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Background: Singapore's healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems., Aim: To explore processes underpinning decision-making for antibiotic prescribing, by considering doctors' experiences in different primary care settings., Methods: Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing., Results: Given Singapore's lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices. These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change., Conclusions: These VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly., (© 2021. The Author(s).)

Background: Personalised care and support planning (CSP) has been shown to improve diabetes outcomes, patient experience and provider morale in the care of persons living with diabetes. However, this has not been confirmed in controlled studies. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) is a pragmatic controlled trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in the public primary care setting in Singapore., Methods: Teamlet-empanelled patients with diabetes at four polyclinics are recruited for this study. Participants who attend either of the two Intervention clinics are sent their investigation results in a care planning letter (CPL) to prepare them for the CSP conversation. This conversation is facilitated by a trained CSP practitioner who engages them in discussion of concerns, goals and action plans, and documents their plans for subsequent review. Participants in the two Control clinics will receive standard diabetes care. Participants will complete two or more CSP conversations (Intervention) or regular consultations (Control) at the annual review visits within the 18 months of the study. The sample size is calculated at 1620 participants, with glycated haemoglobin (HbA1c) as the primary outcome measure. Secondary outcome measures include patient activation (as measured by PAM-13) and changes in healthcare utilisation and cost., Discussion: This study is a pragmatic trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in a real world setting. It promises to provide insights with regard to the implementation of this model of care in Singapore and the region., Trial Registration: ClinicalTrials.gov Identifier NCT04288362. Retrospectively registered on 28 February 2020.

Background: Approximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore., Methods: This study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare., Results: Despite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time. Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients. Although providers could equip patients with self-management and lifestyle-related guidelines, patients' actions are influenced by multiple factors, including work requirements, beliefs and environment., Conclusions: There were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.

Objective: To study the attitudes, concerns, perceived impact, coping strategies, knowledge on avian influenza (AI) and personal protection measures, and institutional and personal preparedness for AI among all Indonesian primary healthcare workers (PHW)., Methods: Questionnaire survey of PHW from four public primary healthcare clinics in South Jakarta (n = 333), with Singaporean PHW from 18 such clinics as controls (n = 1321). Twelve focus group discussions with 51 South Jakarta PHW were also conducted. Quantitative and qualitative data were analysed separately with statistical and thematic analysis, respectively, then combined., Results: South Jakarta PHW had positive attitudes but major concerns about contracting AI, difficulties in diagnosing human AI and inadequacy of personal protection provided. South Jakarta PHW are less knowledgeable about AI and use of personal protection equipment, and reported poorer awareness, availability and participation in AI preparation activities. Only 3% of South Jakarta PHW received influenza vaccination in the preceding 6 months and few felt prepared for AI., Conclusions: South Jakarta primary healthcare workers are not well prepared for avian influenza. There is an urgent need to build their primary healthcare capacity to protect them and contain this global health threat.

Introduction: During an avian influenza (AI) pandemic, primary-care physicians (PCPs) are expected to play key roles in the prevention and control of the disease. Different groups of PCPs could have different concerns and preparedness level. We assessed the concerns, perceived impact and preparedness for an outbreak among PCPs in Singapore., Materials and Methods: A cross-sectional survey of PCPs working in private practice (n=200) and public clinics (n=205) from March to June 2006 with an anonymous self-administered questionnaire on concerns (12- items), perceived impact (10 items) and preparedness (10 items) for an outbreak., Results: Two hundred and eighty-five PCPs responded - 149 (response rate: 72.7%) public and 136 (response rate: 67.3%) private. The majority were concerned about risk to their health from their occupation (95.0%) and falling ill with AI (89.7%). Most (82.5%) accepted the risk and only 33 (11.8%) would consider stopping work. For perceived impact, most felt that people would avoid them (69.6%) and their families (54.1%). The majority (81.3%) expected an increased workload and feeling more stressed at work (86.9%). For preparedness, 78.7% felt personally prepared for an outbreak. Public PCPs were more likely to be involved in infection-control activities and felt that their workplaces were prepared., Conclusions: Most PCPs felt personally prepared for an outbreak but were concerned about their exposure to AI and falling ill. Other concerns included social ostracism for themselves and their families. Public PCPs appeared to have a higher level of preparation. Addressing concerns and improving level of preparedness are crucial to strengthen the primary-care response for any AI outbreak.

Introduction: With the potential threat of an avian influenza (AI) pandemic, healthcare workers (HCWs) are expected to play important roles, and they encounter significant stress levels from an expected increase in workload. We compared the concerns, perceived impact and preparedness for an AI pandemic between HCWs working in public primary care clinics and a tertiary healthcare setting., Materials and Methods: An anonymous, self-administered questionnaire was given to 2459 HCWs working at 18 public polyclinics (PCs) and a tertiary hospital (TH) in Singapore from March to June 2006. The questionnaire assessed work-related and non-work-related concerns, perceived impact on personal life and work as well as workplace preparedness., Results: We obtained responses from 986 PC and 873 TH HCWs (response rate: 74.6% and 76.7%). The majority in both groups were concerned about the high AI risk from their occupation (82.7%) and falling ill with AI (75.9%). 71.9% accepted the risk but 25.5% felt that they should not be looking after AI patients with 15.0% consider resigning. HCWs also felt that people would avoid them (63.5%) and their families (54.1%) during a pandemic. The majority expected an increased workload and to feel more stressed at work. For preparedness, 74.2% felt personally prepared and 83.7% felt that their workplaces were prepared for an outbreak. TH HCWs were more likely to be involved in infection-control activities but the perception of infection-control preparedness in both groups was high (>80.0%)., Conclusions: HCWs in both public primary and tertiary healthcare settings felt prepared, personally and in their workplaces, for a pandemic. Their main concerns were risks of falling ill from exposure and the possibility of social ostracism of themselves and their families. Preparedness levels appeared high in the majority of HCWs. However, concerns of HCWs could affect their overall effectiveness in a pandemic and should be addressed by incorporating strategies to manage them in pandemic planning.