Multimorbidity is both an individual and societal problem. For society, patients with multimorbidity increase healthcare costs. For the individual, living with multimorbidity is complex, and there is an inverse relationship between a patient's Quality of Life (QoL) and their number of chronic conditions. Numerous intervention studies target these problems, yet there is no multimorbidity-specific patient-reported outcome measure (PROM) developed specifically for this group with adequate measurement properties to assess QoL. This study explores what overall needs regarding QoL are affected by living with multimorbidity through qualitative interviews. With this, we conceptualise Needs-based QoL specifically for this group, ensuring high content validity (regarding relevance and comprehensiveness) of using the Needs-based approach to measure their QoL. This is essential as this preliminary study leads to the development of the MultiMorbidity Questionnaire (MMQ), a PROM measuring QoL among patients with multimorbidity.This study draws upon qualitative interviews with fifteen patients with multimorbidity based on a semi-structured interview guide following the Needs-based approach. This approach allowed the patients to cover needs relevant for their QoL in relation to the complexities of living with multimorbidity. The transcribed interviews were thematically analysed, inspired by Braun and Clarke’s reflexive approach.Analysis of the interviews resulted in the construction of six intertwined domains relevant to patients with multimorbidity, covering their Needs-based QoL; “Physical ability”, “Self-determination”, “Security”, “Partner and social life”, “Self-image”, and “Personal finances”. “Physical limitations” and “Personal finances” were stated as core needs implicating the other domains.This study shows six intertwined overall domains relevant for patients with multimorbidity regarding their Needs-based QoL; “Physical ability”, “Self-determination”, “Security”, “Partner and social life”, “Self-image”, and “Personal finances”. These needs are relevant in a Danish context, with a generally high standard of living. Based on this conceptual framework of Need-based QoL for patients with multimorbidity, we will develop items for a new patient-reported outcome measure called the MMQ.The online version contains supplementary material available at 10.1186/s41687-022-00489-0. Health-Related Quality of Life (HRQoL) [The number of adults living with multimorbidity, two or more chronic diseases, is rising . The pre (HRQoL) –9. Quali (HRQoL) , 8, 10 a (HRQoL) . Several (HRQoL) –14."only at considerable sacrifice of quality of life" [health and focus on aspects related to disease or treatment [. HRQoL measurement refers to the impact of clinical conditions on functional capacity by primarily assessing the capacity to perform usual daily roles and activities. This functionalist approach is useful from a clinical perspective [The term QoL moved into the medical sphere with the apparent success of technical treatment in the 70 s, which raised the discussion of prolonged lives of life" . Simple of life" . Hence, of life" . The terof life" , 18. QoLreatment , 19. HRQspective , 21 but spective , 22, 23.spective ; for exaspective .EQ-5D and SF-36 are the most frequently used HRQoL instruments used in intervention studies for patients with multimorbidity , 9, 25. Yet, despite the risk of DIF when using generic measurement among patients with multimorbidity and the lack of a universally accepted and clear operational definition for the conceptualisation of QoL, it is regarded as an essential core outcome in quantitative studies for this group . This poWe systematically reviewed existing patient-reported outcome measures (PROMs) targeted patients with multimorbidity and assessed the identified measures' development, content validity, structural validity, and internal consistency . The assSince 1992, over thirty PROMs based on the Needs-based approach to QoL have been developed for single diseases, for example, depression, osteoarthritis, asthma and Crohn’s disease –35. ThesTherefore, we plan to develop a PROM for measuring Needs-based QoL among patients with multimorbidity explicitly conceptualised for this group: the MultiMorbidity Questionnaire (MMQ).This study focuses solely on the conceptual framework behind the construct of interest, QoL, as it is essential in developing a PROM , 43, 44.Hence, this study explores which overall needs regarding QoL are affected by living with multimorbidity through qualitative interviews. As a result of this, we conceptualise Needs-based QoL specifically for this group which ensures high content validity (regarding relevance and comprehensiveness) of using the Needs-based approach to measure their QoL.Content validity is regarded as the most crucial measurement property of a PROM by the COSMIN initiative , 47. ThiInterviews with 15 informants with multimorbidity living on Zealand, Denmark, were carried out from November 2018 to September 2019. Four of the participating patients were interviewed twice, as preliminary analysis demonstrated new themes relevant to explore, adding up to 19 qualitative interviews in total. To interview the informants in their natural setting, all interviews were conducted in their private homes except for one, who preferred it to take place at his GP's clinic. Table The informants were patients with multimorbidity (hereafter referred to as informants) recruited by general practitioners (GPs). Informants' identities, including their names and occupation, are altered for anonymity. The inclusion criteria were informants over 18 living with more than one chronic illness . Furthermore, the informants were sampled with variation regarding gender, age, diagnoses, marital status, rural or urban areas and level of education to obtain central themes relevant across the diverse sample . After tThe data collection followed a semi-structured interview guide  Normally I would just go out. If I met some friends saying "shall we do this?"–No, I can't.""Some informants voiced how a lack of possibilities for self-determination would deprive them of their authority. Instead, they felt their lives would be determined by, for example, illnesses and treatments or local authority employees. Other informants expressed frustrations when trying to take control of their daily life. Daniel was used to an active life full of impulsive activities with his friends, but with his recent diabetes diagnosis, he felt restrained by his treatment with insulin.Structure, organising and arranging plans around illnesses and treatments became essential to several informants to feel they were in control and to meet the need for self-determination. Lower QoL relating to lack of self-determination was also apparent among those informants that felt restrained because they had become dependent on family, friends, or healthcare workers."What I'm most afraid of is that I will not be there for the children to sufficiently guide and secure them."Many informants spoke of worries regarding their illnesses and the need for certainty either for themselves or their close relatives. The worries concerned uncertainties about, for example, treatments or fear of their health conditions worsening. Mary’s psychiatric condition had been well treated for years and gave her no concerns. Nevertheless, having just been diagnosed with diabetes, the combination and possible drug interactions worried her tremendously. Mary felt frustrated and insecure as she experienced there was nowhere she could turn to with these considerations. Other worries concerned the informants' personal finances (see below) or burdening close relatives with illnesses. For James, with three children, imagining not being there for them because of his illnesses was the most horrific worry.Informants worrying about their close relatives unfolded both the fear of having less ability to support their family and friends and the restrained feeling of being dependent on them. Furthermore, some informants without a partner worried that their need for a partner or romantic relationship could not be fulfilled. They voiced how their illnesses challenged all their social relations towards friends, family, colleagues, and how their illnesses were seen as an obstacle to getting a partner."In the past, I repaired my family’s cars, I helped them with fixing things in their houses and that sort of stuff. But now that I can’t do that anymore, well, then I’m sort of pushed out of the family. (…) that’s actually quite lonely, right?"Peter felt his loss of physical ability had affected his relationship with his closest family.With his back problems followed a severe depression, and he was no longer capable of maintaining his job as a workman. His job had been his identity and this had implications on his social life and self-image.Robert told how, because of his illnesses, he felt his situation affected his possibilities of getting a partner:"You know, sitting down and saying, now I want to have a relationship and a life again. Forget it, Robert, you have nothing to offer (…) I have no financial security, I can't have sex, I can't go out and create experiences, going on holidays together and that sort of thing. I can't really do anything anymore. There is no more to it."As with physical ability, the informants stated how their personal finances was a fundamental unmet need that impacted other needs. Amanda had retired early because of her illnesses and lived with her grown-up daughter in a rented farmhouse. With her low income, she had not been able to pay her bills the last couple of months and had just received a letter from her power supply company warning her electricity would soon be cut off."Money, you see.. Now I'm about to cry again, but the thing about not having money, that social security benefits cover your rent and then basically nothing else. It does something to your quality of life. (…) money influences, well, very many things in life, right? (…). It's like this pillar everything has to lean on. And it doesn't feel like that right now."Amanda makes it very clear that her financial situation was closely related to the feeling of being secure; for others, it was linked to their self-image.The informants expressed a need to maintain a self-image which they could be proud of. This was closely linked to their role in society, working identity and formed by how they believed their surroundings saw them.I have always had the feeling that your job is a part of your identity. So everybody who has looked down at me my whole life, because I was fat or whatever, well, they regained their respect when they heard what I earned and what my job was. And then, all of a sudden, I'm not that anymore.""Robert, a former successful self-employee, was seeking early retirement at the time of the interview because of his physical limitations. Therefore, his need for a self-image he could be proud of was clear:to be industrious". It was of such importance to him that his two children, aged 4 and 12, still believed he went to work every day, even though it was more than two years ago that he was approved for early retirement.For James maintaining a job was a part of educating his children by showing them ""I have always been the sort of person that wanted to educate my children, so that my children know morals and ethics (…). I have felt shameful for a long time that I'm ill and can't work. I still do. The background I come from, well, there you work. (…) There are no other possibilities. It is a disgrace not being able to support your family."James expressed his need to be a role model, followed by a sense of shame when his illnesses hindered this. Several of the informants gave voice to this shame and a linked feeling of guilt.This study points to the unmet needs that reduce the QoL of our informants living with multimorbidity analysed into the domains; “Physical ability”, “Self-determination”, “Security”, “Partner and social life”, “Self-image”, and “Personal finances”. Physical ability and personal finances were voiced as core needs that had a high impact on the other needs. It unfolded as a domino effect where for example, a lack of money due to early retirement, because of a limited physical ability, resulted in a low self-image and a belief they would not be able to find a partner. The impact of unmet needs affecting other needs was outlined differently among the informants, yet, all leading back to problems with their physical ability and personal finances due to their illnesses. This domino effect illustrates how HRQoL measures focusing solely on health do not encompass the complexity of living with multimorbidity, even though physical ability was voiced as a core need. The Needs-based approach obliges to this deficiency, as HRQoL is just one aspect of QoL, and physical ability only becomes essential insofar as it does not allow needs to be fulfilled .intertwined needs, the domino effect of unmet needs. The perceived burden on their QoL was not a simple sum of each unmet need, as the problems were intertwined, causing a more complex and heavier impact on their QoL. The Cycle of Complexity Model incorporates existing models on complexity for patients with multiple chronic conditions [Where Maslow outlined a hierarchy of needs , we argunditions ; among onditions . Patientnditions . NeverthThe pivotal role of the healthcare system's capacity to meet patients' needs stated by Grembowski overlaps with what was voiced by some of the informants from our study. They felt their multimorbidity and its consequences were decisive in terms of how they were met by healthcare professionals, local authorities, as well as friends and family. It was of such importance to the patients that it became a separate topic, which will be discussed in a future article.As with QoL, the definition of HRQoL is not clear and has evolved to be used synonymously with health, health status, and QoL . It shouThe heterogeneity in the measured effects of studies targeted patients with multimorbidity –14, we bThe strength of this study is the thorough analyses of needs related to QoL based solely on patients with multimorbidity perspectives. Additionally, the thoroughly considered specifications of the inclusion criteria ensured that we unfolded QoL for the more complex patients, as this is the group, we believe may benefit from healthcare interventions. The interdisciplinary collaboration between medical doctors and an anthropologist provided in-depth knowledge about patients with multimorbidity through several years of clinical experience, long-term ethnographic fieldwork, and research within this group. This can be seen as a strength and a limitation, as our presumptions of the relevance of the Needs-based approach for patients with multimorbidity may have affected the data collection and analysis process. Furthermore, we claim to move beyond a traditional clinical focus on QoL, but it can be discussed if this is feasible, the first author who conducted most interviews being a medical doctor. We have strived to be reflexive about our position and allowed for the patient perspective to guide all study phases.The inevitable weakness of this study is the heterogeneity of patients with multimorbidity, which raises the question of whether we can generalise on the relatively small sample size of 15 patients in 19 interviews. We argue this is possible due to the purposive sampling ensuring data with high information power . AnotherThis study shows six intertwined overall domains regarding Needs-based QoL relevant for patients with multimorbidity: “Physical ability”, “Self-determination”, “Security”, “Partner and social life”, “Self-image”, and “Personal finances”. Conceptualising Needs-based QoL specifically to this group ensures content validity in the future development of MMQ, a PROM measuring QoL among patients with multimorbidity. “Physical limitations” and “Personal finances” were stated as core needs implicating the other domains. These six domains are relevant in a Danish context, with a generally high standard of living.Additional file 1: Specified inclusion criteria.Additional file 2: Interview guide.


Everybody claims to be ethical. However, there is a huge difference between declaring ethical behavior and living up to high ethical standards. In this paper, we demonstrate that “hidden honest signals” in the language and the use of “small words” can show true moral values and behavior of individuals and organizations and that this ethical behavior is correlated to real-world success; however not always in the direction we might expect. Leveraging the latest advances of AI in natural language processing (NLP), we construct three different “tribes” of ethical, moral, and non-ethical people, based on Twitter feeds of people of known high and low ethics and morals: fair and modest collaborators codified as ethical “bees”; hard-working competitive workers as moral “ants”; and selfish, arrogant people as non-ethical “leeches”. Results from three studies involving a total of 49 workgroups and 281 individuals within three different industries  confirm the validity of our model. Associating membership in ethical or unethical tribes with performance, we find that being ethical correlates positively or negatively with success depending on the context. German army sergeant Anton Schmid was executed as a traitor by the German army for saving 300 Jews by shielding them from the Ponary massacre. While Schmid was recognized by Israel right after the Second World War, Schmid’s widow was refused a pension after the war, and her windows were smashed by the neighbors as the wife of a traitor. Schmid was a true “bee”, while the army and the neighbors acted as “ants”. Human “bees”, just like the real bees pollinating the plants on our planet, are doing good for everybody. However, just like real bees, human “bees” frequently get little recognition for their essential contributions to the good of society. Worldly recognition goes to human “ants” and “leeches”. Just like real ants sacrifice their lives for their hive while fighting to the death with ants from competing hives, human “ants” are competitive workers who are well-embedded in their in-group and work hard to get ahead. It took the human ants in the German army over 50 years to change the moral code of their in-group and give Sergeant Schmid recognition for his ethical behavior by renaming a military base after him. While human ants value loyalty within their in-group, human “leeches” are egoists. Just like real leeches, which steal their victim’s blood for themselves, human “leeches” only care about their benefits with little regard for the welfare of others.2, see ethics as the standard for discerning “good vs. bad” or “right vs. wrong” based on societal values, while they associate morality with the personal attitude of individuals towards others3. This means that ethical people are universally good, in the sense of “universalists” as defined in the Theory of Basic Human Values by Schwartz et al.4. Moral people care for the welfare of members of their in-group while having limited tolerance for behavior that deviates from their norms5. For instance, even people who support gay marriage think that gay sex is immoral6. Morals thus define a personal value system. People who share similar morals aggregate in virtual tribes, such as pro or contra abortion, or pro or contra vaccines7. While social pressure gets human “bees”, “ants”, and “leeches” to claim to act by high ethical standards, their underlying value systems exhibit radical differences. Just pretending to be ethical does not make one ethical. Enron had the most beautifully written code of ethics, while its entire upper-level management definitively behaved highly unethical, following their own “moral code” of personal greed8. Applying the Schwartz system9 of personal values, a “bee” would be an ethical adherent of universalism and benevolence, understanding and protecting all people’s welfare and nature. “Ants” and “leeches”, on the other hand, are strongly motivated by self-enhancement, striving for achievement and power. The key difference between the two is that “ants” highly value tradition and loyalty to other members of their in-group, while “leeches” only care about their own interests, with no concern for the welfare of others. In other words, bees are “ethical”, ants are “moral”, and leeches are “amoral”. Differently from “bees”, “ants” and “leeches” will thus stick to the moral value systems of their in-groups which might be ethical or unethical, with little compassion for the rest of society.“Bees” are ethical, “ants” might have firm morals, while “leeches” are un-ethical. While colloquially the terms ethics and morality are frequently used interchangeably, many philosophers, going back to Aristotle and Spinoza12. Frequently, “who breaks the law without being caught” wins. For instance, personality characteristics of psychopaths and CEOs show worrying similarities14. Frequently the most egotistical person is chosen as the leader of an organization15. On the other hand, ethical leaders are highly appreciated by their subordinates. While authoritative and inflexible leadership might have worked in an earlier era, today’s workers demand inclusiveness, empowerment, and a collaborative approach to problem-solving. Employees do not respond positively to top-down leadership, commonly considered outdated and counterproductive. Rather, they expect managers to follow humble, servant, and ethical leadership styles that are conducive to a work environment that enhances trust and builds positive relationships17.In this paper, we explore the following question: how are ethical values correlated with individual and company performance? Research is contradictory, with some researchers finding that ethical leaders will create higher-performing organizations, while others find that unethical individuals will be promoted faster. Although religion and the law want individuals and companies to restrict competitive behavior and act ethically and according to social and community expectations, the reality is quite different. In business, law, and medicine, the concept of ethics serves as a personal code of conduct for people working in those fields, and ethical decisions themselves are often contested and challenged18. In traditional bureaucratic organizational models, leaders issue commands and expect compliance from subordinates, often through authoritative power. In organizations dominated by a command-and-control style, employees are not empowered to change a course of action even when they witness unethical or unlawful behaviors. Empirical evidence has shown how ethical leadership models enable followers to make decisions moving away from domineering or self-centered approaches18. Ethical and humble leadership has been associated with the perceived effectiveness of leaders, employees’ job satisfaction and dedication, and their willingness to report problems to management. Ethical leaders encourage normative behavior and discourage unethical behavior of their subordinates by being an ethical example, treating people fairly, and actively managing morality19.Leaders in ethical organizations adopt collaborative approaches to promote engagement and fair behaviors without using authoritative power20. Individuals in the same tribe share similar behaviors and similar ethical values and emotional responses to external stimuli21. In the rest of this paper, we will use the term “ethical values” as the goal to aspire to, distinguishing between ethical bees, moral ants, and amoral leeches.Previous research has traditionally explored the association between ethical behaviors and outcomes by adopting qualitative methods, including surveys and self-report questionnaires. Our study contributes to this literature on ethical decision-making by providing a complementary methodology based on the digital traces that individuals leave as they interact online. In this study, we leverage the latest advances in natural language processing (NLP) and build “bee”, “ant”, and “leech” “tribes” of ethical, moral, and amoral people. Tribes are groups composed of members connected through a common belief or ideology. The concept has been used primarily in the marketing literature to describe consumer behavior23. Values are defined as desirable goals that act as guiding principles in people’s lives. They are then translated and become visible through individual behaviors and concrete actions. Values may be important to some people and unimportant to others24. Ethical identity has been positively related to prosocial behaviors such as charitable giving and negatively related to unethical behaviors such as lying25. Ethical identity acts as a “self-regulatory mechanism” embedded in people’s internalized notions of right and wrong, influencing individual ethical behavior26. To help resolve important behavioral and ethical issues—including discrimination or sexual harassment—scholars have stressed the role of universal ethical values in defining corporate codes of ethics9.The relationship between ethical values and behavior has attracted the interest of social scientists for several decades27. Ethical decision-making and ethical leadership have been associated with increased business performance measured at the individual level. For instance, a case study of supervisor-subordinate dyadic data from Taiwanese organizations showed that subordinates’ business ethical values are positively associated with job performance and employee engagement28.The importance of ethical values in organizations is clearly explained by studies that document significant and positive relationships between firms’ social responsibility and financial performance29. Studies show that team members exposed to similar cues regarding norms and ethical behaviors tend to behave homogeneously. Group norms are formed and reinforced by leaders’ behaviors, as they communicate as role models the importance of ethical values and use punishment and reward systems to encourage behaviors that align with cultural and universal values30. Empirical studies across various countries show that the ethical behavior of peers has the most significant impact on both individual moral values31 and group ethical behavior32. Ethical leaders will influence their subordinates to adjust their morals to be more ethical. A 2020 study on ethical leadership in business confirms that ethical values, especially when modeled by leaders, enhance both individual and business performance33.According to the social learning theory, individuals learn appropriate behaviors through a role-modeling process by observing the behaviors of others around them34. Recent empirical studies of European and African managers found that fairness of performance evaluation is associated with job satisfaction and mediated by trust and organizational commitment35. Other research has shown that satisfied employees increase business success36. In combination, this demonstrates that adhering to ethical values such as fairness will increase business performance. For example, research by Bowen et al.37 indicates that just and fair behaviors in the workplace translate into increased customer satisfaction. Other studies exploring the impact of organizational justice in HRM practice provide evidence that behaviors that “honor the justice principles” positively impact both job satisfaction and overall job performance38.A few studies have focused on measuring ethical values and ethical behaviors through the lenses of the big five factors of personality, suggesting that conscientiousness, agreeableness, and emotional stability are most consistently related to ethical leadership and agreeableness with power-sharing and fairness39. Knafo and Sagiv40 conducted 603 phone interviews with Israeli families to explore the relationship between values and occupational environments. Schwartz et al.41 developed the Portrait Values Questionnaire (PVQ) based on Schwartz’s theory of values, which identified ten fundamental individual values influencing human actions42. However, the survey-based approach has considerable disadvantages, as individuals are notoriously bad at self-assessment, either seeing themselves in too positive a light or being overly critical of themselves. Researchers have repeatedly found that an individual’s friends are much better at rating the individual’s personality traits than the individual44. AI and machine learning put new tools at the disposal of behavioral and organizational researchers, allowing them to automatically analyze electronic traces of individuals to predict their personality characteristics. AI thus leverages the “wisdom of the swarm” to extend the judgment of friends by aggregating the assessment of large groups of people of the personality traits of an individual.Traditional approaches to measuring ethical values and ethical decision-making rely on data collected through surveys, questionnaires, or focus groups. For instance, a study involving middle-level managers and engineers at an aviation center relied on questionnaires to demonstrate the impact of ethical behavior on turnover intention45, we use a system called Tribefinder, which scans digital documents—including emails and social media posts—through a deep learning algorithm and considers the use of similar words in similar contexts. Tribefinder identifies tribal affiliations of individuals based on the words used by “tribal leaders”46. Tribefinder builds models of different tribes using LSTM47 and Tensorflow48 and trains their models with the Twitter streams of tribal leaders. The Machine Learning system built into Tribefinder assigns tribal membership based on word usage of individual tribe members on social media. The system proved to reach high classification accuracy values and Cohen’s Kappa49. It computes a dictionary of tribal words and their distribution in the text using a probabilistic distribution of a dictionary of millions of words called “word embeddings”. Once a tribe is created, the tribe members are plotted in proximity to each other, based on word usage and how they fit in with the predefined tribes51.To overcome these limitations traditionally associated with survey methods46 or via email21. For instance, Morgan and Gloor21 analyzed the communication habits of three morality tribes, i.e., nerds, treehuggers, and fatherlanders, and found that these tribes significantly differ in how they communicate by email. Recent research has used digital traces such as emails and social media posts to predict emotional and behavioral traits from email communication. Gloor and Fronzetti Colladon51 found that communication patterns measured through e-mail interaction correspond with the ethical values of a person.Researchers have been using machine learning to identify ethical tribe categories based on the content shared on TwitterMotivated by the discussion on the impact of ethics on performance in the previous section, we explore ethical and unethical behavior via the words used by team members, categorizing individuals into three tribes, ethical “bees”, moral “ants”, and amoral “leeches”.52, where AI-based methods are introduced to identify the personality, moral values, and ethics of individuals based on their body language and interaction with others. Additionally, six other “personality attribute tribes” were created to cross-verify the bees, ants, and leeches. We have chosen the representatives of these personality attribute tribes based on their perception in newspapers such as USA Today and People magazine and on Websites such as quora. Indeed, it has been shown that the language that individuals use in blogs and online forums can be a strong signal of their personality53. For instance, for the “arrogance” tribe, members were chosen from celebrities with a reputation for arrogance, such as Charlie Sheen or Will Smith. For the “modesty” tribe we chose celebrities with a reputation for modesty, such as the Dalai Lama and Emma Watson. For the “fairness” tribe we considered social advocates and human rights activists. Lastly, the “unfairness” tribe was built based on people like the editor of “Breitbart News” and hedge fund managers. The last two tribes are the “interest” tribe – subsuming curiosity, a passion for learning, and exploration of unknowns, with members such as Steven Pinker and Bill Gates—and a “disinterest” tribe of “couch potatoes”, that are individuals who are primarily interested in their hedonistic pleasures with members expressing their boredom on their Twitter profiles. It was quite hard to identify exemplary members for each tribe as, for instance, Lady Gaga has a reputation for being a comparatively modest down-to-earth artist, but artists in general by nature are gregarious extroverts and anything but modest. We, therefore, carefully cross-checked each member of these tribes by looking at their tweets and making sure that the tweets of members of the modesty tribe showed a very low arrogance score, which helped eliminate celebrities like Lady Gaga from the tribe.To identify automatically tribal affiliation of “bees”, “ants”, and “leeches”, three tribes for Tribefinder were created, with the bee tribe leaders being open-source developers and artists, the ant tribe members being competitive athletes, and the leech tribe leaders being hedge fund managers and peddlers of “getting rich quick” schemes. In general, we relied on the procedure suggested by GloorTo verify the validity of our approach, we carry out an email network and content analysis, considering three different e-mail archives. For each archive, we build a social network based on the email interaction of individuals and teams, and we analyze the content of email bodies or subject lines. In this network, each email account is represented as a node, with emails translating into one or more links connecting different nodes.The first dataset, called “COINcourse”, consists of three cohorts of students enrolled in an international seminar on Collaborative Innovation Networks over three semesters, with a total of 89 students working in 21 groups. The performance metric is the final grade for each group, given by three instructors. The email archive consists of 89 students sending a total of 871 emails. The contents of emails sent by the 89 students were used to calculate their behavioral and emotional scores.The second dataset, called “Healthcare Innovation”, consists of emails exchanged by 101 group members working in 11 innovation teams in the healthcare environment. The performance, innovation, and learning behaviors of each team were rated every other month for a year by three supervisors, who individually rated team performance, the capability of a team to learn new things, and the innovativeness of problem-solving methods.The total email dataset includes 1782 actors (the outgroup) sending 286,029 emails, which was used for calculating the network metrics, while the content of the 191,519 emails sent by the 101 group members (the in-group) was used for calculating their behavioral and emotional scores.54. The total email dataset includes 1752 actors who sent 769,125 emails (the outgroup). This was used for calculating the network values, while the subject lines of the 126,978 emails sent by the 91 managers (the in-group) were used to calculate their behavioral and emotional scores. Note that, for this dataset, we were only able to obtain the subject line of emails, instead of the content of the entire email exchange, because of privacy restrictions. However, it has been shown in earlier work that for e-mail content analysis, metrics derived from the subject line are correlated with metrics derived from contents55.The third dataset, called “Service Company”, consists of 91 managers who are part of 17 groups serving 17 large international customers of a global services firm. The managers are rated individually by their supervisors using three categories: outstanding, excellent, and good. The group performance is rated using the Net Promoter Score (NPS) collected from each group’s customers. NPS is a measure of customers’ loyalty to a company and is calculated using the answer to a key question “On a scale from 0 to 10, how likely is it that you would recommend a company (or brand) to a friend or colleague?”56.Research has shown an intrinsic connection between ethical behavior and emotional response to an event. To support our method, we relied on the Basic Emotion theory, which proposes that human beings have a limited number of “biologically basic” emotions, including fear, anger, joy, and sadness57, or various adaptations of the Circumplex model, where each emotion is located on a quadrant that reflects varying amounts of hedonic and arousal properties. Other researchers investigated the role of specific emotions, including shame and empathy, as they play a fundamental role in morality, with guilt being often considered the quintessential “moral emotion”58.A different classification has been offered by the Dimensional Theory of emotion, which uses three dimensions: pleasant-unpleasant, tension-relaxation, and excitation-calm60. The Basic Emotion Theory was adopted by a recent study that used facial emotion recognition to predict emotional response to visual stimuli, which highlights the strong association between personality characteristics and moral values of individuals61. Based on an individual’s moral values, the individual will show different emotional responses. Therefore, besides the personality tribes, we also compute the emotionality of the emails using four categories: anger, fear, happiness, and sadness. The Tribefinder was trained to recognize these emotions, following a procedure similar to that used to classify personality attributes, i.e., training an AI model. We focus on these basic emotions as they have been considered by many to be the prototypical ones62. A combination of these emotions leads to more complex ones, as shown by Ekman’s Basic Emotions Theory63. The Basic Emotion Theory represented an appropriate framework to train the AI algorithm behind the Tribefinder, as it offers a classification of a limited number of emotions  that are biologically and psychologically “basic” to all human beings.To improve the accuracy of the algorithm built within the Tribefinder, we chose the framework of the Basic Emotion Theory, as it proposes a basic classification of four fundamental emotions, namely fear, anger, joy, and sadness. These emotions have been preserved because of their biological and social functions are associated with an organized recurring pattern of behavioral components65, to identify individual prominence  and information brokerage . The average response time (ART) indicates how fast an individual or a group responds to e-mails, offering insights into the degree of respect that an individual commands and the level of commitment they show66. We also distinguished between “alter ART” and “ego ART”, respectively indicating the time taken by recipients to answer an actor’s emails and the time taken by that actor to answer the emails they receive. These metrics are part of the six honest signals of collaboration described by Gloor67. Table In addition to analyzing the language used in email communication, we calculated key social network metrics, including degree centrality, betweenness centrality, and average response timeOur analysis followed two steps. First, we examined the behavior of people classified as bees, ants, and leeches and then related these roles to performance with metrics at both the individual and group level.Figure To evaluate the significance of mean differences, we carried out an analysis of variance, as presented in Tables As shown in Fig. The analysis of social network metrics indicates the presence of different behavioral patterns, again depending on the dataset. For example, we find that bees are much more central in the email network while considering the COINcourse and Healthcare Innovation dataset—both in terms of degree and betweenness centrality. On the other hand, leeches are more active—they send more messages and have a higher degree—in the Service Company dataset.As the second step of the analysis, we looked for a relationship between performance and the individual classification of participants as ant, leech, or bee. The regression analysis produced the models presented in Tables In Table As already mentioned, individual performance was judged by the supervisors of the managers participating in the study, while group performance was evaluated by the company’s clients and measured as customer satisfaction through the NPS indicator.Results from the regression analysis Table  indicateIn Table As Table Table In the COINcourse dataset, student groups that achieved a higher grade had more bees and fewer leeches , leeches are systematically emerging as being more arrogant and with less curiosity and passion for learning than bees. Leeches are also the tribe with the lowest happiness levels. This is consistent with previous studies looking at narcissistic behaviors through the lenses of social media posting. For example, leeches in our study display partially similar traits to the “takers”, a personality type described by Adam Grant69, people tend to be happier when they work together for a worthy, non-individualistic purpose.Our study also found that bees are less fearful than leeches. A possible explanation is that bees are driven by collaborative values of helping others independently of what they can receive in exchange. An interesting result is that ants seem to be happier than leeches. This might be explained by their desire to conform to society and rely on social norms to feel accepted by other members of their organization. Ants may be happier because their behavior better aligns with the social norms of their community, making them feel cheerier and at ease in their community. As demonstrated by Helliwell70. The highest performing groups also had a lower number of leeches and were composed of fewer arrogant employees, which is consistent with previous studies demonstrating the importance of humility and its impact on performance71. For instance, Nevicka et al.72 found that a leader’s narcissism inhibits information exchange between group members, negatively impacting group performance.Results were not always consistent across datasets. In the service company, individual performance was higher when managers were less arrogant and displayed traits typical of the “ant” tribe, such as valuing conformity and security and being tendentially conscientious and fair. This can be explained by a tendency of managers to provide positive assessments to employees who “fit the mold”, who are more aligned with expectations and follow shared values and morals. Since “bees” tend to take more social risks and are open to trying new things, this could translate into less easy behaviors to manage and control. Not surprisingly, groups that received higher evaluations were the ones that answered emails faster. This is aligned with previous studies showing that responding to emails at a reasonably fast rate improves customer satisfaction73. Groups focused on innovation tasks might benefit from having a lower degree centrality, reducing the number of connections to others, and inviting as few leeches as possible. As demonstrated by Buffardi and Cambell73, people who behave like leeches have significantly more friends, often establishing superficial connections with the mere goal of advertising themselves. Because innovation, in particular at the idea generation stage, is a process of trial and error that leads to fluctuating emotions, it was not surprising to see that highly innovative groups were more emotional. Throughout the creative process of idea generation, it is natural to go through happiness when groups push things forward and emotions can turn negative when new problems emerge. Experiencing fear is also a possible sign of commitment, as group members demonstrate attachment to the project and care about the group success. While negative emotions might sometimes act as distractors in the professional and personal sphere, discrete negative emotions like fear and anger may spark proactivity and can be expected during the chaotic innovation process, as shown by studies exploring the relationship between affect and creativity74. Another result from the Healthcare dataset—consistent with the positive effect of bees on group performance—is that groups improve their learning outcome if there are more bees and fewer leeches among them. Again, bees are characterized by a desire for learning and caring for others which are roles often associated with open innovation75. The surprising result that learning abilities are higher when group members are less fair and more arrogant might be explained by the need to incorporate some level of competitiveness within and among groups in order for learning to occur. See Cagiltay et al.76 for a detailed explanation of how competition enhances learning and motivation.In the Healthcare Innovation dataset, the presence of bees—i.e., individuals who are open to learning, try new things, and care for others—has a positive impact on group performance. A possible explanation is that bees might be acting as motivators for the group promoting idea generation, thanks to their tendency to embrace social risks and be open to new things. Results from the healthcare innovation dataset indicate that having leeches in your group may decrease your collective ability to innovate and learn. This might be explained by the tendency of leeches to favor self-promotion and to advertise their accomplishments rather than advancing the group’s goal77. The impact of arrogance on group performance might be explained by incorporating the natural level of competitiveness that students develop prior to any class presentation. Higher group performance was also associated with higher betweenness centrality, highlighting the important role of students who acted as spokesperson  and knowledge brokers between group members, other groups, and the instructors.The results of the analysis conducted on the COINcourse dataset confirm the same conclusion we found in the Health Innovation dataset regarding the importance of forming groups that have more bees and fewer leeches. In this case, groups increased their chance of getting a good grade if there were more caring students and fewer self-centered students. At the same time, a surprising result was that when groups acted more arrogantly, they had a higher chance to get a higher grade, which contrasts with other studies showing that arrogance is negatively related to self-and other-rated task performanceFigure In this study, we investigated how organizations can effectively manage individual and team ethical behaviors—exemplified by bees and ants—while avoiding unethical ones—as exemplified by leeches. To this purpose, we measured the impact of behavioral and emotional traits on group performance, with a focus on the role of ethical behaviors in determining real-world success. Based on three different contexts, our findings indicate that exhibiting moral values, being fair, being open to others and new things, and caring for others, correlate positively or negatively with success depending on the tasks.68 and ethical leadership17 by suggesting that building groups composed of individuals with traits and values typical of bees and ants can lead to success. In contexts where groups are asked to come up with innovative ideas and learn from others, the presence of arrogant leeches might be detrimental to success. In other contexts where groups are tasked with responding to customer questions and solving their issues, or when they are tasked with presenting results in a classroom environment, group performance is higher if individuals are more self-oriented, unfair, and take ethical risks. This is aligned with evidence provided by evolutionary biology studies, where social animals face recurrent opportunities to engage in nonzero-sum exchanges: humans and other mammals who engage in cheating rather than cooperative behaviors and react with emotions that induce them to play “tit for tat” have been found to have an advantage over those who had to figure out their next move using their general intelligence23.This study corroborates evidence from organizational psychologyWhile bees, ants, and leeches represent three fundamental styles of social interaction based on moral and behavioral values, the lines between them are not hard and fast. For example, having ants might be better for some tasks and detrimental for others, and different configurations might be better, depending on contexts and business cases.This study contributes to the theories and practice of ethical decision-making by proposing the adoption of a new methodology based on computational social science that links ethical behaviors with business outcomes. The limited sample of individuals represents the main limitation of the study. Future studies should consider larger datasets and incorporate additional control variables, such as age, gender, or tenure within the organization, which we could not consider in this study due to privacy agreements. To conclude, we hope that in today’s age of big data, aggregating the ethical understanding of large groups of people through machine learning will assist in recognizing and rewarding the ethical courage of today’s “Anton Schmid” without a 50-year delay.The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of MIT (protocol code 170181783) on 16 February 2017.Informed consent was obtained from all subjects involved in the study.


Experimental Sessions, end of second paragraph:There was an error in the original publication . The des“A dorsiflexion was applied in this position. Then, the volunteer performed a cervical extension concomitantly with the release of the ankle toward a neutral position. Subsequently, a cervical flexion was again performed with a concomitant dorsiflexion” should be replaced by “Then, the volunteer performed cervical extension concomitantly with dorsiflexion. Subsequently, cervical flexion was performed again with concomitant plantarflexion”.The authors state that the scientific conclusions are unaffected. This correction was approved by the Academic Editor. The original publication has also been updated.


CAKUT stands for Congenital Anomalies of the Kidney and Urinary Tract, and the acronym first appeared in a review article published in 1998. Since then, CAKUT has become a familiar term encountered in the medical literature, especially in nephrology journals. I reason that the term CAKUT was conceived as not a simple description of various diseases, but more as shorthand for a bold conceptual package that linked the occurrence of diverse types of anatomical malformations with insights from genetic and developmental biology research. Moreover, the angiotensin II receptor type 2 was seen as a paradigmatic molecule in the pathobiology of CAKUT. I contend that the acronym, while appearing as an intellectually good idea at the time it was conceived, has outlived its usefulness. To reach these conclusions, I focus on the complex of research observations that led to the theory behind CAKUT, and then question whether these scientific foundations still stand firm. In addition, it is noted that not all clinicians have adopted the acronym, and I speculate why this is the case. I proceed to demonstrate that there is an incompatibility between the semantic meaning of CAKUT and the diseases for which the term was originally conceived. Instead, I suggest the acronym UTM, standing for Urinary Tract Malformation, is a simpler and less ambiguous one to use. Finally, I contend that the continued use of the acronym is a regressive step for the disciplines of nephrology and urology, taking us back two centuries when all kidney diseases were simply called Bright’s disease. Through his dissection studies undertaken five centuries ago, Andreas Vesalius observed that the kidney was connected to the urinary bladder by the ureter, thus providing the anatomical basis for the idea that these organs acted as a single functional unit that makes and then excretes urine . This coCAKUT stands for Congenital Anomalies of the Kidney and Urinary Tract, and the acronym was first used in the medical literature in 1998 [The acronym CAKUT first appeared in the medical literature in 1998 in a review article by Yerkes et al. . The resNishimura et al.  wrote “PAGTR2 that codes for the angiotensin II receptor, type 2. The variant was shown to perturb the efficiency of AGTR2 mRNA splicing. They further concluded that “…a remarkably strong association exists between the incidence of congenital anomalies of the kidney and urinary tract and the mutation”. These analyses were undertaken in Caucasian individuals from the USA and Germany comprising healthy controls and patients with UPJ. The same research paper explored urinary tracts of mice with null mutation of AGTR2 and the authors wrote that these mice “…have phenotypes that remarkably resemble human CAKUT”. Around one-fifth of males and 5% of females had “grossly identifiable CAKUT”, mostly hydonephrosis, megaureter, or kidney dysplasia. Moreover, on cystometry, VUR was induced at lower hydrostatic pressures in null mutant mice compared with wild-type mice. Investigation of AGTR2 null mutant embryonic mice showed an altered prevalence of apoptotic cell death around the stalk of the ureter [Nishimura et al.  reportede ureter . Indeed,e ureter .AGTR2 null mutant mouse embryos there was an abnormal site of ureteric bud (UB) initiation from the pronephric, or Wolffian, duct. The UB is the epithelial tube that matures to form the urothelium in the stalk of the ureter as well as kidney collecting ducts [A follow-up paper from the CAKUT research group  reportedng ducts . It was ng ducts  who noteIn a review article summarising their breakthrough CAKUT research studies, Ichikawa and colleagues  wrote thTherefore, the term CAKUT was conceived not as a simple description of various diseases, but more as shorthand for a bold conceptual package that linked the occurrence of diverse types of anatomical malformations with insights from genetic and developmental biology research. Moreover, the angiotensin II receptor 2 was seen as a paradigmatic molecule in the pathobiology of CAKUT. With the benefit of hindsight, let us now consider whether CAKUT’s underpinning scientific concepts still stand firm.AGTR2 gene is indeed a key player in human malformations. A statistically significant association between the AGTR2 A-G transition in intron 1 variant was found in an Italian cohort with VUR, kidney hypoplasia, MD, or UPJ [AGTR2 [AGTR2 variant studied by Nishimura et al. [AGTR2  that would parallel the null mutations of AGTR2 mull mutant mice [First, one can seriously question whether the , or UPJ . In cont, or UPJ . MoreoveJ [AGTR2 . FurtherJ [AGTR2  did not a et al. . Finallyant mice , 11 do nAGTR2/CAKUT link appeared attractive to Nishimura et al. [AGTR2 gene is on the X-chromosome; accordingly, males carrying an AGTR2 variant on their sole X-chromosome would be predicted to have more severe disease than a female carrying one variant and one normal copy. Their simple statement about sex distribution in CAKUT [AGTR2 do not, however, have congenital BOO [Second, a key reason that the a et al.  was becain CAKUT , howeverin CAKUT . Congeniin CAKUT  as beingin CAKUT , and is ital BOO . Thus, tital BOO , yet famital BOO .AGTR2 have linked kidney malformations with an aberrant bud origin. An example is provided by forkhead box C1 (FOXC1) mutant mice that are born with duplex ureters and malformed kidneys [FRAS1) or related genes such as FREM2 [hepatocyte nuclear factor 1B (HNF1B); this is currently among the most common genetically defined causes of a CAKUT [Third, how does the misplaced UB origin theory hold up as a cause for the various malformations in the CAKUT term? Certainly, there are other examples of developmental biology studies where mutations of genes other than  kidneys . On the  kidneys , 24. For kidneys  and is cas FREM2 , 26. Theas FREM2 , 24. Ano a CAKUT . Modelli a CAKUT  or with  a CAKUT  each sugFinally, emerging work suggests that ectopic UBs do not explain congenital BOO. While possible genetic bases of PUV remain to be defined , it has It has been noted that when CAKUT runs in families, the particular type of malformation can vary between affected individuals . For exaPaired box 2 and Sine oculis 1 [What might account for this variability is under investigation. One explanation could be that a more severe phenotype requires that the affected person carries variants in more than one gene, as described for oculis 1 . Anotheroculis 1 , 38, or oculis 1 –41, or aoculis 1 , 42 can Thus, variable expressivity may have complex genetic and/or environmental origins. It is here acknowledged that this concept may be more easily explained to families by counselling them that they have a propensity to a disorder called ‘CAKUT’, a term that includes different phenotypes. On the other hand, while it is correct that, for example, kidney hypoplasia and kidney dysplasia can occur in one kindred , the ‘CAIt has been commented that the medical community is attracted to using acronyms  and thatClinicians and scientists are professionals who typically demand precise language in their daily work, but does the term CAKUT serve them well in this manner? What, exactly, does the acronym CAKUT stand for, and do the individual words even make semantic sense? Let us start by breaking down the individual words and phrases using established dictionaries , 46. TheMoving along in breaking down the meaning of individual words that comprise CAKUT, the word ‘kidney’ should pose little challenge to readers of this journal. The dictionary definition is “one of a pair of vertebrate organs situated in the body cavity near the spinal column that excrete waste products of metabolism”. In contrast, the definition of the phrase ‘urinary tract’ may be less familiar and the dictionary definition is “The tract through which urine passes and which consists of the renal tubules and renal pelvis of the kidney, the ureters, the bladder, and the urethra”. Even more explicitly, according to the National Institute of Diabetes and Digestive and Kidney Diseases , the ‘urPutting this all together, a more accurate acronym to describe the collection of CAKUT disorders as originally conceived by Yerkes et al.  and NishPediatric Nephrology, 22 in Kidney International, and 15 in Journal of the American Society of Nephrology. The second most popular speciality appeared to be genetics, for example with eight publications in the American Journal of Medical Genetics, seven in the American Journal of Human Genetics, and six in Human Molecular Genetics. In fact, considering all the articles, the word “gene” plus “CAKUT” appeared in the title or abstract in 235 (43%) of the total 545. Of note, in this CAKUT/gene subset, around 20% of the publications came from just three prolific research groups. This is consistent with observations by Pottegård and colleagues [As assessed by a PubMed search on 23 December 2021, there had been 545 papers published since 1998 that had “CAKUT” in the title of the paper and/or the abstract. Since its inception in 1998, the use of the acronym appears to have reached a plateau, with between 81 and 89 publications per year recorded in the last three years of the search. Classifying journals by topic, CAKUT was most popular in kidney journals, with a total of 26 papers in lleagues  that medJournal of Pediatric Urology, a publication with many articles about urinary tract malformations, only had only five articles with “CAKUT” in the title or abstract. Furthermore, the Journal of Urology, a publication with a subsection devoted to pediatric urology, had only five articles featuring “CAKUT”. Thus, urology journals rarely use the acronym, most probably because it alone transmits no useful anatomical information and surgeons need to know the precise anatomical diagnosis such as PUV, UPJ, or VUR. It is also the experience of this author, having worked in several UK nephrology departments since the inception of the CAKUT term, that the acronym is not generally used in everyday clinical practice, for example as written in clinic notes or referral letters. Instead, specific anatomical diagnoses are used in clinic notes, in-patient summaries, and operation notes. Summarising these observations, “CAKUT” is typically used in the context of a research article with the focus on possible genetic bases, rather than the precise anatomy, of urinary tract malformations.A very different perspective is apparent when looking at urology journals, with few articles that invoke “CAKUT”. Strikingly, the As reviewed in great detail by Cameron , two hunWith the above in mind, we need to ask why a modern nephrologist would want to use the term ‘CAKUT’ when this contains such a wide range of structural malformations and also given that, as discussed earlier, there is no one developmental biology mechanism or genetic cause that links all these malformations. Another way of considering this is to ask whether modern nephrologists would adopt a new acronym covering diseases acquired after birth to complement, or as a mirror image, the term CAKUT. Let us call such a term “AAKUT”, or Acquired Anomalies of the Kidney and Urinary Tract. AAKUT would encompass all structural anomalies of the tract including hydronephrosis secondary to a ureteric stone or prostatic enlargement, as well as the gross distortions of kidney shape produced by autosomal dominant kidney disease or recurrent scarring episodes of pyelonephritis. This author believes that AAKUT would never be adopted by the current clinical and research communities and would be seen as a regressive step back to the era of ‘Bright’s disease’. If one agrees with that line of thought, why would one ever want to use CAKUT?Table


Singapore launched a population-based organised mammography screening (MAM) programme in 2002. However, uptake is low. A better understanding of breast cancer (BC) risk factors has generated interest in shifting from a one-size-fits-all to a risk-based screening approach. However, public acceptability of the change is lacking. Focus group discussions (FGD) were conducted with 54 women (median age 37.5 years) with no BC history. Eight online sessions were transcribed, coded, and thematically analysed. Additionally, we surveyed 993 participants in a risk-based MAM study on how they felt in anticipation of receiving their risk profiles. Attitudes towards MAM  have remained unchanged for ~25 years. However, FGD participants reported that they would be more likely to attend routine mammography after having their BC risks assessed, despite uncertainty and concerns about risk-based screening. This insight was reinforced by the survey participants reporting more positive than negative feelings before receiving their risk reports. There is enthusiasm in knowing personal disease risk but concerns about the level of support for individuals learning they are at higher risk for breast cancer. Our results support the empowering of Singaporean women with personal health information to improve MAM uptake. Breast cancer is the most common form of cancer among females globally and evidence strongly suggests that early breast cancer detection can save lives ,2,3,4. CSingapore has one of the highest age-standardised breast cancer incidence rates in Asia . With thGiven the low mammography uptake despite a multitude of efforts to increase accessibility to screening, a more efficient way forward might be to focus mammography screening efforts on those most at risk of developing the disease ,12. “ForAmong the three types of risk factors , genetic information may be the least familiar to the public ,19. HoweThe advantages of personalised risk assessments and genetic testing may not always outweigh the disadvantages. A significant proportion of women continued to overestimate their risk after receiving their assessment results and may require specific reassurance from specialised medical professionals if they are offered less frequent screening . SchwartAs studies from other countries have shown, in addition to a reduction in costs, risk-based screening can prevent more breast cancer deaths while maintaining the same number of false positives results as age-based screening . HoweverThe study had two components; focus group discussions and surveys.Research design:women with no history of breast cancer. All participants gave their informed consent to take part and the research was approved by the A*STAR IRB (Reference number: 2021-077). The research design and report followed the COREQ checklist . Eight oParticipant sampling and recruitment:women with no history of breast cancer. Fifty-four participants took part in eight scheduled focus group discussions while a further sixteen were not able to attend any focus group session. A consistent response pattern emerged and participants brought up no new information from the sixth session onwards, thus confirming that data saturation had been reached ), Intrinsic motivations include family history  and having a peace of mind (“It’s just kind of peace of mind to make sure that everything is okay” [F18]). 2.Attitudes towards personalised risk assessmentsIn response to the sample breast cancer risk reports, the participants gave feedback on the risk reports. They commented that they wanted more information on the risk level rather than it being just listed as “Above Average” or “Below Average” . The report was also said to be quite lengthy and could include more graphics instead (“…less wordy and more pictures” [F23]). The recommendations should also be more specific and actionable .Nineteen of the fifty-four FGD participants outwardly said they welcome a risk-based screening paradigm, and many said they would be inclined to attend regular mammography after receiving a personalised breast cancer risk profile. Six FGD participants explicitly expressed that they did not feel that risk-based screening was useful or necessary. The sub-themes we identified were related to (1) living in fear, (2) self-fulfilling prophecies, (3) rationalising fear and adapting positively to the information, and (4) suggestions to overcome the hurdles of increasing the acceptability of risk-based breast cancer screening. Sub-theme 1   Living in fearParticipants said they would be living in fear if the report said they were at high risk of developing breast cancer. Many would be psychologically affected and anxious, affecting their lifestyle and life plans.F10: It’s not everyone that can cope in the positive way of knowing the risk, say okay I’m changing my whole life. They could change their life but become depressed. They’re so scared of anything, they don’t want children, they don’t want to pass it on, they don’t want to [do things]. Yes it’s a risk of one in 1000, but I’m not taking that chance.F10: you’ll just keep thinking about it. And sometimes, from my experience in genetic testing, sometimes if you give such a report, they might not get cancer at all, but they will be scared for life.Sub-theme 2   A self-fulfilling prophecyA further deterioration of one’s life could occur if the person receiving the risk report feels resigned that the estimated risk level determines their life outcome. In receiving a high-risk result, some might feel helpless and not change their lifestyle.F39: may become a bit of a self-fulfilling prophecy. I don’t know like if you are showing that you’re high risk, then maybe you will think like aiya I will confirm get it and you continue with your unhealthy lifestyle.On the other hand, those receiving a low-risk result might be less inclined to maintain regular screening and a healthy lifestyle.F31: Oh I’ll consider not doing screening already.F28: I agree with F31, if my risk is below average then I will be less hard working.Sub-theme 3   Rationalising fear and adapting positively to the information receivedDespite the above challenges, most participants felt that they could rationalise the fears and use their risk profiles to their advantage. Participants look forward to possessing the increased amount of information on themselves from the risk reports as they can use it to make better health decisions. They accept that while those people at a high risk of contracting breast cancer may need to go for a more regular mammography, there are those at a low risk that can reduce their number of mammography visits, thereby spending less money on their healthcare. Many also feel that any outcome is beneficial since more regular mammography visits mean the people at high risk can catch any potential breast cancer at an early stage.F17: The more you know, I think it will be better. At first you’ll feel scared right but still have to do something about it, for the sake of your children.F18: Yeah same thing. I mean at the most you’ll be a bit more anxious. But I think it will lead you to make better decisions about your health as well.F10: It’s, this is a strange irrational thought, but it’s really like you’re looking for trouble. But of course, the rational side of you is saying that…like you said, the sooner you know, the better, although your life would change to turn upside down, but at least, there is a better chance of fighting it.Sub-theme 4   Suggestions to improve acceptability of risk-based breast cancer screeningThere are three ways that would help participants address their fears and uncertainty: a. clear communication of risk results, b. follow-up plans for personalised risk assessment, and c. providing actionable steps to manage their personal risk.Clear communication of risk resultsThe process of administering such tests must be properly carried out in such a way that the person fully understands the potential outcomes and consequences before performing the test. F19: I think it was mentioned in the beginning, that fear might be a factor in getting screening or getting your results or something. So, if fear is a factor, knowing more, if the information is not good, then it might deter some people.F4: But I can also see how it will be confusing for people. Well, I think it’s quite dangerous if it (the result) is misinterpreted, because… individually everyone’s interpretation of 70% risk would be very different.F1: So, this means in the result, if you want to show high risk and low risk, then need to interpret. Like what does it mean low risk, what does it mean high risk.b.Follow-up plans for personalised risk assessmentDespite a person fully understanding their risk level, participants expressed the need for follow-on support to help them come to terms with their results or to express their feelings and reactions. Calls for psychological help and support groups were raised by the participants for those who would be categorised as having a high breast cancer risk, while those who are at a lower risk should be encouraged to continue going for screening.F10: I’m concerned with those who will get 90% results, or prediction. Like you just drop the bomb then bye bye… There should be some kind of plan all around. Like encourage those that are low risk to still go screening and those that are high risk, support them through their anxiety. Because you could be predicted to have 90% of getting it but that you never get, and then you live the rest of your life in fear.F10: You know, so it can change your life, whether it’s positive right and the person who gave you that information or did all those tests, they are no longer there. So if there is no comprehensive, discussion program, or psychologist and sociologist, then I’m not really sure [about it].F24: If it’s high risk, so I hope that there is a number, I can call in and seek for advice, what is the next step to be done… So, if only they have a support group. Once if ’you’re diagnosed is the above average not necessarily you contract, but that that is that you can actually call the support group where they can actually advice and encourage you to go for further checkup...c.Providing actionable stepsA common view among participants was that the risk level meant little to them if they could not do anything about it. They wanted actionable steps that could be tailored to their lifestyle in order to improve their well-being and lower the risk of cancer.F25: Unless the doctor has a better way to prevent it, you know by letting us know, and they have a remedy to take for us, otherwise there’s no point to let us know, it is better we don’t know than to know.F23: So what if we know about that risk, we cannot change anything so, what do you want us to do. I mean it is information and then so what? Then, that you go back to the point that. People may not want to know at all, maybe they do not want to go testing because they cannot do anything about that you can achieve this cannot. Certain risk factors can like lifestyle smoking drinking, you can change them, but not your genes, So what can you do?F46: I think actionable is very important. Like what F43 said. If there is nothing I can do about it, then don’t tell me. But if you tell me you are at this risk then you do this this this to mitigate, or reduce your risk, then I think it’s useful information.Sub-theme 5   Personalised risk assessment affects decision to go for screeningDespite all the above concerns, the final point is that the majority of participants feel that the personalised risk assessment is useful and will be more inclined to screen regularly after receiving a high-risk result.F4: I think all things considered, it probably will (make me screen regularly).F7: I think this will definitely help. It will scare us but also help in our future screening. And we will keep this in mind, that we will need to get screening regularly, if there is a percentage.F15: I agree. If I’m told I’m above average risk, I would be more strict about going for regular screenings.F18: So if it’s like an above average risk, it will definitely make me talk to my health care provider more about what I can do to help to make decisions about my health that can prevent me from getting breast cancer and also, I will definitely be more stringent about doing breast screenings.n = 764, 77%), followed by 119 (12%) Malay, 60 (6%) Indian, and 50 (5%) Others  . The maj) Others . Approxi) Others .n = 804, 81%) expressed positive emotions  in anticipation of receiving their risk assessment reports, of whom 85% (688/804) expressed excitement  expressed negative emotions, the most common was anxiety  (n = 204) expressed excitement. The majority of participants  . It shouFrom our study we identified two main themes: attitudes towards mammography screening and attitudes towards personalised risk assessments. The barriers and motivations associated with using the mammography screening services offered in Singapore in this focus group study are largely similar to those reported in previous work. Under the second theme, participants might be living in fear if they received a high-risk classification, or feel helpless, leading to self-fulfilling prophecies. However, the participants said they were largely able to rationalise their fear and adapt positively to the new information and, with further improvements to the risk assessments, felt that the reports would be useful. This finding was supported by results from our survey where women participating in a pilot risk-based screening study felt more positive emotions than negative emotions about the prospect of receiving their personalised breast cancer risk reports. Singapore is the first country in Asia to launch a widespread, population-based organised mammography screening programme in 2002 . HoweverA review examining strategies to encourage more women to take part in community breast cancer screenings in 14 studies found that promotional methods such as mailed educational material and phone calls increased mammography participation while methods such as letter of invitations, and home visits were no different to doing nothing at all in improving mammography attendance . In anotOur study explored how a paradigm shift from the one-size-fits all approach to personalised feedback and recommendations may be received by the population targeted by mammography screening programs, i.e., women with no history of breast cancer. Our results suggest that participants mostly felt ready to use the information in their breast cancer risk level report in the future, but the risk information will only be useful if it is communicated properly and followed-up with appropriate support. As there are already extrinsic cues to encourage mammography screening, a multifactorial approach which includes raising intrinsic health consciousness may be an alternative way to address low participation rates . Most coOther studies have found similar positive attitudes, largely down to the women wanting more information about their health to make informed decisions. A risk-based approach, in particular, empowers women to evaluate their perceived susceptibility to the disease . A studyn = 560) that there is broad support for the use of genetic tests [One important aspect of breast cancer risk prediction is genetics. Our focus groups found participants to be generally keen on the introduction of risk-based breast cancer screening that includes genetic tests. Genomic technology has quickly proliferated around the world as a result of precision medicine programs, prompting concerns about genetic privacy and the ethics of data sharing . It has ic tests . The actic tests . Nonetheic tests . Howeverwhen or if breast cancer will develop may result in negative emotions associated with fear, powerlessness, and the belief that there is no escaping the disease, which may negate the benefits of risk-stratification [n = 31, semi-structured focus group discussions or interviews) showed that the majority of women appreciate the chance for a risk-based screening programme to guide enhanced disease monitoring, but they were reluctant in accepting decreased surveillance if estimated to be at low risk since they are comforted by routine screening [As this risk-based screening is a relatively new concept to the public, there is uncertainty both in how accurate the results are and a lack of clear understanding on how the results would impact screening behaviour and lives . The confication . Discussfication ,51,52. Mfication ,54. Howefication . Resultscreening ,56. ThisIf there is just as much variability in response to risk results as there is variability in individual risk, effective communication of risk, recommendations, and consequences are essential if risk-based screening were to be implemented . The heaTo gain perspectives of a representative sample of a risk-based breast cancer screening population in Singapore, we looked at the survey responses from women who joined the BREATHE study. The quantitative results from the survey support the insights obtained from the focus group discussions. Respondents felt more positive than negative emotions towards the idea of receiving breast cancer risk assessment results. “Excited” was the most common feeling. More than a third of the respondents strongly agreed that they felt all three emotions including “Excited”, “Optimistic” and “Confident”. The high level of optimism towards risk-based breast cancer screening has also been reported by other studies. For example, in Kelley-Jones et al.’s study, women in the United Kingdom responded favourably towards personal breast cancer risk assessment and found it desirable to accept feedback on their individual risk . HoweverThe public’s grasp of genetics is widely believed to be inadequate. A particular issue to address is who should understand what and for what objectives. Experts must be thoughtful about the boundaries of their own expertise as well as the diverse demands of the various potential consumers of genetic knowledge in order to improve public understanding. In recent years, there has been a lot of media interest that oversells the potential of genetic discoveries, but this coverage is not always helpful and can even be deceptive to families who are at risk for genetic disease . What exFinally, it is also important to note a number of other considerations that limit the findings of our study. As the participants in the FGDs were recruited via online platforms, the participants tended to be technology-savvy people. As women with a higher household income are more likely to screen for breast cancer, it is likely that risk-based assessments will not encourage mammography screening attendance amongst women with lower incomes . In addiWe have several suggestions to improve personalised risk assessments based on the participants’ feedback. Firstly, by increasing the involvement of women in the design of risk reports, they are more likely to buy-in to the idea of personalised risk assessments and a risk-based breast cancer screening programme. With their involvement, the information in the report would also be more relatable and comprehensible to recipients of the risk report. There is an increasing emphasis on patient and public involvement (PPI), which seeks to actively engage participants in the design of research studies, policymaking, or programme development . SeveralA different screening approach may be needed to address the low mammography screening participation rates in Singapore. A risk-based approach is promising—high, but not universal, acceptability, was observed. However, it is anticipated that implementing it as a population-wide screening would present challenging problems. Proper communication of risk results and follow-up plans are needed to ease fears and guide women to make informed decisions on their health. Nonetheless, our study participants generally welcomed the adoption of risk-based breast cancer screening despite the obstacles and restrictions found. Our results from FGD and survey responses support the empowering of women with personal health information to increase health ownership and consciousness to improve screening uptake and adherence.