Mobile health technologies are widely being used for delivering health behaviour interventions. However, there is insufficient evidence that they are integrating theory and only a few researchers utilized a qualitative approach in their study. This paper aims to identify requirements in developing a breast examination awareness mobile app based on the component of the Health Belief Model (HBM) for integration in health promotion strategy. A qualitative approach using semi-structured in-depth interview was utilized in this study. A purposive sampling method was conducted among public women attending hospital services, software and content experts in a tertiary teaching hospital in the East coast of Peninsular Malaysia. These interviews were recorded, transcribed and organized using NVIVO 11. The main themes were identified through thematic analysis of the interview transcripts. A total of 37 participants recruited in this study. The themes that emerged from the analysis are vulnerability, forecasting, reactive, influence, outcome and obstacles. The sub-themes findings supported the HBM’s component in terms of the requirement for are an infographic risk factor, video , info , features  and mobile app’s design. The research findings could provide a guide for future app development from public women, content and software experts. The information will be used to develop a breast examination awareness mobile app integrated with health theories. In Malaysia, breast cancer (BC) is the most common cancer among women and it is estimated that the lifetime risk is one for every 27 female . Besides, the number of women diagnosed with late-stage BC (Stage III or IV) were increasing from 43.2% in 2007 to 2011 to 47.9% from 2012 to 2016 . BC awareness among Malaysian women are also reported as poor  and the distributing factors are associated with educational background, social taboo, family history of BC and ineffective promotion . Breast examination awareness is defined as a technique to examine breast performed monthly by inspection and palpation and become familiar with their breast to recognise abnormalities . Facilitation and intervention in breast examination awareness aim to increase awareness among Malaysian women. The common methods of delivery are through audio, video, letter, brochure, booklet, telephone counselling, newsletter, workshop, broadcast, lecture, electronic teaching aids, handouts , WhatsApp group  and smartphone apps . There has been an increasing interest in breast cancer mobile apps that focus on secondary and tertiary breast cancer prevention . This technology has the potential to promote behaviour change . However, there is lacking study that these mobile apps are integrating theory and utilized a qualitative approach to design and develop apps . A study by Ginossar et al., 2017 reported a gap in the expectation for BC apps and suggested that researchers need to identify user expectations for BC apps. In addition, the currently available mobile apps on breast cancer were lack the involvement of medical professionals, personalized  and contextualized elements based on the local culture . A systematic review of the BC care apps study by Jongerius et al., (2019) found that most of the apps focused on BC management. Meanwhile, Kalke et al., (2020) revealed that most of the apps focused on the BC symptoms and breast self-examination (BSE) guidance. Other delivery method studies that employed HBM as a theoretical framework are cervical and breast cancer awareness screening , breast self-examination . Along with the growth of mobile health technologies, however, there is increasing concern over mobile app performance limited by app design, accessibility, accuracy and data privacy . The challenges arise in designing for the ease of use of the mobile app, including considering the app’s accessibility, which affects the end-user acceptance of the app . Moreover, the app data developed and involving the health professional or academician are more relevant and reliable . Meanwhile, the app’s effectiveness could be limited by the lack of theory-based intervention and insufficient tailored content . Mobile app with tailored contents according to end-user requirement such as public women probably could help in their acceptance and effectiveness of the intervention . This paper aims to present a qualitative exploration of requirements and tailored information involving the user and the experts. The finding will be used to develop a theory-based breast awareness mobile app. The development of content and design is based on the component of the Health Belief Model (HBM). Mobile app development with integrating theory could stress and sustain health promotion behaviour change . The mobile app developed will be used in health promotion for public women. Therefore, improving the aesthetic appeal, user-friendly, acceptability and effectiveness of the mobile app is needed. EthicsEthical approval for this study was obtained from the Human Research Ethics Committee (HREC) of Universiti Sains Malaysia (USM/JEPeM/18080380). Participants were informed about the study purpose and procedures by providing the information sheet. Autonomous right to participate in the study and confidentiality of the subject data were informed to the participants. Written informed consent was obtained from each participant before participating in the study.Study designThe study utilized a descriptive qualitative method with individual, face-to-face, semi-structured in-depth interviews among public women, software experts and content experts to identify the requirement. A descriptive qualitative narrative describes a complete overview of the phenomenon . This qualitative method is used to gain insights into mobile app development and design . The interview guide was constructed based on the HBM domain: perceived susceptibility, perceived severity, perceived threat, cues to action, perceived benefit and perceived barriers. The interview guides provide features and contents based on the HBM component. HBM was chosen because it was proven by several studies to be effective in behaviour intervention through awareness . The interviews were recorded, transcribed and organized using NVIVO 11 software.Sample and settingPurposive sampling was used in recruiting all three groups of participants. A total of 37 participants who fulfilled the inclusion and exclusion criteria were interviewed. Twenty-five participants were public women attending hospital services in a tertiary teaching hospital on the East coast of Peninsular Malaysia. As this study was parts of a bigger study, this setting was chosen as the conduct of the whole study was in the tertiary teaching hospital on the East coast of Peninsular Malaysia. Public women were selected based on the following inclusion criteria: (1) Female, age 18 years old and above; (2) owns a smartphone. Public women were excluded if self-reported mobile app literacy is low. Low mobile app literacy is defined as the inability to find, use, understand and evaluate the apps .Six participants were software experts recruited from the Centre for Knowledge, Communication and Technology in the public university located on the east coast of Peninsular Malaysia. The software experts were selected based on their experience in software design. The software experts were excluded if their working experience is less than two years as only two years and more was regards as competent worker in their field .Meanwhile, six participants were content experts recruited from the teaching hospital located on the east coast of Peninsular Malaysia. The content experts were healthcare professionals selected based on their BC patient’s management . The content experts were excluded if their working experience is less than two years as only two years and more was regards as competent worker in their field .Data collectionth interviews for public women, 6th interviews for content experts and 6th interviews for software experts.Data collection was conducted from April 2019 to July 2019 after obtaining ethical approval from the Human Research Ethics Committee of USM (HREC) and relevant authorities. The interview was conducted according to the participant’s preference time, date and location. A semi-structured interview guide  was usedData analysisWe adopted the HBM component as the themes for the interview guide. All the interviews were audio-recorded. The first step was transcribed verbatim using thematic analysis methods. All the individual interview transcripts were transcribed into an Excel spreadsheet. The second step is generating a primary code to help guide the analysis by identifying similar categorized codes. The third step was followed by rereading and establishing the suitable themes, and the redundancies were removed. Explanatory verbatim quotes were selected cautiously to maintain data validity following the themes. A total of 48 eligible people were invited to participate. Eleven public women could not join due to a busy schedule or not interested in joining after explaining the study. A total of 37 agreed to participate in the study (response rate = 77.0%). Twenty-five public women attending hospital services, six software experts were from the Centre for Knowledge, Communication and Technology and six content experts in a tertiary teaching hospital in the East Coast of Peninsular Malaysia. The initials start with P represent public women, S represent software experts, and C represents content experts. The main results described based on HBM components supported by participants’ statement.Theme 1: VulnerabilityAll three groups were asked about risk factors and symptoms of BC topic. The questions asked for P group to explore what they know about the topic. The C group were asked to list down the topic to describe the scope of content that will be covered by the researcher or any contents that might need to be highlighted in the mobile app. The S group were asked about what they know and to describe the best way to present the content in the mobile app. Subtheme 1.1: An Infographic risk factorMost of the public women were able to identify few risk factors of BC and however unable to state them. Some of the public indicated as follows:Obesity, dense breast and what else? If she smokes, it will increase the risk factor. Hormone imbalance, such as high or low estrogen. That’s it. The estrogen hormone is an imbalance. (Laugh) I don’t remember.” [Participant PAA]“For example, if we sleep at night wearing a bra is one of the factors. I’m not sure about the rest. That is the only one I know.” [Participant PCA]“The simple one because if it’s too long, sometimes the one related to disease with include medical jargon and sometimes people felt that it’s it boring to read. So, we just give the simple one” [Participant PSHM]“Some of the content experts in this study mentioned female gender, increasing age, prolonged estrogen exposure, low parity, first birth before 30 years old, smoking, alcohol intake, breastfeeding, family history and genetics are the risk factors of BC. The risk factors mentioned by the content experts are considered to be included as the content of the mobile application. They expressed their answers as follows:Female, age, exposure to estrogen, low parity, and completion of first pregnancy more than 30 years of age is risk factors, alcohol, smoking, no breastfeeding.” [Participant CMM]“Risk factors of breast cancer are mostly among patient with exposure to estrogen, for example, either they consume OCP or hormone replacement therapy. Mostly those with a family history have it strong we would say. Higher risk if the patient has family who had breast cancer, either mother or sisters. Close relative.” [Participant CF]“We can’t just talk like this. Usually, the aunties will not understand. We usually used infographic video with cartoon images.” [Participant CMI]“Meanwhile, the software experts’ suggested in the interview that the components of risk factors should be separated into two sections which are controllable and uncontrollable and use infographic format as it is easier for the user to refer and understand:If it is controllable and uncontrollable means choose one, then followed by content for uncontrollable. Cannot make it left and right, definitely space will not be enough.” [Participant SMN]““For me, it is better in visual form and if possible, with images. It could alert and clearer for the user. In this context, perhaps each point for each image.” [Participant SZ]Subtheme 1.2: Video of BC’s symptomsMost public women were able to identify a lump as one of the BC symptoms. Talking about this issue, some participants mistook by mentioning the symptom of general cancer and the side effects of chemotherapy as the symptoms of BC:Mass and lump around the breast, maybe discomfort around breast area such as pain when wearing a bra perhaps, or throbbing I guess or perhaps breast is usually soft become thicken, then the texture, I guess maybe the nipple is pulled in and then it is sore, then what else I have read. The breast can become sore, but this usually in the late stage, which already too late. It can be sore, puss, smelly, and it is exposed, bigger wound and what else. The symptoms usually fever, loss of appetite, vomiting, dizzy.” [Participant PNNA]“From what I have read, there is lump, pain, tiring, sort of.” [Participant PR]“Want to know the content, the symptoms for example. Is the skin shrink around it or is it painful in the breast or is it swelling all the time? That is the content that could guide us for self-checking.” [Participant PR]“In the interview, the content experts mentioned BC symptoms, including a painless lump or symptomatic without any lump, which probably missed by the public women. This painless lump could be highlighted in the content. As reported in another study that awareness could enforce routine screening since someone could have cancer without having any symptom:Most come with a palpable lump. Most said cancer is painless right? It is painless because it manifest as a lump. Still, when we ask when you start having a symptom, she said it’s started with something very weak, discomfort which is sometimes you cannot differentiate between breast pain during menstruation. Once it already manifests with a lump, it is painless. It’s a painless lump.” [Participant CJ]“Nipple discharge with colour like blood. It is compulsory to check for that. Our concern is that it could cause by cancer cell in the ductus” [Participant CF]“Go see the doctor!” could be the cues to action for the mobile app’s user:The software experts’ suggestion in designing for the symptoms of BC is in the form of multimedia video with the combination of images and text to help the user understand the symptoms of BC. The BSE video, symptoms’ checkbox and pop-up ‘Go see the doctor!’ were designed on one page to alert the user while performing the examination. The pop-up alert of “Multimedia video which combined image and text is clearer for the user” [Participant SN]“Such as alert for example if you have any symptoms, there’s a pop-up, please go see the doctor or please make an appointment, some sort like that” [Participant SZ] “Theme 2: ForecastingThe next questions are based on the topic of those who are diagnosed with BC and what happened if it is not treated. The questions asked to the P group require them to describe their current understanding of the topic. The C group were asked the same questions as the P group and were asked specifically what are important information for the public to know regarding this topic. The researcher asked for suggestions from the S group on how will they design the mobile app for this topic. Subtheme 2.1: MetastasisThe public women mentioned it metastasize or spread to other parts of the body. Some of the women understand the process of metastasizing, and some are unable to describe, as she said, unsure of the process:I think it will metastasis and spread to other organs too” [Participant PAA]“Spread of course. I’m not sure physically how our breast would be. You know maybe there should be pus or how. Cancer we know that it can cause death” [Participant PWK]“Show the photo of it spreading to make them feel a little scared.” [Participant PNI]“Meanwhile, the content experts mentioned that the public should be aware of benign and metastasis cancer. One of the content experts also relates metastasis with BC staging and survival rate. Thus, the benign, metastasis, staging and survival rate will be included in the mobile application content:For public information, we will state there are two types of cancer; one is called benign, second is metastasis.” [Participant CTAD]“So in stage 4 which it metastasis distally, we labelled it as stage 4. Our option to treat the patient until she’s cured is less due to the low survival rate of stage 4” [Participant CF]“The software expert suggested that the contents should be made in one display to simplify the straightforward explanation. Therefore, the staging of BC according to the TNM classification system was designed in infographic and table:Ok, what are the symptoms for stage three or what are the effects to her, so all is already there in one display.” [Participant SWMF]“It might be loading and slow. So, we make it in one display, simple! Use simple sentences such as tired, imbalance hormone. Use clear, straightforward sentences don’t need to explain everything.” [Participant SWMF]“Subtheme 2.2: Survival The public women in the interviews did mentioned and aware of death concerning BC. However, one participant also expressed that she is unsure about BC survivor:Usually, did not get the early treatment, it can lead to death. Or did anyone survive?” [Participant PCA]“It will burst if already stage 4 and followed by death.” [Participant PNI]“Meanwhile, the content experts stated that even though the statistic of BC is increasing compared to ten years back, the survival rate is also increasing due to the increase of awareness. In the development of the mobile app, the currently available statistic of survival rate by stages, year and ethnicity were included:According to breast cancer statistic, the cases are increasing but at the same time, the survival rate is also increasing because of awareness” [Participant CTAD]“Currently it is about 1 in 8 women. Just to let others know that it is getting serious, the incident is more compared to ten years back. Then, highlight the survival statistic; we have a fixed five years survival rate for every stage” [Participant CF]“One of the software experts also stated that the statistic format with appropriate information could have an impact on the users. Need to show the MAKNA cancer patient statistic according to the death rate, survivor or stage statistic perhaps. It depends on which can give an impact to the user, such as the current statistic which is appropriate in giving information.” [Participant SZ]“Theme 3: ReactiveDuring the interview, the researcher questioned the P group on how to detect BC early and how they would like to have it presented in the mobile app. Besides, when the researcher asked the C group how to detect BC early, they shared their current practice and protocol with the public and the feedbacks of their current methods. Moreover, the S group also were asked what their suggestions are and how the presentation could help the mobile application users when using it.Subtheme 3.1: Video of BSE Public women have expressed that they prefer to know BSE steps with simple sentences. The user needs to know their normal breast and check for any abnormal symptoms. Video of BSE and the symptoms of BC were included in the mobile app as a reference for the users:Explain steps by steps, like when we palpate and not sure is it a lump, normal or mammary gland. So maybe can explain how easy it is to identify the hardness of the lump” [Participant PNA]“They have to teach, maybe can show video, it’s like if you’re going to the hospital they give pamphlet right? It had every photo with hand raised to reach the back and everything.” [Participant PNI]“The current practices, as expressed by the content experts, are using infographic video and breast model mannequin to educate the public women. The BSE video in the mobile app could help the users continue to practice the correct technique of BSE on their own. A cartoon animation was also used in the mobile application development:Usually, we will produce an infographic video that uses cartoon diagrams. Secondly, we will bring breast manikin that has a lump to show the normal and the abnormal. If it’s not normal, we put a marble inside. Detect, try to check carefully. It’s easier because it’s more towards the senses. As touches and observes is understandable even if the steps are wrong” [Participant CMI]“Most of these people are not good at it and so when they come to the hospital at the stage with discharge or pain. There are symptoms showing breast cancer. They even claim to perform it but nothing.” [Participant CTAD]“Even the software expert expressed that the animation should be steps-by-steps, using cartoon instead of a real person and marked the area which needs to be check so that it is clear for the users’ reference:Do some animation to sample the object of the breast. Let’s make the animation change colour. It should be step-by-step.” [Participant SZ]“Probably people are shy if the self-exam is using a human being, can use cartoon to show such things. It might be more interesting, and they are not shy to do it on their own” [Participant SZ]“Keep in mind the one that needs to be check. So, the area areas need to be marked. Such as going to the gym, the affected area will be marked. ” [Participant SNS]“Subtheme 3.2: Screening information and triple assessment.Some public women expressed that they knew about mammogram or BSE only. Resulting to add information on screening examination in the mobile app content:I only know mammogram.” [Participant PAA] “Early detection is that we were told to do our check-up.” [Participant PR] “Some said there is a mammogram at the hospital, but the waiting list is long.” [Participant PNI] “Meanwhile, the interview with the content experts has mentioned mammogram, clinical breast examination and BSE. They also stated that triple assessment should be included to educate the public that it is necessary to diagnose for BC and not by physical assessment only. Thus, the researcher has included content on triple assessment in the mobile application:Screening such as mammogram and a professional examination by the doctor or nurse. Examination of the breast cannot detect an early tumour until the patient can palpate it before proceeding with the investigation. To detect early tumour is by mammogram at the age of 40,45 or 50.” [Participant CMM] “They usually asked the doctor either the lump is cancer or not. We wouldn’t know until we completed the triple assessment. Triple assessment is a mammogram or ultrasound with biopsy. Then, we can confirm.” [Participant CMM] “Besides that, the P group were asked to tell what they know about the treatments for BC and what they want to be included in the mobile application. Similar to the C group who were asked to tell about the treatment of BC. Meanwhile, the S group were asked if they know about BC treatment and how would they suggest the layout of the BC treatment content.Subtheme 3.3: Information on the treatment of BCThe public women responded by answering removal of breast, chemotherapy or radiotherapy when asked about treatment. Moreover, one of the public women has mistaken biopsy as the treatment of BC: As I said earlier, near the early stage, she may have the biopsy, second chemotherapy, that’s all. What people call it ra..ra..ra. ” [Participant PWK]“The treatment is because of never been treated; they don’t know very well. I know most people do is the examination; the one that we do ourselves need to be done regularly.” [Participant PCA]“After the test and it is confirmed cancer, they will remove it followed by chemo then followed by radiotherapy. No more I think because my friend after chemo, radiotherapy and that’s all for her” [Participant PNI] “First of all, the most important are the symptoms. For example, if they had symptoms, they will look for resources. Any place she can refer to, treatments option and then any group supports than could ease her sadness and anything else.” [Participant PH]“The content experts mentioned surgery, chemotherapy and radiotherapy. Usually, the treatment management of the patient is decided by the team after the assessment is done. However, for the content development, brief information related to the treatment was included in the mobile application:The treatments are general surgery, chemo and radiotherapy. But to be specific, we follow the patient’s age, cancer size and cancer size but in general, we remove the primary tumour followed by chemotherapy and radiotherapy” [Participant CF] “But even with chemo[therapy], we will inform that not all patients will undergo chemo. After the surgery, the doctor will consult the oncologist first. If the oncologist suggested chemo, the patient would go for chemo. However, patient even though they did not go for operation yet, still they will ask for chemo first.” [Participant CF]“The software expert mentioned that the content on the treatment section should be developed with diagrams to make it more straightforward. Every explanation is constructed in the most specific sentences and point forms. The suggestion to include the steps-by-steps of the treatment was not included due to the different treatment planning according to individual assessment:Then, each treatment can explain. Elaborate on every section separately.” [Participant SMN]“Display such as typography or figures of surgery, the steps” [Participant SN]“Theme 4: InfluenceIn the interview, the researcher queried all three groups on how would they like to be reminded by the mobile application about breast awareness.Subtheme 4.1: Screening reminder features The public women mentioned that they would prefer if the mobile app have a screening reminder feature that can remind them to do BSE, clinical breast examination or another appointment: It would be great if it can remind us to do a self-examination or check-up at the hospital.” [Participant PAA] “Busy people don’t remember. At least the reminder keep on reminding will trigger the user to do it.” [Participant PNI]“The content expert also mentioned that the mobile app should have a reminder feature with a pop-up notification. This feature was included in the mobile application to remind the users: Next check-up or anything. The reminder. Have you checked your breast, a notification will pop-up once a month” [Participant CMI] “Even the software experts suggested for reminder notification feature which repeats once a month and has an option of snooze or alarm:Notification in the apps itself. Then we can send SMS from the apps itself. It’s like push notification but send as SMS or telegram. However, SMS will be charged, if it is free, its telegram such as telegram boat.” [Participant SMN]“Function like notification. We make a notification to remind her.” [Participant SN]“Then, if we made a reminder that repeats every month, perhaps. This repeat should have the option either snooze or alarm.” [Participant SNS]“Subtheme 4.2: Sharing button Some public women mentioned the ‘share button’ as they were already familiar with the feature that is also available on Facebook. However, event updates are not included in the mobile app as it requires an admin to handle all the update:Share it with your friends; that info is important. If we have info even if we don’t have breast cancer, we can share the symptoms. This, we can tell others.” [Participant PNI]“Easy to share this information.” [Participant PS]“Facebook have the share features which is good if can be included in the apps, let say if today there is free health check-up in USM so that we can share the one in the apps and they will know about it.” [Participant PSHM]“The content expert focus on BSE and the researcher have included the sharing button for the users to share their knowledge and reference just by sharing with their family directly from their phone or by sharing the link to download the mobile app BrAware:Focus on BSE, mammogram screening. If she knows BSE, she can share with her family and her sibling” [Participant CF]“The sharing medium can be through Facebook and WhatsApp as expressed by the software expert:Share it doesn’t matter in FB or WhatsApp, we can link with the button.” [Participant SZ]“Subtheme 4.3: Prompt During the interview, the public women suggested for the mobile app to be able to prompt if the user has any symptom:I think I have a lump. What should I do? Even other people probably don’t know what to do. Maybe if those apps explain if you have a lump and we can hit the button yes or no. So maybe if yes, where to go? Then, if no, go to the next page.” [Participant PNA] “The content experts mentioned visual as a powerful tool, so we included images and videos containing BC symptoms with steps of BSE. The suggestion of OT room images was not included due to the probability that the photos will be misused: For me, visual is a powerful way to educate people if they can’t understand the description.” [Participant CJ] “The images we took only to be shown at that place only. We cannot show them to the public because people will use those pictures to offer their product. That’s why the images that we took in the OT room. We will bring if we’re on the move.” [Participant CMI]“The software expert also suggested including the google maps feature to the nearest centre in the mobile app. Even though video could have more impact compared to text and images, it is mentioned by the software expert that too much video could make the mobile app to be heavy due to the file size. So in this mobile app, only one video was included:Following the latest technology using google maps in the Kota Bharu area, she can search if the apps have the features. Perhaps there she can refer from the centres” [Participant SZ] “If there are symptoms, “act early” “please act early” “please act immediately” “go to the nearest health clinic” or “please do urgent check-up” it’s like an alert to her. [Participant SZ]“Of course, video delivers more impact, but if too much video, it is heavy because video size is big. Animation such as cartoon, the animation is heavy compared to text but is less than a video” [Participant SZ]“Theme 5: OutcomeThe researcher also asked group P. C and S about what is the benefit of BC awareness and having a breast awareness mobile application. Subtheme 5.1: The benefit of early treatmentPublic women mentioned in the interview conducted that early treatment could save a life. Even the content expert said that getting early treatment is awareness among women. Meanwhile, the software expert suggested providing a space to leave a message to book or call back from the hospital:There is still treatment by the doctor to save her for stage 1 and stage 2. If she knew earlier, probably the treatment is not as hardcore such as stage 4” [Participant PR] “The component for early treatment is the patient’s awareness. Patients are aware of how to detect any abnormality in the breast. We are doing a breast screening campaign and the most important thing is to know the normal body and if there is any abnormality, she could immediately go for check-up and confirmation.” [Participant CF] “Maybe a hospital or one place that she can send like a message to booked or call back. At least if you are embarrassed, the hospital will have the detail to call back” [Participant SA] “Subtheme 5.2: BC support groupSome of the public women interviewed mentioned that they prefer to communicate with BC survivors due to their experience. The content experts also expressed this suggestion to include the contact number of BC survivors and BC support groups. Meanwhile, one of the software experts suggested having an open forum feature:I prefer a cancer patient who had survived which means she has experienced it herself.” [Participant PH] “Maybe we can put an expert for them to call. She read but probably got the incorrect information or from misleading person or include the phone number of breast cancer survivor” [Participant CTAD]“Another one is the support group. I think this one you can find such as HRPZ, USM Bestari. If we want all over Malaysia because other hospitals have their support group such as Putrajaya have their support group” [Participant CF]“So just make it an open forum. So I will post for an opinion if someone responded, there is a reply. If no one responded there would be no response.” [Participant SNS]“Theme 6: ObstacleIn the interview, the researcher asked all three groups what are the barrier to breast cancer. The C group were asked how they consult patient or the public who expressed their fear. The S group were asked if there is any layout or design that they could suggest for this topic.Subtheme 6.1: Fear of treatmentThe public women mentioned that she would fear if it is already late-stage and fear of treatment. So, information related to BC treatment should be included in the mobile app. Scared to know that it is already staged 4, it’s bad already if knew earlier scared of the treatment. Scared of doing mammogram and everything.” [Participant PCA]“Some people, if they have a lump, they are afraid to go to the hospital, afraid that the doctor will do things because people always said that chemo is painful which causes hair loss.” [Participant PNI]“Lacking awareness of management and the type of surgery of BC could contribute to women’s fear expressed by the content expert. So, the researcher has included information related to BC surgery to provide some insight to the users. It’s associated with losing one’s breast too. That’s probably one of the bittering factors that prevent them from coming. Thinking the doctor will remove it even though it’s not confirmed. If the size is small, we will remove the affected area only.” [Participant CMM]“One of the software experts expressed to include steps by steps for treatment to create awareness:Awareness for her to go for treatment perhaps. Maybe steps by steps for the first stage, maybe she’s afraid of it.” [Participant SZ]“Subtheme 6.2: Myths and factsIn the interview session with the public women and content expert, the participants did mention the sharp object that can cause the spread of BC. Moreover, there is also an obstacle to getting early treatment, such as traditional healer or alternative medicine. Myths and facts could provide information for the users:But some people said cancer is due to metal such as a knife to spread.” [Participant PNI]“There may be some myths that sharp objects may cause it to be even worse. Our body has made a wall around it. When we did a biopsy, we have breached the wall. Some have documented publication that needle track would have seedling because if we did thru cut biopsy that vacuumed and causing pulled out and left behind. This is probably true; however, we need a biopsy to proceed with the treatment. Unlike if we did a biopsy and did not do anything, definitely it will get worse.” [Participant CMM]“The obstacle is alternative medicine because now alternative medicine is not only ‘bomoh’[traditional healer]. We used to think that ‘bomoh’ is the obstacle because patients seek ‘bomoh’ to avoid surgery, but now we have obstacles from modern alternative medicine such as stem cell and many more. ” [Participant CF] “Our concern is towards diagnosed women who cannot accept their condition. When they cannot accept it, they tend to do unnecessary thing such as seeking for ‘bomoh’” [Participant SWMF]“Moreover, the researcher also asked if any barriers cause them to not use the mobile application. The S group were asked on this topic on how the researcher can improve the mobile application.Subtheme 6.3: Mobile app designSome public women mentioned that they are not interested in the mobile app if it is not interactive, complicated and not easy to access.Among the problems that turn me off is when the apps are primary school level. Have you ever used the JPA website, it’s under the government. When we touch, it’s not too interactive.” [Participant PNA] “Make this app simple, easy for people to access; if it’s simple and appealing people will be interested.” [Participant PNI]“For mobile app design, the software experts suggested using monographic and feminine colour. They also mentioned that the mobile app design should be in simple steps with big buttons, infographics, or the explanation should be in short sentences. They also suggested for side menu and limit the page scroll limit to three times the scroll maximum. Meanwhile, the experts told me not to use a weird font, and the font size can be customized to users’ preference. What matters is the colour and font system itself. Like me, I would focus on design. If possible, don’t use a weird font, not striking colour, in many tones. There is a red colour, blue colour, yellow colour and then a green colour which is the Flintstones era; nowadays we use monographic colour.” [Participant SMN] “If anyone doesn’t see it, they can enlarge it; we customise the font size.” [Participant SNS]“Make it simple, suitable colour, probably feminine colour, one more is that not so many steps required. Big buttons, an infographic is important and avoid long essays.” [Participant SWMF]“Make a menu, click on the side to access the menus, side menu, on top or whatever. Don’t put it on the pages which need to scroll, no need. What I remember is 3, 1..2. enough. (While scrolling on the phone screen). This is one, scroll one page 2, (scrolling) page 3, enough. Two times finger movements, so 3-page maximum.” [Participant SWMF]“HBM components and public women guide this study, software experts and content experts’ involvement regarding their requirement and previous experience designing and developing a tailored breast awareness mobile app targeting public women. Together, these findings provide important insights to enhance breast examination awareness in public women using the mobile app. The end-user and experts’ involvement strategy ensures the mobile app acceptance and appropriateness, including selecting tailored content, design template, user interface, and features . A culturally and linguistically tailored content was proven to promote accessible health promotion and engagement towards BC screening . The development of the content has included some facts to encounter some cultural belief. Besides, the contents also were available in English and Malay. The study by H. Lee et al. 2018, even recommended navigation services to facilitate the users to go for BC screening. However, the google maps provided in our mobile application will navigate the users to the support groups according to states all over Malaysia. Generally, in theory, a higher perceived susceptibility, benefit and removal of barrier contribute to higher preventive action taken . Findings in this study revealed participants group P, C and S expressing the video’s requirement related to BC’s symptoms and BSE. Meanwhile, earlier studies with HBM based using video intervention has reported an increase in knowledge, confidence, self-exam intention, practice, ability to detect lump and reduce the barrier in seeking help . In previous video intervention studies, topics included in the video are risk factors of BC, screening, BSE technique and skills . However, despite promising results from the video intervention used in many studies, the video content has not been optimized or standardized by competent authorities . Thus, the involvement of the content and software expert in this study is an appropriate measure to corroborate the mobile app’s content for breast examination awareness among public women. From the qualitative research, the participant’s group S alluded to the notion of designing an infographic BC risk factor. Group P mentioned they preferred it to be simple and group C are already using infographic video. This finding was unexpected, and this result has not previously been described. There are, however, other studies that applied infographic design such as in cardiovascular disease risk factor and HIV-related patient . This finding has an important implication for developing mobile app content in delivering a step-by-step or straightforward message visually . Infographic intervention using symbols, images, cultural adaptation and local language could improve communication  as it is easier for the public to understand health information . Moreover, a study reported that their participants are not attracted to infographic design that is too complex or colourless . The previous study has revealed the need to increase the awareness of BC’s perceived severity, which are defined as beliefs in health issues that will cause harm . When asked about perceived severity in this study, some of the participants’ group P, C and S mentioned metastasize and survival rate statistics. As the information on metastasis is different from other stages  and even patient with metastatic BC also claimed that it is not easy to get it . We find it crucial to include information related to metastasis in the mobile app. The survival rate is affected by several factors, such as the time taken to diagnose, stage of the disease, treatment progress, access to care . The user needs to understand the survival rate for them to act appropriately.Prior studies have noted the importance of interventions to reduce time to diagnosis and avoid treatment delays . In this study, participants’ group P, C and S suggested including info on the screening exam, triple assessment and treatment options in the mobile app. This result is consistent with another study which requested for treatment and side effect to be included . In another study’s participants are also in agreement that knowledge related to treatment is helpful for them . Meanwhile, knowledge related to screening could decrease the death rate and cancer phases . Hopefully, this perceived threat content will increase routine behaviour of performing BSE among the public women. As revealed in a study, those who never perform BSE are likely to have delayed examination . The participants’ group P, C and S mentioned the screening exam reminder, sharing button and prompt, and it is perceived as cues to action. In accordance with the present results, previous studies have demonstrated that the reminder system is an effective and acceptable intervention . Meanwhile, a sharing button matches those observed in earlier studies for resource sharing, social engagement, providing support and promotion to others . Prompt usually used for goal setting, intention formation, self-monitoring and feedback in the mobile app . Moreover, a prompt would lead to user’s engagement, interaction and usage of the mobile app . As for the perceived benefit component, the participants’ group P and C expressed the need for early treatment and BC support groups. This rather interesting finding of support groups that offer emotional or spiritual helps social interaction, perspective, experience sharing, material and knowledge as mentioned in previous studies . This result on early treatment further supports the idea of reducing morbidity or mortality rate , option for less aggressive treatment  and improve survival rate . Another study revealed that an increase in perceived benefit and reduced barrier could lead to a change in users’ behaviour in BSE practice and mobile app usage .Acceptance towards mobile apps is contributed by the mobile app’s value and relevance , such as in a Korean’s study where mobile app effectively promote BSE . Moreover, the findings related to the mobile app are in accord with an earlier study focusing on a design suggesting a preference for bigger fonts, colour scheme, scrollbars, buttons , easy browse, use images and plain language . Furthermore, an interactive mobile app is the preferred one as it provides access to seek help, symptoms reporting and self-care . Besides that, most participants group P, C and S commented about the fear of treatment and myth. This result is in line with those in previous studies which stated fear of cancer treatment due to inadequate knowledge, suffer or fatalistic view of cancer, losing hope, expensive cost, side effects, ineffective treatment and believed that alternative treatments are more effective . This result also supports the previous research suggesting the need for education related to BC’s myths to reduce late diagnosis .From the discussion, the voices of all the women and experts from the interviews are important to generate themes in this study. A qualitative approach used to gain insight from the interviews conducted . A previous study reported physicians roles are important in promoting BC screening uptake but some of them encounter problems when patients do not know about BC screening . Hopefully, the developed mobile application based on the users’ requirements involving content and software experts would cater as a health promotion tools targeting breast examination awareness which include information related to BC detection and management.Limitation This study’s limitation is that the researchers only focus on mobile app content development based on the HBM component except for self-efficacy. Moreover, the present sample is purposive and small from one area in the tertiary teaching hospital thus it cannot be generalised to the other setting. Further ResearchThis research supported by a theory-based to guide the study, and further work is required based on the self-efficacy component such as to identify user’s experience and the ability to execute BSE routine using the mobile app. Besides, the researchers also suggested further exploration of expert consensus of the mobile application using a Fuzzy Delphi method for personalized learning tool. A focus group discussion for phase 2 also is recommended. In conclusion, this study explored breast examination awareness mobile app requirements among public women, software experts, and content experts. It is based on the HBM, a proven effective theory for behaviour intervention using a qualitative approach. The findings may guide the development in improving the app design and usability. A tailored-contents and features according to the participants’ need were designed exclusively. According to the HBM domain, the requirement was described, such as infographic risk factor, video , info , features  and certain mobile app’s design criteria. The authors confirm contribution to the paper as follows: Study conception and design: AY, SLK, YHPI; acquisition of data: AN; analysis and interpretation of the data: AN, AY, SLK, YHPI, ISAH; drafting manuscript: AN, AY, SLK, YHPI. All authors reviewed the results and approved the final version of the manuscript.


While policies to address “obesity” have existed for decades, they have commonly focused on behavioral interventions. More recently, the taxation of sugar-sweetened beverages is gaining traction globally. This study sought to explore individuals’ attitudes and beliefs about sugar-sweetened beverages being taxed in a rural Michigan setting.This qualitative study was conducted using critical policy analysis. Data were collected in 25 semi-structured, audio-recorded interviews with adult Michiganders. Following data collection, transcripts were coded into themes using NVivo software.resistance, unfamiliarity, tax effects, and need for education. While some participants were unfamiliar with sugar-sweetened beverage taxes, many viewed taxation as a “slippery slope” of government intervention, which invoked feelings of mistrust. In addition, participants predicted a sugar-sweetened beverage tax would be ineffective at reducing intake, particularly among regular consumers, who were frequently perceived as mostly low income and/or of higher weight.Four themes emerged in participants’ perspectives regarding sugar-sweetened beverages being taxed: Further research is needed to explore perceptions of sugar-sweetened beverage taxes in different geographic areas in the USA to examine how perceptions vary. Policymakers should be aware of the potential implications of this health policy with respect to government trust and stigma towards lower income and higher-weight individuals. There is already a sales tax on SSB in most states, applied at the point-of-sale; an excise tax would act as a flat tax to increase SSB shelf prices  meaning to and interpret[s], relevant events and conditions in ways that are intended to mobilize potential adherents and constituents, to garner bystander support, and to demobilize antagonists” [ p198]. TA distributional burden exists regarding excise taxes, meaning any excise tax placed on SSB would be regressive. Taxes are considered regressive when they impose a greater burden on those of lower income as compared to those with higher income . Low-incThe majority of literature on SSB taxation is from a public health perspective, where SSB taxes are frequently lauded  in her office between February and April, 2018. Participants also completed a demographic questionnaire with questions regarding gender, age, education, and SSB consumption habits. The interview guide included questions focusing on participants’ understandings and attitudes toward taxation of SSB, the beverages, and people perceived to be targeted by such a tax, and if implemented, their thoughts on what tax revenue should/would be used for. As part of this study, we specifically analyzed participant responses to the following interview guide questions:4. How would you feel about the tax being introduced in Michigan?5. Where do you think the money from the tax would go? Where would you want it to go?Following interviews, field notes were immediately captured regarding the visual and verbal cues not captured on the recorder, reflexive notes on researcher bias, and notes on the interactional nature of the interview . InterviData were analyzed thematically . MeaningFollowing initial coding, tables were constructed to identify patterns across participant characteristics, including age, gender, SSB drinker or non-drinker, etc., for every research and interview question. Summaries for every participant were constructed by the two analysts for each participant that described responses for every research and interview question.n = 25) were adults, men (24%) and women (76%), ranging in age from 18 to 60+ years, with a median age of 22 years. Approximately 88% of participants were Caucasian. Only 8% of participants reported never drinking SSB, 16% drinking SSB less than once per week, 36% drinking SSB one to three times per week, and 20% drinking SSB either four to six times per week or at least once per day. Due to the small sample size, demographic details .Most participants expressed negativity, ambivalence, or indifference regarding the tax. Some participants referenced a belief that putting a tax on SSB is a “slippery slope” that implies the government is trying to control their decisions:We would see no result of it, just like everything else. The money’s supposed to go somewhere, and it never does (Lorraine).There is also resistance toward the government implementing a tax because people cannot trust how the revenue will be used:think that's only in New York. (laughs) No, I don't think we're in the areas…You know, where they ... we do that kind of stuff. We're middle America. We ... I think we kinda leave each other alone and we don't get into everybody's business, you know?For some participants, the SSB tax was another means by which the government would seek to curtail individual autonomy. Such means were often seen as being clouded in obfuscation or deception and were rarely seen to promote stated, agreed upon, or relevant priorities. Possibly due to resistance to government interference in personal decision-making for ambiguous aims, most participants did not appear supportive of government regulation. One participant tied this to a local social and political consciousness. Melinda believed “liberals” would support the tax as “they’re always fighting a cause” and believed that the tax would have less local support:It'd probably be a good idea to keep people in line, healthier (Lisa).Although the majority of participants resisted a tax on SSB, a few participants, who drink pop regularly, thought a SSB tax would be a good idea to encourage healthier behaviors:It would make me say ‘Well, do I really want that pop? Do I really, you know, need that?’ Maybe it's a good thing, maybe…more people would feel that way and they would consume less of it (Amber).Some participants also thought that a tax on SSB would make them consciously think about purchasing pop beforehand, and may even divert them from purchasing it all together:I have no idea. I should probably … I don't pay attention to … I need to pay more attention to the news in general and just like the government, but I don't (Melissa)The sugar-sweetened beverage tax? Nn-nnh (negative), actually I haven't (Katie).In addition to government distrust, younger participants were sometimes unfamiliar with tax procedures, and many had never heard of SSB taxation:I don't know. Maybe, well wouldn't the money go back to … the sugar sweetened beverages people? (Lisa).There was also some confusion among participants of all ages as to how tax revenue is used by the government.In general, participants had little awareness of intended or proposed SSB regulations, suggesting perhaps that this topic has not penetrated the public consciousness in this region. Some participants were also unsure how taxation operated. This might influence the overall effectiveness of the tax.I think it would cause a little bit of outrage just for the people who get pop on a regular basis. They're like, ‘Oh, my gosh, like why all of a sudden do I have to pay extra for this?’ But…I think if somebody really wants it, the tax isn't really gonna matter too much to them (Shannon).Many participants felt an SSB tax would generate opposition among those who consume SSB, but that the tax would not necessarily alter behaviors:I don't think it'll impact it that tremendously... People in New York, they still buy cigarettes. I think it's like $15 a pack or something to buy cigarettes there. They're still smokin' (Denise)Participants sometimes referenced taxes on cigarettes in expressing their doubt over the effectiveness of a prospective tax:The ones who, well, probably shouldn't be drinking them anyway because if you have limited income then you need to use your money to make the healthiest choices you can but that should be for everybody that. But when you are buying pop at the expense of food with nutritional value... If you're buying both and providing both to your family, that's one thing but if you're buying one and now you can't afford the other one, that's a problem for me.And so, but we know that's happening so raising the tax is only gonna hurt the poor people (Anne).Many participants think that lower-income individuals would be most affected by a SSB tax. In response to the question, “who is going to be most affected by the tax?” Linda succinctly stated, “poor people”. Anne similarly felt those of a lower-income would be most affected by the tax, although she qualified her answer by drawing on personal responsibility framing around food choices:I feel like lower income families would definitely oppose it because you're taking the cheapest, easiest accessible like option for them and then putting a tax on it. So, I almost feel like it would be negative for them (Tiffany).Aside from taxes affecting lower-income individuals more than those of a higher income, many participants think lower-income individuals would be affected most by a SSB tax because they believed SSB tended to be the cheapest option for persons of a lower income to drink:Or like more obese people just because they, like, like pop better than water, which I don't get how, but still. I just feel like that's kind of like the stereotypical thing to say, like I said, but I feel like that's the image that media puts out, but that's what I'm thinking. You know people who are bigger, people who don't have as much money and they kind of want that extra treat. You know what I mean, like, they get 'em the pop.Some participants, like Katie, further assume that SSB imbibers likely are of higher weights and therefore that higher-weight individuals be most affected by a tax:anyone really who just loves pop, or loves all that sweet stuff, doesn't really matter if you're, race or class, or anything.Some participants did not differentiate among demographic groups and thought all who enjoy drinking SSB would be affected. Makayla emphasizes that the tax will not discriminate along any other social axis apart from personal preference:probably pop? Because I think that…there's just kind of an idea that juice isn't as unhealthy. Which, I mean, could be true but there's definitely still a lot of sugar in things like orange juice and apple juice and what are people consider, like, typically healthier alternatives...I think they still definitely have sugar in them, but I think that people would ideally focus on pop because that's kind of what you think of automatically (Julia).Makayla’s quote highlights a further pattern in the data—participants focused frequently on pop and believed pop would be the focus of governmental reforms, given its perceived unhealthfulness and popularity. For example, in response to a question regarding what beverages would be the target of the tax, Julia replied as follows:, if a SSB tax were to be implemented, many participants think revenue generated from a tax should be put toward health or nutrition education programs or health/nutrition school-based programs. Rita explains how children should be the priority population regarding these programs:I think it would be nice to see it go to education type… maybe like for the young children, and that way they're learning about it, and just…like nutrition programs.While participants tended to oppose a taxThey should be more concerned and telling, and teaching kids better habits when they're younger (Andrew).Participants felt children should be exposed to these programs at a very young age to deter them from ever drinking SSB in the first place.in my mind if you're gonna put a tax on something like that, let's do something good with that money…Educate people about nutrition. Educate people about why this is, you know important. Or… in the schools and maybe set up programs for the kids that… would be where it would be most used and, and beneficial. But, it doesn't tend to go that way.... Who knows where they'd put it (laughter)…let's do something good with this. But…our government doesn't always focus that way (Amber).However, reflecting the general skepticism regarding governance, participants were doubtful that the revenue would be used to address what they considered to be appropriate programs:Our results suggest that public attitudes in Michigan towards SSB taxation may not be aligned with those of public health agendas. This misalignment may be partially attributed to perceived lack of effectiveness of such a policy, an over-reach on behalf of the government, or the edge of a dangerous slippery slope of government interference. Participants generally felt that pop or soda were the main targets of an SSB tax and that individuals with lower incomes, as well as people of a higher weight would be most affected. Though participants were generally opposed to an SSB tax, if such a policy were implemented, nutrition education, particularly directed at children, was considered an acceptable use of tax revenue.Our findings of unfamiliarity and resistance toward an SSB tax are generally consistent with findings from other studies of acceptability. In a quantitative study conducted in Switzerland, taxation generated higher resistance levels among participants than less intrusive methods aimed at reducing population sugar intake, like front-of-package labeling . In addiRelevantly, research confirms that lower socioeconomic populations, across many countries, are higher consumers of SSB , 79. A FParticipants’ responses revealed the ways in which public policy around SSB and taxation has constructed the “problem” of “obesity”. Participants identified high SSB consumers, those living on lower incomes, and higher-weight individuals as particularly likely to be affected by SSB taxation. Similar to findings reported above in which “pop” or “soda” are viewed as particularly dangerous to health, SSB coded as White and middle-class, were perceived as decadent but did not carry the same widespread risk connotations . CrucialThe linkage between “obesity” and class may also be refracted through a lens of ignorance, such that fatness, the working classes, character deficits, and ignorance are conflated , 84. RurWhile the purported goal of an SSB tax is to address “obesity”, a Swiss survey also found that people with increased health risks, higher-weight individuals, and those consuming higher amounts of SSB, are less accepting of a tax . SimilarSSB taxes are frequently compared with tobacco taxes as both effective at reducing smoking as well as generating government revenue . Howeverinequity in the revenue generation remains. Furthermore, attention must be paid to the inequity in negotiating power of marginalized populations in maneuvering this political quid pro quo, as well as the ethics of utilizing human rights, such as drinking water [Results of the present study indicate that revenue use is an important issue. Research has also demonstrated the importance of acceptable revenue use in garnering political and public support for an SSB tax . It has ng water , to garnng water , and potA common justification for implementing a tax on SSB is to use the revenue for the “common good”: children’s education, health promotion, etc.. Such recommendations may have to be interpreted with caution. Dietary behavior change interventions have produced mixed results . Indeed,Participants in the present study perceived pop or soda as being the main targets of SSB taxes, despite a broader range of beverages included in most SSB taxes. This perception appears to align with both researcher and distributor perspectives of where tax pass-through should occur. “Pass-through” refers to the change in price following the implementation of an SSB tax. In an analysis of tax pass-through at the Philadelphia International Airport, which straddles the city boarder and hence the application of a SSB tax, only Coca-Cola and Pepsi-Cola beverages were selected to determine any differences in tax pass-through . With reIn conclusion, rural Michiganders perceived a tax on SSB with resistance, unfamiliarity, and ineffectiveness. Additional themes among participants included the SSB tax targeting pop, the tax affecting those of higher weights and lower incomes, and tax revenue being used for education. Further research is needed to explore perceptions on SSB taxes in different populations and geographic areas around the USA. Of particular importance would be those of lower income, those who drink SSB, and those who are of higher weight who are the most likely to be affected by the tax or are being framed as the “targets” of taxation.


To develop a more specific understanding of psychological mechanisms in the development of burnout in long-term care as a basis for potential new intervention strategies aiming at improving nurses’ mental health.Two qualitative studies with thematic analysis were conducted. In Study 1, we conducted eight group interviews with 110 nurses from May–July 2019 in the context of workshops at eight nursing homes in Germany. In Study 2, we supplemented these with semi-structured interviews with 14 executives at German nursing homes in December 2019.The thematic analysis in Study 1 identified three main themes: causes of challenges, employees’ opportunities for change, and organisational opportunities for change. Thematic analysis in Study 2 identified three main themes: job motives, reasons for filling in for others, and employee self-care. Further, our results show that the need to stand in for colleagues, in particular, is one of the greatest challenges for geriatric caregivers. In dealing with these challenges we found that self-endangering behaviour—a diminished ability to say no when asked to fill in or to do work overtime—was an important antecedent of nurses’ burnout. Further, high levels of altruistic motivation and identification with the team or organisation were associated with self-endangering behaviour in the presence of adverse working conditions. Low levels of self-worth are a further risk factor for self-endangering.Our findings are at odds with some core tenets of classic models of job demands and burnout that construe motivation and identification as resources. Our results show the need of a holistic intervention program in nursing including individual coaching, team-based interventions and organisational development processes. Employees themselves should be sensitized to this issue and supported in the long term, and politicians should create structures that do not encourage this behaviour any further. We followed the six phases of thematic analysis  for the The whole category system evolved dynamically throughout the coding process, and all eight workshops were coded. We stopped coding when all transcripts were assigned to an appropriate category and the description of the coding system was complete. When the coding process was completed, we checked and rechecked the themes and discussed them with two colleagues who work in the psychological sector. If a statement was not appropriate to a theme, we discussed that and, if applicable, built a new theme. We then discussed the themes’ areas of overlap and the identified relations in-between, which we summarized for visualizing in MAXMAPS.After that, based on the frequency distribution of the topics, we identified the most frequent topics from the employees’ perspective.2.7To improve the rigour of thematic analysis, we used the MAXQDA computer software . Further3The thematic analysis identified three main themes: causes of challenges, employees’ opportunities for change, and organisational opportunities for change. 3.1This category contained the antecedents and causes of job-related challenges that the nurses identified. These included especially structural working conditions  and employee’s psychological characteristics such as missing self-care or attitudes. With 98 mentions, participants referred to the structural working conditions the most frequently, followed by employee characteristics such as missing self-care and employees’ attitudes and values with 38 mentions, team culture and climate with 35 mentions, and leadership behaviour with 19 mentions see .“I could do more.” (NH 1)“You put other people before yourself.”(NH 8)Employee’s psychological characteristics, team culture and climate, and leadership behaviour were the vaguest themes, so we present some examples. Employees’ characteristics as a cause of challenges included missing self-care, missing self-efficacy, and employees’ attitudes and values. Missing self-care means not being able to switch off after work, being too tired to do something in your free time, the thought to still be able to do more, meaning that one does not think of oneself and that employees’ would rather save the other persons weekend than their own.“I would rather save the other person’s weekend than my own.” (NH 6)“I have feelings of guilt towards colleagues and residents.”(NH 5)Employees’ attitudes and values mean especially a strong sense of responsibility and duty and having a bad conscience towards colleagues and residents.“Colleagues relying too much on others.” (NH 3)“You don’t want to stab others in the back.” (NH 6)The team culture and climate included aspects such as remaining silent for fear of consequences, lack of confidence, hierarchical differences between the professional groups, lack of cohesion among staff, ignoring each other, or talking about someone behind their back:The leaderships aspect included a lack of praise and appreciation, pressure, and a lack of acceptance for employees who do not fill in for others.3.2“I could openly say to the team, ‘it’s all too much for me’.” (NH 3)This category contained opportunities for change that the nurses identified. The most frequent topics were self-care (see “I could learn to say ‘no’ and think of myself.” (NH 5)“I could put ‘the brakes on myself’ more often.” (NH 1)“Your own awareness of being able to do something and wanting to do something.” (NH 7)Self-care was in turn divided into five further sub-categories: self-efficacy, self-reflection, consideration of the state of health, separation of work and personal life, and the most important topic from the employees’ view: distancing oneself from something. Distancing oneself from something means, on the one hand, being able to set physical and especially mental limits regarding residents, the leader, or colleagues and, on the other hand, being able to say no when the leader or colleagues ask you to step in for another employee in the event of absenteeism.3.3“They could accept a ‘No’ without making me feel guilty.” (NH 3)“They could give me the feeling that it is allowed to say ‘No’ (e.g. when they ask me to fill in for others).” (NH 1)This category contained the organisational opportunities for change that the nurses identified. The most frequently mentioned topics were work organisation  examine the causes of nurses’ burnout from the leadership and employee perspective, and 2) elaborate potential changes or interventions that might help to mitigate burnout. We aimed to focus on specific people- and organisation-related causes and possible changes. We used the same approach as mentioned in Study 1.4.2At each of the participating nursing homes, we asked for two or three executives to participate in the interviews during the health care project process. None of them knew about the aim of this study, and this research project was independent from the health care project process or aims. We collected data in December 2019.Mean = 45.86, SD = 7.36). The mean years of affiliation with their organisation ranged from 1 year to 3 months to 33 years .Fourteen executives in different units at six of the eight nursing homes took part in the interviews: 12 women and two men aged 36–58 years   semanticAs described in Study 1, we grouped themes or separated them if a thematic differentiation appeared necessary, so we always paid attention to identifying new codes. We stopped coding when all interviews were coded and all aspects were assigned to an appropriate category.The whole category system evolved dynamically throughout the coding process, and all relevant text passages from the 14 interviews were coded. When the coding process was completed, we checked and rechecked the themes and discussed the patterns and relations with two colleagues who work in the psychological sector. If a statement was not appropriate to a theme, we discussed that and, if applicable, built a new theme or renamed themes. After we put the themes in relation to each other, we summarized the results for visualizing in MAXMAPS.Based on the frequency distribution of the topics, we then identified the most frequent topics from the leaders’ perspective.5Thematic analysis identified three main themes: job motives, reasons for filling in for others, and employee self-care .Table 2S5.1This category contained the different job motives that had motivated nurses to choose their job. These included social motivation and general conditions that the profession entails.“Employees go into a deep level with them.” (P7)“Have a feeling of being needed.” (P4)“Feel that the residents, they just love you.” (P4)“Well, it is such a (…) good network that you build up, besides the family structure or acquaintances and friendships that you cultivate. You must have colleagues there as well. I think you profit from it very, very, very much. Teamwork, teamwork is needed.” (P13)The general conditions in nursing, such as earning money, being able to make a career, or to have a secure job were a less common reason for working in a nursing home  It may be pathological or not, it doesn’t matter. (…) Yes, if no peace comes in there. If you feel like you are always driven by love for people and you want to help other people all the time and are NEVER free of that, then I think it’s pathological, so it goes along with it to such an extent that I think it’s really pathological.” (P2)In the context of helping, some of the respondents also mentioned what is so called the helping syndrome, meaning that employees in nursing homes are often over-motivated to help others and that this can sometimes be pathological.5.2This category contained employees’ approach in the event of necessary coverage for absent employees, the general conditions for coverage, differences between employees who fill in for others and those who do not, employee substitution behaviour, and duty of managers to provide for the welfare of their staff.5.2.1In the event of necessary coverage for absent employees, the leaders reported that they pursue two approaches. They can call in employees in their free time to cover for the absenteeism, or they can try to cover for absent employees by implementing an on-call standby service system (this was implemented in only one of the participating nursing homes and only for care assistants), by covering via the existing staff on site, by sharing the working time for the present staff, or by leaders stepping in themselves.“There are people who often fill in, these are our part-time employees. Because you call them first because they are more often out in the open.” (P5)When none of these alternatives are possible, the leaders usually must make use of employees who are on leave Second, they call employees that they know will agree to come in.“Then it was actually fairness, because I always think fairness is above everything. The one who has the least overtime, he is asked first, if he can’t, the next one is asked. So, we looked at the numbers or the rhythm, how often did one person step in and how often did the other. So that everyone feels treated equally, and then you just go through, he was already there, has the least overtime, so the next one comes in.” (P2)Third, they take overtime and replacement rhythm into account when deciding who to ask first:5.2.2“There are people who would always fill in, even if they have worked—I would say—maybe even too much. They would fill in anyway. And others always have other appointments.” (P11)From the leaders’ point of view, all reported that they have employees who always stand in for their colleagues when coverage was needed and agree when they are asked, and all have employees who never fill in for their colleagues and everybody knows that they will not agree when they are asked.5.2.3The differences between employees who fill in and those who do not could be divided into five subthemes: identification with the residents, intrinsic motivation, team spirit, personal characteristics, and structural conditions.“They want to be a good colleague.” (P8)“The attitude could be, I won't let the team down so that could be an attitude. And some people don’t care, so if you don't step up then. Maybe they don’t have such a strong bond to the team or the institution, so maybe the identification is different, I could at least imagine.” (P11)One of the two most frequently mentioned differences between employees was in team spirit. Team spirit means that employees who fill in for each other do not let their colleagues down, they stick together and they do not want to abandon their team.The second most frequently mentioned difference between employees was in personal characteristics, which means personality traits and attitudes. It was mentioned that employees who often or always fill in for others feel extremely responsible, are particularly selfless and helpful, put their private lives on hold, and have a pronounced helper syndrome.5.3This category contained the management’s responsibility for employees’ health care and self-care, the general attitude to self-care, the meaningfulness of self-care, break culture, self-care capabilities, and the ability to distance oneself from something .5.3.1“Yes, exactly, so how should I say, those who are especially connected to the work or the wearer, I think they don’t really take care of themselves, including me (laughs).” (P10)All the participating leaders agreed that the majority of the employees have only limited abilities to look after themselves They described was a lack of awareness of self-care on the part of employees and stated that many do not know what they can do. It was also argued that one reason for the low self-care capabilities is the helping syndrome and that people who work in the care context often tend to be selfless.“I believe I would also like to make this clear to the older employees, who have gone through the old school, I say it now times through the old school, still have such old pictures in their heads. Without me, it does not work and I must somehow go on until ( …) until it is no longer possible, so they really react very selflessly. And so, with the younger employees who come, who, for example, want to combine family and career, but who then also set a few conditions, this sometimes meets with irritation between the generations. You have to do justice to both. For those who are still socialized differently and have gone through the old school of nursing care for the elderly and for those younger employees who, I believe, have a completely different approach to the work-life balance. So, I think you have to create a good understanding of each other. The younger ones I think they already have a different one, so I hope they have a different view of the working conditions and (…) yes, I think they are always the older employees, by older I mean also those who are my age, we are the ones who are perhaps still a bit of the old breed or I would say we got to know them differently. So, the older employees really have to, I think sometimes they have to do a bit more for themselves.” (P13)Further, some executives saw an age effect. They reported that older employees often react selflessly and should do more self-care than they actually do.5.3.25.3.2.1“(…) and all those who have this background working with people in this way often have a problem saying no, because they tend to put others in the foreground rather than their own needs.” (P7)The employees’ ability to say no when they are asked to fill in for their colleagues or do some extra work was one of the main themes in the interviews. All leaders mentioned that saying no is accepted and necessary for a good self-care in the nursing homes. Conversely, this ability is only very slightly developed among the employees.5.3.2.2“My experience is that sometimes nursing staff can not do that. Because they really do have the attitude that they have to help people and on the other hand they have to have this attitude, so that they can work well or are good and what we want for our residents, and that really is a greater challenge in the nursing field than in some other occupational groups in the home.” (P9)Executives reported that employees’ ability to say no depends on the professional activities and thereby on the occupational group in the nursing homes. Especially for the nursing stuff, it is usually difficult to say no, whereas for example for the social services, it is often easier because more flexible in terms of timing. To put it more generally, some processes in the nursing home encourage the employees’ ability to distance themselves from something because they can be rescheduled or cancelled. Further, it was mentioned that the social services staff sometimes know more about themselves or self-care strategies because they learned this during their education and training.“I would say first of all that it also strongly depends on the employee’s personality.” (P13)In contrast to the executives’ view concerning factors influencing the capability to distance oneself from something as described above, some leaders also mentioned that this capability depends on individual aspects.5.4Our results show a vicious circle of high stress and little self-care causing health problems and absenteeism. This absenteeism in turn requires flexibility and coverage by others, which leads to more stress for the nursing staff. With regard to the boundary conditions, our study participants see the greatest potential for change in their own self-care and in the behaviour within the team.In our two qualitative studies, we investigated nurses’ challenges and associated boundary conditions in long-term care in order to examine the psychological mechanisms behind individuals’ resources or even lack of resources.Overall, the thematic analyses led to the main topic of accepting extra tasks or filling in for colleagues in cases of illness or absence, which usually results in overtime, long and frequent work shifts in a row, presenteeism, and lack of recovery. Our results indicate that employees' interpersonal differences in team identification as well as in the personal characteristics determine the way that nurses in long-term care deal with and react to these special demands. One of the most important themes for employees and executives seems to be the ability to say no and the associated general ability to set oneself apart from colleagues and long-term care residents. Participants mentioned that they “find it important for self-care to say no and to say no, but unfortunately, I can’t now.” A lot of participants believed that “there are many who have a particular problem saying no.” Overall, a large number of statements reflected self-sacrificing behaviour among nursing staff. In summary, on the basis of our qualitative results, we construe self-endangering as a central mediator between nursing-specific characteristics and burnout. Basically, based on our findings, we assume that two facets of self-endangering at work can be classified: behaviour and behavioural tendencies and cognitions. We define self-endangering behaviour as a diminished ability to say no when asked to fill in or to do overtime. We define self-endangering cognitions as the nurses’ own inner beliefs with regard to having a moral obligation to fill in for colleagues at the expense of their own health.As we see the introduction of the construct of self-endangering in the context of nursing as a central contribution, we will focus on this aspect and its connections to the mentioned individuals’ resources and characteristics of nurses in the discussion.66.1To our knowledge, there has been only little research on self-sacrificing behaviour in the professional context, but we propose that the concept of self-endangering work behaviour is close to what we found in the context of self-sacrificing behaviour in nursing. Self-endangering behaviour is defined as “actions that aim to deal with work-related demands but simultaneously increase the likelihood of health problems and impede necessary recovery from work-related stress” 50, p.28]. These are, for example, behaviours that are internalized but have a potential health risk, such as extending work time, reducing recovery time, intensifying work, and presenteeism . Self-en, p.28. TIn the long term, self-endangering coping behaviour leads to heavy workloads and reduced performance, well-being, and health . TherefoWhereas Krause et al. (2010)  posit th6.2Several participants mentioned for example that “you put other people before yourself” and “you do not think of yourself” at work. In addition, when we asked the executives about the nurses’ job motives, all leaders mentioned that it is “love for fellow human beings,” “the desire to help others,” the possibilities to enter into deep relationships, and a “feeling of being loved and needed” that motivates nurses in their job.In line with these results, previous studies found out that altruism is the most important work value for nurses . Whereas6.3At our workshops, nurses often reported that they sometimes miss appreciation and open communication culture in their team and that colleagues badmouth others behind their backs. Participants also said that “better to save your colleague's weekend than your own” or that they do not want to leave colleagues in the lurch. We therefore conclude that team culture in the elderly care is typically characterized by strong identification with colleagues; however, this can be associated with the expectation that everyone always stands in for colleagues: “Yeah, I would just say they identify with the team, the people who fill in.”It seems that when nurses fill in for others, they feel responsible for the well-being of the other team members, such that they would rather take on the extra workload themselves than burden their colleagues with it. According to Krause et al. (2010) , especiaAlthough a recent meta-analysis found that organisational and work group identification is positively associated with employees’ health , we assu6.4Kupcewicz and Józwik (2020)  already Because many of the nurses in this study reported that they are often not able to delimit themselves from work or special demands or say no to extra work or filling in for colleagues, we further assume that the more nurses have less self-worth the more they define their self-worth through their work; they therefore show more self-endangering behaviour so they can boost their self-esteem.6.5In summary, recent research shows positive impacts of altruism  and teamWe therefore assume that the antecedents altruism and team identification play an important key role in the emergence of self-endangering in nursing, such that high levels of these variables promote self-sacrificing cognitions and behaviour. Low levels of self-worth are a further risk factor for self-endangering, such that low levels of self-worth promote self-sacrificing cognitions and behaviour. In sum, we assume that nurses who often show self-endangering behaviour and cognitions tend to develop burnout symptoms, in the way that nurses self-sacrifice themselves for their work and go beyond their boundaries see .Fig. 2ThPrevious research already shows the importance of other constructs that are related to self-endangering behaviour for nurses’ burnout such as work engagement , organizFor future leadership research, self-endangering in nursing implies that the leader’s role in the development of self-endangering behaviour and cognitions has to be examined; protecting vulnerable staff through leadership behaviour seems crucial.6.6With a view to the important role of self-endangering and the possible antecedents, further interventions in the context of health promotion programmes should focus on nurses’ special job motivation and attitudes to reduce self-sacrificing within their work. It therefore seems extremely important to train nurses in self-reflection and self-empathy, such as the training in the empCARE programme , but eveIn sum, this means that we need holistic training programmes in nursing care that include: 1) individual training, e.g. coaching, where motivation and personal attitudes toward the job and the definition of one’s own self-esteem are discussed and reflected upon, with the aim that nurses are sensitized and develop personal strategies, 2) team-based interventions, where the team reflects upon their own team values, rules, and culture, with the aim to develop behavioural rules for a healthy cooperation especially in the case of failures, and 3) organisational development processes that reflect upon the organisational structures and culture, with the aim that wards in hospitals and living areas in long-term care facilities are well organised .not entail that a problematic quality on the side of the nurses is partially responsible for their psychological health issues. Self-endangering only surfaces in the presence of adverse working conditions such as too few staff and too many residents. If working conditions in nursing were not as problematic as they are, nurses would not face the difficult choice between endangering themselves for the sake of their colleagues and residents and taking care of their own health needs.Finally, we need to stress that identifying self-endangering as a potential individual risk factor for nurses’ burnout does 6.7To our knowledge, this study is the first to examine self-endangering behaviour in nursing in long-term care. Of course, our study is not without limitations, especially because we focused on only German nurses in elderly care. Therefore, the first limitation is that our results are not generalizable for nurses in other working contexts or from other cultures. Second, our sample is not representative, so further research is needed in the context of nurses in elderly care to further examine our findings. Nevertheless, we believe that our study offers new knowledge and approaches in the context of the health of elderly care workers.7This qualitative study dealt with the question of the challenges faced by employees in elderly care and the opportunities for change that arise from their perspective. Our results show that especially the need for filling in for colleagues is one of the greatest challenges for nurses in elderly care. We found different conditioning factors for nurses’ self-endangering at work, such as the value of altruism, strong identification with the team, and low occupational self-care abilities. Future research needs to investigate whether quantitative verification confirms these assumptions.Adjacent to this, new interventions and programmes can be developed for and implemented in nursing homes to prevent nurses’ burnout and other mental and physical problems. In the long term, this could break the vicious circle of filling in, presenteeism, and illness and enable employees to work more healthily in their everyday work. Of course, it must not be forgotten that these preventive approaches can only be effective in particular or under certain circumstances if working conditions in the nursing sector are also changed.10.13039/100009117Chemnitz University of Technology. This research was partially supported by funds from an association of several German public long term-care organisations under the joint project Healthy Ageing in Long-Term Geriatric Care (gesaPflege).The publication of this article was funded by Lara Luisa Eder: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft, Visualization, Project administration. Bertolt Meyer: Formal analysis, Resources, Writing – review & editing, Supervision, Funding acquisition.We have no known conflict of interest to disclose.