-ended questions, entitled “New Protein Sources in Portuguese Diet”, was disclosed through e-mail and Facebook, using the snowball sampling method , over a The questionnaire was divided into two sections: firstly, sociodemographic data were collected ; secondly, the pulses’ intake frequency was ascertained, considering six different pulses and seven options for frequency of consumption (from “never” to “more than once a day”) and a question about the readiness to include pulses as a partial substitute of animal protein, through a closed question with five options of answer. The self-perception of food pattern was also ascertained. The questionnaire was prepared in Google forms, and the respective link was distributed. The average filling time was five minutes. A total of 1174 valid responses were obtained.Using a qualitative approach, in order to address more information and have a deep description about the drivers and barriers for the pulses’ consumption, a group of ten individuals, selected according to their professional intervention’ areas, were interviewed. Once we intended to interview people dealing with pulses at different steps of the value chain, from production to the consumption, first, we identified the stage that we want to be represented, and second, we identified a person working in this specific stage. This heterogeneous group was composed by representative elements of this sustainable food chain, focusing on pulses. The respondents were linked to teaching and research works, to industry, to agriculture, to the Food and Agriculture Organization (FAO), to a nutritionists’ professional association and to a multinational company that deals with pulse commercialization. There were also two consumers—one professionally active and one without professional activity (“housewife”). Using these face-to-face interviews, data was collected on individuals’ behaviors, attitudes and experiences particularly linked to pulses’ consumption. All participants answered the same set of six open-ended questions . Intervip < 0.05. To analyze the data of the qualitative research, the content analysis method was used  .p < 0.001)  . When ev< 0.001) .Non-omnivores respondents reported much more frequently than omnivores that they already used pulses to replace meat or fish (83.6% vs. 17.4%) .p < 0.001)  .n = 10). Moreover, chickpeas and peas have been frequently reported (n = 8). On the other hand, lupine and grass pea were the less mentioned pulses grains, listed only by four and three participants, respectively. Recognized for their oil content, the soybean and peanut are poorly recognized as food belonging to the pulses’ group.The first two questions of the qualitative study intended to evaluate the knowledge about the diversity of pulses’ species and varieties and to understand the frequency of their consumption. All respondents remembered beans as a human food pulse  or feelings of pleasure and well-being . Although less mentioned, it is relevant to note that two people had pointed out pulse grains as an important element for a well-balanced diet and said that “beauty, color, diversity, balance, variety…” were key characteristics of this food. The person who had a job in management of the wholesale and retail trade of a multinational enterprise said, “the image awakes to a more conscious food pattern”.According to the Portuguese Food Wheel, the consumption of pulses must be one or two servings per day. One portion represents one tablespoon of raw dried pulses (~25 g) or three tablespoons of dried or fresh pulses, after cooking (~80 g).Thus, when the knowledge about this consumption’s requirements was analyzed, it was possible to understand that the interviewees who were aware of these recommendations were industry-related people (linked to new product development), the teacher of higher education, the corporate representative of a public professional association and a nutritionist in a collective food service establishment. On the other hand, six of the ten participants interviewed showed not to know the exact recommendations, including three of them who revealed a total lack of knowledge .Regarding the compliance with these recommendations, it was found that only two persons mentioned they were ingesting this food as recommended. Among the reasons pointed out for that low pulse intake were the lack of knowledge about the great variety of cooking recipes with this ingredient—one respondent said “my food recipes not always match with pulses”, another reported “usually I put it in the soup (…) but not always”.The FAO representative said “I forget that pulses exist”. The second most pointed reason was the preparation’ limitations—the element who works in a food service establishment claimed “we need to think a little when we want to make pulses… I don’t like canned beans… we need to plan meals with pulses and soak them previously”. The interviewed researcher said, “there were social issues linked to a low consumption of pulses; the speed in our daily life does not allow us to use pulses more often”. It should also be noted that one person, linked to the product’s development, did not eat pulses due to an intolerance or other chronic digestion problems—“I feel bad when I eat beans… when I try to eat them I have gastrointestinal problems”.n = 8), the presence in pulses of a “good source of protein” (n = 7) and the concern with environmental sustainability—pulses were considered to be “a good substitute for meat and other animal products...” (n = 3).Finally, when the respondents were asked whether they knew the explanation for current pulses’ consumption recommendations, they all answered affirmatively. Among the reasons listed for this counseling were “nutritional quality” ”. Moreover, the increase in purchasing power was also mentioned. One person stated “(…) it’s a foodstuff which lost their reputation… Not many years ago there were serious economic crises affecting food availability”; another element said “in the past, maybe in our grandparent’s time, people did not have money to eat meat and fish in their daily life or the portions were lower. So, they ate more pulses, there were pulses in all homes, at least, a chickpea soup…”.The food myths were also mentioned as a barrier by half of the interviewed people, as illustrated in the following sentences “pulses are linked to a poor’s man food…”; “ (…) many times we connect the word pulse to a heavy food (…) causing some gastrointestinal disorders (…).” Four respondents, also, said that food preparation was another problem of this foodstuff because “people do not have time…” and “pulse grains require a huge processing time”.n = 8) referred that it was necessary to spread information about their benefits—“more media disclosure…”; “… [need] a certain advertising campaign…”. Moreover, four participants mentioned that it was important to invest in food education, alerting people to the need to raise “awareness among health professionals…” and “educate the general population”. Among the given opinions, the importance of demystifying wrong ideas linked with pulses’ intake was emphasized—“we need to clarify some concepts and put out myths, currently expressed by common sense”.In order to promote pulses’ intake, the majority of respondents  was the need to develop new culinary recipes . This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation as well as the experimental conclusions that can be drawn.Finally, it was possible to verify that one of the most suggested practical ideas (According to the World Cancer Research Fund (WCRF), between 1961 and 2013, the amount of meat available for consumption per capita doubled, from 23 to 43 kg/year . In EuroDue to its geography, Mediterranean diet was practiced in Portugal, and it is characterized by a set of healthy dietary habits that include high consumption of unprocessed and plant foods, such as grains, nuts, pulses, fresh and seasonal fruits and olive oil as the main source of fat. In addition, Mediterranean diet is characterized by its frugality and moderation, and it also stimulates conviviality during meals . HoweverPhaseolus vulgaris L.), curiously as it happens in a study conducted in Poland [Regarding the consumption of pulses, in this project, it was possible to see that, as it would be expected, the pulse most commonly eaten in Portugal is the common bean  packaging to the food, the presence of microorganisms, the loss of nutritional value and the high content of sugar and salt ,48. FromNevertheless, according to several publications on this theme, canned products are a safe and economical alternative, so regardless of the form of consumption, pulses should be incorporated more frequently in the diet ,46,48,49In addition to what was mentioned above, another drawback pointed out by the respondents was related to the gastrointestinal effects of pulses, such as flatulence, abdominal discomfort, cramps and/or diarrhea ,19,49,50Lastly, notwithstanding the valuable inputs that this paper adds, it is important to identify some of its limitations. The present study helps to fill gaps in scientific literature on the motivations that lead to the current drop in pulse consumption. It provides answers to questions regarding prevalence of willingness for the replacement of meat or fish by pulses and data about barriers to the consumption of this food. This useful information helps international and local companies to develop and implement new ways of looking at pulses and reinventing forms that suit the lifestyle followed by the Portuguese consumers. Moreover, this study generates new hypotheses and prompts further, tailor-made research for the Portuguese population. However, we can also highlight some limitations. The first and perhaps the most evident one concerns the selected sampling model—“snowball” sampling—since, when the participants themselves indicate other participants, they probably share certain characteristics under study, which does not guarantee the representativeness, and it makes it difficult to extrapolate the results for the general population. Moreover, in this context, the age of the respondents was another limitation since the questionnaire was filled online and disseminated through social networks or via email. This means that the percentage of older individuals was low. Another disadvantage of using this sampling technique was related to the demographic scope: By not taking a sample at random, it was noticed that the majority of respondents belonged to the region of northern Portugal, the area where the study was developed. We can speculate that if we included in the sample older people, especially men, we would obtain similar frequencies of consumption, considering the results of the national food survey conducted in 2015  but probFrom the analysis of the obtained data, it is possible to conclude that the Portuguese population may not be very receptive to the current possibility and need of replacing meat and fish with “proteins of the future”.After identifying the main barriers to the consumption of pulses, it was realized that it is probably necessary to create food education sessions focused on nutritional, health and sustainability benefits in order to demystify concepts rooted in the Portuguese population. However, it is also fundamental to provide recipes that are not only easy and quick to prepare but also allow their inclusion in innovative and different forms of presentation from those already known and traditional.In conclusion, for the successful replacement, even if partially, of meat by other vegetal protein alternatives, like pulses, it is essential to involve different elements representing multiple steps in the agri-food chain. Agricultural and nutritional policies should be developed or adjusted aiming to optimize food availability and the health of the population as well as reducing the harmful effects on the environment. From a practical point of view, for example, it will be necessary to readjust the rules established in order to encourage young farmers to produce pulses in a sustainable way, which means investing in polycultures and more sustainable farming methods that promote agrobiodiversity. From a nutritional standpoint, it is important to define policies that reduce the use of salt in food industry (a problem commonly highlighted by people who only choose fresh pulses—a less practical version.


While there is strong evidence of the need for healthy ageing programs for older Aboriginal Australians, few are available. It is important to understand older Aboriginal Australians’ perspectives on healthy ageing in order to co-design culturally-appropriate programs, including views on technology use in this context. Semi-structured interviews were conducted with 34 Aboriginal Australians aged 50 years and older from regional and urban communities to explore participants’ health concerns, preferences for healthy ageing programs, and receptiveness to technology. Qualitative data were analyzed using a grounded theory approach. This study found that older Aboriginal Australians are concerned about chronic health conditions, social and emotional well-being, and difficulties accessing health services. A range of barriers and enablers to participation in current health programs were identified. From the perspective of older Aboriginal people, a successful healthy ageing program model includes physical and cognitive activities, social interaction, and health education. The program model also provides culturally safe care and transport for access as well as family, community, cultural identity, and empowerment regarding ageing well as central tenets. Technology could also be a viable approach for program delivery. These findings can be applied in the implementation and evaluation of culturally-appropriate, healthy ageing programs with older Aboriginal people. Australia’s Indigenous peoples comprise two distinct cultural groups: Aboriginal and Torres Strait Islander peoples. Aboriginal peoples are of diverse Aboriginal nations, who have historically lived on mainland Australia, Tasmania, or the continent’s offshore islands. Torres Strait Islander people come from the islands of the Torres Strait and are of Melanesian origin. Aboriginal and Torres Strait Islander peoples  currently comprise 3% of the Australian population . While iAs expressed in the National Aboriginal Health Strategy (NAHS) , health Since Aboriginal Australians often experience a range of chronic health conditions throughout their lifespan , and in Many older Aboriginal people are regarded as cultural custodians, mentors, and caregivers in their communities ,18. It iTwo examples of successfully co-designed health programs for older Aboriginal Australians are the Heart Health program  and the Considering the limited evaluation of these programs across a range of measures, Heart Health and Ironbark have set the stage for further collaborative development of healthy ageing programs among older Aboriginal Australians. Furthermore, shifting the delivery of such programs onto technological platforms could be a valuable future direction, as discussed in the following section.Older people face many barriers to participation in supervised center-based exercise programs, including lack of transport or locally available services, financial issues, or social embarrassment . In addiAlthough Aboriginal Australians have been previously reported to have lower access to technology than non-Aboriginal Australians , recent To date, there has been limited research on the co-design and evaluation of culturally-appropriate technology-based health approaches for older Aboriginal people. One study  exploredDespite the strong evidence of the need for culturally-appropriate, healthy ageing programs and the potential viability of technology as a platform for program delivery, the translation of this evidence into practice among older Aboriginal Australians remains limited. The current study aimed to explore older Aboriginal Australians: (1) perceptions of healthy ageing and main health concerns, (2) preferred approaches to developing culturally-appropriate, healthy ageing programs, and (3) receptiveness to technology.A participatory action research model was adopted for this project to develop and evaluate a novel program to support active and healthy ageing with older Aboriginal people. The current study represents the initial consultation and development stage. This approach “blurs the lines between the researcher and the researched through processes that accent the wealth of assets that community members bring to the process of knowing and creating knowledge and acting on that knowledge to bring about change” . It requA convenience sample of Aboriginal and/or Torres Strait Islander men and women aged 50 years and older, living in regional (mid-north coast) and urban (greater Sydney) New South Wales (NSW), were recruited for this study. NSW is the most populated state of Australia, where ~30% of Aboriginal and Torres Strait Islander peoples reside , and parperceived susceptibility and severity of various health conditions,perceived benefits of and barriers to participation in healthy ageing programs,proposed strategies to activate readiness to adopt such programs,receptiveness to technology.A single semi-structured interview was conducted with each participant from the regional communities in 2014 and from urban communities in 2017. The delay between regional and urban studies related to funding constraints. All consenting participants completed the interview. Questions for the semi-structured interviews were developed collaboratively within the research team, including Aboriginal community-based researchers , in conjunction with W.A. and C.M. . The duration of the interview ranged from 20 to 120 min.Interviews were audio-recorded and transcribed verbatim. Transcripts were coded using a grounded theory approach ,39. The Throughout this process, authenticity and trustworthiness were key considerations. Criteria embedded in the research process to ensure trustworthiness were credibility, transferability, dependability, and conformability . StrategThe constant comparative method involved analyzing data across transcripts as well as comparing and grouping similar instances under the same conceptual label . P.W. deAll participants were provided with a summary of the results and invited to give feedback. All declined to review full transcripts of their interview.The study was approved by the University of New South Wales Human Research Ethics Committee (UNSW HREC 08003) and the Aboriginal Health and Medical Research Council (AHMRC 615/07 and 1171/16). Community approval was provided by local elders who guided the project from its inception as well as by relevant local Aboriginal community-controlled organizations. Written informed consent was obtained from all participants included in the study.The data that support the findings of this study contain potentially identifying or sensitive information that could compromise the privacy of the respondents and are, therefore, not publicly available. Data may, however, be available from the authors upon reasonable request with approval from participating communities and the AHMRC Ethics Committee.The study recruited a total of 34 participants: 20 from regional and 14 from urban communities. Participants included 10 males and 24 females, and all participants identified as being an Aboriginal person. Seven participants were aged 50–59 years old, 14 participants were 60–69 years old, and 13 participants were over 70 years of age.When prompted for the main health concerns of older people in their community, participants discussed a range of concerns, mainly under the themes of physical health, social and emotional well-being, and poor access to services see .Susceptibility to chronic diseases and other health conditions are a persistent worry or fear for some with participants describing the worry as having a ripple effect across the community. A range of chronic diseases were identified, namely diabetes, cancer, cardiovascular disease, emphysema, and liver disease. Participants often raised concerns about experiencing multiple chronic diseases at once. Concern over the prevalence of smoking, alcohol abuse, poor diet, and obesity were also raised by many participants. Participants noted the prevalence of a “bad lifestyle” in the community  and urged that “they’ve got to stop drinking and smoking” . Poor health literacy appeared to play a role in health and ‘lifestyle’ choices for some participants.Among other chronic diseases mentioned by participants, dementia arose as a particularly significant concern. All participants spoke of the prevalence of dementia in the community with some identifying it as a new and growing concern.“‘Onset of dementia’ is a term I’ve been hearing lately… and it’s not good, and they’re young, like, in their 50s” .“Years ago, that (dementia) was never mentioned. (It was) cancer when I was growing up. And we’re living with it now. Dementia, we didn’t even know anything about it. And I suppose it’s been around for years” .Participants also noted the significant impact that chronic disease and ageing have on caregivers with particular attention given to the strain that dementia places on caregivers. Participants commented on the perceived practical as well as emotional impact of taking on the responsibilities of a caregiver.“Oh, I think it’d be very stressful. I don’t know how they (dementia caregivers) do it. Because it’s a 24–7 watch, isn’t it?” .“It changes your lifestyle… They (the family) keep them home as long as they can… it’s more expense, more medication, going out to more appointments. I’ve just had a school friend, my age, and he was heartbroken; he just put his wife in a nursing home; terrible. The family have to make all these decisions, and financially, and it is, it’s very, very–it’s cruel and sad” .Participants also identified falls, pain, and loss of mobility as significant health concerns, with several reporting that they had fallen before. Falls and loss of mobility negatively affected the desired level of functioning for participants. As one participant explained:“When the legs, the knees go on them or the hips, it’s really annoying …because your legs are so important to you…if you can’t use your legs, you’re an invalid. You’ve got to sit down all the time and that’s frustrating, that’s stressing. … Because we do everything when we walk. We go shopping, we stand in our kitchen, we stand in the shower” .Others described the importance of mobility in maintaining their independence, quality of life, and participation in various physical, social, and cultural activities that they enjoy, such as dancing and long walks. Falls were described as having an impact on people “because it brings home the reality that they can’t keep doing things for themselves” .The interviews included specific prompts regarding depression. However, participants’ responses generally focused on isolation and loneliness, grief and loss, and keeping health problems to yourself.Social isolation and loneliness were commonly described by participants, attributed to several factors. Many mentioned chronic health issues, poor mobility, and lack of transport as interconnected hindrances to the ability to leave the house and to care for themselves. Participants shared that the “restriction to do a lot of things they want to do”  results in isolation and a loss of independence. In another participant’s words, “Because we ain’t got a car. We can’t go visit anyone. If anyone’s sick, we’d like to go and see them” . Yet, even when out in the community, the rise of technological devices appears to have impacted older Aboriginal people by exacerbating the sense of isolation that they often feel.“No-one’s talking to anyone anymore, you know … And they’re all there on this (mobile phone) ... (it impacts) especially older people. Because we used to all just talk to one another. But not today” .Another participant shared that loneliness can still arise if opportunities for social contact are not suited to an individual’s needs and preferences, saying “Even when I went out with people, I was still lonely in a crowd. That’s probably why I used to and all that just because they drank and it was somewhere for me to go” . Notably, the lack of available or ongoing culturally safe group programs was also mentioned as a factor contributing to social isolation for older Aboriginal people.Participants spoke openly of the difficulties related to bereavement and losing family members. They expressed the grief and loss they have experienced, and the effects on their mental health and well-being. As one participant described, “It takes a lot of coping with and getting over. It’s the hardest thing to lose someone in your family. It’s very hard” .Participants also expressed how effects of the Stolen Generations and loss of land are with people today. Many participants spoke about their worry regarding the mental health of younger generations, including depression, anxiety, suicide, and drug use. Several participants identified the need for greater support and counselling to help people in the community cope with grief and loss. For example:“Grief and loss that goes right through our society; actually, all over the years, all that’s happened to us. You know, the things we lose, and we don’t get proper counselling for it. A lot of us don’t get proper counselling once we lose a loved one” .Almost all participants indicated that community members tend to be private about their health problems. As one participant stated, “I don’t like asking anyone for help. I don’t like anyone knowing my business” . Sometimes the desire for privacy was related to feelings of shame or stigma. Participants also commonly alluded to a stoic attitude that they adopt to downplay or normalize their own difficulties.Participants explained that older people feel worried about being a burden or dependent on their family, especially their children who have “probably got their own lives to live” . Participants observed that this is why they tend to “wait ‘til they collapse before they go ”  or had “kept that to myself”  in the past.Depression, in particular, is a health issue that is often not heard about in the community because people “cover it up”  or “keep their masks up” . One participant spoke of seeking counselling treatment outside their community, to maintain their privacy . Others explained that community members do not always disclose their concerns to health professionals. In the words of one participant, “I think you can’t see it, though people don’t want to do this or that anymore, but tell the doctors ‘no, I don’t have depression’” .A few participants raised the issue of poor access to health services when prompted for the main health concerns of older people in the community. This was discussed in terms of the shortage of medical staff, distance to services and transport difficulties, and insufficient outreach and awareness of available services.Participants also reported on the difficulty older people face when accessing services through technological platforms. As one participant reported, “a lot of older people don’t know how to access” services , and explained that being competent with the use of technological devices enabled some to “know all about the services” and to “use everything that’s there” but that many people are not aware of what is available, especially because “they don’t like using their mobile phones” . Telephone access could also be a problem, with one participant reporting that they were left “hanging on the phone for ages ... So, I just give them my number and that to ring me and well, I haven’t heard from anyone” .Several participants also explained that there are differences in communication styles between Aboriginal and mainstream health service providers, highlighting the importance of cultural safety in healthcare. As one participant put it, Aboriginal people are often “too afraid to look into a big, well-educated person’s face” . There was acknowledgement of the comfort provided by Aboriginal staff at the local hospital: “you’re not alone, you’re not by yourself, someone’s there looking out” . In a similar vein, one participant also voiced concern over social inequity and discrimination when talking about barriers to participation in health programs, saying that “we’ve been blocked off ... there’s people who can pay for those cures where poor, old, black people, we cannot, so therefore we die, they live” .Participants discussed the barriers and enablers of participation in current community health programs see . An appaParticipants were prompted to describe what a culturally-appropriate, healthy ageing program should look like. Responses centered on cultural safety and the incorporation of various activities into a holistic program. Themes emerging from the interviews further suggested that family, community, cultural identity, and empowerment regarding ageing were important considerations in designing a healthy ageing program.Many participants described how they did not attend any mainstream local community health programs, preferring to attend local Elders’ groups where they are together with other Aboriginal people they have known for a long time.Participants expressed a desire for “the right people in the right services that cater for us in the way that we should be catered for” . As another participant similarly explained,“Make sure that the instructor or whoever the organizers are, that they have the same ideas as us, and that… they have an understanding of Aboriginal culture ... they’ve got to know where we’re coming from as well as know what they’re doing” .“The main thing is the venue. You’ve got to have it where everyone is, and then invite everyone and make them feel welcome” .Overall, participants suggested four main activities of which a healthy ageing program should comprise. This includes physical activity, mentally-stimulating activities, social activities, and health education, as described in Numerous participants described the value of a supportive culture within their communities. One participant explained that, “When anything happened… it’s all the families that come together… They drop everything just to come down and support those families in grieving. That’s always been the culture up home where I come from” . Participants also expressed the responsibility they feel over the younger generations–the need to mentor them as well as the desire to pass on cultural knowledge and values; that is: “…getting them under my wing and try and talk to them” .Several participants volunteered their views on the topic of respect and reciprocal care, further emphasizing the importance of intergenerational connections. Participants observed a loss of respect for older people from younger generations and expressed a desire for their families, especially the younger ones, to help them more. Some indicated that they were frustrated and angry about contemporary attitudes towards older people, which can sometimes result in elder abuse.“If we can get the younger people back on board to show–to give more concern for the older people, things might work out better… it’s a matter of the younger people having a bit more respect for their older people” .“Some of the Elders don’t cope well because they haven’t got the support that they need from their family… I think families, from what I observe, get frustrated with their elders and sometimes it ends up being verbally abused, physically abused, or lack of respect for the older person” .Many participants expressed a positive outlook on ageing, strong motivation, and belief in their capacities to improve their own health and well-being. As one participant explained: “We’re not young anymore, we’re old and we have to learn how to cope with being old and there’s lots of things that you can do” .There was a sense of pride and self-respect expressed by a number of participants regarding the way they had already made positive lifestyle changes  and seen the resulting benefits in terms of their health and well-being.“…I said, ‘I’m done with drinking, I’m done with smoking.’ Oh, I feel a lot better, I would never do it–never look at (smoking or drinking) now” .“At the beginning I hated it, but then I felt good. I was on the walker, I was doing everything with the balls, and I was going up” .Finally, we asked participants about their attitudes towards the use of technology, to explore the acceptability of using technology as a platform for the delivery of a healthy ageing program with older Aboriginal people. A majority of participants were familiar with and use technological devices in their everyday lives to contact others or to play games. Many were receptive to using technology, felt technically competent, and could see the benefits of using technology in terms of being “in touch with the rest of the world”  and keeping their minds active. As described by one participant, “I get on the computer and do all my own loans, funds, change of address, whatever I want to do… your brain’s clicking over all the time” .On the other hand, some participants described a reluctance to engage with technology, saying for example, “I can’t imagine myself sitting there playing with (a computer) … That would, I think, would just annoy me. It’s just not me” . Alternatively, some felt that older people would struggle in terms of technical capability. “For older people it’s very confusing. They don’t know how to use them things … they can’t seem to grasp it” . However, several participants who were not confident in their technical competence, expressed an interest in learning how to use devices, especially if it was made simple and they were given adequate support.The current study found that older Aboriginal Australians are concerned about chronic health conditions, loss of mobility, social and emotional well-being, and difficulties accessing services. A range of barriers and enablers to participating in current health programs was also identified. From the perspective of older Aboriginal people, a successful model of a healthy ageing program is one that is culturally safe, holistic, and responds to their health concerns and previous experiences. For many, the use of technology was also a viable approach to the delivery of health programs.Echoing the available evidence ,15,16, pBased on this study’s findings, a health program that addresses the relevant health priorities of community members, overcomes barriers to participation in existing programs, and incorporates various enablers for participation can be developed.The necessity for culturally safe care, such as having Aboriginal-specific programs, Aboriginal or culturally proficient staff, and a culturally safe venue in the community, was frequently raised. To effectively engage with older Aboriginal people and achieve health promotion goals, culturally responsive approaches are imperative ,44,45,46Findings show that shame and stigma result in many older Aboriginal people concealing their health problems and deter some from participating in health programs. Various studies have reported on shame and stigma as barriers to positive health seeking behaviors among Aboriginal people in the context of mental illness, hepatitis C, or cancer ,48,49. TThe NAHS definition of Indigenous Health includes the ‘well-being of the whole community’. This was reflected by participants frequently referring to their community when discussing their personal health. Community and strong kinship ties are core features of the cultural identity and collective perspective that Aboriginal people have . This reFindings also highlighted that performing the role of mentor to younger generations was significant for many older Aboriginal people, as identified in previous studies ,53. HoweConsistent with literature on the prevalence of multi-morbidity among Aboriginal Australians , the comSpecific concerns regarding dementia risk were apparent in this study, along with a desire for healthy ageing programs to incorporate activities focused on optimizing and maintaining cognitive functioning. Dementia is three to five times more prevalent among Aboriginal than non-Aboriginal Australians . FurtherNotably, the arts such as painting and Aboriginal language programs arose as suggestions to be incorporated into a healthy ageing program. Ware  reports Participants expressed a desire for health education to be a component of a healthy ageing program. Research has shown that Aboriginal understanding of diseases can deviate significantly from western biomedical explanations ,64 and tSome participants described experiencing an increased sense of isolation as a result of the widespread use of technology in modern society. Yet, many participants were interested and willing to use technological devices. Several participants discussed their concerns over the limited technical proficiency older people face, but also expressed a willingness to learn to use technological devices. There is a growing body of literature indicating various technologies provide opportunities to mitigate loneliness and social isolation through social inclusion, engagement in activities of interest, and boosting self-confidence ,68. It iNotably, as highlighted in our model for a holistic healthy ageing program, the use of technological platforms should not be a total substitute for in-person contact. However, this study contributes to the evidence for the acceptability of technology-based health programs among older Aboriginal people ,28. ThisThe authors acknowledge that this project is relevant to the participating communities and the findings may not generalize to other Aboriginal communities. There was also a notable three-year gap between the regional and urban interviews, which could have had a small impact on the findings. Other limitations included a relatively small volunteer sample with recruitment from only one regional and one urban area. There was also the potential for interviewer characteristics, such as non-Aboriginality or Aboriginality and familiarity, to have influenced participants’ responses.Following this study, we aim to apply these research findings in the co-design of a culturally-appropriate, healthy ageing program, which is exercise-based and capitalizes on technology as a delivery platform. The implementation and evaluation of such a co-designed healthy ageing program among older Aboriginal Australians should be explored in future studies.This study has established that the needs of older Aboriginal people as they age are complex, emphasizes the value of the collaborative development of health programs for Aboriginal people, and has identified meaningful aspects to be incorporated into a culturally-responsive, healthy ageing program. These aspects include cultural safety, a holistic program which comprises physical activity, cognitive training, social interaction, and health education, and which maintains family, community, cultural identity, and empowerment regarding ageing well as its central tenets. This study also provides preliminary evidence for the use of technology as a viable platform for the delivery of health programs.


As well, qualitative, open-ended individual interviews with parents (n = 47) and two focus groups were conducted in the period 2018–2019. Children in the BBW cohort were rated by their teachers as having a significantly lower level of emotional and behavioural problems than those in the baseline sample; parents in the BBW cohort had significantly higher levels of social support than parents in the baseline cohort; BBW parents rated their communities significantly more positively than parents at baseline. The qualitative data confirmed these findings. The quantitative and qualitative short-term findings from the BBW research showed similar positive impacts to previous research on program effectiveness, thus demonstrating that the Better Beginnings model can be successfully transferred to new communities.Better Beginnings Waterloo (BBW) is an ecological, community-driven, prevention program for children aged 4–8 and their families. BBW was implemented in two low-income communities with high percentages of visible minorities. Data on Grade 1–2 children and their parents (the baseline comparison group) were gathered through parent interviews ( Better Beginnings, Better Futures (BBBF) is a model for the prevention of mental health problems among children in marginalized communities. We begin by noting the problem that BBBF addresses, the BBBF model, and the original research in three communities on the effectiveness of BBBF. It has long been recognized that children’s mental health is a significant public health problem . In OntaEthnic minorities comprise approximately 30% of Ontario’s population (with rates exceeding 50% in some urban centres of Southern Ontario), with South Asian, Chinese, and Black populations comprising the largest groups , but thaIn Ontario, BBBF was developed in the 1990s as a prevention model to address children’s mental health ,14. The The original BBBF was implemented in three low-income Ontario communities for children aged 4–8 and their families. It has been argued that low-income communities should be the focus of community-wide prevention programs that aim to promote multiple domains of children’s health and well-being by targeting multiple ecological levels . MoreoveThe BBBF model is guided by a set of principles . It is: Ecological and holistic, with neither one single focus nor one single program, but a broad focus on many different programs that address the whole child, the family, the school, and the community; (1) Community driven, with local residents playing a central role in project governance, program planning, and program implementation; (2) Integrated and partnership based, with programs that “blend and unite” existing educational, health, social, and community services; and(3) Prevention focused and universally available to all children aged 4–8 and their families in the community. (4) While BBBF programs must adhere to these principles, local stakeholders have considerable latitude in deciding what programs to offer. Thus, programs can be tailored to the local context. In line with the ecologically-oriented, community-driven approach to primary prevention, the three main goals of BBBF are:(1) To prevent children’s emotional and behavioural problems and to promote positive child development; (2) To enhance resident participation and positive outcomes for parents and families; (3) To promote community development and improve community well-being. Research was undertaken to evaluate the impacts of the original three BBBF projects on children, parents/families, and communities . Two desIn the longitudinal comparison group design, children and their families who participated in BBBF were assessed annually , as they progressed through the four years of the project, and were compared to children and families from two matched comparison communities. Adding a following cohort after the Grade 2 data collection to increase the sample size, participants from the BBBF and comparison communities were again assessed when children were in Grades 3, 6, and 9 to determine the medium-term impacts of the project. Positive impacts of BBBF were found for children’s school and social functioning and emotional and behavioural problems; and BBBF parents reported greater social support, marital satisfaction, family functioning, and more positive neighbourhood impacts . The longitudinal cohort was followed up until age 18 to determine the long-term impacts of BBBF. A lower percentage of children from BBBF communities had been involved in special education, and BBBF children showed higher grades in high school, reported more regular exercise, and fewer reported committing property offences . BBBF yoData on 19 government service cost measures were collected from the longitudinal research sample from the time the children were in JK to Grade 12 (18 years old), 10 years after ending project participation  give kids more chances for social interactions and recognize each other.” As one parent shared:Parents also noted “Yeah, before the school would say ‘why [is] she scared?’ Even when I bring the children to school, like she’s scared still outside. But now she’s good. She’ll play outside with kids, she brings her sister and brother outside.”improved academic skills of their children, especially in reading. Some parents also noted “There was one kid that all year was waiting to get to level J in the reading. She started off I think in level C or D, somewhere around there. And there was a book that she wanted to read in that J bin, more than anything. And every time she’d walk down there she’d look at it and point and say ‘I’m gonna’ get to read that.’ And she did. And the day that she got to read it, it was just the most exciting thing.”“They think they joined Better Beginnings programs to have fun, but in fact they joined it to learn. It’s just we switch it for them… But Better Beginnings, yes they want to go because they think they’re gonna’ have fun and they do have fun, but they learn at the same time. We just put it in the right context for them, that’s why they love joining the programs.”Quantitative findings. There was no significant difference on the measure of depression between the baseline and BBW sample (see t (34) = 2.97, p = 0.05. Further, the Winston Churchill BBW sample showed significantly lower levels of stressful life events compared with the baseline Winston Churchill sample; t (14) = 3.48, p = 0.004.mple see . HoweverQualitative findings. Themes in the qualitative data regarding impacts on parents suggested that participating in Better Beginnings helped parents to reduce isolation and increase social connectedness through new friendships with other parents. As one parent shared: “[Better Beginnings has had] a big impact. If it were not for BBW I would not have that much support from which I consider a family.”reduced depression/anxiety:For several parents, this increased social connectedness helped to improve their mental health, particularly through “… For me … I learned from the program…instead of sitting in the house and being depressed all the time, I leave the house, I make friends, I meet a lot of people, I laugh with them, I talk with them… They give me advice and I give them advice… when we sit at home we have no one to ask. We don’t have family here…”“They brought me out of my bubble. I was stuck home all the time suffering from anxiety. Now I have a different attitude and I have a purpose.”resident empowerment, including knowledge, skills, improvement in English language skills, and personal growth. Early on, a mother of seven children said to one of the staff: “I am poor, I was a afraid to speak up.” That is changing for some women who have gone back to school for retraining and who are carving out careers for themselves. The previously mentioned Action Teams have been catalysts for resident empowerment. Many participants described the personal growth they experienced through BBW. One shared that: BBW staff witnessed a growth in “It changed my life. I wake up every day with something to do every day. I gained a lot of friends. It taught me a lot of techniques to use with my kids.”Another parent reported that:“Involvement with kids gave me a lot more options to work on my field …, like other ways. And being involved, I’m not employed right now but like I can see hundreds of projects, hundreds of ideas coming out of my brain. It’s just like jumping around and say ‘yes, yes, yes, yes.’”Quantitative findings. For Cedarbrae parents, but not parents from Winston Churchill, the measure of neighbourhood satisfaction was significantly lower for the BBW group than for the baseline group, t (34) = 2.12, p = 0.041, indicating that BBW parents were more satisfied with their community than parents at baseline “It is an opportunity to give everyone a chance to be involved. Opening doors for everyone, even if you think you cannot.”“We have lived in Sunnydale four years and half. We didn’t know each other even when we started the program, Better Beginnings. Now I know all my neighbours, my kids’ friends, moms, I know them. Before I say I knew only one kid. … Now when we come in the morning we know each other. Yeah it’s good.”Cultural bridging was a second major community impact, which involved the facilitation of interactions between residents from different cultural and ethnic backgrounds. BBW activities were reported to create “better connection between different races. [Where] kids playing together no matter what your background is,” and “a chance to see people from different cultures having fun together”.“(BBW) brought people together. The Hub is not just a place to hang out, it is a place where people from different cultures and backgrounds can connect, forming a community.” Safety was also an important theme: “Now we know that our kids are in a safe environment when they join BBW programs.”An important issue in prevention science is whether effective program models can be scaled up to new communities and achieve the same positive impacts . DemonstChild outcomes. While there was a positive effect for decreased teacher-rated overanxious behaviour in the baseline-focal analysis of the original BBBF research [research , BBW chiresearch . These fresearch . Further, in the original research, there was a positive effect on children’s social skills at one of the sites. This site had implemented a school-wide social skills program as part of its BBBF programs. The other original sites and the two schools in the BBW project did not have such a program, which may be necessary for achieving a positive impact on children’s social skills. In the BBW research, while there was no significant impact on the quantitative measure of social skills, the parents mentioned improvements in their children’s social skills in the qualitative interviews. Perhaps the lack of convergence between the quantitative and qualitative data in this regard reflects the fact that this impact was limited to some parents, but not all parents in the community. Finally, like the original research, BBW did not show a significant impact on children’s academic achievement. While improved academic achievement was a theme in the qualitative findings, this again may be restricted to a small number of parents. In the original research, academic impacts did not become evident until Grade 6 and became stronger over time (Grades 9 and 12). Perhaps more time is required to observe academic impacts. It is also possible that the brief teacher rating measure of students’ achievement was not sensitive enough to detect effects. The lack of observed academic impacts may also be attributed to a high immigrant population within the communities, since some evidence suggests that newcomer elementary school students may demonstrate lower academic achievement due to factors such as language and acculturative stress . Parent/family outcomes. There was a strong convergence between the quantitative and qualitative findings regarding enhanced social support. This finding is consistent with that from the original BBBF quantitative [titative  and qualtitative  researchWhile there was no significant impact on the measure of parental depression, parents mentioned reduced anxiety and depression in the qualitative interviews, often in the context of enhanced social support. In the original BBBF research, impacts on parental depression were not reported until Grades 9 and 12. It is noteworthy that many participants—the majority of whom were immigrant mothers—emphasized the importance of reduced social isolation, which is consistent with previous research that highlights the importance of social support in the well-being of newcomer women . There was a significant reduction in stressful life events for Winston Churchill parents. In the original BBBF research, the reduction in stressful life events was observed primarily at one site . While WCommunity outcomes. In the BBW research, there was convergence in the finding of enhanced satisfaction with the Cedarbrae community. Similar community effects were observed in the original BBBF quantitative [titative  and qualtitative  researchtitative . This waSecond, residents spoke of the cultural bridging that occurs. The community is quite diverse along ethnic, racial, and religious lines. These findings might help point toward important mechanisms by which BBW improves the mental health of newcomers in particular, given that acculturative integration  and neigFinally, the project was viewed as providing safe spaces for children, parents, families, and community members to come together and for the promotion of a physically and psychologically safe environment.What accounts for the success of BBW in replicating the main short-term outcomes of BBBF? We believe that the principles of BBBF are important for scaling the model up to new communities. Some prevention programs follow a “cookie cutter” approach, in which communities must rigidly adhere to the original program model. In our pan-Canadian knowledge transfer , we founHaving a local grassroots organization as the sponsor for BBW, with a local leader who lives in the neighbourhood and who had credibility with community residents and the schools, was important for establishing trust and a community-oriented approach to prevention. As well, the BBBF principle of partnership was evident in the relationships between the project, the schools, a neighbourhood centre located within the heart of the Cedarbrae community, two nearby universities with multiple opportunities for students for thesis, practicum, and service-learning placements in BBBW, and several other partners. All of this took time and patience on the part of the project founders, who realized the importance of developing trust and earning the respect of community members and other partners. A key element of BBBW practice that helped to achieve successful outcomes was assertive outreach and parental engagement. It was particularly important to engage the mothers who are often isolated at home, living in poverty, not knowing their neighbours, unfamiliar with the Canadian education system, and lacking English language skills. Preventive interventions can be particularly effective for such families, but staff engagement strategies with such families are particularly important for building trust, relationships, and resident empowerment. Moreover, promoting resident participation in parenting and English language learning programs and project events in the community are other important ways to engage parents. Previous research has also pointed to the importance of parent engagement . SpecifiAnother resource included having a BBBF toolkit and video for staff training and education of community members and partners . BBW alsThe community-building approach of BBW also provides many opportunities for resident participation. For example, in 2019, there were 572 volunteers in programs and events: 75 parents, 186 other adults, and 311 youth. With this high level of participation comes a sense of “community ownership” over the project, as was reported in the original BBBF research . Indeed,The high level of volunteerism and hiring people from the community as staff provided community members with opportunities for training and job experience. Many of the volunteers are immigrants or refugees from countries that are plagued by war, violence, gender oppression, religious persecution, and authoritarian regimes that create climates of fear. Coming to the “promised land” of Canada with projects like BBW is a transformative, liberatory experience for many newcomers.Another aspect of the BBBF model that is important for the development of new projects is its flexibility. Rather than following a “cookie cutter” approach, the model can be adapted within certain parameters to the unique circumstances of communities. Barrera, Gonzalex Castro, and Steiker  have conThis study is limited by its examination of short-term impacts. Furthermore, the baseline-focal cohort design has limitations in terms of its ability to control for factors that jeopardize internal validity . Finally, only one site with two school communities was examined and the sample sizes were small relative to the original three-site BBBF study.In summary, BBW is the first new Better Beginnings program in Ontario since the original three BBBF programs were implemented in the 1990s. The quantitative and qualitative short-term findings from the BBW research showed similar positive impacts to those achieved in the original BBBF research. BBW is meeting the main goals of BBBF: prevention of children’s emotional and behavioural problems, the enhancement of parental well-being and participation, and the promotion of community development and community well-being. Prevention programs like BBW are even more important today than they were 30 years ago, as there is evidence that children’s mental health problems have become more prevalent, at least in Ontario . BBBF isEthics approval. This research was reviewed and approved by the Research Ethics Board of Wilfrid Laurier University and the Waterloo Region District School Board.


Numerous studies have been conducted over the past 15 years to assess safety culture within healthcare facilities; in general, these studies have shown the pivotal role that managers play in its development. However, little is known about what healthcare managers actually do to support this development, and how caregivers and managers represent managers’role. Thus the objectives of this study were to explore: i) caregivers and managers’ perceptions and representations of safety, ii) the role of managers in the development of safety culture as perceived by themselves and by caregivers, iii) managers’ activities related to the development of safety culture.An exploratory, multicentre, qualitative study was conducted from May 2014 to March 2015 in seven healthcare facilities in France. Semi-structured interviews were conducted with managers  and caregivers  and on-site observations of two managers were carried out in all facilities. A thematic analysis of semi-structured interviews was performed. Observed activities were categorised using Luthans’ typology of managerial activities.Participants in semi-structured interviews (44 managers and 21 caregivers) expressed positive perceptions of the level of safety in their facility. Support from frontline management was particularly appreciated, while support from top managers was identified as an area for improvement. Six main categories of safety-related activities were both observed among managers and regularly expressed by participants. However, caregivers’ expectations of their managers and managerial perceptions of these expectations only partially overlapped.The present study highlights current categories of managerial activities that foster safety culture, and points out an important gap between caregivers’ expectations of their managers, and managerial perceptions of these expectations. The findings underline the need to allow more time for managers and caregivers to talk about safety issues. The results could be used to develop training programs to help healthcare managers to understand their role in the development of safety culture. Safety culture (SC) has been the focus of numerous studies over the past two decades, with the aim of using it as a lever to improve patient safety in healthcare facilities . Many haThere is no universally-accepted model of SC . Two, clThe constituent dimensions of SC vary across studies , 7 and aIn France, several studies have recurrently found that “management support for patient safety” is a poorly developed dimension of SC despite its importance , 21, 22.Managers’ perceptions and representations of their activities and role in SC are crucial in fostering their commitment and actions . HoweverA manager is often defined as a professional who is responsible for all or part of the facility; his responsibilities include, coordination, organisation, planning and monitoring in order to achieve the facility’s goals and objectives . He or sIn the healthcare domain, little is known about managers’ actual activities, in particular those intended to improve patient safety . TherefoNumerous definitions of SC have been proposed in the academic literature . In the In an integrated view of SC , the two. Three  were public hospitals with over 300 beds, three were private clinics with over 100 beds , and one (facility G) was a private clinic with fewer than 100 beds. Five provide acute  care and two facilities (F and G) provide psychiatric care. One voluntary care unit participated per facility.An exploratory, multicentre, qualitative study was conducted from May 2014 to March 2015 in seven healthcare facilities in southwestern France. These facilities had agreed to participate following a request from the Aquitaine Regional Centre for Quality and Safety in Health CareIn each facility, two qualitative methods were applied. The first was a one-hour, semi-structured individual interview with managers at each level  and three caregivers . All interviews were recorded and transcribed in full. Transcripts were not returned to participants for comment or correction. The interview guide addressed perceptions of safety within the facility, representations of roles, managerial activities with respect to safety, and caregivers’ expectations of their managers in terms of safety. This interview guide specifically designed for this study is provided in Additional file The second method involved direct, one-day observations of two managers at different levels in each facility. The day was chosen with the manager; it had to included, a period of time dedicated to safety issues. The manager was instructed not to change his agenda and to work as he usually does. Activities related to safety were assessed on the following criteria: context, interactions with other professionals, safety messages, and attitudes of caregivers. A case report form was used to record managers’ activities, which were structured into the following categories adapted from categories of effective managerial activities given in Luthans : planninIn each facility, both semi-structured interviews and on-site observations were carried out by one of two experienced sociologists  who also had experience in quality and safety research projects.Interview transcripts were subject to a thematic analysis using NVivo 10 qualitative data analysis software . Data were encoded by the two sociologists (MLL and TR), based on the themes identified in the review of the academic literature and the content of interviews. The two sociologists worked together on coding in order to develop the analysis, and regularly consulted each other.Observations were subject to a categorical analysis by the two sociologists using the same software as for the semi-structured interviews. The categorisation was based on the classification of managerial activities given in Luthans .Participation in the study was voluntary and informed consent was obtained from all participants before enrolment. To ensure anonymity, all identifying information was removed from participants’ responses.In the seven healthcare facilities, 65 professionals  participated in semi-structured interviews. Table the purpose of safety ; ii) the resources needed to achieve safety (means); and iii) the result to be achieved (outcomes). Examples of verbatim for each theme are provided in Additional file 2.The purpose of safety includes individuals, the environment and the facility. The safety of individuals refers primarily to patient safety, but also occupational risks and the safety of accompanying persons and the public. Patient safety was perceived as a priority by both caregivers and managers, and was seen as not only linked to the risks associated with care, but also physical risks (i.e. self-injurious behaviour and aggressive behaviour directed towards other patients or staff) and environmental risks (i.e. fire). The priority given to patient safety is summarised in this statement from a nurse manager at facility E:“Really, the first objective is the safety of patient care, that is, that the patient has the care, treatment, examinations he needs and no more. He should leave in a better state of health compared to how he was when he came in.”Risks associated with care were mentioned more often in acute healthcare facilities, while physical risks were more of a concern in psychiatric facilities. Occupational risks were mainly mentioned by managers in the context of their negative consequences for patient safety, as expressed by a quality director (facility E):“What is interesting to consider when thinking about the safety of professionals is that occupational risks can also impact patients. This is what we see when teams are exhausted, in conflict or where there is a lot of absenteeism.”When safety was defined in terms of the resources needed to achieve it, the adoption of safe working practices was noted most often, primarily in terms of compliance with rules and protocols, followed by ethical practices considered to be inherent in any caregiving activity. A nursing assistant from facility B emphasized the importance of following good practice:“In terms of professional practices, I think that, in general, we have very good professional practices in the facility, and this contributes to safety.”The adoption of safe practices and attitudes also included knowing one’s own limitations and the non-technical skills that promote teamwork:“Knowing your own role, not going too far. Then it’s all about communication, teamwork” .The provision of adequate material and human resources, and effective management were two other issues that were regularly cited as a way to achieve safety, and were considered as managerial responsibilities:“You can't create a safety culture if you don’t already have a minimum level of environmental safety and high-performance equipment” .When safety was defined as the result to be achieved, results were seen as either the management of the most serious or unacceptable risks (i.e. the death of a patient), the most frequent risks, or medicolegal risks. Professionals varied widely in how they saw results, for example: compliance with regulatory requirements; following a reactive, event-driven risk management approach; or the implementation a realistic risk management approach rather than the ideal but unachievable goal of zero adverse events.Although often defined as a vast and multidimensional concept, in this study we describe safety in healthcare facilities in terms of three main themes Fig. : i) the “We have good practices. We’re in a good department and the doctors are aware that they are in a department where we’re doing good work.”However, this shop-floor SC was also considered to be a work-in-progress, and sometimes even detrimental to safety, as expressed by a doctor (middle manager) from facility D:“There are always free electrons that are always difficult to control in this private context, especially with doctors. The institution can look away at times and, in my opinion, sometimes there’s not enough pressure and sometimes that suits us, too. But as a result, there are people who have bad practices, and no-one can do anything about it.”Support from frontline managers and sufficient resources, particularly material, were regularly cited as illustrations of positive perceptions of safety:When you need something, you tell the nurse manager [frontline manager] and she do everything she to make sure you get what you need. We don't have a problem with that .“Our head of unit is very good in his role; he is very efficient! » .“If we are talking about equipment, yes, here, it’s all in the rules to work.” .On the other hand, lack of support from top managers and a lack of appropriate (notably human) resources to provide safe care were regularly mentioned as areas needing improvement, as expressed below in the quotes from three caregivers:“This summer, we weren't safe, we were short of staff. Every day there were staff on sick leave, sometimes having to be replaced at short notice, and all our director told us was that we had to get by. Afterwards, it wasn't the nursing manager's fault, he did everything he could to make up for the lack of staff.” “We had a problem, risk of medication error for babies. I have proposed solutions and alerted our director to this recurring incident. (…) And I'm fighting to correct this problem, but an adverse event occurred (...) Nurses made that mistake of alerting the director and saying that we were not working well, not safe. But then again, since the last big problem, nothing has changed” .“one does not feel heard and supported by our direction. If only we would take the trouble to admit that things are not going well...”.This lack of support from the top management and its consequences was also mentioned by frontline managers, as expressed by this nurse manager from facility D:“Out of three weeks, I've had 9 caregivers in sick leave, and I didn't finish at 6:00 p.m.! Sometimes I didn't have a solution, sometimes I cracked up, I even cried because I didn't want to go home without finding a solution, but the top management does not provide a solution.”Participants expressed positive views about the level of safety in their department and facility. This was mainly justified by the existence of a ‘shop-floor’ SC, in the form of competent professionals who generally followed good practice, had sufficient resources, and an institutional approach to improving safety. A nursing assistant from facility E stated:(Table ). This gap between expressed and perceived expectations was found in each facility. Managers attributed more expectations to caregivers than the latter actually expressed. Conversely, two expectations expressed by caregivers were not perceived by managers: the allocation of time to talk about safety issues, and the promotion of a preventive risk management approach. A nurse from facility C expressed the need to take time to discuss about safety issues:“Currently, we’re trying to find a better way to manage external implants, (...) it's just getting going, but there’s still a lot of inertia (...) I'm hoping that my manager can find the time to talk about it, and that we can try, with the nurses and orderlies to look at this implant management, to try to find ways to improve its management.”A nurse from facility E, also expressed this need for creating work debate space around safety issues between managers and caregivers:“(...) I expect my nurse managers and director of nursing to find the moment to get together, and try with the nurses and nursing assistant who work around this issue, to try to find an improvement. ”On the other hand, managers perceived an expectation of reactive risk management approaches, such as the reporting and analysis of adverse events, an expectation not expressed by caregivers. Finally, one top manager  indicated that he did not know caregivers’ expectations of managers because he had no direct contact with them.There was only a partial overlap between caregivers’ expectations of their managers in terms of safety, and what managers perceived these expectations to be Table . This ga“it would be having enough resources to keep working, it’s trying to keep what you have. It’s not even asking for more, especially in terms of staff, but trying to keep what you have, and since the move is more towards reducing finances, it’s difficult...”This expectation was also perceived by managers, although they seemed more concerned with material than human resources:“Employees can have expectations regarding their working conditions and patients, if there are things that aren’t working, poor equipment” .A second caregiver’s expectation was that managers should monitor their work. They expected managers to enforce rules, check practices and correct deviations:“You still have to remind people of the rules. I think that the role of the medical director is to refocus on the right rules. In terms of safety, we need to refocus. (...) Unfortunately, from time to time, you have to bark a little” .This caregivers’ expectation that managers regulate their practices was perceived by managers, as a top manager pointed out:“When I'm familiar with the recommendations, I don’t hesitate to issue reminders. I do that on a regular basis” .Although this expectation was perceived by managers, the latter tended to consider that caregivers expected recognition, rather than regulation:“Staff expect recognition, and it’s true, in other words, not just telling them “it’s necessary”, “it’s the rule”, they still need to feel that they are valued and recognised. Knowing how to value them is very important, knowing how to acknowledge good work” .Caregivers’ expectations fell into two main categories. The first was the provision of satisfactory working conditions, in particular, sufficient human resources to optimise the organisation of care and guarantee patient safety. A doctor from facility F indicated that:The main activities attributed to managers by interviewees (44 managers and 21 caregivers), and observed safety-related activities (14 managers) are presented in Additional file Most of the activities attributed to managers by interviewees were also observed during direct, on-site observations. These activities, which were both attributed to managers and observed could be divided into six main categories: leading and motivating; monitoring and checking healthcare practices and organisation; communicating information and tools related to safety; coordinating the work of different departments; setting an example; and directing safety policy and its implementation. These six categories were homogenous across facilities, with the exception of facility G, where setting an example, communication and decision-making were less frequently cited than in other facilities.However, observed activities differed as a function of the managerial level. We can take the example of monitoring and checking. For frontline managers, this mainly took the form of checks of caregivers’ professional practices. One example concerned a nurse manager who, while present on the ward, checked that porters had passed through the hospital’s reception before transferring a patient to the ward, and reminded them of the need to do so. As for top managers, a Director of nursing was observed reminding caregivers of the importance of following the facility’s identity monitoring procedure. Planning and keeping up to date were activities that were observed more frequently than they were stated, especially among frontline managers. Planning was mainly observed for frontline managers and concerned short-term tasks that mainly aimed at compensating for the absence of one or more caregivers. The nurse manager from facility G was observed managing the replacement of a nurse on sick leave, the director of nursing from facility D has been seen managing rotas for the department’s paramedical staff and midwives, taking into account holidays, time off for managers, sick leave, and unforeseen absences.Finally, although rarely attributed to managers by interviewees, the presence of top managers in healthcare units was observed in two facilities (D and G). In facility D, the Director of nursing was observed meeting with a nurse manager and a technician repairing toilets in patient rooms. During his visit to the units, the director of facility G was observed mainly pointing out the shortcomings of caregivers in terms of hygiene and reminding the nurse managers that they should plan the implementation of corrective actions decided upon after the occurrence of adverse events.This study showed that the professionals who were interviewed (44 managers and 21 caregivers) expressed positive perceptions of the level of safety in their facility. Support from frontline management was particularly appreciated, while support from top managers was identified as an area for improvement. However, caregivers’ expectations of their managers and managerial perceptions of these expectations only partially overlapped. Provide satisfactory working conditions, enforce rules/ check practices/ correct deviations, organise health care, acknowledge and value the work done by teams, transmit information and promote training, understand and spend time in the healthcare unit, listen and take into account the opinions of caregivers, and provide support in case of difficulty were expectations regularly perceived by both caregivers and managers. Organise time to talk about safety issues and encourage the implementation of preventive risk management approaches rather than reactive approaches were two expectations expressed by caregivers but not expressed by managers. Six main categories of safety-related activities were both observed among managers and regularly expressed by participants: leading and motivating; monitoring and checking healthcare practices and organisation; communicating information and tools related to safety; coordinating the work of different departments; setting an example; and directing safety policy and its implementation.Our results showed that for healthcare professionals (managers and caregivers), the notion of safety within a healthcare facility was polysemic. While patient safety and its management were at the forefront, many other dimensions that seemed to be of concern to professionals were mentioned, such as their own safety and the financial safety of their facility, and mainly for their potential impacts on patient safety. The links between these different dimensions of safety and their impact on each other have been highlighted in recent studies, as the impact of professional safety and patient safety . FurtherSeveral French surveys of the safety climate in healthcare facilities have found that “Managerial support for patient safety” is one of the least-developed dimensions , 21, 22.Our finding of a perception of insufficient support for patient safety from managers does not seem to have changed since earlier quantitative studies carried out in France , 21, 22.Haute Autorité de Santé) recently introduced an experimental safety walkaround in 13 pilot healthcare facilities, which is expected to be gradually rolled out to other institutions [In our study, the need to allocate time to discuss safety issues was clearly expressed by caregivers. However this expectation was not perceived by any of the participating managers, despite the importance of developing a shared vision of risks in fostering SC . Based oitutions .The current work of top managers and, particularly, healthcare facility directors is complicated by the fact that they are increasingly held responsible for results, good or bad. Moreover, they must ensure the smooth running of their facility, while the health system is under pressure as never before . This, sClassically, two styles of leadership are distinguished . The firIn most of the healthcare facilities that participated in our study, managers had implemented a style based on transformational leadership . They weAnother important finding of our study is that although caregivers wanted to see the development of a more dynamic approach, in the form of prevention initiatives based on a proactive view of safety, managers tended to favour reactive, risk management approaches such as adverse event analyses. This result highlights the need to train managers in the most up-to-date safety management models, which place greater emphasis on proactive, rather than reactive, risk management methods . In thisOur study also highlighted different categories of activities that foster safety, and gaps between caregivers’ expectations of managerial support for patient safety and managerial perceptions of these expectations. Such gaps between expressed and perceived expectations seem to be as important as cultural gaps between caregivers and managers .Our study has various methodological limitations. Notably, there are several possible biases: selection – linked to the fact that facilities volunteered to participate; social desirability  – linked.Our findings support the need to allocate more time for managers and caregivers to discuss safety issues, for instance in the form of a safety walkaround , 39, 46 4The present study confirms that managers have a crucial role to ensure the development of a SC in healthcare institutions. It highlighted that support from, and the involvement of frontline managers seems to be perceived as more important than that of top managers. This study also identified categories of activities that foster safety, and highlighted some gaps between caregivers’ expectations of their managers and managerial perceptions of these expectations. This result could be used to develop training programs to help healthcare managers understand their crucial role in the development of SC. Our findings also support the need to allocate more time for managers and caregivers to discuss safety issues, such as safety walkaround , 39, 46 Additional file 1: Semi-structured interviews guide used with managers (n = 44) and caregivers (n = 21).Additional file 2: Example of verbatim for each themes and sub-themes regularly cited by participants (n = 65) to define safety and principal risks in healthcare facilities.Additional file 3: Main categories of activities intended to improve safety attributed to managers by managers (n = 65) and caregivers (n = 21).Additional file 4: Categories of safety-related activities observed among managers (n = 14).