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Background: Poor medication adherence can lead to adverse health outcomes and increased healthcare costs. Although reasons for medication adherence have been widely studied, less is explored about factors affecting medication adherence for patients in non-Western healthcare setting and from Asian cultures. This study aimed to explore cultural perspectives on factors influencing medication adherence among patients with chronic diseases in a multi-ethnic Asian healthcare setting.Methods: We conducted a qualitative study involving in-depth interviews with patients with chronic conditions purposively recruited from a community hospital in Singapore until data saturation was achieved. A total of 25 patients participated in this study. Interviews were transcribed and thematically analyzed. Themes were subsequently mapped into the World Health Organization (WHO) Framework of Medication Adherence.Results: Participants commonly perceived that sides effects (therapy-related dimension), poor understanding of medication (patient-related dimension), limited knowledge of condition (patient-related dimension), forgetfulness (patient-related dimension) and language issues within a multi-ethnic healthcare context (healthcare team and system-related dimension) as the main factors contributing to medication adherence. Importantly, medication adherence was influenced by cultural beliefs such as the notion of modern medicines as harms and fatalistic orientations towards escalation of doses and polypharmacy (patient-related dimension). Participants made various suggestions to foster adherence, including improved patient-physician communication, enhanced care coordination across providers, use of language familiar to patients, patient education and empowerment on the benefits of medication and medication adjustment.Conclusion: A wide range of factors influenced medication adherence, with therapy- and patient-related dimensions more pronounced compared to other dimensions. Findings demonstrated the importance of cultural beliefs that may influence medication adherence. Future efforts to improve medication adherence should consider a person-centered approach to foster more positive health expectations and self-efficacy on medication adherence, supplemented with routine reviews, development of pictograms and cultural competence training for healthcare professionals.

Bis-cyclometalated iridium complexes with highly conjugated cyclometalating ligands and electron-rich ancillary ligands have exceptional quantum yields for deep-red to near-infrared phosphorescence.

Objectives Little empirical research exists on how key stakeholders involved in the provision of care for chronic conditions and policy planning perceive the indirect or ‘spillover’ effects of the COVID-19 on non-COVID patients. This study aims to explore stakeholder experiences and perspectives of the impact of COVID-19 on the provision of care for chronic conditions, evolving modalities of care and stakeholder suggestions for improving health system resilience to prepare for future pandemics. Design Qualitative study design. Setting and participants This study was conducted during and after COVID-19 lockdown period in Singapore. We recruited a purposive sample of 51 stakeholders involved in care of non-COVID patients and/or policy planning for chronic disease management. They included healthcare professionals (micro-level), hospital management officers (meso-level) and government officials (macro-level). Methods In-depth semi-structured interviews were conducted. All interviews were digitally recorded, transcribed verbatim and thematically analyzed. Results Optimal provision of care for chronic diseases may be compromised through the following processes: lack of ‘direct’ communication between colleagues on clinical cases resulting in rescheduling of patient visits; uncertainty in diagnostic decisions due to protocol revision and lab closure; and limited preparedness to handle non-COVID patients’ emotional reactions. While various digital innovations enhanced access to care, a digital divide exists due to uneven digital literacy and perceived data security risks, thereby hampering wider implementation. To build health system resilience, stakeholders suggested the need to integrate digital care into the IT ecosystem, develop strategic public-private partnerships for chronic disease management, and give equal attention to the provision of holistic psychosocial and community support for vulnerable non-COVID patients. Conclusions and Implications Findings highlight that strategies to deliver quality chronic care for non-COVID patients in times of public health crisis should include innovative care practices and institutional reconfiguration within the broader health system context., To mitigate spillover effects of COVID-19 on chronic care, more attention should be devoted to digital care ecosystem, strategic public-private partnerships and psychosocial support for vulnerable non-COVID patients.

Objectives This study aims to examine the impact of COVID-19 measures on wellbeing and self-management in medically vulnerable non-COVID patients and their views of novel modalities of care in Singapore. Methods Patients with cardiovascular disease (CVD), respiratory disease, chronic kidney disease, diabetes and cancer were recruited from the SingHealth cluster and national cohort of older adults. Data on demographics, chronic conditions and perceived wellbeing were collected using questionnaire. We performed multivariable regression to examine factors associated with perceived wellbeing. Qualitative interviews were conducted to elicit patient's experience and thematically analyzed. Results A total of 91 patients participated. Male patients compared with female patients perceived a lower impact of the pandemic on subjective wellbeing. Patients with CVD compared to those having conditions other than CVD perceived a lower impact. Impacts of the pandemic were primarily described in relation to emotional distress and interference in maintaining self-care. Hampering of physical activity featured prominently, but most did not seek alternative ways to maintain activity. Despite general willingness to try novel care modalities, lack of physical interaction and communication difficulties were perceived as main barriers. Discussion Findings underline the need to alleviate emotional distress and develop adaptive strategies to empower patients to maintain wellbeing and self-care.

Yu Heng Kwan,1– 4 Zhi Quan Ong,5 Dawn Yee Xi Choo,1 Jie Kie Phang,2,4 Sungwon Yoon,2,4 Lian Leng Low2,4,6– 9 1Department of Pharmacy, National University of Singapore, Singapore, Singapore; 2Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore; 3Internal Medicine Residency, SingHealth, Singapore, Singapore; 4Centre for Population Health Research and Implementation, SingHealth Regional Health System, Singapore, Singapore; 5School of Computing, National University of Singapore, Singapore, Singapore; 6Population Health & Integrated Care Office (PHICO), Singapore General Hospital, Singapore, Singapore; 7Department of Family Medicine and Continuing Care, Singapore General Hospital, Singapore, Singapore; 8Post-Acute and Continuing Care, Outram Community Hospital, Singapore, Singapore; 9SingHealth Duke-NUS Family Medicine Academic Clinical Program, Singapore, SingaporeCorrespondence: Lian Leng Low, Department of Family Medicine & Continuing Care, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore, Tel +65 63265872, Email low.lian.leng@singhealth.com.sgBackground: Diabetes is a global public health issue, causing burden on healthcare system and increasing risk of mortality. Mobile applications (apps) can be a promising approach to facilitate diabetes self-management. An increasingly utilized approach to facilitate engagement with mobile health (mHealth) technology is to involve potential users in the creation of the technology.Objective: The aim of this study was to use co-design for type 2 diabetes mellitus (T2DM) self-management mHealth development.Methods: Three rounds of iterative rapid prototyping panel sessions were conducted with a total of 9 T2DM participants in an Asian setting between Oct 2020 and April 2021. The participants were recruited through convenience sampling. For each round, feedback was gathered through qualitative interviews, and the feedback was used as a reference by the development team to develop and test a more refined version of the app in the next round. Transcribed semi-structured interview data was analyzed thematically using an inductive approach.Results: Participants’ ages ranged from 40 to 69 years. Data saturation was reached, with no new themes emerging from the data. During the sessions, the participants expressed a variety of concerns and feedback on T2DM self-management using EMPOWER app and raised suggestions on the features of ideal T2DM self-management app. Important features include 1) reminders and notifications for medications, 2) Bluetooth integration with glucometers and blood pressure machines to minimize manual entry, 3) enlarged local food database including information on sugar content and recommendations for healthier options, 4) one touch for logging of routine medications and favorite foods, 5) export function for data sharing with physicians. Overall inputs concerned aspects such as user-friendliness of the app, customization possibilities, and educational content for the features in the mobile app.Conclusion: In this study, we explored users’ opinions on a T2DM self-management mobile app using co-design approach. This study adds to the growing body of literature on co-designing behavioral mHealth interventions and can potentially guide researchers in mobile app design for other chronic conditions.Keywords: type 2 diabetes mellitus, mHealth, mobile app

The review aims to summarize factors that hamper or contribute to Technology-Delivered Motivational Interviewing (TDMI) implementation. Findings from this systematic review may provide a robust set of guidelines for TDMI, as well as a conceptual foundation on which further research on TDMI may be established.

Objective:This study aimed to explore how deployed healthcare workers (HCWs) perceived personal preparedness for response, and their main avenues for coping to maintain resilience during the prolonged COVID-19 (SARS-CoV-2) pandemic.Methods:Semi-structured interviews were conducted with 25 HCWs deployed to the frontline for an extended period to provide acute COVID-19 related care. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically.Results:HCWs demonstrated heightened self-confidence and readiness to deal with public health emergencies owing to the ramped-up efforts in infrastructure for outbreak management and pre-emptive infectious disease training. Despite overall confidence, deployed HCWs had to adopt various coping mechanisms to sustain resilience during the prolonged pandemic. Main themes on coping centred around the value of team leaders and support from family members as an effective buffer for work-induced stress while institution-based counseling services and welfare were viewed as important for fostering the internal locus of control and wellbeing.Conclusion:Our findings suggest that strategies such as on-the-job training, continuous education and improved communication would be essential to maintain resilience of deployed HCWs. Considerations should be also given to the swift implementation of blended wellness support comprising digital and in-person counseling to sustain wellbeing and prepare for endemic COVID-19.

Background Although existing studies have described patterns of social media use in healthcare, most are focused on health professionals in one discipline. Population health requires a multi-disciplinary approach to ensure diversity and to include diverse stakeholders. To date, what is known about using social media in population health is focused on its potential as a communication tool. This study aims to investigate patterns of use and perceived value of social media usage among stakeholders in population health practice, policy, or research. Methods We conducted a web-based survey of delegates attending the Singapore Population Health Conversations and Workshop. We designed a 24-item questionnaire to assess 1) social media use in terms of type of platform and frequency of use; 2) perceptions of social media relevance and impact on population health; and 3) top three areas in population health that would benefit from social media. We used descriptive and logistic regression analyses to assess the relationships between variables. Results Of the 308 survey respondents, 97.7% reported that they use social media in some form. Messaging (96.8%) was the most dominant activity when using social media. Challenges in implementing social media for population health were time investment by health care professionals (56.2%) and patient adoption (52.9%). The top three population health areas that would benefit most from using social media were the promotion of healthy behaviors (60.7%), community engagement (47.7%), and preventive care (40.6%). Older respondents (> = 40 years) were less likely to view social media as useful for the promotion of healthy behaviors (OR = 0.34; 95% CI: 0.19–0.60). Non-social/healthcare professionals were more likely to consider social media to be useful for community engagement (OR = 1.74; 95% CI: 1.10–2.76). For preventive care, older respondents (OR = 0.51; 95% CI: 0.32–0.82) and non-social/healthcare professionals were less likely to view social media as useful (OR = 0.61; 95% CI: 0.38–0.97). Conclusions Our findings suggest that it may be important to select the specific care areas that would benefit most from using social media. The time investment needed by population health professionals should be fully addressed in planning to maximize the application and potential value of social media.

An intriguing new class of two-dimensional (2D) materials based on metal-organic frameworks (MOFs) has recently been developed that displays electrical conductivity, a rarity among these nanoporous materials. The emergence of conducting MOFs raises questions about their fundamental electronic properties, but few studies exist in this regard. Here, we present an integrated theory and experimental investigation to probe the effects of metal substitution on the charge transport properties of M-HITP, where M = Ni or Pt and HITP = 2,3,6,7,10,11-hexaiminotriphenylene. The results show that the identity of the M-HITP majority charge carrier can be changed without intentional introduction of electronically active dopants. We observe that the selection of the metal ion substantially affects charge transport. Using the known structure, Ni-HITP, we synthesized a new amorphous material, a-Pt-HITP, which although amorphous is nevertheless found to be porous upon desolvation. Importantly, this new material exhibits p-type charge transport behavior, unlike Ni-HITP, which displays n-type charge transport. These results demonstrate that both p- and n-type materials can be achieved within the same MOF topology through appropriate choice of the metal ion.

BackgroundENABLE (Educate, Nurture, Advise, Before Life Ends) is a nurse coach-led, early palliative care model for patients with advanced cancer and their family caregivers. Content covered includes problem-solving, advance care planning, symptom management and self-care. The aim was to evaluate the cultural acceptability of ENABLE among patients with advanced cancer and their caregivers in Singapore and identify modifications for an adapted ENABLE-SG model.MethodsQualitative formative evaluation with a thematic analysis approach in two hospitals in Singapore, involving patients (n = 10), family caregivers (n = 11) and healthcare professionals (n = 10) who care for patients with advanced cancer. Semi-structured interviews were conducted to explore (i) the main needs and challenges facing individuals with advanced cancer and their family caregivers; (ii) patient involvement in healthcare decision making; and (iii) content and delivery of ENABLE.ResultsWhile physical needs were largely well met, participants expressed that psychosocial care was delivered too late in the illness trajectory. Healthcare decision making approaches varied from a patient-centred shared decision-making model to a family-centred model where patients may not know their cancer diagnosis and prognosis. The content was considered to be relevant, comprehensive and practical; financial assistance, adjustment to body image, and evaluation of complementary therapy were also recommended. Face-to-face rather than telephone sessions were preferred to facilitate rapport building.ConclusionsENABLE was broadly acceptable with some modifications, including adjusting the content to ensure it can be delivered even if the patient is not fully aware of cancer diagnosis and delivering the first session face-to-face with flexibility for subsequent sessions.

BackgroundMany older adults with severe dementia receive potentially life-extending treatments even when caregivers do not wish to prolong their life inappropriately.ObjectiveExplore factors that influence caregiver preferences for potentially life-extending treatments for older adults with severe dementia, and reasons for discordance between overall end-of-life care goal and treatment preferences.DesignSemi-structured in-depth interviews asking caregivers their overall end-of-life care goal for older adults and preferences for intravenous (IV) antibiotics, tube feeding and cardiopulmonary resuscitation (CPR).ParticipantsA total of 26 caregivers of community-dwelling older adults with severe dementia in Singapore.ApproachReflexive thematic analysis.ResultsMost caregivers’ (77%) overall end-of-life care goal was ‘no life extension’. Yet, 80% preferred IV antibiotics for a life-threatening infection, 60% preferred tube feeding and 45% preferred CPR. Caregivers preferred these treatments because they (1) perceived letting go by withholding treatments as unethical, (2) felt they had no choice as they deferred to the health care provider, (3) wanted to alleviate suffering rather than extend life and (4) desired trying minimally invasive treatments that had the potential to be withdrawn. Themes explaining discordance were (1) feared regret about making the ‘wrong’ decision, (2) considered treatments to address immediate needs even when long-term goal did not match providing that treatment and (3) anticipated disagreement with other family members on overall goal of care.ConclusionTo reduce discordance between caregivers’ overall end-of-life care goal and preferences for life-extending treatments, clinicians can use a shared decision-making approach involving discussions of both their overall end-of-life care goal and treatment preferences.

Background: Caregivers are essential for improved outcomes in patients living with left ventricular assist device (LVAD). There is a paucity of research on a long-term LVAD caregivers' experiences and burdens. Objectives: The aim of this study was to explore long-term challenges and needs of LVAD caregivers in the Asian health care setting. Design: We conducted semistructured interviews with caregivers of patients who were currently or previously living with the LVAD. Settings/Subjects: Caregivers were recruited from the National Heart Centre Singapore. Measurements: Interviews were conducted in English and Chinese. All interviews were transcribed verbatim and analyzed based on grounded theory. Chinese interviews were translated to English before transcription. Results: A multiethnic and multireligious sample of 11 caregivers participated. Median caregiving duration was 45 months. Caregivers described long-term challenges that were multifaceted. Misaligned patient expectations, stigmatization and limited social resources within the family and society affected caregivers' coping. Existing gender roles and spiritual and cultural influences shaped how caregivers appraised, made meaning of caregiving, and assessed support. Long-term caregivers' needs included learning from role models, shifting perspectives, enhancing communication between patient and caregivers, advocacy efforts, and holistic medical care. Conclusions: Gender roles as well as cultural and spiritual influences affected coping and access to support in long-term Asian LVAD caregivers. Future interventions should consider culturally relevant approaches to improve well-being and quality of life of caregivers.

Objective To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)’s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups. Methods We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data. Results We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO’s five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO’s five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups. Conclusion Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence. Protocol Registration PROSPERO Identifier: CRD42020181316

Background In a rapidly digitalizing world, the inability of older adults to leverage digital technology has been associated with weaker social connections and poorer health outcomes. Despite the widespread digital adoption in Singapore, older adults, especially those of lower socioeconomic status (SES), still face difficulties in adopting information and communications technology and are typically digitally excluded. Objective We aimed to examine the impact of the volunteer-led, one-on-one, and home-based digital literacy program on digital literacy and health-related outcomes such as self-reported loneliness, social connectedness, quality of life, and well-being for older adults of low SES. Methods A nonrandomized controlled study was carried out in Singapore between July 2020 and November 2021 involving 138 digitally excluded community-dwelling older adults aged ≥55 years and of lower SES. Older adults awaiting participation in the program served as controls. Older adults under the intervention were equipped with a smartphone and cellular data, underwent fortnightly to monthly digital literacy training with volunteers to learn digital skills, and digitally connected to their existing social networks. Primary outcome was the improvement in self-reported digital literacy. Secondary outcomes included improvements in University of California, Los Angeles 3-item loneliness scale, Lubben Social Network Scale-6, EQ-5D-3L and EQ visual analogue scale scores, and Personal Wellbeing Score. Results There were significant improvements in digital literacy scores in the intervention group as compared to controls (mean difference 2.28, 95% CI 1.37-3.20; P Conclusions This study adds to the growing research on digital inclusion by showing that a volunteer-led, one-on-one, and home-based digital literacy program contributed to increase digital literacy in older adults of low SES. Future studies should look into developing more older adult–friendly digital spaces and technology design to encourage continued digital adoption in older adults and, eventually, impact health-related outcomes.

COVID-19 vaccination in healthcare workers (HCW) is essential for improved patient safety and resilience of health systems. Despite growing body of literature on the perceptions of COVID vaccines in HCWs, existing studies tend to focus on reasons for 'refusing' the vaccines, using surveys almost exclusively. To gain a more nuanced understanding, we explored multifactorial influences underpinning a decision on vaccination and suggestions for decision support to improve vaccine uptake among HCWs in the early phase of vaccination rollout. Semi-structured interviews were undertaken with thirty-three HCWs in Singapore. Transcribed data was thematically analyzed. Decisions to accept vaccines were underpinned by a desire to protect patients primarily driven by a sense of professional integrity, collective responsibility to protect others, confidence in health authorities and a desire to return to a pre-pandemic way of life. However, there were prevailing concerns with respect to the vaccines, including long-term benefits, safety and efficacy, that hampered a decision. Inadequate information and social media representation of vaccination appeared to add to negative beliefs, impeding a decision to accept while low perceived susceptibility played a moderate role in the decision to delay or decline vaccination. Participants made valuable suggestions to bolster vaccination. Our findings support an approach to improving vaccine uptake in HCWs that features routine tracking and transparent updates on vaccination status, use of institutional platforms for sharing of experience, assuring contingency management plans and tailored communications to emphasize the duty of care and positive outlook associated with vaccination.

Introduction: This study aimed to examine the perception of faculty on the relevance, feasibility and comprehensiveness of the Professionalism Mini Evaluation Exercise (P-MEX) in the assessment of medical professionalism in residency programmes in an Asian postgraduate training centre. Methods: Cross-sectional survey data was collected from faculty in 33 residency programmes. Items were deemed to be relevant to assessment of medical professionalism when at least 80% of the faculty gave a rating of ≥8 on a 0-10 numerical rating scale (0 representing not relevant, 10 representing very relevant). Feedback regarding the feasibility and comprehensiveness of the P-MEX assessment was also collected from the faculty through open-ended questions. Results: In total, 555 faculty from 33 residency programmes participated in the survey. Of the 21 items in the P-MEX, 17 items were deemed to be relevant. For the remaining four items ‘maintained appropriate appearance’, ‘extended his/herself to meet patient needs’, ‘solicited feedback’, and ‘advocated on behalf of a patient’, the percentage of faculty who gave a rating of ≥8 was 78%, 75%, 74%, and 69% respectively. Of the 333 respondents to the open-ended question on feasibility, 34% (n=113) felt that there were too many questions in the P-MEX. Faculty also reported that assessments about ‘collegiality’ and ‘communication with empathy’ were missing in the current P-MEX. Conclusion: The P-MEX is relevant and feasible for assessment of medical professionalism. There may be a need for greater emphasis on the assessment of collegiality and empathetic communication in the P-MEX.

Objectives This study aimed to provide an in-depth exploration of follow-up care experiences and supportive care needs in long-term colorectal cancer (CRC) survivors within multiethnic Asian communities. Methods Semi-structured in-depth interviews were conducted on a purposive sample of 30 long-term CRC survivors who had completed all treatment without recurrence ranging 2-17 years in Singapore. Interviews were audio-recorded, and transcribed verbatim. Thematic analysis was conducted following grounded theory approach. Results Four themes represented the experience of the Asian long-term CRC survivors: (1) living with long-term consequences, (2) dealing with unceasing adaptation demands, (3) navigating a healthcare journey with limited direction, (4) regaining mastery through adversity. CRC and its treatment had profound physical impacts on some long-term survivors and these effected their psychological well-being. A sense of abandonment and vulnerability following the cessation of a 5-year follow-up care was repeatedly expressed. Participants defined recovery from CRC as not merely surviving but also having high physical function and full independence. They often sought less conventional remedies and medicine based on cultural beliefs rather than current evidence. Participants noted pervasive social stigma associated with CRC that impeded their inclusion in the workforce. Conclusions Asian long-term CRC survivors experienced multiple challenges and needs relating to the care experience, information provision and workforce stigmatization, several of which were unique to the Asian context. Future work will need to consider the implementation of culturally tailored cancer survivorship care plans that incorporate the specific needs of Asian CRC survivors. This article is protected by copyright. All rights reserved.

Quasielastic Raman scattering arising from spin energy fluctuations is used to extract the magnetic specific heat. To test the applicability of a Raman scattering technique for probing magnetic specific heat, we choose three different classes of quantum magnets: (i) a quasi-1D s = 1/2 antiferromagnetic chain CuSe2O5, (ii) a 3D Kitaev honeycomb magnet γ-Li2IrO3, and (iii) a coupled-spin tetrahedral system Cu2Te2O5Cl2. Despite distinct dimensionality, spin topology, and spin-exchange type, the three materials show a pronounced quasielastic response commonly, enabling the determination of the magnetic contributions to the specific heat. Our work demonstrates that a Raman spectroscopic method is useful, complementing the conventional thermodynamic method, in deriving the magnetic specific heat in quantum magnets.

Background The importance of medical professionalism and its assessment has been well documented in the literature. However, there is currently no culturally-adapted tool to assess medical professionalism in Singapore. This study sets out to find consensus on relevance of the items from the Professionalism Mini Evaluation Exercise (P-MEX) for assessing medical professionalism in Singapore. Methods A two-round Delphi survey was completed by an expert panel consisting of program directors, associate designated institutional officials, and designated institutional official (n = 15) from residency programs in Singapore. Round 1 comprised of 23 items from the P-MEX rated on a 5-point scale (1 = Definitely include, 2 = Possibly include, 3 = Neutral, 4 = Possibly exclude, 5 = Definitely exclude). In round 2, the experts received feedback from the previous round, and were asked to re-rate the items which did not achieve consensus in the previous round. The threshold for consensus in the study was defined as 70% or greater agreement among experts. Results Completed questionnaires for both rounds were received from all 15 experts. In round 1, 18 items (78%) achieved consensus to be included. In round 2, 1 (4%) item achieved consensus to be included. However, none of the remaining items achieved consensus to be removed, and they exhibited stability in responses. A list of 19 items covering four domains of medical professionalism (Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills) was obtained during the two-rounds of Delphi survey. Conclusions Nineteen items in the P-MEX had garnered consensus and is suitable for assessing medical professionalism in Singapore. The findings of this study can provide guidance for faculty and institutions who want to assess medical professionalism of their medical trainees.

Several population-based studies have been conducted to better understand the public knowledge of cardiovascular disease (CVD) and behavior. However, most studies have predominantly focused on Western populations. This study aimed to investigate heart disease knowledge, preventive behavior and source of information on heart disease in a multi-ethnic Asian population. We conducted a nation-wide population-based survey of 1000 participants of three ethnic groups (Chinese, Malay, Indian) in Singapore. A structured questionnaire was used to collect sociodemographics, knowledge on CVD risk factors, symptoms, emergency action, preventive health behaviors and sources of information on heart disease. Univariate and multivariate analyses were conducted to identify factors associated with the CVD knowledge and behavior. Knowledge on CVD risk factors was generally high. Knowledge on emergency actions was low particularly in younger people. More than 60% did not meet the recommended levels of physical activity, and this was more evident for individuals of overweight/obese status, lower education and workforce. Chinese were less likely to be obese/overweight compared to the Malays and Indians. Malays were less likely to seek information from internet and social media compared to their ethnic counterparts. This study highlighted heterogeneity in the levels of knowledge and health behavior across population segments, suggesting the need for a tailored approach to heart health interventions and optimal channels for information dissemination. Our findings will form the basis for contextually and culturally appropriate interventions to combat the growing CVD burden and prevent its toll on a rapidly ageing population.

Background: Hong Kong's construction industry currently faces a manpower crisis. Blue-collar workers are a disadvantaged group and suffer higher levels of chronic diseases, for example, cancer, than the wider population. Cancer risk factors are likely to cluster together. We documented prevalence of cancer-associated lifestyle risk behaviors and their correlates among Hong Kong construction workers. Methods: Data were collected from workers at 37 railway-related construction worksites throughout Hong Kong during May 2014. Tobacco use, alcohol consumption, unbalanced nutrition intake, and physical inactivity were included in the analysis. Latent class analysis and multivariable logistic regression were performed to identify the patterns of risk behaviors related to cancer, as well as their impact factors among construction workers in Hong Kong. Results: Overall, 1,443 workers participated. Latent class analysis identified four different behavioral classes in the sample. Fully adjusted multiple logistic regression identified age, gender, years of Hong Kong residency, ethnicity, educational level, and living status differentiated behavioral classes. Conclusion: High levels of lifestyle-related cancer-risk behaviors were found in most of the Hong Kong construction workers studied. The present study contributes to understanding how cancer-related lifestyle risk behaviors cluster among construction workers and relative impact factors of risk behaviors. It is essential to tailor health behavior interventions focused on multiple risk behaviors among different groups for further enlarging the effects on cancer prevention. Keywords: Cancer, Construction workers, Prevention, Risk behaviors

Background Home-based palliative care (HPC) is considered to moderate the problem of rising healthcare utilization of cancer patients at end-of-life. Reports however suggest a proportion of HPC patients continue to experience high care intensity. Little is known about differential trajectories of healthcare utilization in patients on HPC. Thus, we aimed to uncover the heterogeneity of healthcare utilization trajectories in HPC patients and identify predictors of each utilization pattern. Methods This is a cohort study of adult cancer patients referred by Singapore Health Services to HCA Hospice Service who died between 1st January 2018 and 31st March 2020. We used patient-level data to capture predisposing, enabling, and need factors for healthcare utilization. Group-based multi-trajectory modelling was applied to identify trajectories for healthcare utilization based on the composite outcome of emergency department (ED) visits, hospitalization, and outpatient visits. Results A total of 1572 cancer patients received HPC (median age, 71 years; interquartile range, 62–80 years; 51.1% female). We found three distinct trajectory groups: group 1 (31.9% of cohort) with persistently low frequencies of healthcare utilization, group 2 (44.1%) with persistently high frequencies, and group 3 (24.0%) that begin with moderate frequencies, which dropped over the next 9 months before increasing in the last 3 months. Predisposing (age, advance care plan completion, and care preferences), enabling (no medical subsidy, primary decision maker), and need factors (cancer type, comorbidity burden and performance status) were significantly associated with group membership. High symptom needs increased ED visits and hospitalizations in all three groups (ED visits, group 1–3: incidence rate ratio [IRR] 1.74–6.85; hospitalizations, group 1–3: IRR 1.69–6.60). High home visit intensity reduced outpatient visits in all three groups (group 1–3 IRR 0.54–0.84), while it contributed to reduction of ED visits (IRR 0.40; 95% CI 0.25–0.62) and hospitalizations (IRR 0.37; 95% CI 0.24–0.58) in group 2. Conclusions This study on HPC patients highlights three healthcare utilization trajectories with implications for targeted interventions. Future efforts could include improving advance care plan completion, supporting care preferences in the community, proactive interventions among symptomatic high-risk patients, and stratification of home visit intensity.

Background: It is often difficult for patients with advanced heart failure (HF) to decide whether to live with a left ventricular assist device (LVAD) or not. Little is known about their decisional needs prior to LVAD implantation and if these needs were met in the Asian cultural setting. Aims: We aimed to explore the influences, concerns, and needs surrounding the decision-making process of the LVAD implantation among multi-ethnic Asian patients with HF. Methods: Semi-structured interviews with HF patients and caregivers were conducted, based upon the grounded theory approach. Participants were purposively recruited from the inpatient and outpatient setting of the National Heart Centre Singapore. Results: A total of 31 patients and 11 caregivers participated. Mindsets that shaped decision-making ranged from “having no choice,” “being reflective,” “taking a gamble,” and “fighting on.” Instead of making a sole decision, many patients reported that decisions were shared with the family or medical team. Current LVAD patients who acted as patient ambassadors were also strong influences. Spiritual support was pivotal to decision-making for some participants. Goals influencing decision-making including protecting the family and life prolongation improving quality of life. Values held close included sanctity of life, trusting in a higher power, believing in pre-destination or karma, and preserving family harmony. Participants had concerns about cost, employment, and health outcomes. Conclusions: Asian LVAD patients and caregivers had culturally specific mindsets, goals, and values and concerns around decision-making. Our findings have implications for the design of interventions and supportive care models.

ObjectiveThis study aimed to identify facilitators and barriers to the uptake of a community-based diabetes prevention program (DPP) from the perspectives of decliners with prediabetes in a multi-ethnic Asian community.MethodsSemi-structured interviews were conducted with 29 individuals with prediabetes who declined participation in a large community-based diabetes prevention program in Singapore. Thematic analysis was undertaken to identify themes, which were subsequently mapped onto the Capacity-Opportunity-Motivation and Behavior model (COM-B).ResultsWe identified 16 key themes under three COM-B domains. Health status at the time of invitation, perceived ability of self-management, understanding of prediabetes condition and/or the program intention (Capability) were important determinants. Family commitment had the strong potential to enable or hinder physical and social Opportunity related to participation. Many participants desired involvement of physician as part of program invitation and component. Fear of exacerbation coupled with an automatic aversion for suffering influenced Motivation for participation.ConclusionIdentifying facilitators and barriers embedded in the COM-B will assist systematic program modifications to increase participation of individuals with prediabetes. How information about modifiable risk factors is communicated by physicians at the point of diagnosis and program introduction is key to participation. Co-locating programs with family activity, development of mHealth, readiness assessment, and tailored explanation of program purpose may increase participation. These findings will be used to guide future national interventions in the community to ensure successful implementation.

IntroductionType 2 diabetes mellitus (T2DM) poses huge burden and cost on the healthcare system. Mobile health (mHealth) interventions that incorporate wearables may be able to improve diabetes self-management. The aim of this randomized controlled trial (RCT) is to investigate the clinical and cost-effectiveness of personalized educational and behavioral interventions delivered through an EMPOWER mobile application (app) among patients with T2DM.MethodsThis is a parallel two-arm randomized controlled trial (RCT). Patients with T2DM recruited from primary care will be randomly allocated in a 1:1 ratio to either intervention or control group. The intervention group will receive personalized educational and behavioral interventions through the EMPOWER app in addition to their usual clinical care. The control group will receive the usual clinical care for their T2DM but will not have access to the EMPOWER app. Our primary outcome is patient activation score at 12 months. Secondary outcomes will include HbA1c, physical activity level and diet throughout 12 months; quality of life (QoL), medication adherence, direct healthcare cost and indirect healthcare cost at 6 and 12 months.DiscussionThis RCT will provide valuable insights into the effectiveness and implementation of personalized educational and behavioral interventions delivered through mobile application in T2DM management. Findings from this study can help to achieve sustainable and cost-effective behavioral change in patients with T2DM, and this can be potentially scaled to other chronic diseases such as hypertension and dyslipidemia.

Importance: Safe-distancing measures used during the COVID-19 pandemic may exacerbate social isolation and loneliness with their attending negative consequences. Digital technology may mitigate the negative impact of safe-distancing measures; however, older adults of low socioeconomic status (SES) who may not be digitally literate remain a vulnerable population.Objective: To examine the relationship between digital literacy and social connectedness, loneliness, wellbeing, and quality of life (QOL) amongst older adults. To identify demographic factors associated with smartphone ownership, digital literacy, and willingness to enroll in a home-based digital literacy program. Design: Cross-sectional study. Setting: Convenience sampling of older adults receiving financial aid or living in rental flat referred to a volunteer-led digital literacy program.Participants: 302 community dwelling older adults who are ≥55 years old. Main Outcomes: Smartphone ownership, self-reported digital literacy, willingness to enroll in a digital literacy program; social connectedness (Lubben Social Connectedness Scale, LSNS-6), loneliness (UCLA 3-item scale, UCLA-3), wellbeing (Personal Wellbeing Score), and QOL (EQ-5D-3L [utility index], EQ VAS). Results: Social digital literacy had a positive indirect effect on both the wellbeing and QOL (mediated by social connectedness and perceived loneliness) of older adults, while instrumental digital literacy had a negative indirect effect on the two outcomes. 59.9% of participants owned an internet-enabled phone (smartphone). The median digital literacy index is 3 (score ranging from 0 to 13). Older adults who are younger and more educated were more likely to own a smartphone; while older adults who are more educated, Chinese (ethnic majority), have a smartphone, and lower digital literacy index were more likely to enroll in a home-based digital literacy education program.Conclusions and Relevance: During the COVID-19 pandemic, community dwelling older adults of low SES are socially isolated, lonely, and have low digital literacy. Interventions to improve digital literacy (especially the social domain) may help to reduce social isolation and loneliness, ultimately improving wellbeing and QOL.

A successful public health response during the COVID-19 pandemic pivots on the ability of health care workers (HCWs) to work through immense workplace-related physical and psychological pressures.The aim of current study was to explore support needs of HCWs during the COVID-19 outbreak in Singapore and to identify implications for practice and workplace policies.A descriptive qualitative approach was adopted in this study. HCWs from a major public health care cluster in Singapore (n = 612) responded to an open-ended question in an online survey. Results were analyzed using content analysis via an inductive approach.Five main themes that borrows from Maslow's Hierarchy of Needs emerged from content analysis, with 17 categories under the themes. The 5 main themes are: physical needs, safety needs, love and belonging needs, esteem needs and self-actualization needs.Findings from this study indicate that there were many unmet needs among HCWs during the COVID-19 pandemic. An overview of various need areas identified in this study may guide future research and development of interventions to mitigate the negative impact of disease outbreaks on HCWs.

Background. Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood. Aim. This study aimed to explore clinicians’ perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting. Design. We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed. Results. A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment. Conclusion. Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Background There is a compelling need for an innovative and creative approach to promote social connectedness among older adults to optimize their well-being and quality of life. One possible solution may be through a digital intergenerational program. Objective This realist review aimed to identify existing digital intergenerational programs that were used to reduce loneliness or social isolation among older adults and analyze them in terms of strategy, context, mechanisms, and outcomes. Methods We performed a realist review with an extensive search of published and gray literature. For scholarly literature, we searched PubMed, Embase, CINAHL, PsycINFO (Ovid), and Social Sciences Citation Index databases for articles published between January 2000 to August 2020. A grey literature search was performed using the Google search engine, and the search was completed in May 2021. We included programs that evaluated digital intergenerational programs for older adults, which described outcomes of loneliness or social isolation. We included quantitative, mixed methods, and qualitative studies, as well as relevant theoretical papers, policy documents, and implementation documents. The studies were appraised based on their relevance and rigor. We synthesized the available evidence from the literature into Strategy-Context-Mechanism-Outcome (S-C-M-O) configurations to better understand what, when, and how programs work. Results A total of 31 documents reporting 27 digital intergenerational programs were reviewed. Our final results identified 4 S-C-M-O configurations. For S-C-M-O configuration 1, we found that for community-dwelling older adults, provision of access to and training in digital technology may increase older adults’ self-efficacy in digital devices and therefore increase the use of digital communication with family. In S-C-M-O configuration 2, digital psychosocial support and educational interventions from nurses were found to be useful in reducing loneliness among community-dwelling older adults. In S-C-M-O configuration 3, a video call with a student or family was found to reduce loneliness among older adults residing in long-term residential care facilities. Finally, for S-C-M-O configuration 4, we found that behavioral activation provided through videoconferencing by a lay coach may be useful in reducing loneliness among older adults who are lonely. However, as almost half (11/27, 41%) of the included programs only reported quantitative results, this review focused on screening the discussion section of publications to identify author opinions or any qualitative information to elucidate the mechanisms of how programs work. Conclusions This review identified the key strategy, context, and mechanism influencing the success of programs that promote intergenerational interaction through digital means. This review revealed that different strategies should be adopted for different groups of older adults (eg, older adults who are lonely, older adults who reside in long-term residential care facilities, and community-dwelling older adults). The S-C-M-O configurations should be considered when designing and implementing digital intergenerational programs for older adults.

Background: Research on different models of palliative care should include evaluation of the patients' experience of care. Objectives: To understand the patients' experience regarding care received in a consult model versus an integrated palliative care and medical oncology co-rounding model during a hospital admission. Design: Qualitative study using thematic analysis. Setting/Subjects: Seventeen patients with stage 4 solid tumor admitted to a tertiary hospital in Singapore. Results: Although experiences of care during the hospital stay were similar in both models, patients in the integrated model were able to better articulate the benefits of palliative care involvement alongside oncologists-to facilitate better communication and a more holistic understanding of the clinical context, with a view to effectively addressing the patient's needs. Conclusions: An integrated co-rounding model may possibly smoothen the transition for advanced cancer patients to palliative care, and could perhaps be considered for implementation to foster reach of palliative care services and improve patient experience.

Objectives Motivators and barriers are pivotal factors in the adoption of health behaviors. This study aims to identify patterns of the motivators and barriers influencing heart health behaviors among multi-ethnic Asian adults with behavior-modifiable risk factors for heart disease, namely obesity, physical inactivity and smoking. Methods A population-based survey of 1,000 participants was conducted in Singapore. Participants were assessed for behavior-modifiable risk factors and asked about motivators and barriers to heart health behaviors. Exploratory and confirmatory factor analyses were conducted to identify factors underlying motivator and barrier question items. Logistic regression was conducted to examine the associations of motivator and barrier factors with sociodemographic characteristics. Results The twenty-five motivator and barrier items were classified into three (outcome expectations, external cues and significant others including family and friends) and four (external circumstances, limited self-efficacy and competence, lack of perceived susceptibility, benefits and intentions and perceived lack of physical capability) factors respectively. Among participants with behavior-modifiable risk factors, those with lower education were more likely to be low in motivation factor of “outcome expectations” and “external cues”. The well-educated were more likely to be high in the barrier factor of “lack of perceived susceptibility, benefits and intention” and were less likely to have the motivation factor of “significant others (family or friends)”. Those aged 60–75 years had low motivations and high barriers compared to their younger counterparts. Older age was more likely to be low in motivation factor of “outcome expectations” and “external cues” and high in barrier factor of “limited self-efficacy and competence” and “perceived lack of physical capability”. Conclusions Findings underscore the importance of a targeted intervention and communication strategy addressing specific motivation and barrier factors in different population segments with modifiable risk factors.

IntroductionThe perspectives of healthcare professionals (HCPs) are pivotal to co-development of self-management strategies for patients with diabetes. However, literature has been largely limited to perspectives of patients within the context of a Western healthcare setting. This study aims to explore factors influencing diabetes self-management in adult patients with diabetes from the perspectives of HCPs and their views of the value of mHealth application for diabetes self-management.Materials and MethodsWe conducted focus group discussions (FGD) with purposively selected HCPs in Singapore. All FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted using NVivo 12.ResultsA total of 56 HCPs participated in the study. Barriers to self-management included limited patient commitment to lifestyle changes, suboptimal adherence to medication and treatment, patient resistance to insulin initiation and insufficient rapport between patients and HCPs. Patients’ perceived susceptibility to complications, social support from family and community, multidisciplinary team care and patient’s understanding of the benefits of self-care were viewed as facilitating self-management. HCPs saw mHealth apps as a vital opportunity to engage patients in the self-management of conditions and empower them to foster behavior changes. Yet, there were concerns regarding patient’s limited digital literacy, lack of integration into routine electronic system and reluctance.DiscussionWe identified a set of factors influencing self-management in adult patients with diabetes and useful app features that can empower patients to manage their conditions. Findings will inform the development of a mHealth application, and its features designed to improve self-care.

A family health history-based risk assessment is particularly valuable for guiding cancer screening and treatment strategies, yet an optimal implementation depends upon end-users' values and needs. This is not only true prior to disease development, but also for those already affected. The aim of this study is to explore perceptions of the value of knowing one's family health history (FHH)-based risk, experience using a patient-facing FHH tool and the potential of the tool for wider implementation. Twenty multi-ethnic Asian patients undergoing breast cancer treatment in Singapore completed an FHH-based risk assessment. Semi-structured one-on-one interviews were conducted and data were thematically analyzed. All participants were female and slightly more than half were Chinese. The acceptance and usage of an FHH risk assessment tool for cancers and its broader implementation was affected by a perceived importance of personal control over early detection, patient concerns of anxiety for themselves and their families due to risk results, concerns for genetic discrimination, adequacy of follow-up care plans and Asian cultural beliefs toward disease and dying. This study uniquely sheds light on the factors affecting Asian breast cancer patients' perceptions about undergoing an FHH-based risk assessment, which should inform steps for a broader implementation in Asian healthcare systems. Published version This research was funded by the Duke University School of Medicine and Duke-NUS Medical School, grant number Duke/Duke-NUS/RECA(Pilot)/2017/0033, and the APC was funded by the Duke University School of Medicine and Duke-NUS Medical School.

Introduction The burden of chronic kidney disease (CKD) is rising globally including in Singapore. Primary care is the first point of contact for most patients with early stages of CKD. However, several barriers to optimal CKD management exist. Knowing healthcare professionals’ (HCPs) perspectives is important to understand how best to strengthen CKD services in the primary care setting. Integrating a theory-based framework, we explored HCPs’ perspectives on the facilitators of and barriers to CKD management in primary care clinics in Singapore. Methods In-depth interviews were conducted on a purposive sample of 20 HCPs including 13 physicians, 2 nurses and 1 pharmacist from three public primary care polyclinics, and 4 nephrologists from one referral hospital. Interviews were audio recorded, transcribed verbatim and thematically analyzed underpinned by the Theoretical Domains Framework (TDF) version 2. Results Numerous facilitators of and barriers to CKD management identified. HCPs perceived insufficient attention is given to CKD in primary care and highlighted several barriers including knowledge and practice gaps, ineffective CKD diagnosis disclosure, limitations in decision-making for nephrology referrals, consultation time, suboptimal care coordination, and lack of CKD awareness and self-management skills among patients. Nevertheless, intensive CKD training of primary care physicians, structured CKD-care pathways, multidisciplinary team-based care, and prioritizing nephrology referrals with risk-based assessment were key facilitators. Participants underscored the importance of improving awareness and self-management skills among patients. Primary care providers expressed willingness to manage early-stage CKD as a collaborative care model with nephrologists. Our findings provide valuable insights to design targeted interventions to enhance CKD management in primary care in Singapore that may be relevant to other countries. Conclusions The are several roadblocks to improving CKD management in primary care settings warranting urgent attention. Foremost, CKD deserves greater priority from HCPs and health planners. Multipronged approaches should urgently address gaps in care coordination, patient-physician communication, and knowledge. Strategies could focus on intensive CKD-oriented training for primary care physicians and building novel team-based care models integrating structured CKD management, risk-based nephrology referrals coupled with education and motivational counseling for patients. Such concerted efforts are likely to improve outcomes of patients with CKD and reduce the ESKD burden.

Background The importance of medical professionalism has been well documented in the literature. Cultural background affects the constituents of professionalism. However, few studies have explored the domains of medical professionalism in an Asian context. We aim to describe the views and experiences of both patients and faculty on medical professionalism in an urban Asian city state. Methods Data for this qualitative study were collected through focus group discussions (FGDs) with patients and in-depth interviews (IDIs) with faculty members. The IDIs and FGDs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using a priori framework derived from Professionalism Mini Evaluation Exercise (P-MEX). Sociodemographic data of faculty members and patients were obtained through brief questionnaires. Results A total of 31 patients (58.1% male, all had visited healthcare facilities within the past year) and 26 faculty members (42.3% male, 38.5% from medical disciplines, median years as faculty is 11) participated in this study. The results supported the four domains of medical professionalism - Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills. Two new sub-domains which emerged from data were (1) communicated effectively with patient and (2) demonstrated collegiality. Conclusions The domains of professionalism in Singapore were similar to previous studies. This study allows a better understanding of medical professionalism to enhance the assessment and ultimately, the teaching of medical professionalism in an urban multi-ethnic Asian city.

Five new near-infrared (NIR) phosphorescent bis-cyclometalated iridium(iii) complexes, partnering highly conjugated cyclometalating ligands with quinoline-derived ancillary ligands, have been developed. These complexes have peak NIR luminescence wavelengths from 711 to 729 nm, with photoluminescence quantum yields ranging from 0.042 to 0.36.