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Background The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians’ attitudes and behaviours in four EDs in Singapore. Methods We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework. Results We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor. Conclusions Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

Objectives: In tertiary-care settings, up to 50% of patients are prescribed at least 1 antibiotic. However, patients are often not proactively provided with information nor involved in shared decisions regarding their antibiotic therapies. Understanding inpatients’ knowledge and the extent of their involvement in antibiotic therapy help reduce inappropriate or unnecessary antibiotic use. Methods: A cross-sectional survey was conducted from March to December 2021 in a 1,600-bed, adult, acute-care, tertiary-care hospital. Patients prescribed antibiotics for the past 1 week during their hospital stay were surveyed. Ten questions assessing patients’ knowledge of their antibiotic therapy and 3 questions adapted from the NHS Care Quality Commission Inpatient survey (2013) were included in the survey questionnaire. Results: Among the 323 patients surveyed, 88% knew that they had been given antibiotics, and 80% felt that it was important to be informed of the reason, 76% felt that it was important to be informed of side effects, 74% felt that it was important to be informed of duration, and 72% felt that it was important to be informed of dosing frequency. However, only 71% knew the dosing frequency, 54% knew the side effects, 37% knew the duration, and 13% knew the name of the antibiotic agent administered. Of those unaware of the antibiotic name, 59% had indicated their desire to know. Among those aware of their antibiotic therapy, 85% had trust in their doctors but only 42% felt that they always received answers to their questions on antibiotics in an understandable manner from their doctors. Furthermore, 41% felt that they were often or always not given enough time to question their doctors. To raise their awareness on antibiotic use, 73% of respondents felt that having protected time with the doctors to understand more about their antibiotic therapy would be effective. Conclusions: Most inpatients lacked knowledge of details of their antibiotic therapy, and fewer than half were involved in it. Allocation of protected time with doctors to understand their antibiotic therapy can be a potentially effective strategy to increase patient engagement to enhance hospital antibiotic stewardship efforts.

Antimicrobial stewardship programmes (ASPs) in hospitals are predominantly led by specific ASP physicians and pharmacists. Limited studies have been conducted to appreciate non-ASP-trained hospital pharmacists' perspectives on their roles in antimicrobial stewardship. Focus group discussions (FGDs) were conducted with 74 pharmacists, purposively sampled from the 3 largest acute-care public hospitals in Singapore, to explore facilitators and barriers faced by them in antimicrobial stewardship. Applied thematic analysis was conducted and codes were categorised using the social-ecological model (SEM). At the intrapersonal level, pharmacists identified themselves as reviewers for drug safety before dispensing, confining to a restricted advisory role due to lack of clinical knowledge, experience, and empowerment to contribute actively to physicians' prescribing decisions. At the interpersonal level, pharmacists expressed difficulties conveying their opinions and recommendations on antibiotic therapy to physicians despite frequent communications, but they assumed critical roles as educators for patients and their caregivers on proper antibiotic use. At the organisational level, in-house antibiotic guidelines supported pharmacists' antibiotic interventions and recommendations. At the community level, pharmacists were motivated to improve low public awareness and knowledge on antibiotic use and antimicrobial resistance. These findings provide important insights into the gaps to be addressed in order to harness the untapped potential of hospital pharmacists and fully engage them in antimicrobial stewardship. National Medical Research Council (NMRC) Published version This work was supported by the National Medical Research Council Singapore, Health Services Research Grant, Grant number: NMRC/HSRG/0083/2017).

BACKGROUND Singapore’s national digital contact-tracing (DCT) tool—TraceTogether—attained an above 70% uptake by December 2020 after a slew of measures. Sentiment analysis can help policymakers to assess public sentiments on the implementation of new policy measures in a short time, but there is a paucity of sentiment analysis studies on the usage of DCT tools. OBJECTIVE We sought to understand the public’s knowledge of, concerns with, and sentiments on the use of TraceTogether over time and their preferences for the type of TraceTogether tool. METHODS We conducted a cross-sectional survey at a large public hospital in Singapore after the COVID-19 lockdown, from July 2020 through February 2021. In total, 4097 respondents aged 21-80 years were sampled proportionately by sex and 4 age groups. The open-ended responses were processed and analyzed using natural language processing tools. We manually corrected the language and logic errors and replaced phrases with words available in the syuzhet sentiment library without altering the original meaning of the phrases. The sentiment scores were computed by summing the scores of all the tokens (phrases split into smaller units) in the phrase. Stopwords (prepositions and connectors) were removed, followed by implementing the bag-of-words model to calculate the bigram and trigram occurrence in the data set. Demographic and time filters were applied to segment the responses. RESULTS Respondents’ knowledge of and concerns with TraceTogether changed from a focus on contact tracing and Bluetooth activation in July-August 2020 to QR code scanning and location check-ins in January-February 2021. Younger males had the highest TraceTogether uptake (24/40, 60%), while older females had the lowest uptake (8/34, 24%) in the first half of July 2020. This trend was reversed in mid-October after the announcement on mandatory TraceTogether check-ins at public venues. Although their TraceTogether uptake increased over time, older females continued to have lower sentiment scores. The mean sentiment scores were the lowest in January 2021 when the media reported that data collected by TraceTogether were used for criminal investigations. Smartphone apps were initially preferred over tokens, but the preference for the type of TraceTogether tool equalized over time as tokens became accessible to the whole population. The sentiments on token-related comments became more positive as the preference for tokens increased. CONCLUSIONS The public’s knowledge of and concerns with the use of a mandatory DCT tool varied with the national regulations and public communications over time with the evolution of the COVID-19 pandemic. Effective communications tailored to subpopulations and greater transparency in data handling will help allay public concerns with data misuse and improve trust in the authorities. Having alternative forms of the DCT tool can increase the uptake of and positive sentiments on DCT.

BackgroundWe assessed the preferences and trade-offs for social interactions, incentives, and being traced by a digital contact tracing (DCT) tool post lockdown in Singapore.MethodsWe conducted a discrete choice experiment (DCE) among visitors of a large public hospital in Singapore between July 2020 – February 2021. Respondents were sampled proportionately by gender and four age categories (21 – 80 years). The DCE questionnaire had three attributes (1. Social interactions, 2. Being traced by a DCT tool, 3. Incentives to use a DCT tool) and two levels each. The final dataset comprised 3839 respondents after dropping 53 with “irrational” responses. Panel fixed conditional logit model was used to analyze the data.ResultsRespondents were more willing to trade being traced by a DCT tool for social interactions than incentives and unwilling to trade social interactions for incentives. The proportion of respondents preferring no incentives and could only be influenced by their family members increases with age. Among proponents of monetary incentives, the preferred median value for a month’s usage of DCT tools amounted to S$10 (USD7.25) and S$50 (USD36.20) for subsidies and lucky draw.ConclusionsDCE can be used to elicit profile-specific preferences to optimize the uptake of DCT tools during a pandemic. Social interactions are highly valued by the population, who are willing to trade them for being traced by a DCT tool during the COVID-19 pandemic. Although a small amount of incentive is sufficient to increase the satisfaction of using a DCT tool, incentives alone may not increase DCT tool uptake.

Gay, bisexual and queer men in Singapore are disproportionately represented in prevalent HIV infections, relative to the general population. While anticipated stigma has been found to be a barrier to HIV/STI testing among gay, bisexual and queer men, little effort has been made to contextualise such stigma within the broader sociocultural milieu. We conducted 35 in-depth interviews with a purposively recruited sample of men in Singapore with a focus on topics such as sexual identity development, formative sexual experiences and HIV/STI testing experience. Interviews were analysed through thematic analysis using techniques borrowed from a grounded theory approach. Participants drew on their past interactions with family, friends, religion, the gay, bisexual and queer men's community and the wider society to construct meanings of deviance in the context of their sexuality. Participants articulated how anticipated stigma was rooted in such deviance, and how clinics or other HIV/STI-related health services served as physical spaces of costly disclosure by exposing or imposing 'deviant' identities on individuals who access these physical spaces, which were otherwise concealed. Findings from the study provide a framework for actions and interventions to address the roots of anticipated stigma in the context of HIV/STI testing among gay, bisexual and queer men.

Background Singapore’s national digital contact-tracing (DCT) tool—TraceTogether—attained an above 70% uptake by December 2020 after a slew of measures. Sentiment analysis can help policymakers to assess public sentiments on the implementation of new policy measures in a short time, but there is a paucity of sentiment analysis studies on the usage of DCT tools. Objective We sought to understand the public’s knowledge of, concerns with, and sentiments on the use of TraceTogether over time and their preferences for the type of TraceTogether tool. Methods We conducted a cross-sectional survey at a large public hospital in Singapore after the COVID-19 lockdown, from July 2020 through February 2021. In total, 4097 respondents aged 21-80 years were sampled proportionately by sex and 4 age groups. The open-ended responses were processed and analyzed using natural language processing tools. We manually corrected the language and logic errors and replaced phrases with words available in the syuzhet sentiment library without altering the original meaning of the phrases. The sentiment scores were computed by summing the scores of all the tokens (phrases split into smaller units) in the phrase. Stopwords (prepositions and connectors) were removed, followed by implementing the bag-of-words model to calculate the bigram and trigram occurrence in the data set. Demographic and time filters were applied to segment the responses. Results Respondents’ knowledge of and concerns with TraceTogether changed from a focus on contact tracing and Bluetooth activation in July-August 2020 to QR code scanning and location check-ins in January-February 2021. Younger males had the highest TraceTogether uptake (24/40, 60%), while older females had the lowest uptake (8/34, 24%) in the first half of July 2020. This trend was reversed in mid-October after the announcement on mandatory TraceTogether check-ins at public venues. Although their TraceTogether uptake increased over time, older females continued to have lower sentiment scores. The mean sentiment scores were the lowest in January 2021 when the media reported that data collected by TraceTogether were used for criminal investigations. Smartphone apps were initially preferred over tokens, but the preference for the type of TraceTogether tool equalized over time as tokens became accessible to the whole population. The sentiments on token-related comments became more positive as the preference for tokens increased. Conclusions The public’s knowledge of and concerns with the use of a mandatory DCT tool varied with the national regulations and public communications over time with the evolution of the COVID-19 pandemic. Effective communications tailored to subpopulations and greater transparency in data handling will help allay public concerns with data misuse and improve trust in the authorities. Having alternative forms of the DCT tool can increase the uptake of and positive sentiments on DCT.