SWB was measured as happiness and self-rated health. Statistical analyses were performed using binary logistic regression models replicated across countries. Results indicated that the American sample showed no evidence of relationships between R/S and SWB outcomes capable of improving the model over demographic and service attendance covariates. In Turkey, some R/S beliefs were found to be statistically significantly related to SWB, with positive and negative associations with happiness. No associations were found in the secular countries. Findings were discussed in the light of previous research and interpreted from a terror management theory perspective.The most unique aspect of religiosity/spirituality (R/S), supernatural beliefs, and their relationship with SWB has hardly been examined. This study explores the relationship between six R/S supernatural beliefs and SWB, in a case-based comparative cross-national design including two religious and two secular nations. Data were obtained from the International Social Survey Programme (ISSP) Religion IV module from the religious countries of the USA ( In the last few decades, there has been a growing interest in the study of religion and spirituality in relation to many health and psychological aspects. In particular, attention has been drawn to the question of whether religion and spirituality can be beneficial for people’s general health and subjective well-being (SWB). This is an important question as almost 90% of the world population adheres to some religious faith . Spirituality, on the other hand, can be generally described as belief in God (or a higher power) as well as the subjective experience of having a relationship with this supernatural entity   has been advanced as a theory of SWB to explain the effects of both R/S beliefs and secular worldviews on mental health and well-being  that are selected based on given criteria relevant to the research question or aims. The design aims first to understand each country within its own context, rather than taking each country simply as one of many data points where variables are measured. Then, by comparing similarities and differences among the selected countries, explanations are developed to elucidate possible causes of the observed phenomena. Therefore, the aim of comparative cross-national research is to elucidate to what extent given social phenomena can be explained by patterns that are universal and patterns that occur at the specific level of local cultures or countries De Vaus, .Data for this study were obtained from the International Social Survey Programme (ISSP) 2018 module ‘Religion IV’ . For happiness, participants responded to the question ‘If you were to consider your life in general these days, how happy or unhappy would you say you are, on the whole…’ The four-point scale responses were categorised into two groups, retaining the happiest group (‘very happy’) and combining those who reported being in less happy groups . For SRH, the question was ‘In general, would you say your health is…’ followed by a five-point scale with the options: excellent, very good (which were grouped into ‘very good SRH’), good, fair, and poor (grouped into ‘good SRH or less’).The independent variables consisted of six specific R/S beliefs. Two of these R/S beliefs, related to the concept of God, were taken from two statements from the root question ‘do you agree or disagree with the following?’: ‘There is a God who concerns Himself with every human being personally’ and ‘To me, life is meaningful only because God exists’. For short, these beliefs will be referred to here as belief in a ‘concerned God’ and in ‘God-giving life meaning’, respectively. Each answer consisted of a five-point Likert scale, with responses recoded into the options ‘agree’ (combining agree and strongly agree responses), ‘neither agree nor disagree’ and ‘disagree’ (combining disagree and strongly disagree responses). The remaining R/S beliefs were taken from the question ‘Do you believe in…’ followed by the beliefs: life after death , hell, heaven, and religious miracles. Answers for each belief were on a four-point scale including ‘yes, definitely’, ‘yes, probably’, ‘no, probably not’, and ‘no, definitely not’, and were dichotomised into yes or no.Demographic variables included: sex, age-group , level of education (post-secondary or secondary or less), employment status (working or not working), and marital status (married/partnered or not married). Self-placement in society was used as a proxy for socioeconomic status, based on the question: ‘In our society there are groups which tend to be towards the top and those that are towards the bottom. Here, we have a scale that runs from top to bottom. Where would you put yourself on this scale?’ The answer presented a 10-point scale , which were recoded into two categories: from 1 to 7 ‘middle or bottom’, and from 8 to 10 ‘top’.In addition, religious service attendance, a global measure of religiosity, was included as a control variable, in line with other studies on R/S beliefs . However, this option was abandoned as it increased the amount if cells with zero frequencies, and also was a less parsimonious approach considering that models were repeated several times due to having two outcomes and four countries for analysis. A second variation explored for data analysis was ordinal logistic regression . This extension of logistic regression takes advantage of the fact that the outcome variable is ordinal and describes the effect of each predictor variable in terms of the probabilities of a case ascending or descending in order. The data, however, did not meet the assumption of ‘proportional odds’ Osborne,  and therTable χ2(8) = 43.70, p < 0.001] made a statistically significant contribution to the final model , with an increase in pseudo-R2 values between the first and the second blocks (Nagelkerke R2 rose from 0.033 to 0.086). The R/S belief exerting the strongest effect in the prediction of happiness was belief in heaven , indicating that believers were about 12 times more likely to be in the ‘very happy’ group compared to non-believers. Turkish participants who believed in miracles were also 75% more likely to be in the ‘very happy’ than ‘fairly happy or less’ group  when compared to those not believing in miracles. Other R/S beliefs in the Turkish sample had the opposite effect: those who believed in the afterlife were more than four times less likely to be in the ‘very happy’ group compared to non-believers . Similarly, Turkish participants who endorsed the belief of a God concerned with humans personally were half less likely to report being very happy .In the Turkish sample, the addition of R/S beliefs in the second block [p = 0.028] suggesting that those who held this belief were about 50% more likely to be in the ‘very happy’ category compared to those who did not believe. However, this was not enough to increase the statistical significance of the model already achieved from the demographic variables. No statistically significant associations were found between any of the R/S beliefs and the happiness outcome in the secular countries of Denmark and Czech Republic.For the USA, only belief in ‘God-giving life meaning’ was statistically significantly associated with happiness , compared to those who did not endorse this belief. This effect made a significant contribution to the final model .In the Turkish sample, the only R/S belief that was statistically significantly associated with SRH was agreement with a concerned God, which increased the likelihood of participants reporting to have ‘very good SRH’ by 70% , compared to those who never attended church. In Denmark, it was irregular church attendance which showed a statistically significant association with SRH. Danish participants who attended church services only on an irregular basis were 57% more likely to report having ‘very good SRH’  in comparison with Danes who did not attend services. In relation to the other covariates, the number of demographic variables reaching statistical significance tended to be higher in the secular countries than in the religious ones, for both outcomes  1.97 1.35, 2.88), 5, 2.88, The results of this study indicated that for the US sample there appeared to be no evidence of a relationship between R/S beliefs and SWB outcomes, with only one small positive association between ‘God-giving life meaning’ and happiness that did not significantly contribute to the model beyond the covariates included. However, in Turkey, R/S beliefs made a significant contribution to the prediction of SWB outcomes over the block with covariates alone. Statistically significant relationships indicated that some beliefs (heaven and miracles) increased the odds of people in the Turkish sample falling in the ‘very happy’ category, whereas other beliefs (afterlife and ‘concerned God’) decreased the likelihood of being in the ‘very happy’ group. In addition, the ‘concerned God’ belief was positively associated with SRH. Regarding the two secular countries, Denmark and Czech Republic, there appeared to be no association between any of the R/S beliefs and either of the SWB outcomes.One modest positive association was found in the American sample, between happiness and the belief that life is meaningful because of God. However, the relationship was too weak to reflect any improvement in the prediction of happiness over the other variables in the model. These results suggest that in the American sample, the relationships between each R/S belief and SWB, if present, were not independent from each of the other beliefs or from service attendance. A possible reason for this finding could be the characteristics of the American religious landscape itself. It has been argued that religiosity in the USA is underpinned by a culture of religious pluralism, high competition among Christian denominations and churches, and a positive view towards church attendance and involvement in religious communities . During this period, those who are destined for paradise will experience this time as happy and pleasant, whereas those who are going to hell will go through horrible trials  specific combinations of beliefs in each sample may be small. As there were several categorical variables included in the study, results of the statistical analyses are likely to include cells with zero frequencies at some of the different subpopulation levels of the dependent variables. This might have affected the standard errors, leading to wider confidence intervals. However, this problem of incomplete information is common, and when several variables are included in a model, practically inevitable Field, . FurtherNotwithstanding these limitations, this study has several strengths. First, this study addressed an important gap of research in the field of R/S and health, focusing on the specific characteristic of R/S, that is supernatural beliefs, instead of the much-theorised pathways that could be understood as secular in nature. The combination of a cross-national design and the replication of identical logistic regression models across countries allowed us to explore the associations between R/S beliefs and SWB in different cultures, and to elucidate whether any purported relationship between these variables could be attributed to some universal religious pattern or to specific cultural contexts.The results of this study stress the importance of considering the cultural context when studying relationships between R/S beliefs and SWB, and R/S and well-being and health in general. The importance of religiosity/spirituality in relation to subjective well-being appears to be linked to the type of sociocultural worldview that people engage with in their lives, rather than being some universal phenomenon.


Persisting high rates of worksite accidents and injuries in construction projects indicate the urge to investigate the root causes and revisit safety practices in this industry. Consonance in perceptions and safety approaches has been identified as a fundamental factor in boosting projects’ safety. Discrepancies between how different elements of construction safety are perceived and handled by the key stakeholders, namely managers and workers, could be detrimental to worksite safety. This research studied how, if at all, the perception of four key construction safety components, including 33 sets of pairwise questions, is different in the lens of managers from workers. To explore safety perceptions, 133 construction professionals in the United States participated in the study and expressed their perceptions toward their own and counterparts’ (1) safety knowledge, (2) safety culture and commitment, (3) safety performance, and (4) safety support and communication. The results indicated that massive gaps in safety perceptions do exist between the construction managers and workers (26 out of 33 areas), and the magnitude varies for different safety elements. In all four categories, both managers and workers perceived a superior safety position for themselves and inferior for their counterparts. Further investigations revealed that the common ground between managers and workers is their consensus on proper communication and safety training as the key solutions to address such discrepancies. Construction safety professionals and practitioners can benefit from the results of this study to establish and implement strategies to foster communication and provide more effective safety training to bridge the existing gaps in the perception of safety by managers and workers. Accounting for one of the industries with high rates and numbers of work-related accidents , the conIn addition to the altruism aspect of construction safety, to avoid the massive direct and indirect costs of construction accidents, it is imperative to investigate how current safety practices can improve to achieve more effective measures to prevent accidents. To this end, a myriad of research has been conducted in different countries and various project types. Among them, the involvement of different stakeholders  in the safety management programs is a prominent factor ,5,6,7. DProper perception of safety risk depends on multiple factors that can break the error chain and prevent job site accidents . MultiplSeveral studies have investigated the discrepancies and differences in perception of safety among different project stakeholders ,18. HoweAccording to the Bureau of Labor Statistics ,3, the rA holistic approach to safety improvement in construction projects is administrating comprehensive safety practices to effectively detect potential hazards and the associated safety risks, provide immediate and appropriate preventive measures, as well as proper post-accident response to mitigate accidents’ impacts. This holistic system should include training, monitoring, and tracking as well as record keeping and accident data analysis . AccordiMultiple approaches have been examined to enhance construction safety, and their impacts have been shown in the research focused on safety improvement practices in construction projects. Some of the major studied tools include worker’s training ,29,30,31Assessment of safety perception is commonly conducted through survey data collection. There is a plethora of research investigating this topic in various types of projects and different locations from the perspectives of different stakeholders ,44,45. HTo this end, the fundamental step is identifying the contributing and detrimental safety factors in a construction project. Examples of research conducted in this category are (1) studies focusing on accident theories, including Domino Theory , Hinze’sBy tracking the root and origin of safety behavior, past research has identified multiple factors that can together form the safety climate and impact the safety performance of workers in any project . Figure Safety perception has been identified in the research as a primary factor in creating appropriate responses as well as preventive measures to hazardous situations . One chaAnother challenge of perceiving and determining risks on the job site is due to the inherited uncertainties that normally exist in construction projects. These uncertainties create perceptions and interpretations based on individuals’ insights. The insights, in turn, are influenced by multiple factors such as knowledge and experience that can vary among individuals . This stt-test. To identify the discrepancies between how managers and construction workers perceived safety, four main categories of (1) safety knowledge, (2) safety culture and commitment, (3) safety performance, and (4) safety support/communication were investigated. These criteria are explained in the following.It was mentioned that identifying the root contributors to safety in construction projects is a fundamental step in improving safety in this industry. It was also discussed that safety perception has been extensively identified in existing research as a pivotal factor in preventing job site accidents in construction. In this research, the safety perception was mainly reviewed from the perspectives of construction managers as well as construction workers. Each group of respondents was asked to answer a questionnaire targeted at assessing different criteria of safety perception. The questionnaire included paired questions in which one would self-assess the respondent’s performance, and the other one in the pair focused on the respondent’s assessment of the counterpart group’s performance in the same category. For example, the managers were asked to answer to what extent they agree that “I have sufficient safety knowledge”. In the next question, they were asked to express their opinion on a scale of zero (very strongly disagree) to 10 (very strongly agree) that “The construction workers have sufficient construction safety knowledge”. The idea was to investigate if there is a statistically significant difference between the two evaluations through a two-sample To enhance safety performance, safety knowledge and training are the prerequisites. Lack of sufficient safety knowledge leads to the inability of managers and workers to identify hazards in their workplaces and take corrective actions and prevent accidents . Safety As demonstrated in the figure, this structured process requires designing, administrating, and implementing multiple tasks in each step which indicates the necessity of establishing a knowledge management system. For instance, knowledge transfer requires a combination of information technology and human resource efforts ,63,64 toIn this category, a self-evaluation was conducted, plus an assessment in which the managers and construction workers evaluated the level of safety knowledge of the other stakeholder. In this study, the criteria that were assessed to evaluate safety knowledge are as follows: (1) having sufficient construction safety knowledge, (2) being able to identify safety hazards on the job site, (3) being able to recognize unsafe behavior of the construction workers or managers on the job site, (4) effective safety training programs provided to the construction workers, and (5) construction workers being engaged in the provided safety training.In a study to identify root causes of construction accidents, Abdelhamid & Everett  identifiResearch in this area has identified multiple contributing factors in establishing the safety climate in an organization. The role of managers’ commitment to safety in developing the safety culture has been shown by multiple studies ,74,75. AIn this study, the criteria that were assessed to evaluate safety culture and commitment are: (1) believing that safety is of paramount importance, (2) being dedicated, aligned, and accountable for safety-related issues, (3) not tolerating any unsafe behaviors on the job site, (4) generally caring about safety more than the other group , and (5) believing that safety is more of a priority than finishing tasks.Safety knowledge, in combination with the commitment to safety as a core cultural value, must lead to actions to perform safely and prevent accidents. Sjöberg et al.  defined A clear and precise understanding of the safety performance of managers and workers is integral in identifying a system’s weaknesses and fixing them. Based on the research, the majority of worksite accidents in the construction industry have roots in human errors ,68,80. MIn this study, the criteria that were assessed to evaluate safety performance are the following: (1) using the learned provided safety training materials at daily work, (2) following safety rules and practices on the job site, (3) having an acceptable safety performance, (4) having regular safety meetings held on the job site, and (5) believing that the participants are responsible for preventing construction accidents.Safety support and communication catalyze safety enhancement efforts. The impact of effective communication in preventing safety hazards and collaborative prevention of potential injuries has been shown in countless studies ,82. StudIn this study, the criteria that were assessed to evaluate safety support and communication are the following: (1) explicitly communicating safety commitments and support to construction workers, (2) workers having a concise understanding of their managers’ safety expectations, (3) providing formal and informal safety feedback frequently enough to workers, (4) workers being open to the provided safety feedback by managers, (5) considering enough safety incentives to strengthen the construction worker’s safety performance, and (6) assessing to what extent workers communicate their safety needs and concerns.A total of 80 construction managers and 53 construction workers participated in the study. The respondents were randomly selected from the construction professionals working in Alabama, Arizona, California, Colorado, Florida, Georgia, Kansas, Louisiana, Missouri, New Jersey, New York, North Carolina, Ohio, Philadelphia, South Carolina, Tennessee, and Virginia. To evaluate the safety perception of managers and workers, the participants responded to 33 pairwise questions. Out of 4389 (133 × 33) collected answers, 55 questions remained unanswered. The missing information was substituted with the group average . In the first step, the analysis focused on self-evaluation of safety perception by the construction managers as well as the workers. As detailed previously, the questions were provided in four categories of safety knowledge, safety culture and commitment, safety performance, and safety support/communication. Using the 11-point Likert scale, the respondents were asked to evaluate themselves in these categories by a score ranging from zero (“very strongly disagree”) to 10 (“very strongly agree”). To compare the construction managers’ and workers’ self-evaluations, the bar chart in As part of the study, the managers were asked to assess construction workers and, on the other side, the construction workers were asked to assess the managers in the same four categories of safety knowledge, safety culture and commitment, safety performance, and safety support/communication. The 11-point Likert scale was similarly provided to capture the responses. The results of construction managers and workers evaluating the perception of safety by their counterparts’ groups could be compared to identify the most and least critical categories. The results are shown in The construction workers, on the other hand, ranked managers’ safety knowledge, safety performance, and safety culture and commitment as their strengths. The workers gave the lowest score, among the four categories, to managers’ safety support and communication, which indicates the most critical factor that the managers need to improve.t-test was conducted, and the p-values showed that in all the four categories, the self-evaluations differ from workers’ evaluations of managers. These results can show that managers’ interpretation of their safety perception is different from how the workers assess them.In this part, it was investigated if a gap could be noticed between the way construction managers assess themselves and the way workers evaluate them. To do so, the evaluation results in each of the four categories of safety perception were compared. The results are shown in t-test was performed on the data. The null hypothesis was set as no statistical difference between the scores at a 95% confidence level. The results of the tests are provided in p-value rejected the null hypothesis and validated the difference between the two assessments. In the meantime, test results showed that managers’ assessment of workers and their self-assessment in the two categories of safety performance and safety support/communication are not statistically different.The possible gap between the two assessments, that is, the workers’ assessment of themselves and how the managers assess them, was investigated. To check if the observed gap indicates a statistically significant difference, a t-tests corresponding to each pair of questions are discussed in the following.In addition to the examination of four groups of safety perception, the analysis of each pair of questions further revealed that massive gaps in the perception of safety among managers and workers do exist see . The resp-value < 0.05). Regarding safety knowledge, workers admit that their managers have a higher level of safety knowledge (S1). Their managers asserted that their workers’ safety knowledge is considerably lower than their own knowledge. However, both groups’ self-evaluations scored higher than the evaluation of their peers in the other group, and the differences were statistically significant. Concerning the ability to identify safety hazards (S2) and recognize unsafe behavior (S3), both groups of managers and workers expressed that they are able to better identify job-site hazards compared to their counterparts. Managers think the training that they provide their workers is effective (S4), yet their workers are not highly engaged (S5). This assertion is contradictory since high engagement is an essential aspect of effective safety training ”. One of the participants detailed that “Workers are often the first to point out hazards while managers are often more knowledgeable about the specific rule/codes”. A superintendent cited the language barrier as a contributing factor. Moreover, an electrician with 20 years of experience saw this as a generation-gap problem and said, “I think the lapses in generation have something to do with it as there are guys who worked in the industry that had zero safety standards compared to new guys knowing nothing but regulations. The common ground is filled with those who just let them hash it out”. A considerable portion of both managers and workers blamed each other without trying to put themselves in their peers’ shoes. Among managers, for example, a 56-year-old site superintendent with 40 years of experience criticized workers because “The workers want to do what is easy. Being safe is not always easy”. An assistant project manager who worked in construction for 10 years argued workers’ lack of proper safety risk perception is the root cause and articulated that “The workers do not get penalized for unsafe practices as long as they don’t get hurt”. In addition, a project manager (28 years old with 5 years of experience) claimed, “Workers don’t care about safety because they don’t think anything will happen to them, and if something does, they think our company will pay them for injuries”. Another manager said workers sometimes misconduct in the name of safety and said, “Because workers sometimes use safety to get out of doing work”. A project manager who worked in the industry for 40 years said, “Workers view safety practices as a hardship and typically feel it slows down work progress. Managers view safety as a necessary aspect of wellbeing”. Another manager thought, “The differences are the workers think that managers are unfair when they are just doing their work to make sure everyone is safe”. Similarly, various workers blamed managers for being the source of the problem. For instance, a Hispanic concrete finisher with 30 years of experience said, “All managers care about is getting the job done,” or another worker added, “Time taken away for safety is [the] time taken away from getting the job done. This appears to be how managers view things”. A 33-year-old worker with eight years of experience blamed managers that they do not properly communicate their commitment and explained, “Managers need to do things other than just issuing memos and giving speeches if they expect the workers to believe their safety commitment”. A young carpenter’s apprentice condemned managers’ approach and mentioned, “Managers are only about cost and schedule and don’t care if we are working ourselves to death”.An assistant project manager (39 years old with 12 years of experience) admits that sometimes they compromise workers’ safety as mentioned “As managers, our responsibility is people, time, and money. Sometimes we make time and money our focus instead of people.” A 46-year-old superintendent of a commercial project with extensive years of experience (22 years) criticized both sides and said, “I believe workers think managers prioritize lawsuit avoidance over worker safety, and managers don’t believe workers can understand safety rules and regulations.” Another participant also held both sides accountable for the situation and expressed that “Workers feel that management is only worried about the bottom line . It is ok to take shortcuts to save a dollar. Managers give the impression that time is of the essence.” Many managers and workers pointed out the long-debated balance between productivity-safety as the source of discrepancies. A duct hanger who worked on a commercial project with 22 years of experience mentioned, “We view some safety [practices] as slowing them down. Managers do not understand how much following all safety rules can slow them down”. A 46-year-old carpenter with 28 years of experience pictured the dilemma as a constant battle of safety and productivity and said, “Construction projects are always behind and will always want to be faster, which makes safety difficult”. In addition, it has been argued that the structure of payment nudges workers to perceive safety differently because “A lot of workers get paid based on the amount of work or number of jobs completed; therefore, the workers don’t have the same mindset as the managers”. A 50-year-old project manager who had 24 years of experience explained, “Most of the subs on my job site are paid by the job. Therefore, their goal is to get the job done as soon as possible. I would like for the job to get done quickly as well, but without compromising safety”.Several managers and workers concurrently indicated the lack of communication as the leading cause of discrepancies in their safety perception. A manager admitted that “A difference comes from lack of communication on the job site” and a worker claimed “The managers don’t tell us their point of view enough”. Several factors contribute to the communication problem. For example, workers are afraid of the potential consequences as a manager revealed that “Sometimes the workers are scared to say anything in fear of getting fired”. A worker demanded managers change their communication approach and explained, “If they started caring about us instead of dollar signs and calendars, we would be in a much better spot. All they have to do is talk to us like people and have some form of care and devotion to making sure we are taken care of”. A carpenter highlighted an important yet often neglected safety challenge which is inconsistency in safety culture and practices among different companies. He explained that “We work on different job sites through the week sometimes. Some of our superintendents enforce hardhats and safety glasses as a minimum, but some don’t. We get a little confused going from one job site to the next when it comes to safety”. In fact, this worker explained how there is a lot of inconsistency in the enforcement of safety rules from job to job. This causes some workers to take an unsafe approach to work on construction sites. When they see their immediate supervisor not following safety rules, they feel that they are not mandated to follow the rules.Many workers mentioned that lack of field experience among managers contributes to the gap in perception of safety. For example, a worker asserted that “The managers don’t really know what is going on in the field”. A 21-year-old worker who started construction when he was 18 explained, “From my experience, the managers don’t always get out into the job site nearly as much as the everyday boots on the ground workers. Therefore, they can’t fully understand all the hazards on the job”. A related note was from a 31-year-old machine operator with 10 years of experience that did not perceive differences in safety perception and declared that “The perception is the same. My superintendent used to operate heavy machinery and knows how important safety is”. Contrarywise, a 58-year-old worker who worked in construction as a carpenter for 40 years in response to the possibility of reconciling the disagreements mentioned disappointedly that “Never have been, probably never will be—two different lungs on the social ladder- do what you’re told or will get someone who will!” n = 23) and “safety training” (n = 11) were among the most frequently suggested answers. A 27-year-old project engineer responded that “Yes, I believe it we maintain open lines of communication and set the expectation early in a job and hold each other accountable—we can achieve a mutual understanding. It is important to work with each other and not police, seek to understand the differences, and take the time to make sure a worker understands the safety concerns and OSHA standards”. Another participant simply outlined the solution to be “more communication on reasonable expectation”. A manager explained the novel perspective of proper communication based on the accumulated experience: “In my experience, most workers are able to recognize most safety issues but often do not react because they feel that they do not have the authority”. This statement implicitly encourages managers to give authorities to workers to take control actions to achieve higher safety outcomes. In addition, effective yet comprehensive safety training can help to curb the problem, as explained by a manager: “As a general note, often the GC [General Contractor] spends money on training for safety but has no required safety training for subcontractors in their related trades. What happens is the GC’s superintendent is expected to provide safety to a bunch of employees of subcontractors who are neither trained for safety or care about it”. Another response outlined that “Yes [it is reconcilable] if the companies would be investing more time on training and OSHA would remove the monetary factors from safety training”. Such opinions are promising that despite the massive discrepancies among managers and workers in the perception of construction safety, reconciliation is achievable.Although a few participants (10.4%) were disappointed to reconcile the discrepancies, the majority of managers and workers were optimistic (76.4%). A considerable number of participants (13.2%) argued that reconciliation is contingent on circumstances such as long-term commitments, trust of workers in their managers, transparency, consistency, mutual respect, and avoiding “us vs. them” mentality. Among the solutions that the participants mentioned to address the massive gap in the safety perception of managers and workers, “communication”  safety knowledge, (2) safety culture and commitment, (3) safety performance, and (4) safety support and communication. To answer the research question, a survey was conducted among construction professionals in two groups of managers and workers to evaluate themselves as well as their counterpart peers in their understanding, commitment, and performance in each of the four mentioned categories. The categories were broken down into sub-criteria for a more detailed assessment. The results of the data analysis conveyed a massive gap between the assessment of the two groups on their safety perception versus how the other group perceives. Based on the statistical analysis of each category, the category with the lowest score indicated the highest potential for improvement. The findings show that in the viewpoint of the construction managers, their “safety support and communication” needs more improvement than other measured categories. The workers had a slightly more realistic perception; however, they identified “safety culture and commitment” as the category that requires more determination for improvement. The findings also suggest that the strengths and weaknesses of each of the two studied groups assessed by themselves vary significantly from how the counterpart group evaluates them. t-tests revealed discrepancies in responses of managers and workers in 26 pairs of questions related to the perception of safety. “Prioritizing safety over getting the job done”, “believing that safety is of paramount importance”, and “[being] dedicated and accountable for safety-related issues” are the top three areas with the highest level of disagreement between managers and workers. On the other hand, managers and workers, to some extent, agreed on (1) workers’ [relatively low] level of engagement in safety training programs, (2) managers’ approach to dealing with unsafe behavior of workers, (3) relatively low level of utilizing training materials in the field by workers, (4) managers’ responsibility to prevent accidents, (5) managers providing formal and informal safety feedback to workers, and (6) workers insufficiently communicating their safety needs and concerns. These results could shed light on the paths for boosting safety programs and how the effective improvement measures for construction managers differ from those of construction workers. Finally, the findings of the post hoc investigation discovered “communication” and “safety training” as potential solutions to tackle the problem by professionals and practitioners.Among 33 sets of pairwise questions, two-sample Despite its merits and benefits to the construction industry, the study has a few limitations that must be considered. First, safety perception in this study was limited to 33 questions. However, the perception of safety in construction is more complicated, and further aspects can be considered. Second, the managerial hierarchy in different companies is different, which can impact the safety perception of managers. This important factor was not considered in this study. Lastly, more managers participated in this study than workers. However, in reality, for a typical construction project, the number of workers exceeds the number of managers by far.


This article explores the labour behind local food in the Canadian Atlantic province of Nova Scotia. Based on surveys and interviews with farmers, migrant farmworkers, and farmers’ market consumers in the province, we suggest that the celebration of local food by government and industry is a form of “local washing.” Local washing hides key aspects of the social relations of production: in this case, it hides insufficient financial and policy supports for Nova Scotian farms and the increased reliance on migrant farmworkers via the Seasonal Agricultural Worker Program and the Temporary Foreign Worker Program. Our research found that a growing reliance on migrant farmworkers was not just the case for larger, industrial farms, but also for smaller farms participating in local and alternative food initiatives, like farmers’ markets and fresh produce subscription boxes. Additionally, our surveys show that while farmers’ market shoppers expressed an interest in supporting local foods, they reported knowing little about farm workers or working conditions. Our paper contributes to the literature on local and alternative food initiatives by connecting the relations of production to consumption. Rather than focusing solely on the nature of the relationships between farmers and consumers and the values embodied in direct agricultural markets, this research explores the central role of permanently temporary migrant workers in local agriculture. Efforts to re-localize food and support local food production have gained popularity in North America and elsewhere, as producers, consumers, and policy makers are increasingly reflexive about food and eating, due in part to the growing awareness of the deleterious effects of the conventional food system on the climate, the environment, human health and wellbeing, animal welfare, and livelihoods. More recently, the global COVID-19 pandemic—which caused disruptions and delays in the food chain—has highlighted the importance, and precarity, of the work of growing, processing, packaging, transporting, and distributing the world’s food.An increasing number of farms rely on precarious migrant labour in many parts of the world, including in the Canadian province of Nova Scotia, where our research is based. Located on Canada’s east coast, Nova Scotia has a unique and long-standing reputation for food localization efforts, yet over the past twenty years, the reliance on migrant labour has risen, including on farms that participate in local food initiatives and direct agricultural markets like farmers’ markets and fresh produce subscription boxes. While the labour behind food production and processing is examined in various literatures—especially those focused on commodity food chains, the political economy of food, and labour migration studies—migrant labour remains understudied in alternative agriculture, localization initiatives and direct agricultural markets, with some notable exceptions  farmers who produce for local markets; (2) farmworkers whose labour is required for that production; and (3) consumers who purchase local produce. Additionally, we interviewed 13 key stakeholders across multiple agriculture sectors: nine interviews with farmers’ market organizers and managers and four interviews with agricultural associations and food movement organizations. All interviews were transcribed and analyzed for key themes and information.5We surveyed farmers’ market consumers about local food in two waves. The first wave, conducted entirely online in 2020 due to the COVID-19 pandemic, included 321 shoppers across 40 farmers’ markets, and was posted via social media and sent out in a newsletter from the Farmer’s Markets of Nova Scotia, a non-profit FM cooperative founded in 2004. The second wave, in 2021, captured an additional 43 respondents online and 154 in-person at nine different farmers’ markets located across the province.Fourteen interviews were conducted with farmers and one farm manager speaking on behalf of the farm on topics of local food, type of farm, agricultural practices, farm labour, and the effects of COVID-19. A further 54 farmers completed an online survey about their labour and recruitment experiences. The survey was circulated by the Nova Scotia Federation of Agriculture and shared on social media and was live from January to March, 2020.In-depth interviews were conducted with 12 migrant farmworkers (10 men and 2 women) from Jamaica and Mexico who were between the ages of 30 and 60. Ten workers were employed through the SAWP and two arrived through the agricultural stream of the TFWP. Interviews were conducted in English and Spanish, by telephone, via Skype or in-person, and focused on the workers’ histories of migration, livelihood strategies, and perspectives on SAWP and local food. Interviews were read and analyzed for information on the federal programs, their workday, leisure time, food production, cooking, family, remittances, racism, abuse, farm inspections, and COVID-19. We also conducted interviews with two Canadian-resident (non-migrant) farmworkers.In the late 1960s, Canada’s federal government put forth its vision of the future of the country’s agricultural production in a document called “Canadian Agriculture in the Seventies”  trends toward monocultural crop production and agribusiness conglomeration “appear less pronounced” in the province  make local food products and producers regularly visible in public settings, (2) enable some producers to diversify their enterprises, (3) incubate small businesses that may use non-conventional production methods, such as no-spray  or organic and (4) create spaces for both market transactions and nonmarket social interactions .The economic bottom-line was, of course, an important consideration for the farmers we interviewed and surveyed. One Nova Scotia farmer we spoke with noted that farmers often struggle with pricing products fairly for both themselves and consumers, explaining that farmers are often “price takers, not price setters.” Several other farmers also said they are constrained by the prices that are laid out by larger supermarket chains in the region, and by the perception that consumers will not pay Though not always the case, FM prices are sometimes perceived as higher than supermarket chains in Nova Scotia. This, coupled with the additional time and effort it might take when compared to the one-stop shopping of supermarkets, make farmers’ markets unattractive or inaccessible to some consumers. Additionally, as spaces, farmers’ markets can express a community imaginary of predominantly affluent white consumerism, “ethical posturing” (Guthman 2007b) and a “defensive localism” that discourages lower-income and racialized people from participating . Several studies in the United States and Canada have examined the role of precarious im/migrant labour in local, smaller-scale agriculture and noted their absence in discourses about local, family farms as a more socially just and ecologically sound alternative to the industrial food system  still rely heavily on non-local production inputs. As one farmer engaged solely in local sales recounted “the plastic bins we use, the packaging and labels, the equipment, we try to reuse as much as we can and source as close to home as possible, but none of it is manufactured locally; the closest we might get is, like, Quebec” (interview 2021). In another interview, we heard about one berry farmer who had, for many years, been making his own wooden pint boxes out of poplar growing on the farm property, only to be told by a large grocery chain that they would only carry his fruit if he switched to plastic clamshell packaging.We found in interviews and our online farmer survey that certain farm inputs  are not manufactured nor available locally. Just under a quarter of the 54 surveyed farms said they used mostly or all locally-sourced inputs in production. Moreover, even those who exclusively grow In this vein, farmers spoke to us about a lack of infrastructure and meaningful support for smaller or medium-sized producers and alternative agriculture that would help localize production and consumption in the province. Some of the farmer interviewees identified ways to better support local food producers. For instance, improving SAWP to better compensate and protect workers, and provide a path to permanent residency or citizenship was mentioned. One farmer suggested that public institutions like hospitals and schools could provide healthy, fresh meals using local produce; that the province could make a commitment to regular, large orders from farmers in the region; that perhaps government could restrict imports to give local products a better chance. In the absence of an infrastructure that adequately and flexibly supports small and medium-scale local producers, farmers spend time applying for small programs and special funds for discrete needs . One farmer suggested that government paperwork to apply for programs and funds at the very least be more streamlined and user friendly. In sum, the conditions are not in place to better support the localization of food production and consumption in the province. This is compounded by what farmers perceive to be a lack of locally available labour.Existing research on SAWP is excellent but has not fully examined the program in the Atlantic Region. This is largely a matter of numbers; most migrants who work on farms are employed in Ontario (40%), Quebec (32%), and British Columbia (18%) with only 2.6% in Nova Scotia  and to a lesser extent, the agricultural stream of the Temporary Foreign Worker Program (TFWP). As one farmer we interviewed explained: “we used to get people all from Atlantic Canada come in and pick [produce] and you know, have retired people. And now we just aren’t getting enough local workers” (interview 2021). Another challenge noted by one farmer interviewee was the seasonal nature of farm work. Explaining that with the short season, it was difficult to find and hire, for example, an experienced forklift operator, he said “trying to find people with that experience who want to work for three months. It's very challenging” (interview 2021). Some of this difficulty is due to the aging population in rural Nova Scotia, and the fact that a substantial proportion of younger, less educated workers go west in search of high-wage employment in Alberta’s oilfields . Though farmers in the interviews and surveys would make vague reference to a lack of skills, specific skills were not as commonly mentioned, nor seemingly as important, as simply having the right attitude and work ethic. While some employers said the right workers are less plentiful in local labour markets, others admitted that they were simply unable to pay what local workers with the “right attitude and work ethic” were worth. Here, we encounter an important insight, often acknowledged by farmers, concerning differently positioned and stratified workers, expectations around rates of pay for particular kinds of work, and the food system that structures each.[we waited] “based on the fact that you feel loyalty to your community, you don’t want people to say mean things, which they will, about taking away people’s jobs and all that kind of stuff. But the reality is: as years went by, we are finding it more and more difficult to get people to weed and harvest crops. So in 2006 […] we just couldn’t get anybody to come out and weed anymore. That was it. Everybody was done. So at that time I think minimum wage was around $7.50 an hour, right around there [and] we determined it would take 45 minutes to weed a row, so we figured we allow people an hour to weed a row [and we’d pay $20 a row]. So, they’re going to make really good money and we figure that’s the only way we’re going to save our crop and we had… it was just over 20 people that came out over like a three or four or five day period, we advertised at the time that we needed this help and I think the longest a person lasted was like 15 minutes” (interview 2020).In a similar vein, a different farmer said the issue is not the pay: “If we didn’t have foreign workers, I don’t think our farm would survive. I don’t think it matters how much you pay. There’s just not that pool anymore that wants to do [the] work” (interview 2021). Another farmer interviewed said the program is “the best source of good reliable help for sure. It’s cumbersome from the way the government does it and every year it gets worse” (interview 2020). He continued:“[the government goes] out of their way to make it painful I think, you know we’ve been told point blank – you know, we do not want you to hire these guys, you need to hire Canadians, is what they’ll tell us and they say this is a premium program. In other words, it’s made to cost you more than hiring local. But it makes no difference with the locals, [who] just don’t show up no matter…they’re always like ‘oh, if you paid me 50 bucks an hour I’d come every day’. Yeah, I betcha. He still wouldn’t do anything. So, these [migrant worker] guys cost us more, but they are that much better, they’re more than worth it. Not to mention we have to post job ads every year anyway. And we, you know literally get maybe one, one application [from Canadian residents] every second year, it’s all we get from people applying. Nobody applies.”When asked how to address the shortage of farm labour, one farmer responded: “the problem is, a lot of these jobs are minimum wage jobs and as long as society is demanding cheap food, you’re demanding low wages on farms. And that’s really our problem, so we can talk about how to attract more people to the farm. But how do you attract people who are going stay seven or eight months and keep it up?” (interview 2020). Still others felt that low wages were only part of the problem. Here, again, the perception that local workers are disinclined toward hard work informs recruitment efforts. For example, reflecting on why they had waited to recruit through SAWP, and what prompted the decision to do so eventually, another farmer explained:could.In our interviews with migrant farmworkers, all twelve said they recommended the SAWP to their family members and friends, when asked, mentioning the lack of employment options or difficulties with farming in Jamaica or Mexico. As the literature demonstrates, and our interviews reinforced, farmworker wages in Canada provide needed economic support – “a lifeline to their households back home” Binford , p. 151.Every migrant worker interviewee told us they would like the option to live in Canada—although two who had relatives in other parts of the country said they likely wouldn’t stay in Nova Scotia. When we asked what their experiences with the program were, one Jamaican worker who had been coming to the province since 2010, said, “Well, I can say it’s very hard but at the end of the day, it works. Nothing comes easy” (interview 2020). The same farmworker expressed disappointment at not having a pathway to residency: “I want the opportunity but it’s not coming to me. […] I think they should look into it and give us some form of status.” Not having a pathway to residency or citizenship was consistently mentioned as a negative aspect of the SAWP. Other difficulties discussed were being away from family, feeling isolated on the farms from towns or social activities, encountering racism in the wider community, long hours, and mistreatment on-farm.Two of our migrant interviewees mentioned preferring the work in Nova Scotia compared to Ontario or British Columbia, and that they felt they were treated better in their current jobs. The smaller scale of Nova Scotia farms compared to these other provinces may provide a somewhat more positive day-to-day experience for some workers. In contrast, one farmworker interviewee complained about a previous employer who had imposed a curfew on farmworkers to be back in their accommodations, provided inadequate mattresses covered in mouse droppings, and started to hire Mexican workers after Jamaican workers complained about their living and working conditions (interview 2022). He explained that the Jamaican employees “banded together in a way and, you know, had a conversation with the boss…and there’s twenty of them that didn’t get brought back. [So they brought in] Mexicans instead of Jamaicans” (interview 2022). This supports Binford and Preibisch’s  findingscoerced productivity . One farmworker put it to us this way: migrant farmworkers “work harder, faster, longer” than their Canadian counterparts (interview 2022). This aligns with other research showing that the SAWP is structured to demand higher levels of productivity from workers than is expected from local residents Basok . As workThe COVID-19 pandemic brought some of the plight induced by this structured precarity to national attention. There were many news media stories on the program and a range of difficulties faced by workers, particularly in larger provinces like Ontario. In the summer of 2020, migrant workers at one Nova Scotia farm lodged complaints with Migrant Workers Alliance for Change, claiming that the farm provided unsafe working and living conditions, and that they were not paid for their mandatory quarantine period and were told to keep quiet when government agents visited the farm for inspections . Finally, one Jamaican farmworker suggested raising awareness or educating Canadians about the people who grow their food. He continued by saying, “I would hope that […] Canadians would recognize that we’re here to work, and not only to benefit, but in order to help to feed persons” (interview 2022).Much of the research on direct agricultural markets and local food examines the nature of the relationships and the values embodied in exchanges between farmer and consumer. These exchanges are seen to offer alternatives to the conventional food system that can potentially nurture social ties and community networks, enhance consumer knowledge about where their food comes from, and provide more environmentally sustainable food by requiring fewer travel miles and incubating initiatives for lower input agriculture. While the locality of food alone does not determine its environmental sustainability, there are correlations with reducing food waste and promoting ecologically sound agricultural practices; for example, locally produced food sold at farmers’ markets and subscription boxes requires less food packaging and storage requirements as it can be picked and sold when ripe. Farmers’ markets also often engage in waste reduction, zero-waste, and other environmentally focused projects and act as a hub for less-intensively grown agricultural products.Our research contributes to this literature by foregrounding the increasingly central role that permanently temporary migrant farmworkers play in the production of local foods in Nova Scotia, including on farms participating in subscription boxes and farmers’ markets. Although provincial policies contain goals for strengthening local food production and consumption, these goals have not been met. Furthermore, according to farmers we spoke to there needs to be more direct initiatives to support small-scale and sustainable agriculture beyond marketing campaigns and goals. Thus, we argue that marketing campaigns and reward program celebrating local food by government and industry are “local washing.” These campaigns are not matched by financial and policy supports directed at strengthening provincial farms nor address the causes for an increase in farm reliance on migrant farmworkers. Moreover, during the COVID-19 pandemic, the federal government framed migrant farmworkers as essential workers yet did little to address the central problems of the federal programs. The federal government did open a line of funding for farmers to better follow public health precautions during the pandemic, but unfortunately, in some cases, on-farm conditions remained conducive to outbreaks. Tragically, during the pandemic, farmworkers in other provinces have died (Braum and Grant can and must include labour.The consumers we surveyed, whose purchases were motivated by ethical values or ideas of “good” food, had little to no insight into the labour required to grow that food, the conditions of that labour, or what motivates labour migration in the first place. Although discussions of ethical consumption can overemphasize the agency of individuals and overlook structural inequalities in production, Goodman and DuPuis  remind uBut bringing labour into the localism fold presents new challenges to alternative food movements. For instance, well-known food writer Michael Pollan has argued that if consumers could see who is producing their food and how it is produced, they would change their consumption practices Guthman , though In sum, any real transformation of the food system requires multi-dimensional solutions at home, at the national level, and abroad. It must include practices and policies that support non-conventional, smaller-scale, and more ecologically sustainable farms both regionally and in the global south, improve food workers’ rights, reform immigration policies, and challenge racism. We have emphasized the importance of attending to labour as a blind spot in consumer perceptions of local food and sustainability. Farm work needs to be secure and attractive to local workers; migrant farmworkers need protections against exploitation and arbitrary dismissal, as well as pathways to citizenship; the remaining agricultural land needs to be protected against development and ecological destruction; and farmers need to earn a sufficient income for themselves and their employees.


Patient-Reported Outcomes (PRO) are directly reported by the patient without interpretation of the patient's response by a clinician or anyone else and pertains to the patient's health, quality of life, or functional status associated with health care or treatment. It can provide patients’ perspectives regarding treatment benefit and harm beyond survival and are often the outcomes of most importance to patients. This study aims to describe and analyze outcomes reported by Brazilian women diagnosed with breast cancer and rank the most important attributes for these patients.Observational descriptive study composed of exploratory interviews followed by online questionnaires applied to a convenience sample of women diagnosed with breast cancer.Twelve women were interviewed to explore the main outcomes and preferences about their treatments, such as the most common side effects and the most impacted aspects of life after diagnosis and BC treatment. Psychological, emotional, and sexual impacts were frequently described as impacted aspects. Fifty-three women, from all the five Brazilian regions, answered the online questionnaire. Following an order of importance ranking, the following outcomes were chosen, respectively: overall survival, progression-free survival; and quality of life. The treatment effects that were considered less important, among this sample, were pain and adverse events.Thinking about expanding the therapeutic quality of users, it is essential to take into account the experiences of patients. PRO is a trend in current research to achieve this goal, in order to influence the decisions of HTA agencies about the importance of valuing outcomes that affect patients' lives. Breast cancer has been a major public health problem. It is the second most incident cancer in the world and the most prevalent in women, besides being the second worldwide leading cause of cancer mortality .Data from 1980 to 2006 showed that breast cancer mortality has been increased in all five major geographic regions of Brazil .As therapeutic options for breast cancer, primary tumor surgery, assessment of axillary involvement and radiotherapy as a form of local treatment and systemic drug treatment, which consists of chemotherapy and hormone therapy  In casesIn the Brazilian Public Health System, the current clinical guidelines recommend only hormone therapy as the first-line therapy for postmenopausal women with advanced luminal BC . HoweverOS has long been the gold standard outcome in establishing the efficacy of oncology therapies and PFS, defined in clinical trials as the time from randomization until first evidence of tumor progression or death from any cause, is commonly used as a surrogate endpoint, which has been questioned by some cancer researchers, often without an evaluation of patient preferences .The patient experience has played an increasingly important role in clinical research since it is now understood that a whole system, such as a patient-centered approach, is required for a thorough assessment of the impact of therapy and care . In the Patient-Reported Outcomes (PRO) are directly reported by the patient without interpretation of the patient's response by a clinician or anyone else and pertains to the patient's health, quality of life, or functional status associated with health care or treatment . PRO insAccording to an investigation about how inclusion of PRO evidence has evolved and influenced recommendations by HTA agencies , 72% of the drug indication combinations included PRO data in one or more submissions. It shows that, however it is not yet a standard practice, HTA agencies tend to value the submission of PRO data and it can have a positive influence on recommendations .In Brazil, Progress-free survival (PFS) is considered a substitute outcome in the guidelines for the treatment of breast carcinoma, which means, a PFS is not considered an important factor in this decisive process of incorporating a drug as an option in the Brazilian public health system (SUS) . HoweverIn this way, the influence of patient participation in the decisions of HTA agencies is evident. Therefore, the present study aims to identify the main relevant outcomes for patients with breast cancer in Brazil, as well as to describe and rank important attributes and outcomes for these patients.followed by online questionnaires applied to a convenience sample of women diagnosed with breast cancer. The recruitment was carried out virtually between June and October 2020, through an online form, released by the research team in partnership with patients support Non-Governmental Organizations (NGOs), which are “Oncoguia”, “Recomeçar”, “Zen Cancer” and “Colabore com o futuro”. The recruitment form received 46 responses. The following inclusion criteria was established: Brazilian women diagnosed with breast cancer who already have been or were being treated for breast cancer. After this initial recruitment, we firstly invited 29 women that answered the recruitment form and completed the inclusion criteria to be part of this study.This is an observational study composed of exploratory interviews Data collection occurred first through individual exploratory interviews conducted by a trained researcher over the phone and lasted for approximately 30 min. The aim of the interviews was to capture important outcomes, preferences, and other results from patients, with the potential to provide insights that could help to answer the questions of this research. Twelve women were interviewed using a convenience strategy determined by theoretical saturation of the discourses related to the outcomes of the disease and treatment.Subsequently, an online questionnaire was applied to the interviewed women and other patients that preferred to participate only in this phase of the study. The questionnaires were sent to the same patients who participated in the interviews and the NGOs cited above also helped to spread the survey among other breast cancer patients. The aim of this second phase was to classify and rank the attributes and outcomes previously identified in the interviews, in addition, to explore more the ethical, social, and patient aspects of this disease and its treatment from the perspective of the Brazilian breast cancer patients'.The semi-structured interview questionnaire (Questionnaire 1) was developed considering the literature on the topic and the expertise of specialists, with the objective of collecting reports of patients' experiences and preferences, about important attributes and the classification of these. The online questionnaire (Questionnaire 2) was elaborated with close-ended questions using multiple-choice questions to measure Quality of Life and a Likert scale to rank the attributes and outcomes found in the conducted interviews.All data were collected between September and November 2020. All participants provided informed consent prior to their participation.To analyze the speeches of the interviews, a verbatim transcript was carried out in full, and the data of the interviewees were anonymized, using only the initials and thematic analysis . The theTwelve women were interviewed in September 2020. They were from different Brazilian cities in the Southeast Region , and in the Mid-West Region . Most patients were 50–69 years old, and only three were between 30 and 49 years old. Among the interviewed patients, only two of them were diagnosed with metastatic breast cancer. Only two of the interviewed patients were diagnosed with metastatic breast cancer. Fifty-three women from all five Brazilian regions answered the online questionnaire applied in October and November 2020. These breast cancer patients were between 30 and 69 years old and eleven were diagnosed with metastatic breast cancer. Most participants were diagnosed with BC diagnosis between 2018 and 2020, i.e., in the last two years .n = 8). One of the patients reported that, due to side effects, she recently had to stop taking anastrozole, and is currently taking only tamoxifen (Tamoxifen was the most widely used breast cancer medication among study participants (amoxifen .n = 11) and hair loss (n = 10) (The most reported side effect related to breast cancer treatment was fatigue ((n = 10) . Other sPsychological and emotional impact were frequently described, even though we didn't specifically mention these aspects in the interview . Some of the patients used similar sentences to narrate the difficult moment of the diagnosis, as seen below.“It was such a surprise because I used to take care of myself, I always had healthy habits” “It was a huge surprise… I didn’t have any node, nothing. It was discovered during the annual checkup and I was in shock. Despite we know there's a treatment, you feel too afraid of the future “My life was totally affected. My life was very different before cancer. When I was diagnosed, I got deeply depressed, I was sure I was going to die. It was an enormous suffering” “I feel much more fragile after the diagnosis and with this treatment, I cry frequently… I feel like a baby” Mental health was described as something important during the treatment and it seems integrative practices - such as natural foods, meditation, yoga - have importance on this aspect for some of the interviewed oncological patients, as we can see in the following quotes:“I found the Zen Cancer Institute and I could stop 1 year to take care of myself, look at my mental health, self-knowledge, meditate, integrative practices like yoga. I allowed myself to do things that are good for me, that brings me positivity. That was the greatest positive impact: a better mental health” “I”m pretty sure 50% of my results were due to the integrative medicine associated with the traditional treatment” Impact on self-esteem was also reported and it was frequently related to the loss of hair and to the mastectomy. Many patients continue to undergo psychotherapeutic follow-up since the breast cancer diagnostic.“I never worried about appearance and then, I started to change it, to go out on the streets and even at home with my family. My husband”s support was fundamental for my self-esteem maintenance” “Cancer affected everything, in terms of life expectance, quality of life, sexually speaking, my self-esteem… I had depression and I”m still treating it with a psychiatrist” When asked about what aspects of life were more affected, all patients mentioned that the disease had a strong physical impact, mainly related to consequences of the chemotherapy and surgery (mastectomy and axillary lymph node dissection). Pain, limiting fatigue, appearance changes – due to loss of weight, hair and breasts, loss of strength, and balance limiting exercise routine were some of the described physical impacts.“The physical aspect, because I didn”t do the breast reconstruction surgery, so to look at me in the mirror, my sexuality, my relationship with my husband are aspects that are getting better little by letter. Tamoxifen induced my menopause. I still can”t do exercise; I don”t have good mobility on my left arm because they extracted 4 lymph nodes” “I wake up feeling pain, I have gastric reflux and other gastric adverse effects because of the many medicines I take” Six patients related negative impacts on sexual life. Vaginal dryness and loss of libido were frequently reported as the cause but a strike on self-esteem and emotions was also reported as possible reasons to affect this aspect.“My libido decreased a lot during chemotherapy. But my husband respected this moment, supported and understood me. It was getting better after the chemo and surgery” “It”s so complicated, depressing. There is vaginal dryness, atrophy, there is no libido, the act hurts, it becomes mechanical, it is no longer pleasant. It was the most affected part” According to most of the interviewed patients, the impact on social life was surprisingly positive. Many women reported that, despite they have found some stigma coming from society, they had an improvement in social life, mainly when there was a strong support network like family, close friends and Cancer Support Non-Governmental Organizations. However, some patients described uncomfortable feelings due to the lack of knowledge about the disease. On one hand, some people approached them like cancer was a death sentence or, on the other hand, others didn't understand how the patient was sick if they were apparently doing so great. The importance of cancer awareness, besides better access, was cited as an important action that should be established by health authorities.“Social aspects were positively affected because to deal with other people got easier for me. Since I had to go through all this suffering, I am more empathetic. Things that used to annoy me, don”t bother me anymore. I feel more like a conciliator between people nowadays” “Socially, I felt a lot of support from friends, I was not isolated nor marginalized, I felt welcomed. There were some restrictions, the surgery was in the summer, so I became more secluded, quieter, but it is not difficult to live with herself (…) There were people visiting. At work, I didn't feel any prejudice. Although there is still a stigma, people are terrified, scared. It was difficult to deal with a diagnosis that nobody wants to have” “The social aspects were very affected. With close people, I didn”t have any problem, I have friends and family supporting me. But I had difficulty with other people, mainly after I cut my hair before losing it completely, they noticed I had something. Most people didn”t know at work, so it was hard to deal with it” “Someone asked, “You have cancer, are you going to die?” and I replied, “I'm going, aren't you?” Cancer is not punishment, I do not see it as punishment, but as a school, a great learning experience, I am a better person than I was before.” n = 6) reported breast cancer brought an economic impact on their lives, mainly for patients that rely on public health system or those who were unemployed or had to stop working because of the disease or its treatment. But even patients who have health insurance reported impact due to the need for expending more money on healthier food, medicines, exams, and doctors which were not covered. All patients that mentioned not having an economic impact had health insurance.Half of the interviewed patients “I used to work but now I”m retired because of the disease. I spent a lot of money on physiotherapy and medicines. I do not have health insurance, my treatment is under SUS, but some medicines are not available, they are costly, and we have to buy it” The exam routine was another frequently mentioned stress factor. The fear of another diagnosis was present in most analyzed discourses.“When we have a diagnostic like this, you live with fear all the time, because it”s something that you would never imagine happening in your life… it comes from nowhere and it can always come back” “Every year I do mammography and I get so scared; I don”t want to go through everything again. We”re always scared, every year I go to do mammography I get scared and nervous” “I”m terrified of having a recurrence. I have depression and anxiety, so something that affects me a lot is this fear of having cancer again” n = 27, 51%), followed by “good” , “moderate”  and “bad”  (n = 25), followed by “good” (n = 22), “moderate” (n = 3), and “bad” (n = 2) and “very bad” (n = 1)  . Similar (n = 1) .n = 19) reported tamoxifen as part of their current oral therapy, followed by patients who were not taking any medicine (n = 14) and patients taking anastrozole (n = 8) — in association with other drugs or not. Both patients that reported being under chemotherapy were diagnosed with metastatic breast cancer at the time of this survey  and pain (n = 25), respectively (n = 24) and progression-free survival was considered an important effect (n = 25).The treatment effects that were less and the least important were adverse events , progression-free survival (n = 7) and quality of life (n = 5) as the main goals of their treatment - even if they were diagnosed with metastatic disease. When faced with the possibility of cure, overall survival increase (n = 1) ranked behind quality of life. One patient who was under chemotherapy treatment mentioned “to reduce tumor size” as her main treatment objective . The economic aspect was considered important (n = 15) by the Brazilian patients, followed by the sexual aspect, considered moderately important (n = 15). Social aspect was considered less important (n = 19) and physical aspect was evaluated as the least important (n = 18)  .As far as we know, this is the first study that sought to understand the most important outcomes for breast cancer patients in Brazil. Typically, studies focus almost exclusively on clinical outcomes, that is, they focus only on what researchers consider important. In this study, we found that clinical outcomes such as cure, overall survival, survival free of progression , and quality of life are important for Brazilian patients, but so are other secondary outcomes that showed large impact on these women's lives. For example, for patients who responded to the online questionnaire, the condition itself and its treatment have a great psychological and emotional impact, an aspect considered as the most important when compared to physical outcomes or social, sexual and economic impact. The sexual aspect was found as moderately important, and is related to frequently reported adverse effects, such as decreased self-esteem and libido, vaginal dryness, but may also be related to the emotional impact of the disease on these patients lives.According to our findings, overall survival and progression-free survival are the most important treatment outcomes, showing that our findings are aligned with a recent survey that sought to rank the most valued outcomes for cancer patients . DespiteIt is noteworthy to highlight that the women interviewed frequently reported the condition and its treatment as having a significant physical impact. Adverse events such as pain and fatigue have often been described. However, when analyzing the sample of women who answered the online questionnaire, the physical aspect was described as the least important, when compared to other aspects. For these patients, cure or an overall survival were the most expected treatment results, followed by progression-free survival and quality of life. The treatment effects considered less important were adverse events and pain was showed as the least important effect. Here, it is important to consider the main profile of this sample, formed mainly by patients with breast cancer without metastatic disease. Of a total of 65 women who participated in this study (through both interviews and online questionnaires), only thirteen were diagnosed with metastatic cancer.A limitation of this study is the small sample of participants, mainly when compared to the total population of Brazilian women with breast cancer. The estimation for the triennium of 2020 to 2022 was 662,80 new cases in Brazil . TherefoIn this sense, the importance that health-related quality of life has for women diagnosed with breast carcinoma is evident. However, this outcome is often overlooked in clinical studies of different cancer treatment options, in which priority is given to overall survival, for example . To propDespite all the negative impacts addressed, the benefit that integrative practices provided for the cancer patients interviewed is notorious, when it comes to mental health and good prognosis. Traditionally, researchers tend to focus on the negative consequences of cancer, however going beyond this one-sided view and studying the positive aspects also promote improvements in the line of care. This finding corresponds to the process of personal development and can be called post-traumatic growth, taking into account that breast cancer is a psychosocial process and includes positive and negative consequences for the individual .The present study highlighted the perspectives of patients diagnosed with breast carcinoma regarding the challenges of the disease and their preferences about the lines of treatment. Given the relevance of the presented findings and the scarcity of studies that reflect this scenario, it is necessary to explore the experiences of women in this context, to ensure improvements in the process of health technologies assessment are patient-centered, encompassing the cultural and socioeconomic aspects of the different contexts and countries.


The sense of belonging is a fundamental human need. Enacting it through face-to-face social activities was no longer possible during the COVID-19 pandemic. In this study, we investigate how the sense of belonging, and how it is enacted, changed longitudinally amongst older adults in the UK. In addition, we examine the interplay of the sense of belonging and resilience over time.We employed a longitudinal qualitative research design to explore the experiences of older adults during one year of the COVID-19 pandemic (April 2020-April 2021). The analysis was undertaken with constructivist grounded theory.Before the pandemic older adults were free to engage in social relationships with family and friends, often enacted within social activity groups where they felt valued and gained positive experiences. During the pandemic face to face enactment of belongingness was reduced; adjustments needed to be made to maintain the sense of belonging. The experience of older adults was heterogeneous. We examine three themes. First, how belongingness was enacted prior to the pandemic. Examples include: family holidays, visiting each other, sports activities, eating with friends and family, and visiting cultural events. Second, how participants adapted and maintained their social involvement. Examples include: distanced face-to-face activities; and learning new technology. Third, for some, a belongingness gap emerged and persisted. There was an irretrievable loss of family members or friends, the closure of social groups, or withdrawal from groups as priorities changed. As a consequence, of challenged belongingness, participants expressed increased loneliness, anxiety, social isolation, frustration and, feelings of depression. For many, the disrupted sense of belonging no longer fostered resilience, and some previously resilient participants were no longer resilient. By January 2022, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known as COVID-19, has persisted for two years, changing the lives of people worldwide. Health and safety measures have been introduced to stop the virus from spreading. In the UK, for example, lockdowns, shielding advice, social distancing (staying 2m apart), wearing face masks, and using hand sanitizer regularly were imposed at various times since March 2020 . Older aThe COVID-19 pandemic had additional impacts, one of which had been the disruption of the sense of belonging. Relationships with those who are proximate, physically close with whom people have face-to-face contact, have been disrupted most which, in turn, has challenged the sense of belonging for older adults. Our interest in the sense of belonging, was woken by participant M15W1 who told us: ‘but we’ve never been totally removed from the family’ (M15) . The network produced a concept analysis , so that was six people, three households, and that was it. We’ve seen them since, but not indoors obviously.th of December), one participant F9 could not see her family as they live far away. She expressed her frustration and the impact on her well-being. Not only that her wellbeing was impacted by the missing proximity of loved ones, but it also impacted her resilience and this changed from W1 resilient to W2 not resilient as she was elsewhere reporting using medication :Despite the option to meet family members indoors on Christmas day  I think being shut in all the time and just being on your own, it does make you, not nervous but apprehensive.(F9 W2)The lack of proximity hit many participants hard like F7 expressed. The disrupted sense of belonging and missing resources for resilience made it difficult to manage a stressful situation. She disclosed her signs of distress and was identified as not resilient in W2 :Obviously missing my daughter. Well, lonely I guess, from that point of view, or sad from the point of view of missing her. Anxious, I don’t know; yes, anxious that the Government’s not going to do as much as it could do.(F7 W2)Another participant F12 talked about her experience with limited time to live and missing the proximity of her family in particular the grandchildren. She had been identified as resilient in W1 but due to the missing protective factors of seeing the family face to face, it changed to not resilient in W2 :But I have found it very difficult, because I think as you get older you know you’ve only got, I don’t know, 10/15 good years of life left and to take a year out, that’s a high percentage of that time, high proportion of that time and I’ve got family overall that I can’t see and I’m missing my grandchildren that I can’t see.(F12 W2)Another participant F8 received traumatic news and expressed her pain at the approaching loss of her beloved brother. In W1 she was able to maintain an active life and took part in online courses, but her brother’s diagnosis took her protective resource away which affected her wellbeing. :I have four brothers, one of them, the youngest has just been diagnosed with an advanced stage four brain tumour which is inoperable‥ (…). Well yes, losing family members, because although as a family we’ve never lived in each other’s pocket, we don’t communicate constantly, but there is a very strong bond and the thought of, for example, losing my brother who is of my four brothers my favourite brother, I couldn’t really conceive of it. I still haven’t got my head round it because him not being in the world will completely change things for me.(F8 W2)One participant W2 M4 had been involved in activities with family and friends almost every day pre-pandemic and was identified as resilient in W1 but the sudden challenge of belongingness and missing proximity made him suffer :For some people, that may not be a problem but to us, we have missed the social interaction with friends and family.(M4 W2)For many, meeting friends continued to be very important as they were part of the daily social life pre-pandemic. Notably, many participants reported that they had more contact with friends during the pandemic than before. They maintained social activities and lived a meaningful life in both interviews and maintained resilience :I am probably in contact with more people than I would normally be. I would normally meet people. I am possibly in touch with people further away than I would normally be.(M3 W2)Similarly, F6 was not impacted by the restrictions since she felt happy on their own. :I am fine. I don’t get depressed. I am quite happy to be on my own. I like to go out and see people, but I am quite happy on my own.(F6 W2)When all clubs closed, the participants’ involvement in group activity was greatly disrupted. M9 expressed his frustration. Despite the frustration he showed no sign of distress and maintained resilience as his family maintained his resource of joy :We gave up golf when it shut down in November. We gave up even meeting in groups of two. The golf course is closed so my secretarial role is null and void at the moment. (…) Everything is on hold. The social activity I do with my friends is play golf, which is curtailed currently.(M9 W2)Then he explains what makes him happy:Everyday occurrences make me happy. My son has a silly sense of humour, (…) He keeps me amused. My wife (…) keeps me amused as well.(M9 W2)The motivation to exercise with a group face to face was also very important for F15. She discussed the lack of motivation to exercise on her own. Her sense of belongingness through the gym was no longer accessible during the lockdown. This in turn impacted her resilience. Elsewhere in her interview, she reported using medication to help her cope (W1+W2 NR):My hobby really was the gym and that’s not happening at all. They have started to do classes online and I’ve tried to do that, but it’s not very motivating. (…) I think I need the company of other people to motivate me to do it.(F15 W2)Many participants wanted to be close to family and friends and used the new virtual meeting options to stay connected. However, their experiences were varied. One participant F1 explained how she could do grandparenting remotely this sense of belongingness from the family helped her to maintain resilience :I have enjoyed having a daily Zoom conference with my four-year-old grandson. (…). I feel I am doing childcare remotely!(F1 W1)For others, the technical substitute was not easily accessible and F11 struggled to adapt to virtual meetings but used at least text messages to maintain the bonds. She disclosed in the first interview her nervousness about going out and in the second interview reports elsewhere she is drinking more than she used to. These are signs of not being resilient :I’ve tried a couple of Skype or Zoom calls with the family and, to be honest, I haven’t been able to connect because I’m hopeless. (…) I do use my mobile more, I think. I think I do communicate quite a lot on WhatsApp now, with more of the family than I did before. Yes, most probably that’s all, but not really any improvements on my side.(F11W2)The sense of belonging was shaken over the space of one year. Thus, participants needed to find new strategies to enact belongingness. Our findings demonstrate that many participants created new ways of symbolic proximity to maintain belongingness, whilst others struggled. But overall, the change over time of belongingness stretched older adults’ ability to endure the missing interpersonal relationship. Therefore, the loss of resources such as family proximity and group activities, made it hard to maintain resilience over time.The sense of belonging had not only been challenged for many participants during the COVID-19 pandemic but was not replaceable for others. This occurred when participants continued to avoid seeing family and friends even when it was allowed, when loved ones had died or had withdrawn from society, or when participants withdrew themselves from group activities. Some were anxious about getting infected and followed the recommendations of social distancing more strictly than the governments’ advice.One gap of belongingness occurred when participants could no longer attend activity clubs as they had closed and did not open again. However, we acknowledge the heterogenous experience and impact on resilience.Despite the closure of the clubs F18 attended in person pre-pandemic, she managed to join the meetings during the pandemic provided online and demonstrated, therefore, signs of active participation. In W2 she reassessed her social priorities, demonstrating maintaining meaningful life and satisfaction and can be identified as resilient :I shall not be going back to everything because I’ve realised that some things are not as important as I thought they were. (…). I don’t want to be involved with that anymore, I don’t want to be on their committee, which I did nothing but moan about and I thought why put yourself through it then.(F18 W2)Many participants experienced the death of friends or family members and suffered pain from the loss, as F17 comments. Despite her bereavement, she expressed no current distress and, therefore, we argue she was resilient at both waves :A few months ago, one of my close relatives died due to Covid in India,—and I feel quite miserable about her. She was younger than me, we were very close.(F17 W2)Similarly, F 16 was resilient in both interviews, although she had experienced losses in the interim. A sign of managing has been identified when she told she speaks to her sister :I speak to my sister, mmm, every other day probably. (…) I was very upset, particularly when my friend and my brother-in-law died and that was a difficult period.(F16 W2)In contrast, another participant F14 spoke about her the multiple losses and the impact they had on her life :Sad because my daughter lives in [place]. I have lost a friend and two relations (…). I haven’t been able to go to the funerals. (…). You could have 30 there (…). I went to one in November and three this year. They are nothing to do with Covid, they are just people who were all older than me so it was inevitable. It didn’t feel… this word I don’t like. Closure. I didn’t think there was any closure because I wasn’t actually there. [upset] Sorry.(F14 W2)The sense of belonging was disrupted when activities could not go ahead like for F9’s dancing class. She decided not to continue her beloved hobby as she was hindered by her anxiety-driven thoughts. Thus, she was not resilient :I started going to dancing one afternoon, a tea dance, one afternoon a week and I found that was great, it was giving me exercise, I was meeting people, and of course all that stopped because of COVID and I don’t know if I will ever have… I don’t know what the word is, not strength but I just don’t think I’ll be able to do it again because I won’t be sure that the person dancing with me is not breathing germs on me.(F9 W2)M14, who could have joined the family Christmas party but decided not to because he felt safer of staying on his own. Missing the proximity of his loved ones left a gap of belongingness. This in turn led to feelings of depression, and loneliness and the disruption of proximity changed his resilience. :So, I must admit, I have been feeling a bit depressed, at having to be stuck in, with nothing but books and the TV as company. (…). I could have gone to one of my granddaughter’s on Christmas day but I decided it was going to be… Well, since I hadn’t had a first vaccine at least it was going to be doubtful whether I could steer clear of COVID-19 by doing so. So I didn’t go. My other half, my daughter-in-law’s mother, went. She’s now dead. (…). Yes, I suppose I tend to be a bit lonely, being stuck in all the time. Yes, I can pick up the phone and talk to friends, and check up on some of my more elderly friends who aren’t doing too well at the moment, unfortunately, but as the time goes on that’s how it is. (…) No, I’m afraid not much makes me happy at the moment. (…). No, I think just being on my own for a long period of time tends to make one more lonely, and possibly anxious.(M14 W2)For many the loss of a sense of belonging was irreplaceable and participants suffered from the loss of loved ones, leaving an unfillable gap. In addition, staying apart from groups and activities they enjoyed increased the gap of belongingness. This gap left many participants missing the resources that family and friends provide in facilitating resilience.Participants experienced a sense of belonging before the pandemic when they joined family events, met each other, or supported family members via grandparenting. They engaged with friends in cultural or sports activities or found pleasure in going out for meals together. These activities enabled the maintenance of secure bonds and interpersonal relationships , 21. TheOther older adults experienced gaps of belongingness when they withdrew themselves from activities or lost loved ones. The ongoing disruption and gaps of the sense of belonging, persisting uncertainty around the severity of the virus, the unknown individual consequences, and the losses of loved ones impacted people’s well-being. Many participants reported increased anxiety, isolation, frustration, loneliness, feeling of depression, and lower mood. This in turn impacted the older adult’s resilience.The authors found commonalities amongst participants who changed from being resilient to not being resilient, as well as for participants who were in both interview waves not resilient. First, resources such as community and society  could not be enacted to foster a sense of belonging and in turn resilience. Second, one year of the COVID-19 pandemic has worn out participants’ resources. Other aspects impacting participants’ resilience like the winter season and the ongoing uncertainty will be published in a later paper.Many participants managed to maintain a sense of belonging during the study but were despondent about staying apart from family and friends. They felt that their sense of belonging had been fractured and they were no longer resilient. However, it is important to recognise the heterogeneity of older adults’ sense of belonging and resilience during the time of the COVID-19 pandemic. Our results are important for policy and risk communication both in the light of this pandemic but also in the light of future health threats. Media and communities are required to consider the impact of reporting and communicating risk as well as offering support over a long time of confinement . The sense of belongingness needs to be maintained as does social proximity to reduce the risk of poor psychological well-being and to maintain resilience. Future participatory research could investigate how belongingness as a resource for resilience could be maintained in a health crisis.et al., [One limitation of the study was that initial recruitment was via Qualtrics which is an online platform, therefore participants were already online  for a fThere were potentially additional challenges in conducting interviews remotely. However, in practice, this proved not to be problematic. Rapport was established and distress, on the rare occasions it occurred, was managed effectively with our distress protocol outlined in our ethical approval. This study took place in a western European country and might not reflect the experiences of low-income countries.