The 2019 novel coronavirus (2019-nCoV, later named SARS-CoV-2) pneumonia was first detected and confirmed in Wuhan, China at the end of 2019. This became a global pandemic over the following months (Phan et al, 2020). On 30 January 2020, the World Health Organization (WHO) declared the outbreak a ‘Public Health Emergency of International Concern’ (WHO, 2020). The Chinese health authorities implemented prompt public health measures including intensive surveillance, epidemiological investigations, and deployment of national medical forces (Chinese Center for Disease Control and Prevention, 2020). In China, up to 10 March 2020, there was a total of 80 778 confirmed cases, some of which developed into severe or critical disease. Fortunately, the spread of the epidemic within China has been minimal since March 2020. The epidemic outbreak has caused patients with COVID-19 to suffer physical pain and psychological pressure. In addition, there is an increased awareness of patients with negative feelings such as anxiety, depression, and social isolation with some developing mental illness (Lima et al, 2020).
Benefit finding is defined as a positive-oriented coping model, which can promote or enhance the positive emotions and behaviours of people who are experiencing unpleasant life situations or diseases. Within this study, benefit finding is defined as the awareness that patients (in this case following COVID-19) have developed of experiencing growth and discovery of a beneficial meaning of life (Lloyd et al, 2016). Where individuals find positive benefits in hardship (Affleck and Tennen, 1996; Helgeson et al, 2006; Pascoe and Edvardsson, 2013), such as better quality of life and more harmonious relationship with family members (Linley and Joseph, 2004), it may be seen to be beneficial to individuals' physical and mental health outcomes. Several studies have confirmed that benefit finding can reduce emotional negative effects and promote better quality of life (Pakenham, 2005; Lee et al, 2014).
Current research has focused on the alleviation of negative conditions that affect emotions and onset of health conditions experienced by patients with COVID-19, such as hypertension, which manifest in patients with symptoms such as depression, anxiety, sadness and post-traumatic stress disorder (PTSD) (Zhu et al, 2020; Sun et al, 2021). It is also acknowledged that COVID-19 may also bring positive behaviour changes and benefit finding to patients. In the literature a variety of professional terms have been used to describe the positive impacts of disease-related adversity, such as benefit finding and post-traumatic growth (Affleck and Tennen, 1996; Calhoun et al, 2000). Opportunities for nurses to assist patients and families in the development of benefit finding exercises have not been explored in full. The impact of this is particularly of benefit to patients following serious illness or at the end of life.
International research has found that benefit finding affects the health outcomes of patients with different diseases. Affleck et al (1987) reported this in a study of 287 men who had recently experienced their first heart attack. They found that over 50% of the men highlighted personal benefits following this short-term event, and proceeded to report these men were significantly less likely to have a subsequent heart attack and also exhibited lower morbidity rates 8 years later. Similar results were seen in other studies; for example, patients diagnosed with AIDS demonstrated a decrease in anxiety and depression (Bower et al, 1998); benefit finding reduced the risk of further heart attack in patients with cardiovascular disease (Affleck and Tennen, 1996); Dunn et al's (2011) study on patients diagnosed with cancer reported how benefit finding helped them develop healthier living habits, establish closer relationships with other and assisted them to clarify and appreciate priorities in their life. The outcome experience can add both quality and longevity to the life of the patient.
A small number of studies have also explored the importance of benefit finding during war/conflicts, disasters and public health emergencies. Helgeson et al (2006) explored this concept in a meta-analysis of 235 studies between 2001 and 2006, which demonstrated increasing reports of more positive wellbeing and lower levels of depression among a range of participants who had experienced chronic illnesses, war/conflict, sexual assault, disasters, and for people with a chronically ill child. This becomes a more significant concern after the recent global pandemic.
With increasing acknowledgement of the importance of benefit finding in clinical practice, research has emerged that focus on the influencing factors of benefit finding, such as demographic characteristics (eg gender, age, education level) (Lechner et al, 2003), disease-related features (eg type, severity) (Jansen et al, 2011), and other sometimes short-term health outcomes (eg anxiety, depression, social support, resilience, coping style, quality of life) (Pascoe and Edvardsson, 2013; Harding et al, 2014). However, previous research on benefit finding had focused mainly on patients with cancer and other long-term diseases (Lechner et al, 2003; Helgeson et al, 2006; Jansen et al, 2011; Pascoe and Edvardsson, 2013; Harding et al, 2014). No study has demonstrated the level of benefit finding and its impact and influencing public health factors among COVID-19 patients. In the context of the global fight against the epidemic of COVID-19, this study aims to show the importance of benefit finding in the psychological development and rehabilitation of COVID-19 patients, so as to provide reference for COVID-19 and other similar outbreaks.
Methods
Design and sample
This study was a cross-section correlational design. Between 15 February and 31 March 2020, a total of 313 patients with COVID-19 were recruited from Huoshenshan Hospital in Wuhan, China. Inclusion criteria were: confirmed COVID-19 patients; 18 years old or older; had no obvious cognitive or language disabilities; understood the purpose of the study and consented to take part in the study. Of the initial study population, 25 participants did not complete the questionnaire. This resulted in a total of 288 participants who completed the questionnaire. The response rate was 92%.
Survey questionnaire
The questionnaire comprised five sections.
Sociodemographic characteristics
A template was designed to capture general information from the participants on gender, age, education level, residential location, marital status, employment status, religious affiliation and whether they had experienced a previous adverse major event in their life.
Benefit finding
Participants completed a benefit finding measure to assess the ways COVID-19 could have a positive impact on one's life. The Benefit Finding Scale (BFS) as used in this study was originally developed by Antoni et al (2001), revised by Tomich and Helgeson (2004) and the Chinese version used here was translated by a Chinese academic (Hu, 2014). It is a 19-item self-report tool. Each item is rated on a five-point Likert scale of 1= ‘strongly disagree’ to 5= ‘strongly agree’. The total score ranges from 19 to 76 and higher scores indicate higher levels of benefit finding. The pilot data on 32 COVID-19 patients in this study found a Cronbach's alpha of 0.941.
Resilience
The Chinese version of the Connor–Davidson Resilience Scale (CD-RISC) (Connor and Davidson, 2003) was used in this study to estimate the mental resilience of COVID-19 patients. CD-RISC is a 25-item scale using a 5-point Likert-type response scale from not true at all (0) to true nearly all of the time (4) (Wu et al, 2017). It also consists of three dimensions: tenacity (13 items), self-improvement (8 items) and optimism (4 items). Participants rated each item with reference to the past month. Total scores range from 0 to 100, with higher scores corresponding to higher levels of resilience. The pilot data on 32 COVID-19 patients in this study found a Cronbach's alpha of 0.899.
Social support
A Chinese version of the Multidimensional Scale of Perceived Social Support (MSPSS) measured the extent to which participants perceived social support from three sources: family (FA) (4 items), friends (FR) (4 items), and significant others (SO) (4 items) (Dambi et al, 2018). The MSPSS is a self-report questionnaire containing 12 items, each rated on a 7-point Likert scale with scores ranging from 1= ‘very strongly disagree’ to 7= ‘very strongly agree’. The MSPSS has been proven to be psychometrically sound among diverse participants and to have good internal reliability and test–retest reliability and robust factorial validity (Clara et al, 2003; Pedersen et al, 2009; Hannan et al, 2016). The pilot data on 32 participants with COVID-19 in this study found a Cronbach's alpha of 0.887.
Medical coping modes
The medical coping modes were assessed by a validated Chinese version of the Medical Coping Modes Questionnaire (MCMQ) (Feifel et al, 1987). The MCMQ contains 20 items and three dimensions that correspond to three disease-related cognitive and behavioural coping modes: confrontive, avoidant and resigned. Each item was scored on a four-point Likert scale from 1 to 4, with each score indicating a different frequency of a coping mode's use: never, sometimes, often, always. The Cronbach's alpha was 0.60–0.76.
Data collection
Huoshenshan Hospital was a purpose-built emergency hospital, established within 10 days in response to the level of coronavirus occurring in Wuhan, China. The hospital (non-operational since April 2020) had a total construction area of 33 900 m2 with intensive care units and general wards, including 1000 beds. The study explored the psychological status and influencing factors of patients with COVID-19. Approval for the study was obtained from the Institutional Review Board of Huoshenshan Hospital. A signed written informed consent was obtained from each participant with assurances that they could refuse/withdraw from the study at any time. Trained nurses collected the data during face-to-face interviews. Questionnaires were photographed, stored and locked in a computer after collection as per data collection guidelines.
Data analysis
Data analysis was performed using SPSS version 22.0. Mean, standard deviation (SD), frequencies and percentages were used to describe the basic characteristic of COVID-19 patients and study variables. T-test and chi-square test were used for single-factor analyses. Pearson correlation analysis was used to examine the association between the level of benefit finding and resilience, social support and medical coping modes. For multiple factor analyses, multivariate regression was performed. All P values less than 0.05 indicate statistical significance.
Results
Participants' characteristics
The average age of the 288 participants was 48.2±13.8 years old. This included 160 male (55.6%) and 128 female participants (44.4%). The total average score for BFS was 61.26±10.25.
Single factors influencing benefit finding
As seen in Table 1, benefit finding was statistically related to age, gender, education level, religious affiliation and whether they had experienced major events (P<0.05). Residential location, marital status and employment status were not statistically related to benefit finding in COVID-19 patients.
Table 1. Comparison of different participant characteristics in relation to benefit finding scores (n=288)
| Factor | No. of participants | Prevalence (%) | Benefit finding score | χ2 | P |
|---|---|---|---|---|---|
| Gender | -2.466 | 0.015 | |||
| Male | 160 | 55.6 | 59.73±10.25 | ||
| Female | 128 | 44.4 | 63.86±9.67 | ||
| Age | 2.533 | 0.044 | |||
| 20–30 | 16 | 5.6 | 57.25±10.53 | ||
| 31–40 | 32 | 11.1 | 62.25±14.33 | ||
| 41–50 | 64 | 22.2 | 63.87±8.49 | ||
| 51–60 | 76 | 26.4 | 57.82±9.79 | ||
| Over 60 | 100 | 34.7 | 63.02±9.32 | ||
| Education level | 4.429 | 0.005 | |||
| Primary school | 4 | 1.4 | 54.46±8.222 | ||
| Junior high school | 76 | 26.4 | 58.84±10.83 | ||
| Senior high school | 112 | 38.9 | 63.96±9.05 | ||
| Junior college or above | 96 | 33.3 | 62.57±10.37 | ||
| Residential location | 0.844 | 0.400 | |||
| City | 186 | 64.6 | 61.65±10.05 | ||
| Village | 102 | 35.4 | 60.14±10.63 | ||
| Marital status | 0.68 | 0.934 | |||
| Unmarried | 24 | 8.3 | 54.50±9.78 | ||
| Married | 232 | 80.6 | 62.00±6.325 | ||
| Divorced | 32 | 11.1 | 61.86±10.54 | ||
| Career | 0.68 | 0.508 | |||
| Teacher | 20 | 6.9 | 59.40±7.99 | ||
| Civil servant | 12 | 14.6 | 56.67±14.87 | ||
| Worker | 114 | 38.9 | 62.02±9.47 | ||
| Farmer | 20 | 16.7 | 60.20±13.85 | ||
| Others | 122 | 22.9 | 61.69±10.20 | ||
| Religious affiliation | -2.037 | 0.043 | |||
| Yes | 48 | 16.7 | 63.79±9.18 | ||
| No | 240 | 83.3 | 58.89±11.04 | ||
| Previously experienced major event | -3.321 | 0.001 | |||
| Yes | 76 | 26.4 | 56.68±10.90 | ||
| No | 212 | 73.6 | 62.91±9.54 | ||
Pearson correlation analysis of factors influencing benefit finding
Presented in Table 2 are the correlations between the scores of benefit finding, resilience, social support and medical coping modes. The total average score of CD-RISC was 65.44±13.18, MSPPS score was 64.69±10.03 and MCMQ score was 49.42±3.86. Benefit finding was significantly and positively correlated with resilience (r=0.634, P<0.001), social support (r=0.512, P<0.001) and confrontive medical coping mode (r=0.314, P<0.001), but negatively correlated with resigned medical coping mode (r=-0.244, P=0.003).
Table 2. Correlations between benefit finding and resilience, social support, medical coping modes among COVID-19 patients
| Factor | Mean | Standard deviation | Benefit finding | |
|---|---|---|---|---|
| r | P | |||
| CD-RISC | 65.44 | 13.176 | 0.634 | <0.001 |
| Self-improvement | 22.78 | 4.633 | 0.637 | <0.001 |
| Tenacity | 32.78 | 7.590 | 0.571 | <0.001 |
| Optimism | 9.89 | 2.345 | 0.458 | <0.001 |
| MSPPS | 64.69 | 10.027 | 0.512 | <0.001 |
| Family (FA) | 22.85 | 3.667 | 0.529 | <0.001 |
| Friends (FR) | 20.70 | 3.931 | 0.398 | <0.001 |
| Others (SO) | 21.15 | 4.146 | 0.394 | <0.001 |
| MCMQ | 49.42 | 3.857 | 0.252 | =0.002 |
| Confrontive | 19.57 | 2.134 | 0.314 | <0.001 |
| Avoidant | 16.50 | 2.602 | 0.106 | =0.063 |
| Resigned | 12.78 | 1.972 | -0.244 | =0.003 |
Multivariate regression analyses of factors influencing benefit finding
Multivariate factor analysis listed in Table 3 included age, gender, education level, religious affiliation, previously experiencing major event, resilience, social support and medical coping. The results show that benefit finding revealed an independent relevance with education level, whether they had experienced a previous major event, social support, optimism, confrontive coping mode or resigned coping mode. In other words, the positive factors for benefit finding in COVID-19 were high education level, no major events, high social support, optimism, and confrontive coping mode. The negative factor was resigned coping mode (Table 4).
Table 3. Factors' values assigned in the multivariate regression analyses model
| Variables | Value |
|---|---|
| Age | Primary value |
| Gender | 1=male, 2=female |
| Education level | 1=primary school, 2=junior high school, 3=senior high school, 4=junior college or above |
| Religious affiliation | 1=yes, 2=no |
| Experiencing major emergencies | 1=yes, 2=no |
| Tenacity | Primary value |
| Self-improvement | Primary value |
| Optimism | Primary value |
| Social support | Primary value |
| Confrontive coping | Primary value |
| Avoidant coping | Primary value |
| Resigned coping | Primary value |
Table 4. Multivariate regression analyses on the benefit finding among COVID-19 patients (n=288)
| Factors | B | SE | β | t | P-value | 95% CI |
|---|---|---|---|---|---|---|
| Constant | 5.817 | 9.097 | — | 0.570 | 0.570 | -12.805~23.178 |
| Education level | 2.444 | 0.865 | 0.193 | 2.824 | 0.005 | 0.733~4.156 |
| Experiencing major event | 3.301 | 1.603 | 0.142 | 2.059 | 0.041 | 0.130~6.473 |
| Social support | 0.244 | 0.69 | 0.239 | 3.548 | 0.001 | 0.108~0.380 |
| Optimism | 0.650 | 0.223 | 0.294 | 2.915 | 0.004 | 0.209~1.092 |
| Confrontive | 0.624 | 0.289 | 0.130 | 2.161 | 0.033 | 0.053~1.196 |
| Resigned | -0.676 | 0.252 | -0.163 | -2.686 | 0.008 | -1.147~-0.178 |
B = unstandardised coefficient; SE = standard error of the unstandardised coefficient; β = standardised coefficient; t = validity coefficient of the regression
Discussion
Benefit finding among COVID-19 patients
In a previous study, it was found that patients diagnosed with COVID-19 were at higher risk of acquiring traumatic stress, leading to anxiety and depression, because of the factors of prolonged isolation, non-defined treatment and unpredictable prognosis (Torales et al, 2020). If patients could find a positive attitude towards the infection/disease and isolation and approach the disease with positive emotions, they were more likely to find the benefits of the disease. This would encourage a gradual generation of positive adaptive behaviors during treatment resulting in a conducive physical and mental relief for patients (Zhong et al, 2020). The basis of benefit finding is to tap into our personal potential in adversity, to develop positive cognitions and behaviors in response to adversity, rebuild confidence of returning to family and society, and aim to have a better life (Harding et al, 2014). This study found that the average BFS score was 61.26±10.25. Although COVID-19 patients suffered from adversity and negative emotions, they also discovered some benefits from the COVID-19 epidemic. Therefore, nursing and medical staff should take measures to guide patients to positively think about the benefits of the COVID-19 epidemic, encourage the reduction of negative effects such as induced isolation, to improve health status on discharge.
Influencing factors of benefit finding among COVID-19 patients
Multivariate regression analyses all showed potential factors that might influence the score of benefit finding.
Education level
The level of education is positively correlated with the score for benefit finding, which is consistent with the conclusions drawn in cancer patients and caregiver populations (Broughton et al, 2011; Gardner et al, 2017). The patients with a high education level had a greater ability and motivation to learn, so they would actively look for relevant information regarding COVID-19. This resulted in these participants responding in a comprehensive, rational, deep and dialectical manner to address potential adversity caused by the disease and a different understanding of life (Westerhuis et al, 2011; Leigh-Hunt et al, 2017; Santarnecchi et al, 2018). Medical staff and community workers—those employed to assist in the community—should focus on people with relatively low education levels, and develop easy-to-understand disease-related information, to reduce their anxiety and improve their mental health. This has significance for community nurses who understand that health outcomes are affected by many variables within the social determinants of health such as literacy, housing and environment. Resources need to be provided to develop these proposed services for patients in similar circumstances.
Experience of a previous major event
Based on the analysis of whether or not the participants had encountered a previous major event, the benefit finding score was relatively low (56.68±10.90 vs 62.91±9.54, t=-3.321, P<0.001). Following the pandemic, patients who had been affected by the disease would have uncertainty and insecurity, which may lead to stress disorders such as depression, anxiety, fear and poor concentration that may impact on their psychological wellbeing (Wang et al, 2020a). The impact of the epidemic will be wide and lasting, which would lead to the reinforcement/recurrence of some negative psychological stress of some patients who have suffered from major events (Wang et al, 2020b). Healthcare staff and community workers should identify this group of people early and proactively assist in establishing positive thinking orientation, providing social support, and promoting training in relaxation methods, so that they can gradually generate positive emotions and adaptive behaviours. A proactive approach for similar outbreaks or a disease diagnosis that can impact on the quality of life should be developed for nurses and others to share and educate patients and families.
Optimism
Previous work by Manne et al (2004) showed that a positive coping mode helps to improve the level of benefit finding. This is consistent with the positive correlation between level of optimism and BFS score of COVID-19 patients in this study. Optimism emerges from positive psychology and a dimension of psychological resilience and can provide support for individuals in dire straits (Hajek et al, 2019). Gardner et al's (2017) study showed that optimism has a unique predictive effect on benefit finding. Therefore, optimistic patients are more likely to adapt to the changes in work and life brought about by the epidemic. In a post-pandemic phase there is a need for optimism and a positive psychological ability to cope with the aftermath of the epidemic. Having an optimistic and positive psychological outlook is very useful when facing the multiple changes brought about by emergencies. Development of integrated interdisciplinary pathways post-COVID (or post diagnosis in other populations) is needed, for nurses to manage care of patients that require it and for the development of care pathways.
Social support
A number of studies (Weiss, 2004; Baek et al, 2014) have shown that the level of patients' benefit finding is positively correlated with social support, which is consistent with the conclusion of this study. COVID-19 patients treated in quarantine areas have been exposed to a change of identity, closure of their surrounding environment, and separation from family/friends leading to potential increased risk of developing anxiety, fear and nervousness. The comfort and companionship of family members and the support and encouragement of friends are key to reducing the negative emotions of patients and maintaining a stable psychological state. The care and encouragement from family and friends can provide invisible spiritual and mental support, encouraging mental flexibility needed to adapt to the disease (Zhong et al, 2020). Healthcare staff should pay attention to assessing the family and social information of patients, and actively mobilise their families/friends to use devices such as mobile phones or video chat. They should also spend more time and energy listening and accompanying patients who have less family support, to take care of their mental, spiritual and relationship health. At this time, community workers should also pay attention to care of the patients' family and help them to solve the problem encountered in the epidemic, so that the family can provide a better support for the patient. Health policy direction should review the inclusion of voluntary services/participants to assist the nursing and medical services in the delivery of accessible support services in local community settings.
Confrontive/resigned coping modes
Within this study multivariate regression analysis showed that the ‘resigned’ coping mode is a negative coping style. Insecurities and reduced confidence results because of the uncertainty of the disease and treatments. This results in some patients succumbing/forcing themselves to submit to some established facts instead of taking the initiative to face them, which is not conducive to the treatment and recovery of the disease (Shuja et al, 2020; Zhong et al, 2020). In contrast, the confrontive coping mode is a positive coping style. The coping mode of confrontation can make the patients face the risks and find the benefits brought by the disease. Patients take the initiative to face the troubles that can promote themselves to overcome the practical difficulties, find a way to recognise the disease and treat the prognosis of the disease correctly (Atay and Erturan, 2020). The support of necessary information about disease is the basis to promote patients to take positive and active coping modes (Lee et al, 2017). In clinical practice, medical staff should also promote patient's knowledge of COVID-19, correct the patients' subjective negative perception of the disease, encourage the patients to adopt a positive coping mode, discover the potential benefits of the disease, and establish a correct concept of disease treatment. This results in a better treatment effect, quicker recovery and discharge as soon as possible to return to family and society. The relevant national departments and community workers should update the relevant knowledge and research progress and widely carry out health promotion and education in the community. Nurses and in particular community nurses are proficient in the delivery of health literacy and self-management education needed to enhance the coping mechanisms of patients and families.
Facilitators and limitations
Several limitations were noted in this study. First, the study used convenience-sampling method and the COVID-19 patients only from one department of Wuhan Huoshenshan Hospital. A national and global investigation of similar studies will offer a broader view on the concept. Second, a causal relationship between benefit finding, resilience, social support and medical coping modes were not interpretable due to the cross-sectional design. Longitudinal study methodology may identify the dynamic mechanism among benefit finding, resilience, social support and medical coping modes in COVID-19 patients to explain the possible causal associations more clearly. Finally, at present, the researchers have shown that benefit finding is affected by external as well as internal factors and it is very likely that a person's external circumstances would affect both their ability to engage in benefit finding and the extent to which this would help them. For example, a person who recovers from severe COVID-19 and goes home to a financially secure situation with loving family and no long-term disability would likely benefit from reflecting on their experience to find the positives. Meanwhile, a person in similar circumstances and goes home to a situation in which they are financially struggling because of time off work and facing the longer term effects of the virus (fatigue, cognitive impairment, respiratory dysfunction etc) may not find benefit finding very helpful. Therefore, the external influences on health and benefit finding need to be investigated in future research.
This study found that the number of the questionnaire items was relatively large, and took the participants approximately 30 minutes to complete. Due to the high-level risk of COVID-19, the best way to prevent infection is to avoid being exposed to the coronavirus. Thus, patients diagnosed with COVID-19 need to be isolated in a designated place, away from healthy people. They also expressed that there was enough time to complete the questionnaire. An added comment was how most participants thought the process of completing the scales not only occupied time but also helps them to explore and understand their current psychological state. Moreover, it also helped promote their communication with the medical teams. Therefore, completing the questionnaire did not demonstrate a specific burden on either physical or mental states.
Conclusion
The concept of benefit finding for COVID-19 patients needs to be enhanced and informed. In addition to the education level and whether the patients have suffered from a previous major event, other factors such as social support, optimism, confrontive and resigned coping modes are associated with enhanced levels of benefit finding impacting on their quality of life. Relevant government departments must focus on promoting disease-related knowledge, and sharing information on public health epidemic control and treatments. Nurses are well-positioned to provide assistance to the families of hospitalised patients and offer continuous support to discharged patients on the benefit finding factors. In the meanwhile, the vaccination programme is rolling out, which brings hope for the prevention of the worst symptoms of COVID-19. However, the effectiveness of vaccine remains to be observed in more populations for a longer time, as the production of vaccine remains slower than the demand. So, we still need to identify the high-risk groups, offer the public proactive comprehensive information and assistance, which will improve life for the person, their family and society.
KEY POINTS
- Benefit-finding is (within this study), defined as the awareness that patients, in this case post COVID-19 infection, have developed to experiencing growth and discovery of a beneficial meaning of life.
- Nurses are well placed to assist patients and families in understanding benefit finding in their situations.
- Community nurses are educated and competent to understand the concepts of benefit finding for patients after discharge from hospital.
- Benefit finding offers a psychological reference point for patients following serious illness such as those affected by COVID-19.
CPD reflective questions
- How have you experienced benefit finding with your patients? How have you experienced benefit finding in yourself?
- What areas do you feel you may need to develop to assist patients and families in exploring the concept of benefit finding?
- Think about the supportive pathways that exist in your interdisciplinary teams. How can they be improved to include benefit finding?