Throughout the COVID-19 pandemic, healthcare workers (HCWs) have been exposed to highly stressful situations, including increased workloads and exposure to mortality, thus posing a risk for adverse psychological outcomes, including acute stress, moral injury, and depression or anxiety symptoms. Although several reports have sought to identify the types of coping strategies used by HCWs over the course of the pandemic , it remains unclear which factors may influence HCWs’ choice of these coping strategies. Accordingly, using a qualitative approach, the purpose of the present study was to gain a deeper understanding of the factors influencing HCWs’ choice of coping strategies during the COVID-19 pandemic in Canada. Fifty-one HCWs participated in virtual, semi-structured interviews between February and June 2021. Interview transcripts were analysed through an inductive thematic approach, yielding two primary themes. First, HCWs described an ongoing shift in their approach to coping depending on their mental “bandwidth”, ranging from “quick fix” to more “intentional effort” strategies to engage in proactive strategies to improve mental health. Second, many HCWs identified various barriers to desired coping strategies during the pandemic, including the preponderance of pandemic- and other circumstantial-related barriers. The findings from this study offer a unique understanding of the factors influencing HCWs’ choice of coping strategies under novel and increased stress. This knowledge will be central to developing appropriate forms of support and resources to equip HCWs throughout and after the pandemic period, and in mitigating the potential adverse mental health impacts of this period of prolonged stress and potential trauma. Throughout the COVID-19 pandemic, healthcare workers (HCWs) have been exposed to stressful pandemic-related situations, including witnessing an increased numbers of deaths, heightened workloads and work hours, working with inadequate supplies of equipment or resources, and fear of contracting and/or transmitting COVID-19 to loved ones ,3,4,5,6.Given the nature of healthcare occupations, particularly those in hospital settings, many HCWs are familiar with working in stressful situations, including exposure to life-or-death decisions, treating life-threatening injuries, and delivering the necessary care response after natural disasters . The COVGiven the high stress nature of healthcare occupations and the elevated threat of adverse psychological outcomes during the COVID-19 pandemic, HCWs would be expected to utilize coping strategies to mitigate stress. Snyder ,11,12), Notably, ongoing research during the COVID-19 pandemic has revealed various coping strategies that HCWs employ to deal with the stress of the pandemic. For example, Smallwood et al.  examinedTaken together, these findings point towards the urgent need to identify whether Canadian HCWs have coped during the pandemic and, if so, which types of coping strategies they employed, in order to promote further adoption of strategies associated with resilience and enhanced wellbeing. Indeed, understanding how HCWs attempt to individually mitigate adverse experiences is likely to be crucial in identifying the types and duration of different forms of support required to help HCWs cope and achieve positive long-term mental health outcomes throughout and after the pandemic. Despite current knowledge of the types of coping strategies employed by HCWs globally, little is known about the coping strategies used by Canadian HCWs and the factors that influence their choice of specific strategies. Accordingly, the present study aimed to obtain first-hand insight from HCWs to better characterize the use of coping strategies by Canadian HCWs and the factors underlying these behavioural choices during the COVID-19 pandemic.This study is part of a broader project examining the mental health of Canadian HCWs during the COVID-19 pandemic, where HCWs from across Canada were invited to partake in both a qualitative semi-structured virtual interview and a quantitative mental health survey. This study was approved by the Hamilton Integrated Research Ethics Board (#12667). The analysis included solely qualitative findings. The eligibility criteria included: HCWs , who worked during the COVID-19 pandemic within Canada, were able to speak and read in English, and were at least 18 years of age. Recruitment consisted of virtual flyer distribution to healthcare organizations and associations, as well as targeted social media ads. Upon receiving electronic informed consent forms from participants, interviews were conducted via Personal Health Information Protection Act (PHIPA)-compliant Zoom video conferencing to ensure the privacy and security of all parties and personal data. An interview guide was developed that included 27 open-ended questions, which was piloted with two HCWs prior to study launch. This study analyses responses prompted by a central question: “Some people use various types of coping strategies when they are experiencing stressful situations. Have you used any particular strategies to help you cope?” Coping strategies mentioned at other instances times during the interview were also included in the analysis. All interviews took place between February and June 2021. This period in Canada was characterized by vaccine approval and initial distributions, increasing SARS-CoV-2 variants of concern, travel restrictions, lockdowns— nationwide and localized, and mask mandates . InterviData were analysed according to Braun and Clarke ,17 and tTo begin data analysis, an immersion into these data allowed for an in-depth familiarization with the information at hand. Two diverse transcripts were selected for the development of the coding framework, using an inductive approach. Two independent coders (K.R. and A.B.) developed a coding tree for the entire interview dataset based on these two representative transcripts using MAXQDA 2020 software . Next, aResearch rigor was maintained through the five criteria proposed by Lincoln and Guba ,21; credFifty-one (N = 51) HCWs participated in this study, the majority of whom were female respiratory therapists residing and working in Ontario. This group represents the majority of participants as, prior to expansion of the study to include all healthcare occupations, the original goal of the larger study was to characterize the experiences specifically of respiratory therapists. Demographic data for the study participants are presented in Qualitative thematic analysis revealed two primary themes, each with two subthemes. The themes are not mutually exclusive, but together provided a more holistic understanding of how Canadian HCWs coped during the COVID-19 pandemic. The following Despite the described difficulties for HCWs to cope with stress during the pandemic, many HCWs still found ways to use coping strategies. This theme encompasses two main approaches to decision-making which influenced HCWs’ choices of coping strategies. As an overview, the first subtheme, Intentional Effort, refers to HCWs making a purposeful choice to engage in activities that improved their mental health. The associated coping strategies were often described in positive terms . The second subtheme, Quick Fix, refers to lower-effort strategies that HCWs engaged in to obtain instant outcomes  to cope with stress. These strategies were often described in disparaging terms, although they still offered an instant relief from negative affective states. Importantly, as the pandemic went on, HCWs adjusted their coping strategies according to their needs, presenting fluctuation between the two approaches to decision-making in question. Outlining these shifting approaches to coping, HCWs shared:And to replace the alcohol with things like meditation, I have a sleep routine that I use that [psychologist’s] encouraged me to use so that I sleep well” “(59RT)Yeah, a few things come to mind. I actually—I—Facebook was a bad one for me, because again, it was like everyone’s opinions on what was going on and I didn’t really want to hear anyone’s opinions, I just wanted the facts. So I actually deleted my account last July after all this stuff happened and I haven’t been back on since, which has been great for me. […] Also, I figured—I came up with new hobbies, because I can’t do [social media], I need to come up with something else. So I started doing more artistic things, like wood burning and carpentry and stuff. And I play piano”“(20RT)Here, HCWs chose to terminate their “quick fix” strategies such as alcohol use and social media, and switch to more intentional strategies such as meditation, adequate sleep, and hobbies. The second quote further captures the common fluctuation between approaches to coping as the pandemic went on, where this HCW chose to terminate their social media use due to pandemic-related content and switch to more intentional choices of coping strategies  being described positively. The following sections offer further exploration of what it meant to have a particular approach to coping.Many HCWs reported making an intentional effort to invest time and energy to cope with pandemic stress and improve their mental health. Some HCWs described intentionally seeking out coping through personal hobbies, while others leaned towards therapy or routine social interactions. Such strategies were deliberate and planned, demonstrating the intentional effort within the approach to decision making. Many personal hobbies were described positively, including arts, quilting, and gardening as various means to feel better. For example:Gardening too, but now gardening is not all year round. I do have a lot of indoor plants and also we’ve been renovating our house for the last four years so I really much enjoy decorating and changing my decor with the way I feel. So yeah. I think I’m pretty good at coping”“(47RT)In describing intentional effort strategies, many HCWs sought out activities that they anticipated would help them feel “happy” or “better” for a prolonged period of time. Some would describe such choices of activities in terms of self-care practices, including yoga, exercise, and meditation. The following HCW described many of these positively perceived activities:Yeah I have started doing like my yoga at home which has been helpful, and I am going to therapy which I started in October, so that’s been helpful for me to do that and I kind of take it as like a self-care kind of day; and like I have been doing little things. I spend a lot of money on like stuff that I enjoy like facials, like skincare kind of stuff just to provide like a little bit of like self-care. […] I’ve seen a lot more like doing a lot more cooking at home and saving more money and, you know, maybe making healthier food choices and working out and having to get creative with workouts and like “I’m going to try some meditation. I’m going to try this actively or watch this video or read this book I’ve been meaning to get to.” Those are great things. Like I’m so happy. A lot of behaviours I think will carry on well past, you know, lockdown and the pandemic”“(04HCW)HCWs identified intentional effort strategies as long-term solutions to cope with pandemic stress that were aimed at positively impacting mental health.By contrast, some HCWs sought lower-effort coping strategies that were more accessible to them. A significant number of HCWs described these strategies as a means to avoid processing their emotions, often due to a lack of bandwidth or capacity to make an intentional effort, and a more urgent need for distraction, relaxation, numbing, and comfort. Some HCWs described an awareness that their quick fix was not a long-term solution, but that it still offered a temporary way to feel comforted or better that was desired in the moment, resulting in continued use. Such coping strategies were often described negatively and were associated with the onset of guilt after being employed. Coping strategies reported as quick fixes included alcohol use, substance use, and binge eating, as illustrated by the following quotes:But it’s hard, you know, some days I just don’t want to do anything and I just want to sit and drink. […] And I guess [alcohol] numbs, right, it kind of takes off that pain that you might be feeling, or that stress, or whatever. It just kind of numbs everything, so yeah” “(05HCW)I’ve definitely—I don’t know, because I definitely have increased my alcohol definitely and definitely binge eating after a shift. It’s always chips or popcorn and I know that it’s not a long term solution, but I think I just kind of am seeking comfort and that’s going to give me endorphins and I know it’s going to feel good. And then of course that’s—then I feel guilty the next morning and it’s a big old cycle”“(21RT)Well, I was never a drinker, never one who—well I mean, I very seldom, I mean like once a year would socially have one drink, now I’ve, I could very easily have a couple of drinks a week, or every couple weeks. Again, that could be one cooler or something, which is more than I’ve ever had in my life. And chewing a gummy, CBD, I never did that before. Now, oh yeah, it helps me sleep and some of that. So that’s something I never thought in a million years. But I do that, it’s a coping strategy for me”“(30HCW)As evident in the aforementioned example, many HCWs in our study experienced first incidences of increased alcohol and substance use during the pandemic in an attempt to quickly and effectively reduce stress. Moreover, others HCWs engaged in media activities including social media, phone games, and video games. Many HCWs described such experiences:And you don’t have to like turn your brain off to flip through other people’s photos and stuff, so it definitely—like scrolled through Instagram while I was on my break because I couldn’t focus on reading a book. It was just not ideal, but it happened. But, yeah, definitely that was like the bad coping”“(65RT)I would say probably—yeah, probably more social media again, phone I’m really bad with my phone. It’s more so games than social media though I do like a lot of like puzzles or something. Like I need to be constantly doing something I think to keep my brain busy so, it doesn’t think about other things” “(52RT)As HCWs described, activities such as social media required minimal attention and effort, reducing the lingering cognitive load from work, and satisfied more urgent needs .When asked about their use of coping strategies during the pandemic, many HCWs discussed a range of barriers that impeded their usual ways of coping in managing work-related stress. Whereas some barriers were related to pandemic restrictions, others were related to changing circumstances. Oftentimes, barriers were described as out of the individual’s control, affecting their ability to find alternative strategies.Government-level policies created prominent barriers to HCWs’ use of coping strategies. All individuals were required to adhere to the policies enacted where they lived . Furthermore, there remained prolonged periods of time in which differing degrees of pandemic restrictions were in effect. During these periods, many HCWs were not able to continue or initiate their usual coping strategies, such as physical activity/exercise , outings , and social gatherings . A few participants shared:And then when you go home, you know, maybe I’ll go out for dinner with some friends. Oh, guess what, we can’t do that. Or maybe I’ll do something as simple as, you know, go bowling and just blow off some steam, have a beer and go bowling with friends. Oh, geez, I can’t do that”“(05HCW)I sing in like two different choirs, and I’m really missing that because that’s something that I’ve done my whole life and I’ve now learned that it is quite therapeutic for me that whole experience. So, I’m really, really missing that”“(29HCW)These HCWs had previous employed coping strategies involving centres in the community , but pandemic restrictions prevented access to them. Similarly, many HCWs spoke about the influence of social restrictions on their ability to utilize desired coping strategies:We weren’t allowed to see our families in some situations. So that was hard on people, because they wouldn’t have the coping mechanisms or the tools that they would normally have”“(35RT)And I can’t hug my co-worker and we can’t sit in the corner and cry and hug each other, because it’s not allowed. So that kind of support you know. Of course, we talk and try to support each other, but nurses, we’re physical, we need that physical connection and that physical touch, and we can’t have that”“(05HCW)Among HCWs who previously relied on contact with family and friends as a prominent coping strategy, this was a great change for many, resulting in negative affective states. The inability to use desired coping strategies took a great toll on many HCWs:So any sort of kind of support mechanisms that we had, anything that … helped to process things and blow off steam, those are all gone. So it’s just kind of in your face, this grief all the time, and there’s no way out to get rid of it, you know”“(05HCW)This subtheme addresses the desire of HCWs to engage in coping strategies, which was impeded by various pandemic-related restrictions.Various circumstances during the pandemic influenced HCWs’ ability to engage in coping strategies to reduce stress. Circumstantial barriers were specific to the HCW’s situation and included communication barriers with family and friends, exhaustion/lack of motivation, and seasonal barriers in terms of weather and the associated available activities. Some HCWs refrained from speaking with friends and family as they were fearful of traumatizing others with their experiences, stories, and challenges, or being portrayed as insensitive to the matter. Other HCWs felt like a burden to their friends and family, or that it would be taxing to speak to friends and family because they would not truly understand their experiences as HCWs. One HCW said:So basically it’s just talking with coworkers and venting it out […] and talk to my family about it, they’re not going to get it because it sounds cold. ‘You want to let someone die?’ ‘Well yeah but that’s in their best interest’. So it sounds cold talking to your family about that so it’s mostly just talking with coworkers. […] Like I think I have a really great family. There is an underlying—they don’t really get it because they’re not there so they can’t, you know, if I had a bad day and I want to come home and talk about it, they can listen and be like “Oh yeah, OK, yeah, uh-huh” but they don’t really get it”“(10RT)In addition, HCWs anticipated that differing political opinions about the pandemic, including vaccines and masks, would lead to arguments. These HCWs preferred to avoid these altercations altogether and interacted less with family and friends instead of turning to these relationships for support. One HCW shared:So, of course, [families are] going to talk to a doctor and a nurse about [COVID] and get all the information. And it became very difficult to like talk to family and some friends because that’s all they would want to talk about. And so it was a lot of like we wanted to interact with our families, we want to see our parents, we want to talk to our friends but not like this”“(02HCW)Critically, many HCWs were simply too exhausted, burnt out, or unmotivated to engage in any coping strategy at all. At times, participants were unable to fit coping strategies into their schedules due to an increased workload, tending to children at home, and working overtime. Some examples include:And I wish that exercise was a thing, but I used to exercise a lot and kind of—but now it’s just kind of finding the time doesn’t really work out, or when I do have the time I don’t want to”“(36RT)[…] our kids are small and we would often be like—not necessarily working late, but kind of running from work and straight to like getting them dealt with their schoolwork and dinner and all that kind of stuff. So kind of find a challenge to like where can I fit exercise in? But I find even more so now like I am doing even less [exercise]”“(08HCW)Many HCWs were left too burnt out to use any coping strategies, resulting in heightened negative physical and psychological effects. One HCW stated:There was no black and white and then for me it was just that I ended up not coping and then I ended up just not going to work. I don’t know how you cope. I ran out of coping. I felt clearly burnt out. I just felt completely burnt out. I described it as being literally physically and mentally exhausted where I just, I just couldn’t make myself get there and I just couldn’t and right before I went off I actually started to notice and it kind of half scared me”“(48RT)Further, many described the winter as a particularly difficult season in coping with pandemic-related stress, as it was too cold to engage in desired outdoor activities, such as going for walks or engaging in socially distanced outdoor gatherings. One HCW explained:But then it got into winter and winter just, with my own personal mental health, it wasn’t good. Winter was terrible. It was a terrible environment at work. It was just a heaviness that winter can be being in a cold place. But it was just…It was just heavy in all regards, lack of sun, lack of being able to social distance outside”“(12HCW)The combination of pandemic-related and circumstantial barriers left many HCWs at a standstill, feeling unable to engage in coping strategies to successfully reduce stress.The purpose of this study was to better characterize Canadian HCWs’ coping strategies during the COVID-19 pandemic and to identify the factors driving selection of and barriers to using particular strategies. To our knowledge, there exists limited literature on Canadian HCWs’ coping strategies during the COVID-19 pandemic, particularly the factors influencing the choices of coping strategies—something which we have elucidated through our rich dataset of HCWs’ recollections of their experiences. With the nationwide impact of the pandemic varying from lockdown periods to new variants of concern, knowledge of coping strategies is of great significance in furthering our understanding of how HCWs’ can best be supported during this time and beyond the pandemic. In this study, most Canadian HCWs interviewed were able to identify strategies they used to combat exposure to stress and potentially, trauma, during the pandemic, with many strategies identified similar to those utilized by non-Canadian HCWs. Here, many of the coping strategies identified by Canadian HCWs were similar to those described in Shechter et al.  and SmalIn the face of new and difficult circumstances during the pandemic, many Canadian HCWs struggled to find useful means of reducing stress. The current study suggests these struggles were influenced by government restrictions, seasonal barriers, perceived impacts on family and friend relationships, and exhaustion. Few studies have commented on the barriers HCWs experience with regards to choosing and engaging in coping strategies, particularly in relation to the circumstantial barriers identified here. Nonetheless, our study findings align with those of Smallwood et al. , who fouIn the present study, HCWs described frequent fluctuations between Intentional Effort and Quick Fix coping strategies throughout the pandemic. One way that HCWs observed these fluctuations was in terms of their social media use. Many HCWs initially used social media as a coping strategy to “numb out” and distract themselves after a difficult workday, but then moved away from using social media (and engaged in other coping strategies) to avoid the high stress induced from the volume of pandemic-related content on social media. Similarly, Reilly et al.  surveyedThis study highlights HCWs’ own perspectives surrounding their use of coping strategies during the COVID-19 pandemic, including what HCWs perceive as positive or negative coping strategies. According to Snyder’s  found thIn the present study, many HCWs described their first instances of substance use as occurring during the COVID-19 pandemic, and for HCWs who already engaged in substance use, many described a significant increase in substance use during the pandemic period. It is notable, however, that although some HCWs in our study chose to switch from the Quick Fix of substance use to an Intentional Effort strategy, many continued to rely on substances despite an awareness of the potential for negative long-term impact. This points towards the urgent need for further investigation of HCWs’ substance use during the pandemic. Such work is currently being undertaken in our research group with Patel et al. , reportiTaken together, the results of the present study and a growing body of literature ,6,20,24 Significantly, the present study strongly suggests that HCWs have faced numerous challenges to engage in positive coping strategies throughout the pandemic. Addressing these barriers, as much as is realistic and possible, may play an integral role in the development of psychoeducation resources aimed at assisting HCWs during and after the pandemic. Such institutional approaches require adequate funding allocations towards mental health benefits that may provide HCWs with some of the tools they so urgently require. For example, increased benefits for HCWs can help support use of Intentional Effort strategies described in this study to provide positive mental health outcomes . Here, the planning of such resources and strategies will need to acknowledge that HCWs fluctuate between an Intentional Effort and a Quick Fix approach to coping, influenced by barriers occurring across the waves of the pandemic. Acknowledging such fluctuations and the decision-making processes that underlie them will be beneficial in understanding HCW perspectives when planning resources and interventions to assist them during and after the pandemic period.The results of this study highlight the nuances of coping strategies used by HCWs during the COVID-19 pandemic. Qualitative thematic analysis was utilized to examine HCWs’ first-hand recollections of their experiences during the COVID-19 pandemic. The flexibility of this qualitative approach allowed for an in-depth latent and semantic analysis of transcripts, contributing to expanding our understanding of our findings in relation to barriers and approaches to coping.Importantly, however, this study is not without limitations. As our sample was composed primarily of a large number of female respiratory therapists residing in Ontario, our results are not generalizable to the entire Canadian HCW population, including those who differ in occupation, sex, gender, ethnic identity, and province or territory of residency. Given the possible influence of geographical location on many of the barriers identified here as impeding coping strategies, it is possible that some of the barriers identified here may not apply to HCWs across Canada. Future research may seek a balanced representation of Canadian HCWs and an understanding of factors influencing the imbalance of demographics of participants. Finally, the present study did not explore organizational or systems-level factors that may significantly influence the coping strategies selected by healthcare workers.Future work in this area is required to identify differences in psychological  and demographic  characteristics that may influence HCWs’ use of various coping strategies, including those that are intended as quick fixes and those that are intentionally oriented. In this regard, the choice of coping strategy may be influenced by the biological, dispositional, personal, and family characteristics an individual brings to a scenario ,30. WhenThis study indicates that Canadian HCWs faced challenges in making use of usual coping strategies during the pandemic due to various barriers. Nevertheless, HCWs did still engage with coping strategies, shifting between different selection approaches. HCWs fluctuated between Intentional Effort decisions and Quick Fix decisions, influenced by contextual factors. These findings can inform forms of support and resources at both the individual and organizational level to equip HCWs to cope in times of increased stress with the overall aim of improving mental health and wellbeing. Future studies should continue to explore factors involved in choice of coping strategies, as well as identify coping strategies that empirically reduce stress and adverse psychological symptoms among HCWs. Overall, this study underscores the critical need to assist HCWs in coping with occupational stress and the unique psychological and physical burden of the COVID-19 pandemic on them and on their families.


Current evidence demonstrates that few patients complete anterior cruciate ligament reconstruction rehabilitation according to evidence-based guidelines. It is important to investigate the viewpoints of our patients to identify patient-reported barriers and facilitators of anterior cruciate ligament reconstruction rehabilitation. Qualitative analysis can provide insight into potential methods for improving the delivery of rehabilitation services.In this qualitative study, utilising a social constructionism orientation, viewed through the social phenomenological lens, three focus groups were conducted with individuals 1–20 years post anterior cruciate ligament reconstruction . Utilising a semi-structured interview guide, participants were asked about their experiences during anterior cruciate ligament reconstruction rehabilitation. Focus groups were recorded, transcribed, and coded using an inductive semantic thematic analysis methodology.Five organising themes were identified (consisting of 19 sub-themes) to provide a framework to present the data: psychological, physiological, rehabilitation service, rehabilitation characteristics, and interaction with others. Each theme details aspects of rehabilitation, such as exercise delivery, informational support, frequency, and duration of care, kinesiophobia, weight management and interactions with teams and coaches, which present barriers or facilitators for patients to adhere to and participate in rehabilitation. Example quotes are provided for each theme to provide context and the patient’s voice.This qualitative investigation identified key aspects of a patient's rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as the rehabilitation characteristics, service delivery, psychological and physiological factors, and interactions with others, were consistently identified by this cohort as factors which affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation and deliver patient-centred care. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.The online version contains supplementary material available at 10.1186/s13102-022-00499-x. A typical anterior cruciate ligament (ACL) reconstruction rehabilitation lasts approximately 12 months before return to sport . CurrentAs a result, it is important to seek the viewpoints and investigate the experiences of our patients ACL reconstruction rehabilitation to gain insight into potential methods for improving the delivery of rehabilitation services. Previous research has provided evidence on the key role the treating health practitioner plays in setting an appropriate rehabilitation environment to reduce treatment-related barriers and enhance rehabilitation facilitators . ThroughQualitative methodologies, such as focus group analyses, are an appropriate methodology to investigate patients’ barriers to and facilitators of rehabilitation. Qualitative methodologies enable a more complete picture of a person's experience than quantitative research alone . Whilst This qualitative study utilised a social constructionism orientation and is viewed through the social phenomenological lens . ConstruAt the end of the survey , particiForty-two potential participants were contacted via email, with 20 consenting to participate in the focus group. Participants completed an online survey to collect personal, injury, sport, and demographic information. Participants were then allocated into one of three focus groups, based on availability and personal demographics, to create heterogeneous groups based on age, gender, injury, sport level and type to facilitate variations in personal experiences.Each focus group was allocated 6–8 participants and was estimated to last no longer than 60 min. Each participant was provided with an explanatory statement and signed a consent form informing them of the purpose, requirements, ethical considerations, and their rights in undertaking the research. The project lead (AW) conducted the focus groups at the University guided by a semi-structured interview guide  has extensive knowledge and experience within qualitative research methodology and thematic analysis. All authors assisted in reviewing and defining themes to check for consistency and stability and producing the report.We conducted three focus groups with six or seven participants, with a total of 20 individuals 1–20 years (mean 6.5 years) post ACL reconstruction. Focus groups lasted between 65 and 72 min. Each group consisted of a mix of genders , age ranges (19–51), sports, concomitant injuries, and participation levels. Twenty-five percent of participants had returned to their previous level of participation, and 85% reported having ongoing problems with their knee. All participants returned to a lower level of competition, changed, or did not return to sport due to factors relating to their knee, except participants 16 and 19 who returned to a lower level of competition due to other factors not related to their injury. When asked about their return to sport, participants reported that fear of movement (kinesiophobia) or reinjury and ongoing symptoms were the primary factors that affected their ability to return to their previous level of sport. Details of the selected participants are presented in Table Five organising themes were identified as key aspects of rehabilitation that present barriers and facilitators of rehabilitation adherence and participation on a patient’s journey back to sport. The research team developed a visual framework representing each theme as influencing factors of a patient's rehabilitation journey to return to sport Fig. . The orgParticipants detailed psychological factors which impacted their rehabilitation. Four subthemes were identified: (1) the participant's expectations for rehabilitation, (2) the impact of kinesiophobia and fear of re-injury on rehabilitation, (3) the difficulties in staying motivated throughout rehabilitation, and (4) the need for support from clinicians, friends, family, their team, and external sources.Most participants expected a 12-month recovery but underestimated the effort required in completing rehabilitation to a sufficient standard and intensity to address post-operative deficits. They felt health practitioners failed to inform them of the possibility of ongoing pain and other injuries. However, they believed that physiotherapists are in the best position to set realistic expectations with their patients due to the ongoing relationship and early input . As explained by one participant, "If they were to see a physio beforehand, maybe they would have an understanding of what you've got to do here and that it's going to be a longer journey because if those expectations are, I guess, worked out beforehand, you're less likely to have that disappointment or that depression and things that go on after surgery” (participant 20).Participants consistently reported that exposure to situations associated with their injury, such as jumping and change of direction, were the hardest to overcome. However, repetition and controlled exposure to these situations aided their ability to overcome their fears. As explained, “just making it more sport-specific, just recreating some of those scenarios that are scary. So, make sure you're comfortable with what you're doing and relate it into your sport” (participant 7).Some participants lost motivation to complete rehabilitation due to not feeling supported in their return to sport ambitions. Slow progression and other priorities through the mid-stages of rehabilitation made it challenging to maintain motivation in completing rehabilitation; however, striving for and achieving key milestones and goals assisted in maintaining motivation over the long term. For example, "that one stage where it's like, yes, you can run for as long as you can. That was super … It was motivating” (participant 15). Exposure to athletes who had returned to high-level sport also increased motivation.Having a supportive team to guide you through surgery, recovery and rehabilitation aided in achieving a successful outcome. Support could be from external sources, such as online support groups, friends and family or the treating health practitioners. As explained by one participant, "one thing that's come out of just hearing everything today is that such a massive part of rehab is between the ears… that mental side and it all starts from the minute you walk into the door to your surgeon, and then you pick your physio and that person, and how they understand what you are going through” (participant 1).Participants mentioned physiological factors which impacted their rehabilitation; three subthemes were identified. These are: (1) older individuals feeling discriminated against, (2) post-operative weight management, and (3) the challenge of pain during rehabilitation.Unlike younger individuals, older individuals felt surgeons and physiotherapists failed to consider their return to sport goals. As detailed by one participant, “he must have said five, six times, well, at your age, women your age tend to. Do you want to just do Pilates? Do you want to just walk on the beach, because if that's the case, you don't need your ACL done? And I felt very patronised" (participant 2). Older individuals also felt it was slower and harder to recover from the surgery.Participants were seeking alternative means to exercise and dietary information to adjust to post-surgical inactivity. Many participants reported weight gain hindered rehabilitation and failed to lose it long term. As suggested by one participant, “I think a nutrition plan will help as well. Like you said, gaining weight is a potential issue…. And you're just like, I don't even know how to eat at all. I think that is really important” (participant 13).Participants reported persistent pain and complications such as patellofemoral pain, delayed rehabilitation progression and reduced adherence. "The fear, for me, was that I couldn't get rid of kneecap pain for so long and whether that was ever going to go away” (participant 19).Factors related to the delivery of the rehabilitation service were identified, resulting in five subthemes. These are: (1) challenges during their initial utilisation of health services, (2) difficulties in accessing health care, (3) the factors which influence the frequency and duration of supervised rehabilitation and (4) the utility of group rehabilitation and (5) telehealth as modes of service delivery.Initial interactions within the health care system were reported to present barriers to rehabilitation progression through delays in diagnosis and a failure of first contact practitioners to hear patient concerns. Many participants had similar stories, “I found it was kind of disconcerting when everyone's going around sharing their ACL stories that like half of us, when we were initially diagnosed was saying, oh, it's just bone bruising, like, oh, it's just a sprain." (participant 15). Participants also had a desire for a plan that encompassed a variety of options for their care to prepare for the entirety of rehabilitation adequately. Remarkably few participants completed any form of prehabilitation, but it was highly valued in those who did.Having the time to travel to and attend appointments was a common barrier for participants. Access issues were particularly evident in the early phases due to post-operative driving restrictions and others with high family and work commitments. “I think probably the difficulty for me was being a mum of two, working full time…. That was my difficulty” (participant 17).As rehabilitation progressed, the ever-increasing cost became a burden to participants and may result in early cessation of care; "So, I think the biggest barrier is access to physio being more affordable in Australia…. I'm at the start of my journey, that could be quite expensive over nine months for me to afford” (participant 6). Participants who ceased rehabilitation early (before six months) reported wishing they had continued longer to avoid long term problems. Some participants reported periodic review in the later stages of rehabilitation, at the recommendation of the physiotherapist, made it difficult to maintain motivation and overcome physical impairments, build confidence and physical capacities for return to sport.Group rehabilitation was widely supported across participants to facilitate rehabilitation progression by developing physical capacities while also providing support and motivation through interaction with others. One patient noted, "Just to be part of a group of people that we had gone through the same thing, just for accountability and motivation because you lose your self-confidence until you can really get going again” (participant 8).articipant 10).Telehealth was accepted as a mode of service to reduce financial and travel burdens but only in combination with in-person appointments to monitor pain, exercise technique, overcome kinesiophobia and deliver hands-on therapies. As one patient expressed, “I think there're some things that you could've done fine with telehealth that probably would've helped with the cost of some of it and the access…. but like some of the stuff that I had to do with my physio, I don't think I would ever have been able to do it if I didn't feel they were right there to catch me if I fell off a block. I just wouldn't have done it. I don't think” (pParticipants spoke about barriers and facilitators they encountered during rehabilitation sessions and interactions with their physiotherapist. The four subthemes identified were: (1) difficulties in completing exercises independently, (2) the desire for informational support, (3) the need for clear and progressive goal setting and reassessment and (4) the relationship with their physiotherapist built on trust and collaboration.Participants consistently reported difficulty completing their rehabilitation as prescribed due to therapists providing unclear instructions and excessive use of technical language. As one participant described, “I probably didn't feel like I was getting very good instruction as to what to do… It wasn't that I wasn't willing to commit to the time, it was I just wasn't sure what I was supposed to be doing” (participant 19). However, participants highly valued being informed of the reason for exercise selection and a clear path for progression. To enhance exercise adherence, they recommended using exercise prescription applications and the therapist considering individual circumstances such as work, family, and exercise competency. Further, participants often expressed that the late stage of rehabilitation was poorly executed and failed to expose them to training to prepare them for a return to sport; “I think the other barrier for physio is once you get to nine months, and you're doing most of your strengths pretty equal, is that specific skills that you want to be outside running, changing direction, and you can't do that in a small clinic, and that's kind of where I left once, I wanted to be outside” (participant 7).Due to the long rehabilitation process, participants consistently reported seeking external sources of information to assess their progress, answer questions and provide motivation. They did express concern over verifying external sources of information. They recommended therapists “not give all of the information the first time you see someone, because it's just too much. It's like a drip-feed, and then building on it each time” (participant 5).Participants highly valued the process of collaboratively setting and achieving relevant goals and milestones but reported that it was poorly executed  or never provided to them; "’Here's where you are. This is where you're going. These are our checkpoints along the way.’ And then let's talk about it, and see if you're happy with it, and if we're there and if not, why not? What are we going to do about it to get you to where you should be? I mean, that didn't happen to me, and I thought it should've done” (participant 1). Setting non-clinical goals  should also be considered.Many participants described how a strong therapeutic relationship built on trust, knowledge and support enhanced rehabilitation and guided them through a lengthy rehabilitation process. For example, one participant stated, “it's the relationship that you build which is based on trust. You trust that that physio will get you there, and the physio has also got to trust that you're going to do your job, and you're not going to let the physio down. So, it's building that” (participant 2). They also expressed that the selection of the wrong therapist can significantly hinder rehabilitation.Participants spoke on how their interactions with others or the wider community impacted their rehabilitation. Three subthemes were identified: (1) the ability of the surgeon to influence the plan for care and rehabilitation, (2) the importance of supportive family and friends and (3) the desire to stay involved with their team.Some participants reported a positive, motivating, and supportive interaction enabled rehabilitation; however, some initial surgeon interactions were perceived as impersonal, negative, and demotivating, which inhibited recovery. The surgeon is in a highly influential position, “whatever they say, you believe because…. you put your trust in them…. they need to build some comfort and warmth inside, warm and fuzzy to make you feel that it's going to be okay” (participant 1). Participants also reported never being recommended to undertake a period of prehabilitation from their surgeon.Participants valued friends and family who facilitated rehabilitation through offering transport, encouragement, and supervision during rehabilitation. However, they often felt that others failed to understand the significance of the injury; “I think people around you didn't understand either, isn't it? Because it's like when you hurt your back because it's not a big gaping wound and people can't see it, they don't… Not as much empathy” (participant 11).The opportunity to stay involved with their team through coaching and support roles was highly valued by participants. They often felt isolated from their team when unable to participate in training and games. As one participant detailed, “I was a little bit isolated. Because the team, they're doing a real intense workout and you're like, I'm just going to use some TheraBand’s and hope for the best” (participant 10).The current study investigated the patient-reported barriers and facilitators of ACL reconstruction rehabilitation. The five organising themes identified and associated subthemes provide the clinician with a patient’s perspective of the barriers encountered as patients pursue their activity and sport goals. The specific themes, contexts and examples identified during this qualitative investigation provide targets for clinicians to improve the rehabilitation experience and facilitate adherence to evidence-based rehabilitation.Patients’ psychological response to injury, surgery and ongoing rehabilitation is heavily influenced by the practitioners involved in their care. Patients typically have high expectations for returning to sport that is often not met, highlighting the importance of setting clear expectations early in rehabilitation , not onlConsistent with previous literature, kinesiophobia and fear of re-injury were significant barriers to completing rehabilitation and returning to sport . KinesioIn some patients’ referral to a sports psychologist may be appropriate.Several factors influenced motivation to participate in rehabilitation. Common factors included the lengthy rehabilitation process, competing life demands, time commitment, rising costs, setbacks, or plateaus in rehabilitation. As self-motivation has been linked to home exercise completion , ongoingACL reconstruction may result in a vicious cycle of injury, sedentary lifestyle, weight gain and increased risk of musculoskeletal injury and cardiovascular disease . ImpairmConsideration of the goals and return to sport aspirations of older individuals need to be respected. Despite their age, they often had the same goals and aspirations to return to sport as their younger counterparts. However, older individuals were often told not to play sport again based on their age, creating a barrier to applying themselves to rehabilitation and meeting physical benchmarks, which, regardless of age, will enhance reaching long-term function . The majPatients are seeking a plan which encompasses all phases of rehabilitation. A clear area of deficiency within the participant's rehabilitation was the lack of early physiotherapy input to prepare physically for surgery and set expectations and goals for rehabilitation . This isIn contrast, others feel they did not need frequent reviews and felt prepared to continue working towards their mid-stage goals independently. In the later phases, participants are often finding it hard to complete rehabilitation due to lack of confidence, technical exercise prescription knowledge, failure of the physiotherapist to progress the rehabilitation to sports-specific activities and rising costs. In combination with the competing demands of work and family, it potentially results in early cessation of supervised rehabilitation.In our cohort, most participants either failed to complete rehabilitation or did not participate in any form of sports-specific rehabilitation, which is consistent with previous literature . All parEffective exercise prescription to achieve appropriate functional levels before return to sport is an essential component of a successful ACL reconstruction rehabilitation . As demoFinally, despite recent evidence questioning the validity of return to sport tests , 37, a fThe initial interactions with the surgeon play a role in preparing for rehabilitation. Facilitating a supportive environment builds confidence and motivation for rehabilitation and cohesive messaging across the treatment team. Negative interactions with family and friends, team and coaches, and the media may create barriers to rehabilitation. On the other hand, supportive family and team environments that facilitated rehabilitation by encouraging exercise completion, allowing ongoing involvement with the team, and drawing motivation from public sports figures enhanced their rehabilitation compliance.There are several limitations to the current study. The identified factors are a representation of the perceptions and opinions of the individuals involved in the research. These may not be able to be extrapolated or be representative of a different population or context. The identified themes were unable to be weighted; as such, we cannot determine the strength of one of them over another to influence a patient’s rehabilitation. The cohort included a wide range of participants, as such perspectives may differ in a more homogeneous population based on age, gender or return to sport goals. On average, participants were 6.6 years post ACL reconstruction introducing a recall bias due to the relatively long period since active rehabilitation. The analysis and coding for themes were completed by one researcher, influencing the trustworthiness of the thematic analysis. Finally, the semi-structured interview guide and coding were guided by a-priori themes based on previous literature, creating bias within the coding structure. Some participants also had a prior relationship with the researchers. Future research should confirm these factors, explore the weighting of these factors, and investigate the effect of implementing a tailored rehabilitation program addressing the barriers and promoting rehabilitation facilitators on patient outcomes.There are many reasons why patients may fail to adhere to or participate in rehabilitation, which may be a key factor in high re-injury and low return to sport rates after ACL reconstruction. This qualitative investigation identified key aspects of a patient’s rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as psychological and physiological factors, the rehabilitation service, rehabilitation characteristics, and interactions with others, were consistently identified by this cohort as factors that affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.Additional file 1. Focus group semi-structured interview guide, the semi-structured interview guide used in each focus group as referenced on line 98 of the manuscript.Additional file 2. Themes and additional verbatim quotes, additional verbatim quotes from each of the identified themes and subthemes as referenced on line 148 of the manuscript.


I propose a new concept of solidarity, which I call “solidarity from below,” that highlights an aspect of solidarity widely recognized in popular uses of the term, but which has hitherto been neglected in the philosophical literature. Solidarity from below is the collective ability of otherwise powerless people to organize themselves for transformative social change. I situate this concept with respect to four distinct but intertwined questions that have motivated extant theorizing about solidarity. I explain what it means to conceptualize solidarity from below as a form of power, rather than as a feeling, disposition, duty, or scheme of social arrangements. Finally, I suggest that the moral-relational aspects of solidarity emerge secondarily from the process of collective power, and not the other way around. But solidarity is variously conceived of as a feeling, sentiment, or disposition; a type of action; a relationship; or a scheme of social arrangements. These are examples of what I will call “moral-relational” concepts of solidarity. Of late there has been a resurgence of philosophical interest in solidarity, particularly in the wake of the COVID-19 pandemic, which has thrown into sharp relief just how truly interconnected our lives and interests are. Solidarity has been widely promoted as a solution to this unprecedented crisis, particularly by global institutions such as the United Nations and World Economic Forum, which took up the motto of “Shared Responsibility, Global Solidarity,” established Solidarity Response Funds, and celebrated displays such as people singing songs together on balconies and applauding healthcare workers ?How should we relate to (specific) others (in our own group)?How can we collectively bring about social change?I will not attempt here to provide a full literature review, exhaustive list of existing conceptions of solidarity, taxonomies of its varieties, or detailed history of the idea , where it refers not only to a general feeling of community and disposition to help those in need, but also more specifically to a scheme of social insurance and collective repayment, a guaranteed minimum income, and public support for  family providers  welfare state.Stjernø, , p. 28. Stjernø, . Most faStjernø, , p. 47 hcare, which take center place in feminist care ethics and political theory. Thus theorists like Iris Marion Young (In declaring that the relationship between justice and solidarity is “not so much of two moments that supplement each other as of two aspects of the same thing” (47), Habermas’s work exemplifies the use of solidarity as the bridge concept mediating between inviolable individual rights and wider community obligations Scholz, , betweenon Young  and Ann on Young  have alson Young , public on Young , and clion Young .group solidarity—in both its descriptive and normative dimensions—has been well-theorized by contemporary philosophers. Tommie Shelby’s  for some while excluding others Stjernø, , p. 28. Shelby’s  celebratShelby’s  conceptiShelby’s . Alison Shelby’s  has alsoThe phenomenon of group solidarity has been sharply criticized, however. Audre Lorde /2007, becan be deeply pernicious, as in Clarence Thomas’s notorious declaration that his Supreme Court nomination trial was a ‘high-tech lynching’, which rallied the loyalty and special concern of Black racial solidarity in his defense—at the expense of Anita Hill (a Black woman), who was vilified for testifying that Thomas (a Black man) had sexually harassed her repeatedly Feelings of brotherhood were to be a means of realising equality, and the Jacobins established Historically, the early Christian idea of fraternity shifted in meaning from purely religious to more political connotations during the French Revolution, where it took its place in the famous call for  Stjernø  writes:Fbourgeoisie) and the poorer classes, consolidating a powerful force that successfully overcame the centuries-old rule of the French monarchy.By subverting class hierarchies, however temporarily, French revolutionaries were able to momentarily link up the otherwise divergent interests of the emerging middle class . For the first time in history, the exploited classes had the capacity—through their concentration in factories, where they could recognize their shared material interests and organize themselves—to achieve a collective power strong enough to overthrow their exploiters. Subsequent theorists and practitioners would call this the power of “solidarity.”6The idea of “brotherhood” and “unity” amongst the oppressed and exploited soon evolved into the idea of working-class solidarity, which has played a starring role in the revolutionary Marxist tradition.through the struggle itself, that is, through a distinctive political practice , anti-Fascists in the 1930s Spanish Civil War, 1960s Black Power activists, and even co-opted by right-wing reactionaries  constrain the choices of the latter such that they act in ways they otherwise would not Notably, Allen disagrees with Arendt that power-with is always legitimate, because a group can generate power-with that stems from relations of “receptivity and reciprocity” within the group, while using that power-with to dominate and oppress others.As such, it has several notable features. Allen derives the concept of power-with from Hannah Arendt’s conception of power, which is contrasted with both “violence” and “authority,” as follows:structural injustice understood as the sum total of distinct but interlocking forms of domination, oppression, and exploitation we face today—in other words, with injustice conceived of as a systemic wholesolidarity from below—the collective ability of otherwise powerless people to organize themselves for radical, wholesale social transformation—specifically as theory of social change . As well-known labor organizer Jane McAlevey succinctly puts it: “The employer class has many sources of power , but the working class has one: our large numbers [emphasis mine]”  forming one side, such that a small group of people at the tip of the cone possess power along every single axis: white, male, Christian, heterosexual, cisgender, able-bodied, and so on. Every form of difference along any axis locates a person further away from the top; and having power along some axis is still parasitic on the way that power is concentrated overall by a relatively homogenous group of elites in the center. Thus there are many people who are white, male, or otherwise fall on the dominant side of necessary role in maintaining existing systems of domination. As Sharp (Appreciating the way that power(-over) requires the subjection of many also brings to light the sense in which the powerless play an ineluctably As Sharp , p. 17 wten air traffic controllers called in sick following their second missed paycheck. This is something of a unique example, as air traffic controllers perform highly specialized jobs that require substantial training, and the current pool of workers is at a 30-year low . Or, voting blocs can be organized in which people withhold their votes from certain parties or politicians . Because economic elites require money, political elites require votes, and society as a whole requires essential forms of labor, the powerless can gain leverage if they are properly organized to withhold these. The fact the solidarity can be constituted by these distinctive forms of leverage—which derive essentially from relations of domination and exploitation—is what distinguishes solidarity from below from other forms of collective power.advocacy or mobilizing, but must focus on organizing  conceived of the phrase “Black Lives Matter” or “Me Too”—broadcast widespread feelings of anger, frustration, and defiance against the status quo.could or should lose control. To maintain order, then, elites can be forced via mass protest to make concessions, such as pulling back an unpopular policy, or terminating prominent individuals from their posts. Mass protests can also drastically shift public discourse in a very short amount of time, as both #BlackLivesMatter and #MeToo have demonstrated .organizing is the process of building up long-term (often membership-based) associations that unify around concrete demands and a collective decision-making procedure. A labor union, for instance, systematically formulates a list of demands based on the particular working conditions faced by its members, votes formally whether or not to go on strike, and disciplines its members to go out door-knocking, collect signatures, guard picket lines, etc. This structure enables the union to most effectively wield the collective leverage of its members to target and extract highly specific concessions from employer, through periodic bargaining.By contrast, new organizers who will expand the base of ordinary people involved   mobilizing relies on the regular participation of the ‘usual suspects’. As Han , p. 11 wrs) Han, .At its best, organizing occurs within a finite constituency—a workplace, an apartment building, a church—in which a high enough percentage of people, regardless of their ideological and demographic differences, participates in collective action that forces a powerful decision-maker to act as they want. Workplace stoppages, rent strikes, nonviolent direct action, and electoral majorities all represent organizing victories .Consider the following testimonials from teachers who participated in the 2018 #RedforEd teachers’ strikes that swept through ‘red’ states  such as West Virginia, Oklahoma, and Arizona in deeply conservative U.S. states, which scored previously unthinkable victories. One Arizona teacher reports:I can’t describe the feeling. It was- it- we’re Singaporean; we’ve never experienced democracy in this way before. It was in front of our eyes; we were there. We screamed, we shouted, we voted, we- we protested, we agreed, we cheered, we booed, and then we voted, and then the result was in our favor! It was like, [inhales sharply] this is what democracy feels like!This kind of transformational experience can occur through mobilization as well. In early 2000s Singapore, for instance—a country in which there is no freedom of assembly, and political speech is highly regulated—a small (but prominent) women’s advocacy group found itself in the position of needing to defend itself against a hostile takeover by anti-LGBTQ Christian evangelicals. After weeks of mobilizing which included contacting their networks, speaking to the press, and practicing how to give oral comments, the original members called for an extraordinary general meeting, which attracted three thousand participants. After hours of debate, voting, and waiting, the original core regained control of the leadership. Over a decade later, they recounted the ineffability of this transformational experience. “I mean, how do you describe a feeling? You know, it was happiness, joy, and then—but it’s also this sense of being one of many,” said one. Another stated: “Reliving it now, I’m quite overwhelmed [because] I never wanted anything more in my life… that I’ve worked as hard for, that I really really wanted.” In the words of one particularly memorable account:Thus, it is worth emphasizing that mobilizing and organizing are both crucially important—and indeed interrelated—processes of effecting social change. Strategic organizing is always directed toward specific moments of mobilization that will force decision-makers’ hand, and moments of successful mobilization represent key opportunities for identifying and developing new organizers. A West Virginia teacher testifies: “[M]ore than anything, the strike changed people’s ideas of what is possible, I now have coworkers asking me about when we’re going to have a nationwide teachers’ strike, which I could have never imagined being uttered even a few months ago” . This kind of experience is typical of involvement in large-scale social movements, and the effects can endure for a lifetime. A sizable empirical literature comparing people who did and did not participate in 1960s radical movements, for instance, demonstrates that participation had “dramatic and durable politicizing effect upon individuals”  might perhapsIn reply, let me make a few clarifications. Although I have (as Allen does) characterized solidarity from below as a specific type of normatively legitimate power-with, this legitimacy is not simply stipulated by definition as it is on her account. Instead, it arises from the fact that people acting in concert with the aim of improving their social conditions is always in principle a legitimate end in itself.So much can be said from within a pre-existing, independent normative framework that provides standards for distinguishing between morally good and evil ends. However, the connection between solidarity from below and moral goods is not wholly contingent. Because this particular form of power depends essentially on collaboration and collective action, it grows in proportion to the numbers of people involved in such a project. Hence, efforts to build solidarity from below that inherently contain exclusionary, hierarchical, or otherwise unjust features will eventually be limited, because of the way that solidarity from below is grounded in the power of numbers. No matter how many white Americans join such efforts, they will always be outnumbered—and hence potentially overpowered—by the greater solidarity from below that can be achievedmoral or prudential reasons to engage others in building solidarity from below? Are these reasons categorical or hypothetical, that is, do they apply to everyone or only those antecedently committed to the project of social change?A second question which follows naturally from the first is this: do we have if one is antecedently committed to fighting some aspect of injustice, then one also has prudential reason to fight all its other aspects. This claim follows from what I have previously called the “intersectionality thesis,” the idea that we cannot successfully rectify any one oppression without overcoming all others These are all empirical claims, to be sure. But let me advance here some evidence in favor of the perhaps more surprising direction, that is, the claim that building solidarity from below can generate moral sentiments, relationships, and duties where these were previously fraught or nonexistent. This is supported by a significant body of social psychological research demonstrating that intergroup conflict and prejudice is reduced when groups share “superordinate goals” to which they can all contribute, and for which they must interdependently rely on one other Allport, . ExampleIn other words, often the most effective way to cultivate intra- and intergroup feelings of solidarity is through the process of building the collective power of solidarity from below—and testing it in the actual experience of struggle (cf. Brueggemann & Boswell, disproportionately and directly affect only certain segments of a marginal group.”Of course, all of this is much easier said than done, and there are far more numerous examples of solidary efforts torn apart by racial, gender, class, and other divisions. Historically, many of the workers’ movements that popularized the notion of class solidarity did not include low-skilled, women, or non-white workers; conversely, many prominent feminist and antiracist movements have paid very little attention to class. McAlevey  describeIndeed, solidarity from below—unlike that of weapons or wealth—dissipates as people cease to act collectively, because powerless individuals only potentially wield that power, which can only be achieved in collaboration with others. Hence, cross-cutting divisions are deliberately exacerbated by the powerful. Temptations to what W. E. B. Du Bois /1990 calThe power of solidarity, then, is not easy to unlock. But we have little hope of overcoming the devastating injustices that plague our world if we do not learn to do so. While ultimately this task can only be accomplished through concrete struggle on the ground, I hope that the conceptual work I have done here will aid in that task.