Despite the preventive nature of oral diseases and their significance for general wellbeing, poor oral health is highly prevalent and has unfavourable ramifications for children around the world. Indigenous children in Australia experience disproportionate rates of early childhood caries compared to their non-Indigenous counterparts. Therefore, this paper aims to collate parental experiences and generate an understanding of facilitators for Indigenous childhood oral health. This project aggregated stories from parents of Indigenous children across South Australia who were participants in an early childhood caries-prevention trial. This paper explores facilitators for establishing oral health and nutrition behaviours for Indigenous children under the age of three through reflexive thematic analysis. Fisher-Owens’ conceptual model for influences on children’s oral health is utilised as a framework for thematic findings. Child-level facilitators include oral hygiene routines and regular water consumption. Family-level facilitators include familial ties, importance of knowledge, and positive oral health beliefs. Community-level facilitators include generational teaching, helpful community resources, and holistic health care. Recommendations from findings include the following: exploration of Indigenous health workers and elder participation in oral health initiatives; inclusion of Indigenous community representatives in mainstream oral health discussions; and incorporation of child-level, family-level, and community-level facilitators to increase support for efficacious oral health programs. Childhood oral health is fundamental to overall health and supports essential functioning, enables painless eating, speaking, socialising, and smiling, and strengthens quality of life and self-esteem ,2,3. TheAcross unique geographic locations, cultures, and histories, Indigenous peoples experience strikingly similar poor oral health outcomes , relatedDental public health efforts to improve childhood oral health in Australia are not reflected in Indigenous children, as evidenced by high oral disease burden, high rates of dental surgery requiring anaesthesia, and low rates of dental visits ,23,24,25It is imperative that the exploration of Indigenous children’s oral health is framed by Indigenous experiences, beyond the traditional biomedical focus of oral health ,31. The Dominant discourse in Australia centralises notions of failure on the part of Indigenous communities to thrive. Resilience literature underscores the importance of highlighting a more holistic narrative of Indigenous wellbeing, challenging stereotypes, and substantiating the immense individual and collective strength in defiance of continuous obstacles ,43. WhilThis project is part of a randomised control trial of an ECC intervention that prioritised collaboration and partnership with Indigenous communities and families across South Australia . The findings from this analysis have been reported in alignment with the Consolidated Criteria for Reporting Qualitative Research  47] and and47] aIn this trial, MI occurred at baseline and when the child was aged 6, 12, and 18 months for the intervention group. The respective directives for each motivational interview were: (1) supporting dental care during pregnancy; (2) discussing the significance of non-cariogenic drinks and foods for children; (3) emphasising the role of fluoride in ECC prevention; (4) encouraging the child’s first dental visit. The control group had interviews when the child was aged 24, 30, and 36 months; the first interview combined directives (1) and (2). Due to the patient focus of MI, there were no set questions for each session; however, guides were developed in partnership with MI training facilitators and included prompts, key messages, and activity guidelines for each interview. Each session guide was piloted by interviewers prior to trial commencement. These data were collected from February 2009 to May 2013. All interviews were audio recorded and transcribed verbatim at the end of data collection. Interviews varied in length from 20 to 90 min.The project received ethical approval from the Aboriginal Health Council of South Australia (04-09-362) and the University of Adelaide Human Research Ethics Committee (H-057-2010). Procedures for confidentiality were adhered to and informed written consent was obtained from all participants.Interviews were purposively sampled for this analysis due to the variation in MI delivery and fidelity scores across the four trained staff involved in the interview component. Successful MI is contingent on interventionist competency in eliciting statements of self-motivation from participants . FidelitReflexive thematic analysis embraces researcher subjectivity and acknowledges that researchers are embedded in project design and analysis, and that findings are inescapably influenced by researcher interpretation . As suchReflexive thematic analysis, as detailed by Braun and Clarke, guided this analysis ,62,63. SDue to the immersion of oral health behaviours in complex daily life , ECC preFactors of employment, income, and education relate to broader socioeconomic and historic environments and influence oral disease, as well as utilisation of oral health services for Indigenous peoples in Australia ,66,67,68Eligibility for public dental services in Australia is defined by Centrelink, a Commonwealth Department of Human Services agency, which includes a health care card program that assists cardholders with medical fees . Health N = 224), child-level influences (N = 204), and community-level influences (N = 194)  . In thisN = 194) . “Because it’s my duty, it’s my duty… I’ve got to step up to the plate, don’t I?” . Parent ownership of their child’s oral health related to parent initiative and determination. Initiative and determination facilitated oral health for children because parents took steps to learn new information, which prepared them for their child’s evolving oral health needs, such as wiping baby teeth after feeds, making dental appointments, and introducing a toothbrush. Rationale for wanting to learn more was succinctly explained by one mother, as follows: “Yes, always wanting to learn more about, you know, the nutrition and the wellbeing and how what I do as a mum can affect that with my kids” . Even within motivational interviews, parents exemplified a desire to take action; once learning something new, parents wanted to implement their knowledge as quickly as possible and began brainstorming ways in which they could: Parent ownership of their child’s oral health facilitated personal responsibility for parents who identified oral health as a central component of their role as a parent; when discussing why one father ensures his child brushes his teeth every day, he replied: “I probably will give less juice and yes, wow, yes, maybe try and rethink some choices like, because … when you go out to places and you get kids meal deals and various things, you get the juice, like you pick that one, but I’ll pick differently in future”.“You know, you only get two sets of teeth in your life. I don’t want her to have dentures before she’s 20, you know” . Parents discussed learning from previous experiences as a facilitator to prioritising the importance of their children’s oral health. Both personal experiences and observation of friends and families’ experiences taught parents how individual behaviours can impact oral health outcomes; this notion held true for both positive and negative experiences. For example, some parents were very proud of their healthy teeth; therefore, they wanted the same outcome for their children. Meanwhile, other parents identified personal oral health problems and were adamant to avoid this outcome for their children: Ownership of child’s health related to an appreciation of the importance of the dentist and the life-long importance of teeth. These beliefs facilitated oral health for children because these notions underscored the importance of oral health for parents and elevated priority of oral health related behaviours and routines, “Well like I said, I’ve got [dental caries] in my mouth, so I don’t want my kids to have them, because they’re horrible. I’ve got yucky teeth, and that’s from growing up where I didn’t brush my teeth because nobody told me I had to brush my teeth. I just don’t want that [for them] because my teeth are all falling out and it’s horrible”.“(Interviewer): So, knowledge is power? (Interviewee): Yes. I wish we had a lot more” . Those with knowledge shared stories about going out of their way to share their understanding with others and strengthen their family health. Accessibility to education and correct knowledge varied among participants. Many parents cited nutrition education as a result of a health condition, such as diabetes mellitus, or previous dieting. In particular, the ability to read nutrition labels and knowledge about the impact sugar has on one’s health resulted from disease-related education: “That’s why I’ve been really cautious on what he does have and don’t really agree with him having too many sweet things at all just for like family diabetes issues as well. Not only like teeth” . Regardless of the source of knowledge, parents agreed that correct knowledge and access to education was one of the most important things to ensuring oral health and general wellbeing. The importance of oral health and nutrition knowledge and education opportunities were frequently discussed: “Like I said to my doctor … it’s being educated. When you have that education and understanding, you can change things in your life. Where beforehand I didn’t have that understanding of what foods are good and some foods that you’d always considered good, turn into sugars and you eat them and all that, so education [is the most important] I think”.Associations between individual health behaviours and potential outcomes heavily increased awareness for participants and facilitated healthy behaviours. Associations included the relationships between bottle, fluoride, sugar, water, general health, and oral health. Many parents cited correct information shared during initial motivational interviews in subsequent sessions: “Yes, because you told me about that, so that’s just made me aware of, you know, letting him sleep with a bottle, because the milk just lays on their teeth, and see I never knew that… because the first boy, he was on the titty all the time, and then when he come off, he was just on water, see, so, he had no problems with his teeth, but [this child] just wanted bottle all the time”.Parents were quick to identify unhealthy practices in other parents, in particular with regard to giving children sugar and dental surgery, justifying their judgment by assessing the lack of prevention efforts other parents made. These comparisons facilitated oral health of children because parents were hyper-aware of their own actions in comparison with those they observed in others: “Just sad, you know, kids going to have to go under a local anaesthetic to get their teeth out…the parents should, you know, should know better, not to… Like I said, they need tough love, you know, not to give in straight away. A lot of kids do cry to get their way, but that’s where I just, no, I’m not going to give in to you, you can cry, chuck a tantrum all you want”.We all go. My whole family goes. If [my sons] got an appointment my whole family will go” . Parents appreciated when they were able to communicate expectations with their partners and they were supported in attaining oral health goals. Familial ties provided parents with readily available help and unwavering support: “Me and [my wife’s] brother and sister, we all work together, all as one. Yes, we all work as one. And we just all go together, support one another” . This support extended to oral health practices; parents expressed deep gratitude for family members that respected or shared their values with regard to their child’s oral health. Family members who assisted with appointment transportation, maintained oral health habits, and encouraged reduced sugar consumption facilitated oral health for children. Some parents even mentioned that once they had clarified the impact sugar can have on children’s teeth, grandparents began giving toys and games to their grandchildren, instead of lollies. Family support was discussed for many as “just how it is” and something that was important to teach to children: Dynamic and supportive relationships in the home, between parents and children, as well as between parents created an environment conducive to the establishment of oral health practices for children, ““Family have helped in getting us to where we are now. So it’s like looking after babies and everything like that. It is like a necessity basically that we teach our children and in that way they can teach their children and so on, and so on and so on. So it does play a big role in healthy teeth”.Strong familial ties related to positive household role models, both in terms of parent influence and sibling influence. Siblings were primarily described as aiding with tooth brushing and dental visits as younger children would follow their example. Parents discussed limiting their own sugar and changing their dietary patterns for the benefit of their children’s health:“Well even with me, I’ve gone on a diet myself, so I’ve cut out the cool drinks and the juice… so I’ve been more on the water myself. So maybe the kids are seeing that too, because all I’m doing is drinking water, so they’ll end up grabbing my water bottle and, you know, if it’s got a pull top then they’re drinking that. So that’s good”.“We rarely had packaged stuff growing up, I think…My mum’s not so big on ingredients but just like growing up, we never had pre-packaged stuff. It was always healthy whole food” . Parents who made most of their food at home stressed the importance of knowing exactly what they are giving their child as well as a decreased reliance on processed foods, often high in sugar. The ability to read and understand a nutrition label, as well as having sufficient time for shopping, further facilitated healthy food choices for parents. Some parents discussed the impact sugar had on their children’s health and behaviour and made efforts to limit sugar consumption by watering down SSB and treating with something other than sugar, such as toys or stickers. Parental effort to establish oral health and nutrition behaviours included the prioritisation of bush tucker at home and limiting sugar or processed food consumption. Many participants reflected on the influence their parents and grandparents had on their eating habits: “I don’t give into lollies, I don’t give into that. They do have their odd ice-cream every now and then, but not every time…Yes, so it’s not always about lollies or soft drinks, or things like that. I give them treats in other ways, like buying them a toy, or you know going to the street, go to the beach, going to the playground, and things like that”.“They’re not looking after baby teeth they’re not likely to look after adult teeth, you’ve got to start the routine early” . Parents identified routines as a mechanism to avoid unnecessary dental procedures, potentially saving money. Routines were also discussed in terms of decreased child reliance on night-time bottle feeds. Older siblings were mentioned as helpful in decreasing bottle use because their example helped children “grow up a lot quicker.” Enjoyable and fun tooth brushing enticed children to adhere to routines; strategies mentioned by parents included colourful and themed brushes, using phone applications with brushing songs and dances, enlisting the help of older siblings, praise, or the use of a sticker chart. Parents discussed routines as fundamental to establishing oral health-promoting behaviours for their children at a young age. Routines were deemed important for parents to prepare their children for the future, “I think it’s just the toothbrush I bought for him, it’s a little Batman light up one, it’s lights up for [the time] that you have to brush for and as soon as it stops you stop brushing, yes, so I think that’s what it is, the toothbrush, he likes it”.Well I know it can strengthen your teeth and your gums… It helps your liver. Everything like that. It’s more or less a cleanser for your body, your whole body” . Some parents struggled with resistance to water from children and noted if they had prioritised water consumption earlier, the process would have been made easier. For many children, water was initially introduced on hot days to quench thirst, or when children were sick. Many parents identified the importance of water for their child’s health, especially in terms of reducing sugar-sweetened beverage (SSB) consumption, and tried to increase water availability for their children. Parents believed that water was important for the entire body: ““He’s been looking for the water … we’ve got one of those water fountains, you know, that you can go on press and it’ll come out. We’ve been finding water on the floor, because he’s going and standing underneath it and drinking it. His dad growled him, and I said don’t growl at him, you encourage him, he’s drinking water, you know, that’s the best thing for him”.“He sits really still and he’s very co-operative [at the doctor]… it’s just new to him and when it’s new to him he’s just like really quiet and observing and he doesn’t run amok” . Positive parent perceptions eased worries or apprehensions, facilitating dental appointment attendance. Perceived positive child reaction at the dentist was mentioned by parents as a facilitator to attend child’s first dental appointment. This perception was grounded in children’s previous health care experiences, reactions, and behaviours. Some parents shared stories about previous positive experiences with other healthcare professionals: “Well he just loves being the centre of attention. I guess being the second child he always… The first ones always try to get all the attention and I think him being up in that chair with the dentist and everyone focused on him, I think he will like it”.The majority of community level factors that parents discussed as facilitating improved oral health for children were grounded in relationships with others, such as helpful community resources and sharing oral health information with others. Helpful community resources mentioned by parents included the Aboriginal Community Controlled Health Services (ACCHS), AHW, midwives, dental services, hospitals, parenting classes, Mum groups, online sources, friends, and school programs. In particular, home visits from the Child and Family Health Service (CaFHS) nurses were cited as extremely accessible and useful, with many parents discussing the approachability of this service and emphasising their ability to discuss any concerns or questions during visits. Additionally, some parents discussed the usefulness of various community services in bridging the gap between community members and health services, especially with regard to improving the accessibility of dental services for community members. Some communities provided transportation to the dentist or had a community liaison to provide support for parents before, during, and after appointments.“If you want your dental work … [the support person] can go with you and pick you up and take you to a dental clinic… You know, for the fella’s that have got really bad teeth … I suppose she explains to the dentist beforehand that, you know, like be prepared more or less, like don’t say this is this… You know, don’t let these fella’s walk in and be like oh my God you didn’t brush your teeth, because obviously they haven’t… She prepares them so you don’t feel bad about not looking after your teeth”.School programs were discussed as helpful by parents, not only in terms of dental services provided at schools but regarding food school policies, which included the provision of nutrition information and the restriction of certain items, such as packaged foods and SSB. Specifically, water only policies in kindy and daily tooth brushing at day care helped parents strengthen existing efforts at home. Some parents talked about having certain processed snacks, typically ones high in sugar, sent back home because they did not follow nutrition guidelines, which influenced parent shopping: “[The school] keep[s] carrying on about the packaged foods and things so that’s helped us with our snacks and things like that I’ll get other things… because [some snacks have] higher sugars and higher salts… And even though they might be labelled school snacks not necessarily healthy so being quite conscious since we’ve come to this school it’s helped to you know, open our eyes up a bit more. As in the packaging’s and yes, so we tend to read and they’ll be like but it’s in the school snack aisle. I’m like yes but look what it says here in the little bar of how high the sugar actually is in this and the school’s going to go you can’t eat that”.“I was attached to my teeth, the teeth were attached to me” . Other parents mentioned the importance of the whole mind, body, and spirit when considering oral health efforts, especially the interconnected relationships between oral health and child self-esteem. Participants heavily valued the holistic approach to healthcare accessible through ACCHS, as well as the trusting and supportive relationships that AHW prioritised with their patients.The prioritisation of holistic health within healthcare systems was identified as a facilitator by participants. One mother discussed the importance of the whole body and variety of life factors that are considered when she utilises ACCHS, in comparison with the singular treatments she has experienced with other health professionals. Another Mum described feeling lost after having her teeth removed: “I go [to the Aboriginal health workers] a lot. Like, even if it’s got nothing to do with health, when I need, just, to chat about something, I will go there… So they’re good not just for health but for everything, whereas, when you go to the doctors it’s not really the same”.“Always listen to the elder ones. They always know the best” . Many participants talked about the importance of maintaining generational teaching for family health in generations to come. An underlying notion within the concept of generational teaching was the effort to preserve connection and longevity that has been disrupted for generations: Generational teaching heavily influenced parental oral health beliefs and in turn, children oral health habits, including nutrition, teeth cleaning, breastfeeding, dental visits, water consumption, and the conceptualisation of the importance of teeth. Parents established the importance of elders and ancestors in their oral health journey: “It was good that my mum and dad were so concerned with our oral health, you know, that’s why I’m so with my kids…Yes, well, I want our line to stay strong. Do you know what I mean? For generations my family was always wiped out, and then it was only in my mum’s generation that we’ve just sort of started to come back together”.Generational teaching also related to experiences of knowing family or community members with poor oral health. Parent observations of family members with poor oral health influenced their oral health understanding and was often a learning experience for what not to do with their own children. Many parents mentioned siblings or cousins who relied on sugary drinks in baby bottles. Some participants used older family members with rotten or missing teeth to encourage oral health with their children: “[The kids] understand that, you know, you’ve got to look after their teeth otherwise… Because my Dads got all falsies and I try and explain to them, oh you’ll have no teeth when you’re old. You’ll look like your Poppa”.“I like the dentist, I want a good memory of the dentist. So I want my kids to have good memories of the dentist so that they look forward to going to the dentist in the future” . Some parents discussed having older siblings help ease early dental experiences and others noted how much their children enjoyed receiving stickers and new toothbrushes at the end of appointments. Many parents utilised the dentist as a source of reassurance that they were on track with their child’s oral health: “I’ve actually got in mind now I want to make a dentist appointment so I can see how [his] teeth are going. I’m quite curious. Then I can get some more information too” . Parents identified the importance of being comfortable with the dentist as a facilitator to attending appointments, many wanting a dentist that regularly works with children: Positive dental experiences facilitated recurring dental visits, central to the establishment of oral health. Past parental experiences, as well as experiences with children, impacted frequency of dental visits: “I know, you know, [the dentist] can detect things that I can’t see and catching anything, you know, at an early stage would be good. And it gets her used to it too, you know, she won’t be scared of the dentist when she goes in kinder or school or whatever. She’ll know that going to the dentist is a good thing not a scary thing like other kids”.This research sought to collate parent experiences and generate an understanding of facilitators for improved Indigenous childhood oral health in South Australia. The results emphasise the importance of considering facilitators beyond an individual child to include family and community-level facilitators. Key results from this analysis include familial ties, learning from previous experiences, positive oral health beliefs, generational teaching, helpful community resources, and holistic health care as facilitators for parents in this project. Oral health interventions have had varying success in Indigenous communities due to fragmentation from other areas of health, counterintuitive to the multifactorial nature of ECC ,36,75,76Parental knowledge was critical to establishing oral hygiene and healthy nutrition practices for families in this project. Findings highlighted that some mothers had developed food literacy skills as a result of dieting or education related to a health condition, such as diabetes, rather than through preventive oral health programming. Parent and carer nutrition knowledge impacts child oral health due to food provision responsibilities and the influence of dietary patterns established early in life on dietary behaviours later in life ,78. ThroParents’ oral health beliefs and understanding of consequences related to poor oral health have previously been identified as facilitators to maintaining oral health practices for children ; similarRoutines that prioritise oral hygiene were identified as essential to maintaining oral health behaviours for parents in this study. Regular water consumption was discussed by parents as important not only regarding fluoride exposure but also reduced sugar consumption. Just under half of the families included in this project live in non-metropolitan areas, where many houses rely on un-fluoridated rainwater. Routines that include enjoyable brushing time and reduced reliance on bottle use have previously been identified as critical to childhood oral health ,81,84. TWhile parents in our study identified positive dental experiences and compassionate practitioners as facilitators for dental service utilisation, these services are not easily accessible or available for all parents. Holistic health care and helpful community resources, such as ACCHS, AHW, and CaFHS nurses, were extremely important to parents in our project, especially those in regional areas with intermittent access to dental professionals. While many Indigenous peoples in Australia have priority access to dental care through the publicly funded system, various barriers prevent regular utilisation of mainstream preventive care ,21,67,87Exploring alternative options for preventive oral health may increase accessibility for families and communities, such as the utilisation of AHWs in oral health promotion. Limited attention has been given to the potential for AHW involvement in oral health promotion in SA. Although the SADS have identified the importance of AHWs in oral health, utilising AHWs in a more official capacity could help address the challenges of maintaining oral health where services are not regularly available . TraininThe prioritisation of Indigenous partnerships in dental services would honour the significance of culturally determined understandings of illness and prevention and enhance cultural safety for Indigenous peoples accessing services ,101. DueGenerational teaching, particularly from parents, grandparents, and elders, heavily influenced parent oral health beliefs and practices in our project. Previous research has demonstrated benefits to all aspects of wellness from Indigenous elder participation in educational and health-focused initiatives . Elders This paper adds to the limited strength-based qualitative research on facilitators for improved Indigenous oral health in Australia. The utilisation of MI, importantly, respects Indigenous traditions of yarning and enabled participant engagement throughout the research process. The findings are unique in that they are framed within Fisher-Owens’ conceptual model for childhood oral health, which considers child-, family-, and community-level influences. While the unique directives for each interview may have influenced findings, the trusting relationships between the interviewer and participants and the MI skills exhibited by the interviewer enabled a free-flowing conversation and topics ranged widely between participants. The number of interviews and participants included in this analysis makes it unlikely that any significant issues were missed and the timing of interviews from 6–36 months of age gives good coverage of a variety of stages in first 2 years of life. A limitation of this paper is that MI is a behaviour change methodology—some findings may have manifested because of the intervention itself; nevertheless, participants identified these factors as benefits from participating in the project and facilitators for their children’s oral health. It is unlikely that the results discussed here would be the same from another interviewer; the variation in interviews across the staff conducting the MI was immense, hence the decision to include the interviews with the greatest depth and best quality to answer the research questions. Additionally, the dataset is from 2009–2013; therefore, findings do not consider the impact of oral health policy changes that have happened since data collection. Due to baseline recruitment occurring during pregnancy, the majority of all the interviews were conducted with mothers, despite the critical role of fathers, families, and communities in strengthening holistic oral health behaviours. The facilitators to better oral health of Indigenous children exist across child-, family-, and community-level influences. Prioritisation of community knowledge and experiences enables greater insight to factors that facilitate oral health and can contribute to the development of parent oral health understandings. Oral health professionals, researchers, and policy makers are encouraged to build upon facilitators identified by Indigenous peoples and centralise Indigenous leadership and partnerships in oral health service delivery and prevention programming. Future research should explore the perspectives of AHW regarding the incorporation of oral health programming through ACCHS, as well as dental professionals, regarding the feasibility of enhancing culturally accepted methods of care for Indigenous patients. Our recommendations from these findings include the following: (1) an exploration of AHW and elder participation in community oral health initiatives and mainstream dental services; (2) an inclusion of ACCHS representatives in mainstream oral health discussions and planning in South Australia; (3) an incorporation of child-level, family-level, and community-level facilitators, reflective of holistic understandings of health, to increase support for efficacious oral health programs.


In patients with breast cancer, physical exercise reduces the toxicity of treatment; however, this physical exercise must meet a set of criteria, such as being guided by knowledgeable instructors. Thus, the aim of this study was to explore the perceptions of female breast cancer patients regarding the impact of an online physical exercise programme in the context of the COVID-19 pandemic. Nineteen female breast cancer patients participated in four focus group interviews as part of a qualitative study using a thematic analysis between December 2020 and May 2021. Three major themes emerged: “Experiences and perceptions of online physical exercise with breast cancer”; “Incorporating exercise-based activity for cancer-related side effects”; and “Increasing self-esteem and empowerment”. Online, live-streamed, and supervised group activities help breast cancer patients engage and prevent the recurrence of cancer-related side effects, as well as to control COVID-19-related fear and provide an alternative to promote mental health-related quality of life. Female breast cancer is one of the most prevalent malignancies worldwide, accounting for 25% of all diagnosed cancers . CurrentOne strategy to control the side effects of these treatments is the prescription of physical exercise . SeveralStrict isolation and social distancing measures were implemented in response to the COVID-19 pandemic ,13,14, pThe objective of this study was to explore the perceptions of female breast cancer patients undergoing treatment regarding the impact of an online physical exercise programme on quality of life in the complex context of the COVID-19 pandemic.To gain an in-depth understanding of breast cancer patients’ experience towards online group-based physical exercise during the COVID-19 pandemic, the study adopted a qualitative approach using focus groups interviews . This stA purposive sampling approach was used at Jaume I University. The selection criteria included female patients who: (i) were 18 or older; (ii) were diagnosed with breast cancer  undergoing cancer treatment ; (iii) participated in bi-weekly online physical training in streaming offered by M.E.G.-R. and supervised by their oncology team for at least 6 months; and (iv) prior to taking part in this research agreed to provide written informed consent.An online physical exercise program was designed to increase strength, joint mobility, and cardiovascular capacity, with the purpose of improving quality of life by increasing patients’ tolerance to cancer treatments. This programme, delivered via streaming as a result of the pandemic, was designed by a multidisciplinary team  to allow participants to benefit from physical exercise supervised and directed by a specialised professional.n = 19) completed the entire program, while 24% (n = 6) dropped out; eight percent of the participants (n = 2) dropped out due to disease progression, another 8% (n = 2) due to scheduled surgery, and the remaining participants  gave no reason. The women who completed the program (n = 19) attended 95% of the scheduled sessions.A total of 25 women participated in the physical exercise program and were divided into two homogeneous groups based on age and physical fitness variables, the values of which were obtained from baseline measurements. Aerobic capacity , strength , flexibility (sit and reach test), and daily physical exercise were the variables studied (continuous monitoring with accelerometery for 7 days). Each of these groups was further divided into two groups per schedule, yielding two groups of eight patients, one group of six patients, and one group of five patients. The frequency of the programme was two 60 min sessions per week. Seventy-six percent of the participants . The final 10 min segment included flexibility exercises for the large muscle groups. At the end of the session, a fatigue scale  was applied, and the intensity of the subsequent sessions was programmed based on the percentage of fatigue reached. The intensity was adapted to reach fatigue values of 60 to 75% in the two subgroups that obtained better values of the physical variables in the baseline measurement, while the two subgroups with lower values worked at intensities that resulted in fatigue values of 50 to 70%.Four focus group interviews (FGs), with 4 to 5 female patients participating in each interview, were carried out. Researchers developed and agreed on an interview protocol designed to encourage participants to give detailed responses . All theAll interviews were transcribed and anonymised prior to their analysis with the ATLAS.ti 9 software. In this regard, a thematic analysis elaborated by Braun and Clarke  was usedThe Ethics Committee of Jaume I University approved the study, which adhered to all of the principles of the Helsinki Declaration and its subsequent revisions. Before conducting the study, participants provided informed consent and the data collection design ensured confidentiality and anonymity. Participants were also notified that their experiences, opinions, and perspectives would not affect their academic grades.This study was developed using the recommendations of the consolidated criteria for reporting qualitative research (COREQ) . Two autn = 12) of the participants. A total of 84.2% of the participants (n = 16) received surgery and 42.1% (n = 8) received chemotherapy (doxorubicin and cyclophosphamide) in addition to radiotherapy. The qualitative analysis disclosed three major themes, which are presented in A total of 19 female breast cancer patients participated in four FGs conducted in May 2021. The participants’ average age was 49.2 years old (SD = 9.2), with a range of 28 to 66. The most frequent tumour stage was stage II with 63.1% (This first theme addresses two sub-themes and depicts the participants’ expectations and experiences with an online group-based physical exercise programme while undergoing cancer treatment during the COVID-19 pandemic. In particular, our data revealed the potential effects of this group-based physical exercise programme on patients’ well-being during cancer treatment.Physical exercise during cancer treatment was something that some participants had not previously considered to be beneficial to the cancer disease process. In fact, the participants emphasised the significance of the breast oncology team’s recommendation of physical exercise while undergoing cancer treatment in order to feel it was a part of the treatment. On the other hand, others were convinced that sports were beneficial for them, but government restrictions imposed as a result of the COVID-19 pandemic forced them to forego some of their sports activities:I wouldn’t have considered sports to be a core element of my treatment, but I believe it also has an impact on who makes the recommendation. You sort of say, “hey, this looks like a treatment”. True, it is a different kind of treatment, but when a health professional says so, it is because it is going to help me. Being honest, I take it into account more than if someone else who isn’t a healthcare professional says it”“G4-P4I have always been active, but since being diagnosed with breast cancer, I have become more cautious in all aspects of my life, especially with the COVID-19... I couldn’t risk going to the gym, so when I heard about the online group, I thought it was perfect because it was about much more than just doing sport by my own; it was about being able to speak with other people who are dealing with the same thing as you, a two-for-one, sport and group therapy with people who have your same issues”“G2-P3Likewise, the majority of the participants stated that taking part in a well-planned and organised online group-based physical exercise programme, as well as having a knowledgeable instructor and being supervised, was an important factor in feeling motivated, being person-centred cared, and being able to socialise and empathise with the other women:It is well worth it. I genuinely think that sport is very essential, but I also believe that the instructor’s work is important, when she said to us, “come on, you are doing very well”; aside from the exercise, it is the motivation that you had during that time, it was a therapy, it was supervised, and there was feedback of what we were doing. There is a person who is following you, who is following you up”“G1-P1This exercise programme has been a huge lifesaving boat for me that allowed me to interact with others who gave me a lot and helped me not to make the day-to-day life of being alone so challenging. I had my time of sociability, my time to talk with the instructor, mitigating all of the negative aspects of the pandemic”“G3-P2This second theme identifies the importance of participating in a group-based exercise programme during cancer treatment for patients’ biopsychosocial well-being, as well as how this experience helps them promote and engage in physical exercise in their daily lives.Many of the participants emphasised that this group-based physical exercise experience had an impact on every aspect of their lives, but most notably on the relief of cancer treatment side effects, such as pain, tiredness, motivation, and attitude and behaviour problems, among others:I used to have to go to bed because I was in so much agony. “I’m still and I’m exhausted!” I cried. The next day, I was unable to do anything. However, you get up, warm up, and exercise at the start of the supervised exercise programme... Of course, you get tired, but you rest a little, and the next day, you feel great. I’ve been performing the exercise training for months, and I’ve found that the pain returns after 2–3 days of not doing it, so I have to keep doing it!”“G2-P1My joints hurt when I first started the training programme, I had more hot flashes, and I could hardly sleep. Yet, I have almost no hot flashes, no joint pain, and I sleep a lot better with this treatment and exercise routine. My quality of life has improved significantly, so I intend to continue the supervised programme”“G1-P5Despite the overall benefits of online group-based exercise training, the lack of physical interaction and face-to-face activities was the most significant disadvantage for participants:I have missed being able to get together and spend some time conversing with others after the training class. The COVID-19 pandemic made me realise how much I need physical contact; I enjoy interacting with others and having a chit-chat every now and then”“G3-P4Not seeing each other, not laughing when we are knackered and soaked in sweat... Definitely, the main drawback for me was that there is no physical contact”“G4-P2One of the aspects most frequently mentioned by participants was how their physical and psychological well-being improved during this supervised group-based physical exercise experience, prompting them to introduce exercise into their daily routine as any other important aspect of life and ensure adherence to physical exercise:I said at the beginning “What a hassle, but well… Let’s see if I can make it through the next six months”. Now, when we are not with the instructor, I am working hard as well. I will never stop because the difference between how I used to be and how I am now is breathtaking. I feel strong and, most importantly, confident since my biggest anxiety was with my bones, and now that I have the muscles to support everything, it offers me a lot of peace of mind”“G3-P1Although there are days when I am exhausted because my medication or have things to do, it is true that I have made physical exercise a part of my daily routine. My quality of life has drastically improved, it is like my treatment now... And it has influenced others to support me. We are moving like chess pieces so this, which is a priority for me, can keep going”“G1-P2The last theme offers some insight into the importance of group-based physical exercise in which all the participants share similar characteristics, allowing them to relate their experiences with the cancer disease and treatment process and support each other. Interestingly, the participants also identified other perks, such as how participating in an online physical exercise training environment made them feel safer from infection during the COVID-19 pandemic.A large number of participants described how sharing this exercise programme with other women experiencing similar disease symptoms made them feel accompanied, understood, and stronger in their fight against cancer:I believe that in this disease, the support between each other is critical. I believe that when we are all in the same situation, the amount of empathy that can be awakened among us increases enormously. I don’t feel your friends or family truly comprehend what is happening to you. When we talk, you are never delighted that the other person is also hurting, but you are soothed by the notion that your bones hurt because we all do”“G4-P5Doing the exercise programme and deciding to form a group in which we could express our feelings, what was going on in our lives, and even laughed at ourselves. That was hugely helpful for my self-esteem since we could normalise the situation. We chatted about what was going on with us, our fears, and our rejection of our own image… We encouraged one another, we supported each other. Joining the group has been a liberating experience for me”“G2-P4One of the key topics was the online approach for the group-based physical exercise programme in which the women participated that allowed them to feel fearless and safe from infection, despite the immunosuppression induced by cancer treatment. Although they were particularly concerned about COVID-19 infection since it would halt their cancer treatment, the online fitness programme appeared to be a useful alternative for balancing physical exercise with family, job, and other responsibilities:The COVID-19 horrified me; if you got it, your treatment would be delayed, which was unthinkable to me. To be honest, I felt really alone, but I started with this online exercise training here and gradually improved. You can see that there are more people like you; thus, you must participate in activities and keep moving forward. If it had been in person, I would not have gone out of fear, but rather out of caution”“G1-P4I find the fact that it was done in streaming was extremely positive because I feel that all of us were worried of the COVID-19 during our chemotherapy or radiotherapy process. Between that fear and personal circumstances such as kids, jobs, travel and time constraints, it was a positive change to do it in streaming”“G2-P2This study aimed to explore breast cancer patients’ perceptions towards the impact of online physical exercise in their quality of life whilst receiving cancer treatment through the understanding of their experiences in a complex scenario as a consequence of the COVID-19 pandemic. Following the analysis of our findings, it was found that almost all participants reported a revamped engagement, motivation, and self-esteem with the use of the online supervised group-based exercise training. Although the importance of exercise for women during breast cancer survivorship has been discussed ,25,26, tOur findings, similar to those of face-to-face training programmes, showed that structured and supervised online exercise training is a safe strategy for breast cancer patients, offering improvements in fitness, physiological and psychological functions, and cancer-related side effects ,27. AlthIn contrast to recent studies ,33, mostThat being said, our participants highlighted novel and specific psychological implications of the COVID-19 pandemic on their quality of life. Aside from previously documented cancer-related side effects, such as upper extremity issues, fatigue, pain, depression, or body image disturbance ,43, fearNevertheless, there are certain limitations that should be considered. To date, there is limited research investigating the impact of physical exercise on female breast cancer patients receiving cancer treatment, which has limited the discussion of our findings. Future research should explore the experiences and perceptions of instructors in order to gain a deeper understanding of the use of group-based physical exercise programmes, as well as possible alternatives to the identified drawbacks. Moreover, these findings warrant further discussion, for example, surrounding the inclusion of prescribed exercise programmes into cancer care treatments or the use of group-based programmes with other types of cancers.Our findings indicate that group-based physical exercise has the potential not only to instil self-esteem and address self-compassion, but also empower women to be confident during their treatment and prevent cancer-related side effects. Given the physical and psychological health benefits of regular physical exercise for this population, promoting physical activity in women diagnosed with and being treated for breast cancer must be an essential public health priority. Cancer care teams and experienced instructors may facilitate person- and cancer-centred care in a timely, accurate, and tailored manner, whereby providing a caring and group-based supportive climate may offer a safe environment in which breast cancer patients can feel comfortable, engage socially, and acquire exercise adherence. Thus, online and live-streamed physical exercise programmes are a viable approach for promoting physical and mental well-being among female breast cancer patients while they are undergoing treatment.


As trends of social and economic change allow precarity to inch into the lives of those who may have been more accustomed to security (Standing,  This paper presents and discusses the experiences of those who find themselves in the “missing middle” of class analysis and sociology. Those who “drink Carling out of Stella glasses,” as a participant shared, when attempting to describe a middling (or inauthentic) status of place and people. Drawing together concepts of the “missing middle,” meritocracy, and social mobility, which interact, overlay, and obfuscate class (dis)advantage in the “borderlands” between the traditional working and middle classes, this article presents analysis from an empirical research project asking the following questions: What is it like being in the missing middle? How secure is the status? What, ultimately, does this mean for people's understanding of fairness, choice, and advantage? Specifically, these questions are asked of a population in a place where “middling” dispositions appear to manifest largesse, seemingly built in to a private housing estate designed to be intentionally different from working-class neighborhoods.Liminality is an anthropological concept that describes a “betwixt and between” status. Specifically, it denotes progressing through the in-between stage of a rite of passage, when one has ceased to be who/what one once was yet has not completed the full transition into who/what one will go on to be Turner, . Given tThe concept of the “missing middle” used herein has two similar but discrete meanings, alluding to both sociological analysis and social class stratification. For the former, it refers to an in-between status, between working and middle class, in which people feel themselves to be not quite fully one or the other oftentimes because of the accumulation (or not) of resources or due to inter-/intragenerational mobility and associated class cultural legacy. For the latter, it refers to claims of an apparent lack of sociological analysis of those in the middle of UK society by a discipline attracted to extremes Byrne, . As clasClass location is perhaps most messy for those on the borders of “traditional” class categories. Social positioning blurs as people move over the working–middle class boundary, backward and forward, taking up characteristics of both sides. Consequently, this is what Tyler  describeare not as much as what we are and that actions are undertaken to create this “distinction.” The working classes, Bourdieu . Furthermore, although an external labor market outside of their control was noted by participants to exist, it would be equally “explained away” with various ideas of agency frequently elevated above this structural constraint. Bourdieu's , any disruptions to that income stream could attract serious consequences. Therefore, should economic precarity be returning in new form, as Standing , 2014 suIt is important to investigate these life experiences and judgments  anonymity would be misleading. That said, to protect participants, all were given pseudonyms and minor changes made to identifying characteristics to protect confidentiality.Fieldwork took place between 2015 and 2017, starting with focus groups, which took place at a local FE college, a local sixth-form center, and a youth center in Ingleby. From these, the framing and approach of the semi-structured interviews were devised. To understand youth transitions, how, what, where, when, and why forms of questioning are required. Participants were asked to talk through major transition stages , be that looking backward, discussing current events, or projecting forward. Each interview was between 45 and 75 min and was individual or in a small familial group. The “corrections” and questioning of participants by other participants in real time that arose in the group interviews were of huge interest and added a richness to the responses. Overall, some 70 people contributed to the research, recruited through gatekeepers, the researcher's local connections, engaging with residents in community spaces , and snowball sampling. Informal interactions and conversations were written up as field notes, and stakeholder interviews took place with community members such as estate agents, retail managers, and local politicians.Interviews were recorded and transcribed verbatim before qualitative data was analyzed following thematic analysis, searching for patterns and “instances” told as a matter of fact.Ingleby is situated in Stockton-on-Tees Borough in the Northeast of England, an area that falls within “Teesside,” a legacy place name taken from a local authority district in the late 1960s and early 1970s that encompassed the industrial towns situated around the River Tees. The original development was based on the creation of multiple “villages” that would make up a larger whole. Six “villages” have been built consecutively, the most recent addition is The Rings, currently viewed as the most desirable location to live according to a local estate agent, who shared that clients most often would prefer a smaller property on The Rings over a larger property in an older village at the same price. Many others move within the estate itself, taking part  in an internal social mobility process. The estate is increasingly self-contained and hosts six primary schools, two secondary schools, general practice surgeries, dentists, vets, supermarkets, takeaway outlets, hardware stores, newsagents, funeral directors, estate agents, hairdressers, beauticians, churches, pubs, a golf course, and both a public and a private gym .During the time of the fieldwork, most house sales in Ingleby Barwick were detached properties that sold for an average of £228,411. The overall average price for a house in Ingleby in 2016 was £205,673. Comparing this with neighboring areas, this is nearly double the average for predominantly working-class Thornaby, which stood at £114,241, yet is significantly cheaper than Yarm, a predominantly established middle-class area where the average was £241,013. The average wage in Stockton on Tees in 2015 was £25,200 advantages when making housing, education, and employment transitions. In discussion, these structural circumstances were often mediated through ideas of individualism and cultural practices  who perhaps most neatly brought together these ideas of the (un)real, drawing together what I would suggest as multiple layers of liminal in-betweenness of class, place, and people:Do you think they [people from Yarm] look down on people in Ingleby?”Kathryn: “Probably yeah, the thing is though I can understand why, everyone is financed up to death, everyone has all these houses and flash cars, and they are all just drinking Carling*out of Stella glasses and stuff.”Brent: “: “If you had to say what class people on Ingleby are what would you say?”Kathryn: “If there was a class between lower and middle I would put them in there, cos I think a lot of people think they are middle class on Ingleby, but I would say they are in between, because the housing and that they probably are middle class, but their personalities, really friendly, I would associate that with lower class people. Like if it was a Venn diagram thing, I would put them in the middle of it.”Brent*Carling and Stella Artois are both brands of lager sold in the UK. In a major supermarket in England at the time of writing 10 × 440 ml cans have only have a £1 difference in price (both under £10). Marketing is consistently different for these brands. Stella is advertised as a continental product and used the slogan “reassuring expensive” from 1982 until 2007, and Carling advertising is focused on football, pubs, and “banter.”boundary” of middle and upper, and this boundary concept was also referred to by Annie (52), who described her class as “borderline working-middle class.” Richard (55) used language that described his position in a physical manner; he might be “leaning” toward the middle class, he said, but he would not define himself as such, his feet seemingly rooted in their working-class preposition. Over his interview, Richard frequently used the history, geography, and class embodiment practices that Emery (Rebekah's (22) parents, she shared, told her she was on the “at Emery  suggestsSuch forms of intermediate positioning were often discussed as a consequence of familial amalgamation, so parents or grandparents of differing class status and backgrounds were blended to create an intermediate or liminal transitional position through that heritage mix. Warren (18) describes,My stepdad has come from a very working-class family, my mum a more upper-middle-class family, and now she is a very happy medium almost” .“Jonny (21) and Francesca (25), brother and sister, describe a similar circumstance although one that also includes the important reflection of what this means for them intergenerationally. When I asked them what they thought their class status was, they answered,How many different ones are we going for? As I wouldn't say we were quite middle class, but I wouldn't say we were working either. Probably lower middle class.”Francesca: “I would say working class for me.”Jonny: “It depends on what you say by working class though cos for me, some people have opinions of the working class as those you see every day that go into the benefits office. I have heard it called in the Daily Mail the non-working class. A lot of people have an opinion of them as being the working class, and I don't, wouldn't consider myself that, not that there is anything wrong with it, but I don't think we are quite middle class, like your Middleton type family people, we are not up there.”Francesca: “I don't know because I go to work, I am on minimum wage and stuff, like I don't know, I don't know what the definition of a working-class person is, but I think I don't have my own house yet, I don't really have a lot.”Jonny: “Alright, well take it as us as a family as a whole, so me, you, mum, Mike.Francesca: “working middle?”Jonny: [unsure tone] “Yeah, that is what I mean, so in-between, not quite middle class not quite working class, so I would put us in between.”Francesca: “Jonny and Francesca were both in working-class occupations, yet their parents were both senior managers with high salaries. Francesca believed that she and her brother would do well-over time, so their current occupations were not reflective of who and where they were in a bigger sense; she would “work her way up” as her parents did.Social mobility and fluidity have been presented to the UK public as an unquestionable good, purported to offer individuals the opportunity to fulfill their potential, and as such, to “better” themselves  had been successful in his career to date; he had secured a well-resourced apprenticeship and had recently been appointed to a well-paid permanent contract on completion. Now in skilled employment, having been a call center operative previously, it would be fair to say he had undertaken upward social mobility, yet the thought of making this change was not attractive to him in the way it was to Jonny and Francesca, and he described it as an unwanted fit:I don't want to be associated with them people though. I like the lower class, they are more friendly, aren't they? They don't look down their nose at ya; you always find that people with nothing are always a lot friendlier, they are always happy to talk to you, have a laugh with you. Even just total random people waiting in the queue or whatever, but I don't think you get that with middle-class people, they keep themselves to themselves in public” .“roots to fade.” Emery  appeared to describe when he said it allowed the “.” Emery , p.3 notI think I consider myself more of a working class if it was just me, but with my parents, like the way they are, I think it's aiming more towards middle class if anything […] I know my granddad on my dad's side is working class, [Cumbrian town] has always been a working town and a working-class place. So, I would say before he moved here my Dad would have been working class, but he has bettered himself by coming here” .“complete form of social mobility:Conspicuous consumption in this middling place and people was frequently remarked on by participants in the interviews. Rebekah (22) discussed being in the middle as a potential opportunity, which allowed for slightly higher economic resources that could be converted for use. However, she believed this did not translate into passing through a liminal or intermediate position or phase into a new genuine position and so undertaking a A hundred years ago, class was just money [.] whereas you can sort of trick people now, you can have a really nice car, and you can have a really nice house and all of this” .“This class masking was also noted by Melissa (28), who had recently moved to Ingleby from a traditional working-class area and who described uncovering this class “trickery,” where a middle-class habitus was being performed so apparently effortlessly it passed as “genuine” at first glance:I spoke to a lady on the school playground, and I thought she was going to be a doctor or something and she said oh yeah I am a nail technician and I thought, what, I thought you were going to tell me you were a doctor, the way that some people act is that they put themselves a lot higher than other people” .“Alternatively, some do not even attempt this “mask.” Brent (26) shared those using economic capital alone could not “pass” as having undertaken complete social mobility as they have not utilized all the capitals Burke,  required: “I mean look at some of the offshore lads, they earn a fortune, but they are thick, they are common, they are horrible, aren't they?”BrentThis notion of incompleteness of identity and status, of the masquerade of one thing as another and the associated pitfalls, begs the question of whether class is indeed mutable Byrne,  and whetSkeggs , p. 4 tiFor all those who indicated this liminal and indeterminate class stratification or position as incomplete or some form of “class trick” or masquerade, the societal and familial pressure to undertake upward social mobility did not appear to be abated. Rebekah (22) explained she felt under pressure from her parents to continue, or at the least sustain, their attempts toward upward social mobility. Furthermore, as her grandmother resides in a far “less than” place, she feels this as a spur, reminding her that, if she does not work hard, she may have to face downward mobility and return to the original position of her father. In Ingleby, the geographical and economic proximity of those in a lower social class or even closer still in a lower stratification of the same class instigates what Ehrenreich  characteupper class” through maintaining the trajectory they started. Rebekah notes that most overwhelming is how much of the responsibility for this rested on her own shoulders; further social mobility is a project of herself by herself. This is all indicative of what Byrne  father held a middle-class well-remunerated position, but he had left the family home a year previously and had ceased providing any financial support to his family. Phoebe's mother, in a working-class occupation, was unable to sustain the family's position on her own, which had an inevitable impact on what financial resources were available for their daughter to compete effectively in the art world in which she had chosen to train. This precarity did not seem to be particularly unique to this family. Indeed, one participant explained that the 2008 financial crisis had triggered what felt like a “flag day” on the estate with many houses  going up for sale subsequently as the fallout and austerity that followed restricted employment opportunities and wages.But as long as I work hard, I will get there; it doesn't bother me.” Although this may well be true in part, all the same, Phoebe frequently indicated individual and personal responsibility for the structural constraints she faces. This reflects the findings of Mendick et al. , who had experienced upward mobility to Ingleby before returning to a local working-class area at the end of a relationship. Jay's conceptualization of class reproduction accessed through parenting advantage was expressed as he recalled outcomes of his school friends:The kids whose parents had proper jobs, kids whose […] dads done real stuff, rather than just a job, like they had careers, kids whose parents had careers, they've all got careers now” .“It would appear that, although social mobility is accepted as an unquestionable good, in practice, this is rather about successful collation of resources that places people into an exalted stratification of the working class rather than moving people up into the middle class. Indeed, even if the resources had been available to manage the latter, which was unlikely, it was also resisted due to the stigma of anti-pretentiousness Skeggs, . Even thIngram and Allen , p. 729 Say if there is someone who lives in Pallister Park [working-class estate in Middlesbrough] who wants the same, to achieve the same things, as someone who lived in Wynyard [exclusive housing estate near Sedgefield], if they both want it, I don't see why they couldn't” “We had nothing, [spouse] and I. We didn't have great upbringings, we've done alright, it was just hard work, no handouts” .“Josh recognized things might be more difficult but saw these as hurdles rather than barriers:if someone is from a lower background or a higher background, I think you can get the same goals, it might be harder, but I think if you persevere with what you are doing I do believe that anyone from anywhere can get what they want” .“This belief, that the power of aspiration and intention can (and should) overcome all, ignores what Hanley  describeAlthough in an objectively relatively advantaged social group, Rebekah (22) explained her family had significant housing costs, which meant that, although they appeared “better off,” the family had little disposable income. She was aware that many in her peer group at university received more through the student loan system as they came from lower income households and, alongside living with meritocratic ideas of individualism, she described being lost in the middle managing this:I do feel like the middle amount of people are getting a bit disadvantaged, especially in the North East cos is you are relying on your parents, and they just don't have that money, then you are kind of stuck, and you can't get on and yet everyone is saying you need to get on, it is you that needs to do it, so you kind of feel a bit stuck” .“The objective circumstances of young people's lives in the “missing middle” means they have access to finite resources with which to enact (or maintain) social mobility and so be able to achieve or sustain “middling” class positions. Furthermore, this was frequently “explained away” by notions of positive individualism, “resilience”  and their parents whenever possible to compare and consider differences. The field of study was a large private housing estate in Teesside called Ingleby Barwick with multiple schools and amenities, situated in between more traditional working- and middle-class areas in the region. The estate was known locally as a destination of social mobility, a place where one had “made it” by moving up and moving in.The “missing middle” was described as a “betwixt and between” status of class—an often self-selected stratification, which participants describe as taking on a hybrid identity because of inter-/intragenerational mobility, which includes elements of both working- and middle-class cultural practices and practicalities. Another mode of the “missing middle” is the lack of sociological analysis in the middle of society by discipline attracted to extremes. The argument is developed that the “missing middle” is, therefore, an interesting site to research people's experiences in what many researchers, theorists, and commentators have claimed to be changing or at least challenging times.This paper asks, what is it like being in the missing middle? How secure is the status? What does this mean for people's understanding of fairness, choice, and advantage? It answered that “middling” positions were purposefully sought out and claimed to attempt to gain control of an insecure and uncertain status and avoid class stigma and shame. Further, that this “middle ground” allowed for the denial of class (dis)advantage that was at odds with the meritocratic language of the neo-liberal ideology that were cloaked as “common sense.” Participants mobilized varying degrees of economic, social, and cultural resources across the “levels” of liminality to gain or maintain their position, yet revenue streams were not guaranteed, and the prospect of another “flag day” was a consistent specter on the horizon.Much felt uncertain with the in-betweenness often felt to be rejected by those in the classes above and below them as unreal or inauthentic. Ingleby manifested largesse that one could “move on” and “move up” away from industrial working-class origins. It offered, from conception, a “neat” and “clean” estate, perhaps where you could keep your white collar immaculate unlike in the neighboring town known colloquially as “smoggy land.” Ingleby offered a place free of the stains of industrial heritage writ large on many working-class neighborhoods. However, the social mobility offered through meritocracy worked as an apologist and cover for social class, which, for all its denial of import, was nonetheless apparent in macro and micro experiences of lives.The “levels” of liminality accorded participants with varying degrees of resources to mobilize. Participants often appeared to be involved in “classificatory struggles,” which provoked heavy defense of positioning and privilege in this class borderland. The residents who participated in the research discussed what cultural practices they recognized as being of the “missing middle” and what these meant to them (and outsiders). Overall, these created a “moral place for moral people,” that was aspirational in its presentation and participants. However, this was often described to be not genuine by residents, in relation to themselves, others, and how they were perceived by those on the outside. Those who were accused of “drinking Carling out of Stella glasses” were reproached as a pretend (or pretentious) group of people.Given this, it is fair to ask, what is the win, and is it worth it? Insecure status was reflected in the wider economic circumstances, homes, and lives were often built on unstable resources, such as mortgages and wages. Opportunities for the younger generation to perpetuate or even, in some circumstances, maintain the social mobility started by their (grand)parents were contracting; young people's wages are lower in real terms than in 1997, and housing and services costs are high. However, such structural constraint was rarely discussed, particularly so by younger participants who instead often subscribed to neo-liberal notions of meritocracy that push public accountability onto the shoulders of private individuals. Class was thrown into a “middling” place as it was, all at once, agreed to be important and not important at all, claiming the liminal, in-betweenness allowed for the denial of class (dis)advantage, which was not in keeping with people and place.For all this appears an unflattering picture of place and people; it's fair to ask what is so wrong with the attempts being made to secure any form of advantage of oneself or family? Rather, the research suggests the shame should not be on those who wish to accrue advantage, security, and avoidance of “smog” for them and their children, but a societal structure and governance that allows the acute risk of maintaining it to be so privatized. Meritocracy appeared to offer a sense of control of one's fate with inequality or injustice  pathologized or individualized. In this belief system, the virtue of unquestionably striving would be rewarded with success, no matter that social mobility has, by most measures, stagnated.“Making it” to Ingleby was (and continues to be) indicative to many who live there and those who know this place locally of deservingness. This matters as the missing middle make up significant numbers of the UK population, and understanding their beliefs and motivations is critical for social policy makers, academics, and those who hope to influence them to participate in politics with a potential new “flag day” on the horizon following the Covid-19 pandemic.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by Teesside University. Written informed consent to participate in this study and for publication of their verbatim quotes was provided by the participants.KM undertook proposal, data collection, analysis, and wrote up of the empirical research this article is based on.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.