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This study aims to determine the risk factors associated with glycaemic control of ambulatory patients with type 2 diabetes mellitus (T2DM) who are managed in primary care.The data was retrieved from a primary care site within the Singapore Consortium of Cohort Studies-Diabetes Cohort (SCCS-DC). Demographic and clinical variables were described, in association with the risk of having a deteriorating glycaemic control (defined as an absolute increase of at least 1% HbA1c from one year to a subsequent year). Next, multivariate model was performed to define the independent effect of each factor. The longitudinal analysis of the HbA1c was performed using Generalised Estimating Equation (GEE).The 5 year longitudinal data of 1256 patients (54% Chinese, 25% Malays, 12% Indians, 9% others) were analysed. Their mean HbA1c decreased by0.1% in the initial 3 years, but increased thereafter. 12% of them had absolute HbA1c increment of ≥1% in the first year, and 22% over 5 years. Based on GEE analysis, insulin, was associated with an increase of HbA1c (≥1%) from one year to another (all p0.05). Compared with Chinese patients, Malays had higher HbA1c (+0.3%), Indians (+0.3%), and others (+0.2%), (all p0.01). Patients with retinopathy had higher HbA1c (+0.2%) and those with cataract had lower mean HbA1c (-0.2%) (p0.01).Most cohort patients achieved glycaemic control within the initial 3 years. Patients of Malay and Indian ethnicity and those with retinopathy were associated with subsequent risk of glycaemic control deterioration. Those with cataract were associated with trend towards improved glycaemic control.

Chronic non-specific respiratory symptoms are difficult to manage. This trial aimed to evaluate the association between baseline fractional exhaled nitric oxide (FeNO) and the response to inhaled corticosteroids in patients with non-specific respiratory symptoms.In this double-blind randomised placebo-controlled trial, we enrolled undiagnosed patients, aged 18-80 years, with cough, wheeze, or dyspnoea and less than 20% bronchodilator reversibility across 26 primary care centres and hospitals in the UK and Singapore. Patients were assessed for 2 weeks before being randomly assigned (1:1) to 4 weeks of treatment with extrafine inhaled corticosteroids (QVAR 80 μg, two puffs twice per day, equivalent to 800 μg per day beclomethasone dipropionate) or placebo. Randomisation was stratified by baseline FeNO measurement: normal (≤25 parts per billion [ppb]), intermediate (25 tp40 ppb), and high (≥40 ppb). The primary endpoint was change in Asthma Control Questionnaire (ACQ7) mean score. We used generalised linear modelling to assess FeNO as a predictor of response, estimating an interaction effect between FeNO and treatment on change in ACQ7. We did our primary and secondary analyses in the per-protocol set, which excluded patients with non-completion of the primary endpoint, non-compliance to treatment (ascertained by patient report), and study visits made outside the predefined visit windows. This study is registered on ClinicalTrials.gov, number NCT02294279.Between Feb 4, 2015, and July 12, 2016, we randomly assigned 294 patients to extrafine inhaled corticosteroid treatment (n=148) or placebo (n=146). Following exclusions due to protocol violations, we analysed 214 patients (114 extrafine inhaled corticosteroids and 100 placebo). We observed a significant interaction between baseline FeNO and treatment group for every 10 ppb increase in baseline FeNO, with the change in ACQ7 greater in the extrafine inhaled corticosteroids group than in the placebo group (difference between groups 0·071, 95% CI 0·002 to 0·139; p=0·044). The most common adverse events were nasopharyngitis (18 [12%] patients in the treatment group vs 13 [9%] in the placebo group), infections and infestations (25 [17%] vs 21 [14%]), and respiratory, thoracic, and mediastinal disorders (13 [9%] vs 17 [12%]).FeNO measurement is an easy and non-invasive tool to use in clinical practice in patients with non-specific respiratory symptoms to predict response to inhaled corticosteroids. Further research is needed to examine its role in patients with evidence of other airway diseases, such as chronic obstructive pulmonary disease.Sponsored by OPRI with partial funding by Circassia and study drugs provided by TEVA.

ObjectivesThe disease burden of type 2 diabetes mellitus (T2DM) is rising due to suboptimal glycaemic control leading to vascular complications. Medication adherence (MA) directly influences glycaemic control and clinical consequences. This study aimed to assess the MA of patients with T2DM and identify associated factors.DesignAnalysis of data from a cross-sectional survey and electronic medical records.SettingPrimary care outpatient clinic in Singapore.ParticipantsAdult patients with T2DM.Main outcome measuresMA to each prescribed oral hypoglycaemic agent (OHA) was measured using the five-question Medication Adherence Report Scale (MARS-5). Low MA is defined as a MARS-R score of ResultsThe study population comprised 382 patients with a slight female predominance (53.4%) and a mean±SD age of 62.0±10.4 years. 57.1% of the patients had low MA to at least one OHA. Univariate analysis showed that patients who were younger, of Chinese ethnicity, married or widowed, self-administering their medications or taking fewer (four or less) daily medications tended to have low MA to OHA. Logistic regression revealed that younger age (OR 0.97; 95% CI 0.95 to0.99), Chinese ethnicity (OR 2.80; 95% CI 1.53 to5.15) and poorer glycaemic control (HbA1c level) (OR 1.27; 95% CI 1.06 to1.51) were associated with low MA to OHA.ConclusionsYounger patients with T2DM and of Chinese ethnicity were susceptible to low MA to OHA, which was associated with poorer glycaemic control. Polytherapy was not associated with low MA.

ObjectivesSelf-efficacy and self-care measures are key attributes to optimal control of essential hypertension. Self-efficacy can be measured by the Hypertension Self-Care Profile (HTN-SCP) tool but its utility is dependent on the literacy and understanding of the subjects. A Malay version of the HTN-SCP Tool was developed to assess self-efficacy of Malay-literate patients with hypertension in the multi-ethnic Asian population in Singapore. The study aimed to determine the test-retest reliability of this tool which has been translated in Malay language.Methods and Material145 Malay-literate patients, aged 41-70 years, with essential hypertension were recruited in a polyclinic (primary care clinic) in Singapore. Forty-three percent of them completed both the first and second HTN SCP tool online, with a period of two weeks in between. The Cronbach’s alpha and Intra-class correlation coefficient (ICC) were computed to assess its test-retest reliability and internal consistency.ResultsThe Cronbach’s alpha/ICC for “Behavior” (0.851/0.664)), “Motivation” (0.928/0.655) and “Self-efficacy” (0.945/0.682) domains showed high internal consistency, fair to good reliability and stability. No floor or ceiling effect was found for the "behavior" and "motivation" domains. However, the borderline ceiling effect (15.2) for "self-efficacy" suggested limited discriminating power of the tool for patients with high self-efficacy. Positive association was shown between the HTN-SCP score and reported self-care measures but it was not statistically significant.ConclusionOverall, the translated HTN-SCP tool showed satisfactory test-retest reliability and internal consistency amongst the Malay-literate study population. Further research is needed for its application in general practice to identify patients with low self-efficacy for possible intervention.

Objective: Public primary healthcare clinics in Singapore manage a large proportion of elderly patients with chronic diseases. Inappropriate prescribing of medications and polypharmacy in the elderly are associated with adverse outcomes. It is hence important to stop potentially inappropriate medications in this vulnerable group. An approach coined ‘deprescribing’ has been used to describe a patient-centred process of optimising medication regimens. The study aimed to elucidate patients’ attitudes towards the number of medications they were taking and identify factors that might influence acceptance of deprescription. Method: A cross-sectional study using the validated Patients’ Attitudes Towards Deprescribing (PATD) questionnaire was performed at two public primary healthcare institutions in Singapore. Participants were on regular follow-up at the clinics for chronic disease management and had at least five regular prescription medications. Results: The study found that participants (with a mean age of 68) had an average of four medical conditions and six prescription medications, with the majority (60.3%) expressing that they were taking a large number of medications. Of note, 93.4% of participants were willing to stop one of their medications if advised by the doctor. This was associated with a younger age (Conclusions: This study showed that majority of the participants were willing to cease a medication that their physician thought was no longer required. Factors were also identified which potentially may be targeted to facilitate deprescription.

Background: Fractional exhaled nitric oxide (FeNO) can predict treatment response in asthma, but little is known of its utility in patients with non-specific respiratory symptoms (NSRS). Aims and objectives: To evaluate the association between baseline FeNO and response to treatment with inhaled corticosteroids (ICS) in patients with NSRS. Methods: This was a multi-centre randomised, placebo-controlled trial, carried out in UK and Singapore. It consisted of a 2-week assessment period to establish baseline measurements and a 4-week treatment period with either extrafine ICS (200 µ beclomethasone bid) or placebo. NIOX VERO (Circassia) was used to measure baseline FeNO. The primary endpoint was change in ACQ7 score (Asthma Control Questionnaire, 7 questions). Analysis was carried out in a Main Analysis Set (MAS), which contained all randomised patients who complied with their study treatment and completed follow-up within 6 weeks of randomisation, and in a Per Protocol (PP) set, which included all patients in the MAS but excluded protocol violations. Results: In the PP set (n=214), we found that higher baseline FeNO was associated with a greater treatment effect. Improvement of ACQ7 was 0.071 (95% confidence interval [CI], 0.002-0.139) greater in patients receiving extrafine ICS compared to patients receiving placebo, for every 10 ppb increase in baseline FeNO. The equivalent effect was not significant in the MAS set (n=259) (0.049; 95% CI, -0.012-0.110). Conclusions: FeNO measurement is a simple, near patient, quantitative and non-invasive diagnostic tool that could support treatment decisions for patients with NSRS. Further research is needed to establish a treatment paradigm.

Background: Men differ from women in their cardiovascular mortality and morbidity globally, possibly due to their varying dietary and lifestyle behavior and usage of medications in dyslipidemia control. Objectives: The study aimed to compare the gender differences among community-dwelling Asians in their dietary habits, physical activity, their perception and use of lipid-lowering medications towards achieving their LDL-Cholesterol goals. Methods: A cross-sectional study was conducted, which included patients with physician-diagnosed dyslipidemia, aged 31–80 years in two public primary care clinics in Singapore. They were administered a questionnaire survey on their diet, exercise and lipid-lowering medication. Their latest laboratory fasting lipid tests, retrieved from their electronic health records, defined their treatment goals based on adapted Framingham risk scores. Results: Amongst 1093 patients, 61.9% were female. Fewer men (65.9%) achieved LDL-C treatment goals compared with women (75.2%). Comparing with their counterpart, more women were willing to change their diet (75.8% vs. 46.2%) and exercise (78.4% vs. 70.9%) to achieve their LDL treatment goals. However, men who were treated with lipid medication were more likely to reach LDL-C treatment goals. Conclusion: Fewer Asian men in Singapore attained their LDL-C treatment goals than women, which appeared to be associated with greater reluctance to embark on dietary and lifestyle changes. Gender-specific interventions should be considered to address these differences.

Background: Obesity is a global public health problem. A systematic review showed that intensive behavioural counselling is effective in weight management amongst patients with obesity, but little is known if primary care physicians (PCPs) are involved in delivering such counselling. Studies revealed that patients had weight reduction if they were counselled by PCPs who used the 5As (Ask, Assess, Advise, Agree and Assist) method, but PCPs varied in their use of this tool. We aimed to explore the local PCP modalities of obesity counselling and if their approaches and methods corresponded to the 5As tool. Methods: Qualitative data were obtained from interviews with 50 PCPs from public and private primary care practices during six focus group discussions and seven in-depth interviews. The interviews were audio-recorded, transcribed, audited and analysed iteratively based on the grounded theory. Emergent themes were first externally validated, and then finalized after rounds of deliberations amongst the investigators. Results: PCPs varied in their approach in obesity counselling, focusing predominantly on “Ask”, “Assess” and “Advise” in the 5As tool. “Asking” was indirect and “Assessment” rarely covered the effects of obesity on psychosocial functioning. Dietary and lifestyle modifications were the main foci in “Advise”. “Agree” was least performed. Polyclinic doctors tended to “Assist” patients with referral to other healthcare workers for further weight management, but few deliberately “Arrange” to review progress in weight management, citing barriers. Conclusion: PCPs varied in their method of obesity counselling, pending on context and setting of their practices. In contrast to “Ask’, “Assess” and “Advise”, the use of “Agree” and “Arrange” was uncommon.

Background Many people with diabetes have suboptimal glycaemic control due to not being adherent to their treatment regimen. Behavioural economic theory suggests that the lack of adherence results from the disconnect between the timing of when costs and benefits accrue. One strategy to address this discontinuity is to offer patients a near-term benefit, such as a financial reward. Whereas there is evidence that rewards can improve treatment adherence and sometimes health outcomes, further research is needed to determine whether rewards are more effective when targeting processes or intermediary health outcomes. In the Trial to Incentivise Adherence for Diabetes (TRIAD) we test whether adding financial incentives to usual care can improve HbA1c levels among people with diabetes and whether the financial incentives work better when targeting processes (adherence to blood glucose testing, medication, and daily physical activity) or the primary intermediary health outcome of self-monitored blood glucose within an acceptable range. Methods/design TRIAD is a randomised, controlled, open-label, single-centre superiority trial with three parallel arms. A total of 240 patients with suboptimally controlled diabetes (HbA1c ≥ 8%) from a polyclinic in Singapore are block-randomised (blocking factor: current vs. new glucometer users) into three arms, namely (1) usual care (UC) only, (2) UC with process incentive and (3) UC with outcome incentive, in a 2:3:3 ratio. Masking the arm allocation will be precluded by the behavioural nature of the intervention but blocking size will not be disclosed to protect concealment. The primary outcome (change in HbA1c level at month 6) will be measured by a laboratory that is independent from the study team. Secondary outcomes (at month 6) include the number of blood glucose testing days, glucose readings within the normal range (between 4 to 7 mmol/L), medication-adherent days, physically active days, and average incentives earned and time spent administrating the incentives. Discussion This study will provide evidence on whether financial incentives can cost-effectively improve glycaemic control. It will also provide evidence on the benefit incidence of interventions involving financial incentives. By comparing process to outcome incentives, this study will inform the design of future incentive strategies in chronic disease management and beyond. Trial registration ClinicalTrials.gov registry, ID: NCT02224417. Registered on 22 August 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2288-6) contains supplementary material, which is available to authorized users.

In Singapore, medication labels placed by clinics on packets/bottles of dispensed prescription medications are primarily in English. This poses a challenge for elderly Singaporeans (≥65 years) as 61% of them cannot read in English. However, nearly half of them can read in ≥1 of the other three official languages (Chinese/Malay/Tamil), thus suggesting a potential strategy, i.e., adding another language, for improving prescription medication labels. Pictograms, shown to be helpful for low-literacy populations elsewhere, are another potential strategy. We assessed the utility of these strategies, i.e., bilingual labels and/or labels with pictograms, in improving the understanding of medication labels among elderly Singaporeans. Respondents were randomized to 4 different label types - (A) English-text (n=357); (B) English-text with pictograms (n=357); (C) Bilingual-text (n=353); and (D) Bilingual-text with pictograms (n=350) - for the same three medications, and questioned on their understanding of the label content. While 65% of those randomized to Type A reported difficulty reading the labels, corresponding proportions were significantly lower with the addition of pictograms and/or another language (57%, 32%, 37%, for types B, C, D, respectively). However, even among those able to read English, 12%, 14%, 10% and 9%, respectively across each label type still reported difficulty. Use of bilingual medication labels is a promising strategy for improving prescription medication labels for elderly Singaporeans. However, careful assessment of the label design and content and of non-label-related factors that may limit the elderly’s understanding is warranted. Our findings can support future empirical studies evaluating real-world prescription medication labels for elderly Singaporeans.

Background: Chronic kidney disease (CKD) is a major global public health challenge. We investigated determinants of CKD and their clinical utility in an ethnically diverse Southeast Asian population. Methods: Electronic health records (EHR) of adults ≥40 years who visited any one of 4 government polyclinics in Singapore from January 1, 2012 to ­December 31, 2015 were analyzed. CKD was defined as an estimated glomerular filtration rate 2 or 1+ dipstick proteinuria excretion, based on 2 measurements ≥3 months apart. CKD-associated factors and their clinical utility for predicting odds of CKD were investigated using multiple logistic regression analysis. Results: Based on the study criteria, 25.9% (95% CI 25.6–26.2) of the 88,765 eligible study individuals had CKD. The factors (OR and 95% CI) independently associated with CKD were older age ≥65 years (2.54 [2.44–2.64] vs. ≤65 years), respectively; men (1.13 [1.09–1.18]); Malay (1.27 [1.20–1.33]) and Indian (0.77 [0.71–0.83]) vs. Chinese ethnicity; overweight (body mass index [BMI] ≥27.5 kg/m2; 1.10 [1.04–1.16]) vs. normal weight (BMI 18 to 2); government (1.22 [1.15–1.31]) vs. private housing; and with hypertension (3.32 [3.09–3.56]), diabetes (6.93 [6.67–7.20]) or stroke (1.46 [1.36–1.56]) vs. without each co-morbidity, respectively. The area under the receiver operating characteristic curve (95% CI) for the model to predict the probability of CKD using hypertension, diabetes, and age was 0.808 (0.805–0.811). Only 28.5% (27.9–29.1%) of individuals with CKD had physician documentation of their CKD status. However, documentation of CKD status was associated with age ≥65 years (1.11 [1.04–1.20] vs. Conclusions: CKD prevalence in our Southeast Asian population is high and under-documented even in high-risk patients. Our findings highlight factors associated with CKD, and the predictive value of hypertension, diabetes, and advancing age as EHR-based screening targets for CKD. Our results also suggest that complementary educational efforts will be needed to increase physician detection and optimize the management of CKD, especially in high risk and marginalized groups across all clinics in Singapore, and possibly in the region.

Background Patients with type 2 diabetes mellitus (T2DM) may develop color vision impairment. This study aimed to determine the prevalence and factors associated with impaired color vision in patients with T2DM but without diabetic retinopathy. Methods Enrolment criteria included multi-ethnic Asian participants, age 21 to 80 years, with known T2DM for a minimum of 2 years. Their diagnoses were affirmed from oral glucose tolerance test results and they were screened for impaired color vision using the Farnsworth D-15 instrument. Demographic characteristics were described and clinical data for the preceding 2 years were analyzed using logistic regression. Results Twenty-two percent of 849 eligible participants had impaired color vision with higher involvement of the right eye. Impaired blue-yellow color-vision(Tritanomaly) was the commonest impaired color vision. Participants with impaired color vision were significantly associated with age and lower education; longer duration of T2DM (median 6 years vs 4 years); higher HbA1c level and HDL-Cholesterol in 2nd year; lower mean total cholesterol, mean LDL-Cholesterol and mean triglyceride in 2nd year. They also have poorer vision beyond 6/12 in the affected eye. Logistic regression showed that impaired color vision was associated with older patients (OR=1.04), increased duration of T2DM (OR=1.07); prescription of Tolbutamide (OR=3.79) and lower mean systolic blood pressure (OR=0.98). Conclusion Almost one in four participants with T2DM had impaired color vision, largely with tritanomaly. Color vision screening may be considered for participants who develop T2DM for 6 years or longer, but this requires further cost-effectiveness evaluation.

Background Clinicians have increasing access to longitudinal data on hand grip strength (HGS), often measured for frailty or sarcopenia assessment, of their older clients. Evidence on the association of change in HGS with mortality is mixed. We investigated whether baseline hand grip strength (HGS) and annual change in HGS are associated with mortality among older Singaporeans. Methods Data from a national longitudinal survey (3 waves: 2009, 2011 and 2015) of older people (≥60 years) in Singapore was utilized. All-cause mortality, until end-December 2015, was assessed primarily from administrative databases. Two datasets, with 4446 (Dataset 1: baseline HGS with mortality) and 2673 (Dataset 2: annual change in HGS with mortality) participants, with maximum follow-up time of 7 and 4.6 years respectively, were derived from the survey data. Associations of interest were assessed using Cox proportional hazard models. Results 835 (18.8%) and 317 (11.9%) participants died during follow-up, with mean survival times of 3.6 and 2.6 years, in Dataset 1 and 2 respectively. The likelihood of mortality was lower by 4% (Hazard Ratio [95% Confidence Interval]: 0.96 [0.94-0.97]) for each unit (kilogram) increase in baseline HGS, and by 13% (0.87 [0.82-0.93]) for each kg increase in HGS over 1-year. Conclusions Higher (alternatively, lower) baseline HGS and an increase (alternatively, decrease) in HGS over 1-year were associated with lower (alternatively, higher) likelihood of all-cause mortality among community-dwelling older people. There is clinical value, for assessing the risk of mortality, of both the cross-sectional and longitudinal measurement of HGS among older people.

IntroductionSelf-care has been shown to improve clinical outcome of hypertension. Gauging the level of self-care among patients with hypertension enables the design of their personalized care plans. This study aimed to determine the self-care profiles and its determinants among patients with hypertension in the Malaysian primary care setting.MethodsThis was a cross sectional study conducted between 1 October 2016-30 April 2017 in three primary care clinics in the state of Selangor, Malaysia. All adults aged 18 years and above with hypertension for at least 6 months were recruited with a systematic random sampling of 1:2 ratio. The participants were assisted in the administration of the structured questionnaire, which included socio-demographic information, medical information and the Hypertension Self-Care Profile (HTN SCP) tool. Statistical analysis was done using SPSS version 20.0. Multiple linear regression was performed to determine the determinants for self-care.ResultsThe mean age of the participants was 59.5 (SD10.2) years old. There were more women (52.5%) and most were Malays (44.0%) follow by Chinese (34%) and Indians (21%). Majority (84.2%) had secondary or primary school level of education. A third (30.7%) had a family history of hypertension. The mean total HTN-SCP score was 124.2 (SD 22.8) out of 180. The significant determinants that influenced the HTN-SCP scores included being men (B-4.5, P-value0.008), Chinese ethnicity (B-14.7, P-valueConclusionsThe overall hypertension self-care profile among patients in this multi-ethnic country was moderate. Being men, Chinese, lower education level and without family history of hypertension were associated with lower hypertension self-care profile score. Healthcare intervention programmes to address self-care should target this group of patients.

BackgroundReliable home blood pressure monitoring (HBPM) is essential to effective hypertension management; however, manual recording is subject to underreporting and inaccuracies. Mobile health technologies hold great potential as HBPM tools, but the fidelity of a smartphone app in HBPM has not been adequately assessed. ObjectiveThe primary aim of the trial was to compare the fidelity of a smartphone app to that of a handwritten logbook in making HBPM data available to clinicians at follow-up visits. Fidelity was defined as the percentage of scheduled blood pressure (BP) recordings over a 3-week period that were properly recorded and reported to the clinic. The secondary aims were to investigate patient factors associated with HBPM fidelity and to explore the effect of time on the fidelity. MethodsA 2-arm, parallel, unblinded, randomized controlled pilot trial was conducted in a government polyclinic in Singapore. Hypertensive adults, aged 40 to 70 years, who were on antihypertensive medication and owned a smartphone were recruited and randomized by a computer-generated randomization schedule to 3 weeks of either semiautomated HBPM utilizing a Bluetooth-enabled BP monitor and a smartphone app or a fully manual process utilizing a conventional handwritten logbook. The primary outcome was home BP recording fidelity. ResultsOf the 80 patients randomized, 79 (smartphone app: 38 and logbook: 41) were included in the final analysis. Although fidelity was higher among the app users, it did not differ significantly between study arms (smartphone app: 66.7% and logbook: 52.4%; P=.21). Chinese and Indian ethnicities were associated with higher fidelity (absolute percent and 95% CI) by 35.6% (4.27 to 66.9) and 45.0% (8.69 to 81.3), respectively, in comparison with other ethnicities (P=.03); longer smartphone ownership increased fidelity on an average of 10.5% (0.83 to 20.2) per year (P=.03); the number of apps on the smartphone decreased fidelity at a rate of −0.32% (−0.58 to −0.05) per app (P=.02); years of hypertension morbidity increased fidelity at a rate of 1.56% (0.03 to 3.09) per year (P=.046); and the number of people working in the household decreased fidelity at a rate of −8.18% (−16.3 to −0.08) per additional working person (P=.048). The fidelity of the app was significantly higher in the first week (64.4%) than the second (55.1%, P=.001) and third (58.2%, P=.03) weeks of monitoring. ConclusionsAmid the increasing integration of health technologies into clinical practice, our study demonstrates the feasibility of smartphone app–assisted HBPM in hypertensive adults of Singapore. Our pilot study found no statistically significant difference in mean BP recording fidelity between a smartphone app and conventional handwritten logbook. However, the small sample size precludes definitive conclusions and highlights the need for a larger, adequately powered trial. Trial RegistrationClinicalTrials.gov NCT03209024; https://clinicaltrials.gov/ct2/show/NCT03209024 (Archived by WebCite at http://www.webcitation.org/78EVWBg0T)

Background: Caregivers of children with asthma provided with a written asthma action plan (WAAP) are reported to be more confident in their ability to provide care for their child during an asthma exacerbation. However, little is known about how a WAAP impacts on their care processes that contributed to this increased confidence. Aims: To determine the effects of a WAAP on caregivers' understanding of asthma symptoms, their use of asthma medications for their children, and acute care visits to consult their physicians. Methods: A questionnaire survey to caregivers of children with a WAAP (CW) and without a WAAP (CNW) who were followed up at nine public primary care clinics in Singapore. χ2 test was used to determine the differences in outcomes between the CW and CNW groups, followed by logistic regression to adjust for potential covariates. Results: A total of 169 caregivers were surveyed (75 CNW, 94 CW). Caregivers in the CW group were more likely to understand bronchoconstriction (adjusted odds ratio (AOR) 4.51, p=0.025), to feel capable (AOR 2.77, p=0.004), safe (AOR 2.63, p=0.004), and had increased confidence (AOR 2.8, p=0.003) to change doses of inhaled medications during an asthma exacerbation. The CW group perceived inhaled asthma medication to be safe (AOR 3.42, p=0.015) and understood the use of controller medication (AOR 3.28, p=0.006). No difference was noted between caregivers in their likelihood to stop medications without consulting their physician, seek acute care consultation, and confidence in self-management of their children's asthma at home. Conclusions: The WAAP improved caregivers' understanding of the disease and use of inhaled asthma medications during asthma exacerbations but did not affect their decision regarding acute visits to their physician.

Introduction: The prevalence of tuberculosis (TB) is rising in Singapore. The affected patients are provided with free directly observed therapy (DOT) at local polyclinics. The impact of DOT on their daily living activities (DLA) and quality of life (QOL) may affect their treatment adherence. The study aimed to evaluate the effect of DOT on the DLA and QOL of patients with TB and to quantify their socioeconomic burden. Material and methods: This questionnaire survey recruited adult multi-ethnic Asian patients with TB who were on DOT at nine local polyclinics. The questionnaire collected data on their demographic characteristics and DLA, anti-TB medications, the validated WHOQOL-BREF instrument, and socioeconomic costs. The associations between DOT and independent variables were tested using Student’s t-test and ANOVA. Results: The 356 patients recruited comprised 63% males with mean age of 43 years; 73% of them were employed, 73% reported increased travel time (mean 41 minutes/DOT visit) and DOT-related cost (mean S$260–S$389 for 6–9 months’ treatment); 47% indicated reduced participation in social functions and 45% felt that DOT had caused disruptions to their work, especially among younger patients. The WHOQOL-BREF scores were 13.3/20 “Physical Health”, 12.6/20 “Psychological”, 13.4/20 “Social Relationships” and 12.3/20 “Environment” domains, respectively. Some 52% of them rated their QOL as “good” or “very good”, 47% reported satisfaction with their health but 74% experienced negative feelings such as despair, anxiety and depression. Conclusion: The DOT affected patients’ DLA, QOL and increased their socioeconomic burden, which should be addressed by appropriate mitigating measures in the community.

Introduction The prevalence of orthostatic hypotension (OH) among the elderly population in Singapore, as defined by a decline in blood pressure upon a change in position, is not well-established. Studies associate OH with clinically significant outcomes such as falls. This study aims to determine the prevalence of OH among elderly patients attending a public primary care clinic (polyclinic) for chronic disease management, and examine the relationships between postulated risk factors and OH. Methods Patients aged ≥ 65 years attending a typical polyclinic in Geylang were identified and targeted for recruitment at the study site. A questionnaire on symptoms and postulated risk factors was administered, followed by supine and standing blood pressure measurements. Cross-sectional analysis was performed with independent sample t-test for continuous data and chi-square test for categorical data. Prevalence rate ratios with 95% confidence interval were calculated for the latter. Results A total of 364 multiethnic patients participated in the study. The prevalence of OH was 11.0%. Older age, comorbidities such as cardiac failure and kidney disease, being physically inactive at work, fatigue, self-reported dizziness in the past year, and the use of loop diuretics were found to be significantly associated with OH. Conclusion About one in ten elderly patients at a local polyclinic was affected by OH, which was associated with multiple factors. Some of these factors are modifiable and can be addressed to reduce the incidence of OH.

SummaryWhat is known and objective Dyslipidaemia is the key risk factor for arthrosclerosis, leading to myocardial infarctions and strokes. Achieving LDL cholesterol (LDL-C) treatment goals using lipid-lowering therapy (LLT) mitigates such cardiovascular risks. This study aimed to determine the proportions and factors influencing patients with dyslipidaemia on LLT who achieved their recommended LDL-C treatment goals. Methods Adult Asian patients with dyslipidaemia, aged 31–80 years, were enrolled in a questionnaire survey. Using simplified Framingham risk scores, these patients were classified into low (LR), medium (MR) and high (HR) cardiovascular risk groups. Their lipid-lowering therapy was classified into low-intensity (LI), medium-intensity (MI) and high-intensity (HI) groups according to the 2013 American College of Cardiology and American Heart Association (ACC/AHA) Blood Cholesterol Guidelines. Data on their demographic, clinical, self-reported attitude and adherence to LLT were correlated with their latest lipid profiles from their electronic health records. These data were analysed using chi-square test, or independent t-test where appropriate for categorical variables and continuous data. Logistic regression was used to identify factors relating to LDL-C goal attainment. Results and discussion Amongst the 917 patients treated with LLT, 60·9% were females and 56·2% aged >60 years. The commonest statins prescribed were simvastatin (77·7%), atorvastatin (15·3%), rosuvastatin (4·3%) and lovastatin (3·4%). Those who attained LDL-C treatment goals included 89·4%, 77·4% and 70% of the LR, MR and HR groups. Overall, 72·4% of the patients achieved LDL-C treatment goals. Despite 98·4% of them self-reported LLT adherence, only 85·5%, 69·5% and 50% of the LI, MI and HI subgroups attained the desired outcomes, respectively. What is new and conclusion Overall, 27·6% of patients with dyslipidaemia, including 30% of the HR group, did not achieve LDL-C treatment goals, despite on LLT. Addressing their concerns and adjusting medication doses of their LLT are needed for better outcomes.

Hypertension is a chronic disease that is mostly managed by the patients themselves inbetween consultation with their physicians. Self-efficacy, which is an individual’s belief in their capabilities to produce given attainments, is a desirable quality to enable the person to take charge of their health and any long-term illness. Assessment of self-efficacy is thus pivotal in developing a holistic patient-centric care plan to optimize their disease control. For hypertension, self-efficacy is associated with better self-care and outcomes of the disease.This literature review aims to identify self-efficacy assessment instruments, evaluate their origin, quality and development, compare their strengths and limitations, and applicability in specific target population.Searches performed using PubMed, Scopus and The Cochrane Library eventually yielded 34 relevant articles and 12 instruments. All instruments were validated in specific populations. Two instruments were specific to hypertension, two instruments measured multiple domains of self-management, while medication adherence was the most common single domain assessed. To select an appropriate instrument, one should take into consideration the clinical context and study design. An algorithm is proposed to facilitate the selection of instrument that is best suited for the specific purpose.

Background An AD8 cut-off score of ≥4 has been reported to successfully detect 90% of dementia cases in elderly patients aged 75 years and above. Objective We investigated the benefits of a pilot clinical service conducted in primary care that used the AD8 to identify patients with dementia in an at-risk population. Method Patients ≥75 years of age were recruited from a primary health care center in Singapore. Trained nurses administered the AD8 to informants of eligible patients. Patients screened positive (AD8 score ≥4) were referred to specialist memory clinics by primary health care physicians for further evaluation. Results Of the 551 eligible patients in the primary health care center, 168 (30.5%) consented and the AD8 was administered to their informants. Among the recruited patients, 23 (13.7%) were screened positive and 7 (30.4%) of them accepted referrals to specialist memory clinics. The clinical diagnoses for these patients were as follows: no cognitive impairment (NCI) (n = 1), cognitive impairment no dementia (CIND) (n = 5), and dementia (n = 1). Most of the (98.8%) nurses found AD8 user-friendly and could track functional decline. Eighteen of the 23 (78.3%) primary health care physicians who referred patients to specialist memory clinics considered the AD8 useful for facilitating referrals. The remaining physicians (21.7%) preferred performance-based tests. Conclusion The AD8 is easily administered by nurses and useful to a majority of primary health care physicians to generate referrals. However, physician preference for performance-based tests and a lower prevalence of dementia in the at-risk population may indicate the need to consider a “2-pronged assessment approach” that combines both performance-based and informant-based brief tests to reduce false positive rates and better detect dementia.

A symptom-based written asthma action plan (WAAP) was introduced to both adult and pediatric patients as part of the evidence-based local clinical practice guidelines to educate patients in asthma self-management in Singapore in 1998. This article aimed to explore the issues pertaining to the parental use of the WAAP for their children with asthma. A qualitative method using focus group discussions was used to gather qualitative data from parents of children with asthma who are on review at primary care clinics in Singapore. Qualitative data analysis based on grounded theory was carried out to identify emergent themes. Parents expressed difficulty in differentiating asthma-related symptoms from early symptoms of an upper-respiratory tract infection. Because of the failure to recognize cough as an asthma-related symptom, they focused more on symptomatic treatment of cough. They often relied on their own assessment of their children’s asthma status and sought medical consultation soon after onset of the children’s symptoms, rather than adjusting their inhaled medication. This deviated from the WAAP given by their physician. Their threshold to consult a doctor was thus variable, reflecting their confidence in self-management of their children’s asthma condition. Factors that hinder the implementation of the WAAP for children included difficulty in symptom recognition, parental focus on symptomatic treatment, and confidence issues in using the tool.

IntroductionThe rising prevalence of chronic disease is leading to an increase in the demand for primary care services and a shortage of primary care physicians globally. Addressing these challenges calls for innovations in the healthcare delivery model with greater use of healthcare technology tools. We previously examined the feasibility of using an automated healthcare kiosk for the management of patients with stable chronic disease in the primary care setting. The aim of this follow-up study is to evaluate the health outcomes of patients with chronic disease who are on kiosk management compared with patients who are on routine management by nurse clinicians.Methods and analysisThe pilot study will be a two-armed randomised controlled trial of 120 patients with well-controlled chronic disease on 4-monthly follow-up visits over a 12-month period. Patients with prior diagnoses of hypertension, hyperlipidaemia and/or diabetes will be included in the study and will be randomly assigned to intervention or control groups to receive kiosk or nurse management, respectively. The main primary outcome measure is the overall chronic disease control of the patients. Other primary outcome measures are the blood pressure and low-density lipoprotein cholesterol levels for patients without diabetes, and blood pressure, low-density lipoprotein cholesterol and haemoglobin A1c levels for patients with diabetes. Secondary outcome measures are visit duration, patient satisfaction with the management process, health-related quality of life and the occurrence of any adverse event. Data will be captured longitudinally at baseline, 4 months, 8 months and 12 months, and will be analysed using multiple regression models.Ethics and disseminationThe study has been approved by the Singapore Health Services (SingHealth) Centralised Institutional Review Board (2017/2715). Findings of the study will be submitted for publication in peer-reviewed journals and presented at national and international conferences.Trial registration numberNCT03274089; Pre-results.

Introduction: The Singapore National Asthma Program (SNAP) was launched in 2001 to address the high burden of asthma in Singapore. One component of the SNAP was directed at improving asthma control in the community by promoting preventive treatment with inhaled corticosteroids. This paper describes the program on prescription patterns of preventor and reliever medication for asthma in the polyclinics. Materials and Methods: We monitored the prescription pattern for asthma as the preventor-reliever (PR) drug ratio. The PR ratio was employed both as a positive feedback tool and as a key performance indicator (KPI) for the program. Individual clinics were encouraged to implement locally relevant and effective initiatives to increase the KPI and facilitate this process. The different methods included chronic care models, multidisciplinary teams, enhanced primary care clinics, pre-counselling screening, decision support tools, self-management support, a patient information system and community education. Results: In the course of the program, the case load for asthma in the polyclinics increased by 31%. During the same period, the average PR ratio increased significantly from 0.68 to 1.80 (P

Objectives What are normative values for hand grip strength (HGS) for elderly Singaporeans? Which elderly characteristics influence the normative values of HGS for elderly Singaporeans? Design Nationally representative, cross-sectional observational study. Setting Singapore. Participants A total of 2664 community-dwelling elderly Singaporeans aged 60 to 89 years. Measurements HGS was measured in a standing position with elbows extended twice for each hand; a Smedley spring-type dynamometer was used. Elderly characteristics known to affect HGS, including age, sex, hand dominance, height, weight, occupation, education, and ethnicity, were also assessed. Results We present single-year age, sex-, and hand-specific graphs for normative values (5th, 20th, and 50th percentiles) of HGS. The influence of specific elderly characteristics on the normative values of HGS varies by sex, hand, and considered percentile. We present equations for considered percentiles of HGS that account for such influences. Conclusions This study uses a large, nationally representative sample to establish normative values for HGS for elderly Singaporeans aged 60 to 89 years. These results will facilitate the interpretation of HGS measurements conducted using Smedley spring-type dynamometers in clinical and research settings in Singapore, and potentially other Asian countries.

Dyslipidemia is the primary risk factor for arthrosclerosis. It is the most common chronic disease among the multiethnic Asian population in Singapore. Local national health survey has shown ethnic variability in achieving control of dyslipidemia.This study aimed to determine the proportion of patients in primary care, who achieved their low-density lipoprotein (LDL)-cholesterol treatment goals, stratified by the local major ethnic groups. It also evaluated the factors that affected their dyslipidemia control, including diet, exercise and medication usage.Research assistants administered questionnaires on adult patients with physician-diagnosed dyslipidemia to determine their views on diet, exercise, and medications in this cross-sectional study in 2 local primary care clinics. Their lipid profiles were retrieved from their laboratory reports in their electronic health records. Chi-square and Fisher exact tests were used for the categorical demographics and questionnaire variables, (P.05: statistically significant). Logistic regression was performed using these significant variables to determine the adjusted odds of the ethnic groups.A total of 1093 eligible patients completed the questionnaires. The proportion of Chinese, Malay, and Indian patients who achieved LDL-cholesterol goals was 78.3%, 67.9%, and 68.5%, respectively. Among those who self-reported taking their favorite cholesterol-rich food occasionally when their cholesterol became controlled, 35.8% Indians failed to achieve treatment goals, compared to 20.1% Chinese and 30.9% Malay patients. Regular medication adherence was associated with 81.8% Chinese, 69.0% Malay, and 69.7% Indian reaching treatment goals.More Chinese met LDL-cholesterol treatment goals compared to Malays and Indians. Lipid-lowering medications enabled but smoking hindered their achievement of these treatment goals.

Background: In the primary health care setting, patients interact directly with their healthcare workers (HCW), which include their primary physicians, nurses and pharmacists. Studies have shown that such interactions, when interrupted by phone calls received by either party, can lead to adverse outcomes and negative experiences. There is insufficient data however on the factors affecting the reaction and responses of both patients and HCWs when phone calls occur amidst their interaction. Understanding these factors will allow for the introduction of targeted measures to mitigate the negative impact of such interruptions and improve patient-HCW relationships. This study therefore aims to understand the impact of unplanned phone calls during primary health care consultations on patient–HCW interactions and the factors affecting the patient and the HCW responses. Method: This study used focus group discussions (FGD) to gather qualitative data from patients and HCWs who had visited or worked in a major public primary healthcare institution in Singapore. The FGDs were audio-recorded, transcribed, audited and analyzed using standard content analysis to identify emergent themes. Results: 15 patients and 16 HCWs participated in 5 FGDs. The key themes that emerged from these FGDs were patients’ and HCWs’ attitudes toward professionalism and respect, task and thought interruption, call characteristics, the impact on patient safety and stakeholders’ experiences. Phone calls during consultations answered by either party often resulted in the answering party feeling apologetic and would usually keep the phone conversations short as a sign of respect to the other party. Both stakeholders valued the consultation time and similarly reported negative experiences if the phone-call interruptions became prolonged. Calls from the desk phone answered by HCWs were perceived by most patients to be relevant to healthcare services, with the assumption that HCWs exercised professionalism and would not attend to personal calls during their clinical duties.HCWs expressed their concerns and distress about potential medical errors due to phone-calls interrupting their clinical tasks and thinking processes. However, they acknowledged that these same phone-calls were important to allow clarifications of instructions and improved the safety of other patients. Conclusion: Phone interruptions affected patient and HCW interaction during consultations and factors leading to their adverse reactions need to be recognized and addressed.

Background This study aimed to assess the measurement equivalence of the 5-level EQ-5D (EQ-5D-5L) among the English, Chinese, and Malay versions. Methods A convenience sample of patients with type 2 diabetes mellitus were enrolled from a public primary health care institution in Singapore. The survey questionnaire comprised the EQ-5D-5L and questions assessing participants’ socio-demographic and clinical characteristics. Multiple linear regression models were used to assess the difference in EQ-5D-5L index (calculated using an interim algorithm) and EQ-visual analog scale (EQ-VAS) scores across survey language (Chinese vs. English, Malay vs. English, and Malay vs. Chinese). Measurement equivalence was examined by comparing the 90 % confidence interval of difference in the EQ-5D-5L index and EQ-VAS scores with a pre-determined equivalence margin. Multiple logistic regression models were used to assess the response patterns of the 5 Likert-type items of the EQ-5D-5L across survey language. Results Equivalence was demonstrated between the Chinese and English versions and between the Malay and English versions of the EQ-5D-5L index scores. Equivalence was also demonstrated between the Chinese and English versions and between the Malay and Chinese versions of the EQ-VAS scores. Equivalence could not be determined between the Malay and Chinese versions of the EQ-5D-5L index score and between the Malay and English versions of the EQ-VAS score. No significant difference was found in responses to EQ-5D-5L items between any languages, except that patients who chose to complete the Chinese version were more likely to report “no problems” in mobility compared to those who completed the Malay version of the questionnaire. Conclusions This study provided evidence for the measurement equivalence of the different language versions of EQ-5D-5L in Singapore.

Nocturnal asthma symptoms result in poor quality of life and morbidity. This study primarily examines key factors predicting and mitigating nocturnal symptom risks among asthma patients, who were enrolled into a Singapore publicly funded asthma care programme. It also studies the association between nocturnal symptoms and medication changes as the secondary outcome. A longitudinal study was conducted on 939 multi-racial Asian patients with persistent asthma. Patient clinical and therapeutic data were retrieved retrospectively from the programme’s database established in 2004. Association between nocturnal symptoms (defined as night-time cough, wheeze and breathlessness at least twice monthly) and each categorical predictor was tested. The generalised linear mixed-effects model (GLIMM) was used to model the primary and secondary outcomes. Having nocturnal asthma symptoms was significantly associated with the number of days with breathlessness, off usual activities and off work, and asthma severity at baseline (all P values

Infant walkers are widely used by caregivers in Singapore despite being recognized as a household hazard. The study determined the effectiveness of nurse counselling in dissuading caregivers from using the walker. Caregivers of children 4 months of age were recruited and divided into the intervention group (nurse's advice and illustrated pamphlets), a conventional group (questionnaire alone) and a control group (without any intervention in a separate polyclinic). The percentage of the caregivers, who used the walkers in each group when their child was 9 months old, was taken as a surrogate indicator of effectiveness of nurse's intervention. The study analyzed 708 caregivers. Fewer caregivers (62.7% intervention vs. 80.4% questionnaire alone vs. 83.0% control) used the walker after nurse's advice with illustrated pamphlets. 8% of the users reported walker-related injuries (n=43). Nurses' counselling could be a simple yet effective method to discourage the use of walkers. Asia Pac J Public Health 2004; 16(2): 104-108.

The objective of this study was to explore the roles and perceptions of general practitioners (GPs) in the management of erectile dysfunction (ED). This qualitative study used focus group discussions and in-depth interviews. This study was conducted based on 28 GPs from an urban area in Malaysia who had managed patients with ED and prescribed anti-ED drugs. Main outcome measures included the roles of GPs in managing patients with ED (active or passive), perceptions regarding ED and the treatment, and factors influencing their decision to prescribe. Majority of the GPs assumed a passive role when managing patients with ED. This was partly due to their perception of the disease being nonserious. Some also perceived ED as mainly psychological in nature. The anti-ED drugs were often viewed as a lifestyle drug with potentially serious side effects. The fear of being perceived by patients as 'pushing' for the drug and being blamed if the patients were to develop serious side effects also hampered the management of this disease. GPs who participated in this study remained passive in identifying and treating patients with ED and this was attributed to their perception of the disease, drug treatment and patient's background.

Aim: To determine the factors that deter the initiation of insulin therapy among type 2 diabetes patients with secondary drug failure. Methods: An observational cross sectional study of 72 refusors (cases) and 72 acceptors (controls) of insulin therapy in primary care polyclinics in Singapore. Results: Refusors have more concerns about insulin injections than acceptors (69.4 vs 22.2%, p < 0.001). Refusors cited ‘fear of pain from the needle’ as the main reason for refusing to start insulin therapy (45.8%), followed by ‘financial constraint’ (18.4%) and ‘inconvenience’ (12.5%). Refusors were less aware of the action of insulin (58.2 vs 34.6%, p = 0.015), perceived that insulin ‘is unnecessary (because) other treatment is available’ (70.8 vs 36.1%, p = 0.001) and regard regular injections as a hassle (50 vs 26.4%, p = 0.001). Acceptors were more likely to perceive insulin injection as ‘effectively controls blood glucose levels’ (84.7 vs 59.7%, p = 0.002), ‘helps one feel better’ (77.8 vs 40.3%, p = 0.001), ‘helps one feel more energetic’ (68.1 vs 31.9%, p = 0.001), and ‘more effective than oral medication’ (72.2 vs 43.1%, p = 0.001). Nonetheless, both groups were as likely to perceive that being put on insulin therapy is an indication of an ‘advanced phase of illness’ (65.3 vs 63.9%, NS), and a ‘failure to care for oneself’ (66.7 vs 55.6%, NS). Conclusions: The two major barriers to insulin initiation among refusors are perception of pain and financial constraints. Refusors are more likely than acceptors to have concerns over insulin injection and regard insulin therapy as a last resort, although both groups possessed a number of negative perceptions regarding insulin therapy, which need to be addressed. © 2003 Blackwell Publishing Asia and Wonca

Aim : Infant walkers are widely used in Singapore despite reports of injuries associated with their use. This study of 445 principal caregivers at two primary care polyclinics aimed to determine their knowledge and practice of use of walkers for their children/wards. Methods : This was a prospective descriptive study, carried out in two polyclinics in Singapore. Care-givers of children brought to the clinic at 4–6 months age for routine immunizations were recruited. A questionnaire was administered which had been previously piloted. A follow up survey was conducted at the next immunization session. Results : The study found 66.7% of young infants caregivers were unaware of walker related injury and only 37.5% of them were aware of alternatives to walkers. In addition, 48.3% thought that the walker helped the child to walk faster than the normal age of child development, although current evidence suggested that a walker could delay the walking milestone. The study also found 20.1% of caregivers who plan or have already started their child/ward on a walker would take precautions. Conclusions : Factors that seemed to influence caregivers use of walkers include parental education, total household income, housing type, walker availability and the perception that walkers promote walking. Awareness of walker-related hazards, alternatives to walkers, and the total number of children in the household did not have a significant impact on the caregivers’ decision to use the walker. There were 24 self-reported cases of walker-related injuries representing 7.7% (n = 311). The main types of injuries included toppling over flat ground (5.5%) and falling over stairs/steps (1.9%). 2003 Blackwell Publishing Asia and Wonca

BackgroundSelf-management plays an important role in maintaining good control of diabetes mellitus, and mobile phone interventions have been shown to improve such self-management. The Health Promotion Board of Singapore has created a caloric-monitoring mobile health app, the “interactive Diet and Activity Tracker” (iDAT). ObjectiveThe objective was to identify and describe short-term (8-week) trajectories of use of the iDAT app among patients with type 2 diabetes mellitus in a primary care setting in Singapore, and identify patient characteristics associated with each trajectory. MethodsA total of 84 patients with type 2 diabetes mellitus from a public primary care clinic in Singapore who had not previously used the iDAT app were enrolled. The app was demonstrated and patients’ weekly use of the app was monitored over 8 weeks. Weekly use was defined as any record in terms of food entry or exercise workout entry in that week. Information on demographics, diet and exercise motivation, diabetes self-efficacy (Diabetes Empowerment Scale-Short Form), and clinical variables (body mass index, blood pressure, and glycosylated hemoglobin/HbA1c) were collected at baseline. iDAT app use trajectories were delineated using latent-class growth modeling (LCGM). Association of patient characteristics with the trajectories was ascertained using logistic regression analysis. ResultsThree iDAT app use trajectories were observed: Minimal Users (66 out of 84 patients, 78.6%, with either no iDAT use at all or use only in the first 2 weeks), Intermittent-Waning Users (10 out of 84 patients, 11.9%, with occasional weekly use mainly in the first 4 weeks), and Consistent Users (8 out of 84 patients, 9.5%, with weekly use throughout all or most of the 8 weeks). The adjusted odds ratio of being a Consistent User, relative to a Minimal User, was significantly higher for females (OR 19.55, 95% CI 1.78-215.42) and for those with higher exercise motivation scores at baseline (OR 4.89, 95% CI 1.80-13.28). The adjusted odds ratio of being an Intermittent-Waning User relative to a Minimal User was also significantly higher for those with higher exercise motivation scores at baseline (OR 1.82, 95% CI 1.00-3.32). ConclusionsThis study provides insight into the nature and extent of usage of a caloric-monitoring app among patients with type 2 diabetes and managed in primary care. The application of LCGM provides a useful framework for evaluating future app use in other patient populations.

This observer-blind study (clinicaltrials.gov NCT01462357) compared the immunogenicity and safety of 2 doses of the HPV-16/18 AS04-adjuvanted vaccine (HPV-16/18(2D)) vs. 2 or 3 doses of the HPV-6/11/16/18 vaccine (HPV-6/11/16/18(2D) and HPV-6/11/16/18(3D)) in healthy girls aged 9-14 y. Girls were randomized (1:1:1) to receive HPV-16/18(2D) at months (M) 0,6 (N = 359), HPV-6/11/16/18(2D) at M0,6 (N = 358) or HPV-6/11/16/18(3D) at M0,2,6 (N = 358). The primary objective was non-inferiority/superiority of HPV-16/18 antibodies by ELISA for HPV-16/18(2D) vs. HPV-6/11/16/18(2D) at M7 in the according-to-protocol immunogenicity cohort (ATP-I) and total vaccinated cohort, respectively. Secondary objectives included non-inferiority/superiority of HPV-16/18(2D) vs. HPV-6/11/16/18(3D) at M7, non-inferiority/superiority at M12, HPV-16/18 neutralizing antibodies, frequencies of T-cells/B-cells, reactogenicity and safety. Antibody responses at M7 for HPV-16/18(2D) were superior to those for HPV-6/11/16/18(2D) and HPV-6/11/16/18(3D) (lower limit of 95% confidence interval for geometric mean titer ratio (GMR) was >1): HPV-16/18(2D)/HPV-6/11/16/18(2D) GMRs were 1.69 [1.49-1.91] for anti-HPV-16 and 4.52 [3.97-5.13] for anti-HPV-18; HPV-16/18(2D)/HPV-6/11/16/18(3D) GMRs were 1.72 [1.54-1.93] for anti-HPV-16 and 3.22 [2.82-3.68] for anti-HPV-18; p = 0.0001 for all comparisons. Non-inferiority/superiority was also demonstrated at M12. Among initially seronegative girls in the ATP-I, neutralizing antibody titers were at least 1.8-fold higher for HPV-16/18(2D) vs. HPV-6/11/16/18(2D) and HPV-6/11/16/18(3D) at M7 and M12. Frequencies of HPV-16/18-specific T-cells and B-cells were in similar ranges between groups. Reactogenicity and safety were in line with the known profile of each vaccine. In conclusion, superior HPV-16/18 antibody responses were elicited by 2 doses of the HPV-16/18 AS04-adjuvanted vaccine compared with 2 or 3 doses of the HPV-6/11/16/18 vaccine in girls (9-14years). Funding: GlaxoSmithKline Biologicals SA

Importance A deep learning system (DLS) is a machine learning technology with potential for screening diabetic retinopathy and related eye diseases. Objective To evaluate the performance of a DLS in detecting referable diabetic retinopathy, vision-threatening diabetic retinopathy, possible glaucoma, and age-related macular degeneration (AMD) in community and clinic-based multiethnic populations with diabetes. Design, Setting, and Participants Diagnostic performance of a DLS for diabetic retinopathy and related eye diseases was evaluated using 494 661 retinal images. A DLS was trained for detecting diabetic retinopathy (using 76 370 images), possible glaucoma (125 189 images), and AMD (72 610 images), and performance of DLS was evaluated for detecting diabetic retinopathy (using 112 648 images), possible glaucoma (71 896 images), and AMD (35 948 images). Training of the DLS was completed in May 2016, and validation of the DLS was completed in May 2017 for detection of referable diabetic retinopathy (moderate nonproliferative diabetic retinopathy or worse) and vision-threatening diabetic retinopathy (severe nonproliferative diabetic retinopathy or worse) using a primary validation data set in the Singapore National Diabetic Retinopathy Screening Program and 10 multiethnic cohorts with diabetes. Exposures Use of a deep learning system. Main Outcomes and Measures Area under the receiver operating characteristic curve (AUC) and sensitivity and specificity of the DLS with professional graders (retinal specialists, general ophthalmologists, trained graders, or optometrists) as the reference standard. Results In the primary validation dataset (n = 14 880 patients; 71 896 images; mean [SD] age, 60.2 [2.2] years; 54.6% men), the prevalence of referable diabetic retinopathy was 3.0%; vision-threatening diabetic retinopathy, 0.6%; possible glaucoma, 0.1%; and AMD, 2.5%. The AUC of the DLS for referable diabetic retinopathy was 0.936 (95% CI, 0.925-0.943), sensitivity was 90.5% (95% CI, 87.3%-93.0%), and specificity was 91.6% (95% CI, 91.0%-92.2%). For vision-threatening diabetic retinopathy, AUC was 0.958 (95% CI, 0.956-0.961), sensitivity was 100% (95% CI, 94.1%-100.0%), and specificity was 91.1% (95% CI, 90.7%-91.4%). For possible glaucoma, AUC was 0.942 (95% CI, 0.929-0.954), sensitivity was 96.4% (95% CI, 81.7%-99.9%), and specificity was 87.2% (95% CI, 86.8%-87.5%). For AMD, AUC was 0.931 (95% CI, 0.928-0.935), sensitivity was 93.2% (95% CI, 91.1%-99.8%), and specificity was 88.7% (95% CI, 88.3%-89.0%). For referable diabetic retinopathy in the 10 additional datasets, AUC range was 0.889 to 0.983 (n = 40 752 images). Conclusions and Relevance In this evaluation of retinal images from multiethnic cohorts of patients with diabetes, the DLS had high sensitivity and specificity for identifying diabetic retinopathy and related eye diseases. Further research is necessary to evaluate the applicability of the DLS in health care settings and the utility of the DLS to improve vision outcomes.

Congenital colour vision deficiency (CVD) has a prevalence of 8% for men and 0.4% for women. Amongst people born with normal colour vision, the acquired form of CVD can also affect them at later stages of their lives due to disease or exposure to toxin. Most CVD persons have difficulties dealing with colours in everyday life and at work, but these problems are under-reported due to a lack of its awareness in the general population. This literature review seeks to present findings of studies and reports on the impact of CVD on the affected persons chronologically through different stages of their lives and their coping measures. Scientific publications and corresponding references relating to how CVD affects individuals were searched, identified and retrieved from PubMed, National University of Singapore and Cochrane electronic databases. Books that were not available electronically were manually searched. Paramedical literature was also included through online searches using Google and Google Scholar. Inclusion criteria were English-based studies pertaining to effects of CVD on everyday life and respective coping measures, including experimental, observational studies, symposium proceedings and systematic review. There was no timeframe restriction for these publications. Articles using anecdotal evidence were excluded with the exception of those used to describe the effects of CVD on play age and school age. Our literature search found 136 articles, 60 of which were used in this review based on the respective selection criteria. CVD affects many aspects of life from childhood to adulthood. The implications extend across play, sports, driving, education, occupation, discrimination, and health and safety issues. Awareness of CVD helps to identify and develop corresponding coping strategies. More work needs to be done in raising awareness of CVD and its implications, as well as implementing measures to overcome these difficulties.

INTRODUCTION Dyslipidaemia leads to atherosclerosis and is a major risk factor for cardiovascular diseases. In clinical trials, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, or statins, have been shown to effectively reduce dyslipidaemia. Despite the availability and accessibility of statins, myocardial infarctions and cerebrovascular accidents remain among the top causes of mortality in developed countries, including Singapore. This enigma could be attributed to suboptimal adherence to statin therapy. The present literature review aimed to evaluate patients' perceptions of statin therapy. METHODS We searched PubMed and other databases for articles published in English from October 1991 to May 2012 containing keywords such as 'patient', 'views', 'perceptions', 'adherence', 'statin' and 'dyslipidaemia'. Of the 122 eligible studies retrieved, 58 were reviewed. The findings were categorised and framed in accordance with the Health Belief Model. RESULTS Patients with dyslipidaemia appeared to underestimate their susceptibility to dyslipidaemia-related complications, partly due to their demographic profiles. Failure to appreciate the severity of potential complications was a major hindrance toward adherence to statin therapy. Other factors that affected a patient's adherence included lack of perceived benefits, perceived side effects, the cost of statins, poor physician-patient relationship, and overestimation of the effectiveness of diet control as a treatment modality. CONCLUSION Existing evidence suggests that the cause of poor adherence to statin therapy is multifactorial. The use of the Health Belief Model to present the results of our literature review provides a systematic framework that could be used to design a patient-centric approach for enhancing adherence to statin therapy.

Background Primary care research is at a crossroad in South Pacific. A steering committee comprising a member of WONCA Asia Pacific Regional (APR) council and the President of Fiji College of General Practitioners garnered sponsorship from Fiji Ministry of Health, WONCA APR and pharmaceutical agencies to organize the event in October 2013. This paper describes the processes needed to set up a national primary research agenda through the collaborative efforts of local stakeholders and external facilitators using a test case in South Pacific. Method The setting was a 2-day primary care research workshop in Fiji. The steering committee invited a team of three external facilitators from the Asia-Pacific region to organize and operationalize the workshop. The eventual participants were 3 external facilitators, 6 local facilitators, and 29 local primary care physicians, academics, and local medical leaders from Fiji and South Pacific Islands. Pre-workshop and main workshop programs were drawn up by the external facilitators, using participants’ input of research topics relating to their local clinical issues of interest. Course notes were prepared and distributed before the workshop. In the workshop, proposed research topics were shortlisted by group discussion and consensus. Study designs were proposed, scrutinized, and adopted for further research development. Results The facilitators reviewed the processes in setting the research agenda after the workshop and conceived the proposed 6E model. These processes can be grouped for easy reference, comprising the pre-workshop stages of “entreat”, “enlist”, “engage”, and the workshop stages of “educe”, “empower”, and “encapsulate”. Conclusion The 6E model to establish a research agenda is conceptually logical. Its feasibility can be further tested in its application in other situation where research agenda setting is the critical step to improve the quality of primary care.

Asthma is a common childhood disease, and paediatric patients with asthma rely on caregivers to administer domiciliary asthma care. This study aimed to explore the knowledge, understanding, perceptions and main concerns of caregivers and its influence on their home management of children with asthma.Data from 14 caregivers of children with asthma was collected during three focus group discussions held in two polyclinics in Singapore. The collected data was analysed using standard content analysis and classified into themes.The caregivers' main concerns included the perceived effects of infection, food and exercise on children with asthma. Several caregivers considered the disease to be infectious and had a lower threshold for physician consultation, as they believed that any delay in treating the infection would be detrimental to the child's health. Some also perceived asthma to be episodic and self-limiting, and that their children could 'outgrow' it. Many caregivers believed that asthma could be modified by abstinence from, or intake of, certain foods. Others had the perception that sports, including swimming, would worsen asthma. These perceptions resulted in unnecessary restrictions of the children's diet and activities. Most caregivers were unaware of influenza vaccination as a preventive measure to reduce triggers due to respiratory viral infections.We found that the caregivers' perceptions of asthma aetiology, its triggers and preventive measures affected their help-seeking behaviour and care of children with asthma. Healthcare professionals managing paediatric patients with asthma should recognise such caregiver misperceptions, and take a proactive approach to rectify and bridge the gaps in caregivers' knowledge and understanding of the disease.

Acute respiratory infections are prevalent and pose a constant threat to society. While the use of facemasks has proven to be an effective barrier to curb the aerosol spread of such diseases, its use in the local community is uncommon, resulting in doubts being cast on its effectiveness in preventing airborne infections during epidemics. We thus aimed to conduct a literature review to determine the factors that influence the use of facemasks as a primary preventive health measure in the community.A search for publications relating to facemask usage was performed on Medline, PubMed, Google, World Health Organization and Singapore government agencies' websites, using search terms such as 'facemask', 'mask', 'influenza', 'respiratory infection', 'personal protective equipment', 'disease prevention', 'compliance' and 'adherence'. Findings were framed under five components of the Health Belief Model: perceived susceptibility, perceived benefits, perceived severity, perceived barriers and cues to action.We found that individuals are more likely to wear facemasks due to the perceived susceptibility and perceived severity of being afflicted with life-threatening diseases. Although perceived susceptibility appeared to be the most significant factor determining compliance, perceived benefits of mask-wearing was found to have significant effects on mask-wearing compliance as well. Perceived barriers include experience or perception of personal discomfort and sense of embarrassment. Media blitz and public health promotion activities supported by government agencies provide cues to increase the public's usage of facemasks.Complex interventions that use multipronged approaches targeting the five components of the Health Belief Model, especially perceived susceptibility, are needed to increase the use of facemasks in the community. Further studies are required to evaluate the effectiveness of implemented interventions.

INTRODUCTION Not much is known regarding how primary care physicians (PCPs) in Singapore keep themselves healthy and mitigate ill health. This study aims to determine the health-seeking behaviour of local PCPs and to identify the predictors of local PCPs attaining the recommended level of exercise. METHODS This study was a cross-sectional questionnaire survey, which included questions on the demographic characteristics, practice profiles and health-seeking behaviour of PCPs. The sampling frame was the 1,400 listed members of the College of Family Physicians Singapore. The anonymised survey was executed in two phases: a postal survey, followed by a web-based survey on the College of Family Physicians Singapore website. The two data sets were collated; the categorical variables, summarised; and the differences between subgroups (based on exercise engagement), compared using Fisher's exact test. The effect of each risk factor on exercise duration was quantified using odds ratio (OR) estimate and 95% confidence interval (CI). Multivariate logistic regression analysis was performed to identify significant predictors of exercise engagement. RESUlTS A total of 631 PCPs participated in the survey - 26% were ≤ 34 years old, 58% were male, 21% were single, 34% were singleton practitioners, and 56% were private practitioners. The percentage of PCPs who exercised ≥ 2.5 hours weekly was 29%, while 28% exercised < 0.5 hours weekly. Of the PCPs surveyed, 1% currently smoke, 0.8% drink more than 14 units of alcohol weekly, 60% undertook health screening, 65% had blood investigations done, and 64% had taken preventive measures such as getting influenza vaccination. CONClUSION While local PCPs generally did not have undesirable habits such as smoking and alcohol abuse, they could further increase their exercise intensity and undertake more preventive measures such as getting vaccinated against various diseases.

Background In Singapore, SingHealth Polyclinics (SHP) is an accredited Family Medicine (FM) training centre which managed 1.8 million primary care patient-visits in 2012. To promote research in the institution, research consultation clinics (RCC) are being introduced in 2010 to enable free face-to-face consultation between experienced and novice researchers on specific research topics. Each RCC session allows about an hour or more for the SHP staff, medical undergraduates and general practitioners to seek advice and clarification on key research areas, ranging from research question refinement, study design and execution, data analysis, result presentation to publication. The consultants comprise of two FM researchers with postgraduate research qualification. Aim This article aims to review the implementation of RCC from 2010 to 2012 and its impact on research activities and outcome indicators in the same period of time. Methods The study comprised of two segments. Part I was a three-year retrospective review of the RCC administrative record. The total number of RCC sessions, hours utilised, participants’ profiles, the number of research studies initiated by them and their research presentations at local and overseas scientific meetings/conferences were computed. Part 2 was an anonymous web-based questionnaire survey fielded to RCC participants to collect their feedback on the RCC service and their self-reported initiation and completion of research study after the RCC consultation. Results The RCC sessions increased from 17 to 40 sessions, resulting in increment of 2 to 14 research presentations and from 2 to 6 initiations of new research studies per annum from 2010–2012. The response rate to the questionnaire survey was 70.3%, with the majority of multi-disciplinary respondents rated the RCC service to be accessible, adequate and were satisfied with its quality. Study design, data management and study execution were ranked as important areas of research for consultation. 79% of them had started a research project and 36% had completed their studies. Conclusions The RCC is a feasible model to catalyse multi-disciplinary research in primary care institutions. Further study is needed to evaluate its relevance when research advances and novice researchers become experienced investigators to take on more complex projects.