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Abstract Background Chronic kidney disease (CKD) poses a global health challenge with high morbidity and mortality rates. Early detection and prompt intervention are critical in preventing progression to end-stage kidney disease (ESKD) and cardiovascular complications. Effective CKD management requires comprehensive care packages that integrate both pharmacological and non-pharmacological interventions within collaborative, team-based models, aiming to enhance patient outcomes and overall quality of life. The goal of the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) study is to establish effective multicomponent intervention (MCI) strategies for evaluating and preventing kidney outcomes in patients with moderate to advanced CKD within primary care settings in Singapore. Methods This study is a 3-year randomized controlled trial among 896 participants aged between 40 and 80 years with moderate or advanced CKD in five government-subsidized polyclinics in Singapore. The components of the MCI are (1) nurses/service coordinators trained as health coaches for motivational conversation and CKD-specific lifestyle counseling on diet and exercise, using a hybrid follow-up approach of in-person, telephone, and secure video meetings; (2) training physicians in algorithm-based standardized management of CKD; (3) subsidy on SGLT2i medications for CKD; and (4) regular CKD case review meetings. The primary outcome is the estimated glomerular filtration rate (eGFR) total slope from randomization to final follow-up at 36 months. Discussion If shown to be effective, cost-effective, and acceptable, SKOPE should be considered for scaling country-wide and in similar regional healthcare systems. Trial registration ClinicalTrials.gov NCT05295368. Registered on March 25, 2022.

Background Coca-Cola and Cola-Cola Zero Sugar are commonly consumed beverages by healthcare professionals. Medical superstitions abound about whether Cola-Cola Zero sugar consumption affects night call outcomes. Objectives The current study aimed to determine whether Coca-Cola Zero Sugar, compared to regular Coca-Cola, is associated with any differences in inpatient admissions and mortality of patients on night calls. Methods A double-blinded randomized controlled trial was conducted in the Division of Medicine, Singapore General Hospital, Singapore involving junior doctors from January 2024 to February 2024.The primary outcome was the number of ward admissions under the night call doctor’s care. Secondary outcomes involved the number of inpatient deaths, high-dependency or intensive care admissions, the number of hours slept by the doctor, the number of steps walked by the doctor, and the level of sleepiness of the doctor on call. Results 203 participants consented and were randomized (44.9%). The data of 198 participants were included for analysis (97.5%). No significant differences were detected in the number of ward admissions between the Coca-Cola Zero Sugar group and the regular Coca-Cola group. For secondary outcomes, a significant difference was present between the two groups in the Karolinska Sleepiness Scale score ( p -value = .0413). Other secondary outcomes did not demonstrate significant differences between the two groups. Conclusions No convincing evidence was present to support the consumption of Coca-Cola Zero Sugar versus the regular Coca-Cola had significant differences in the number of inpatient admissions and mortality in night call duties.

Abstract Background Medical students in Singapore engage in short term medical missions, locally known as Overseas Community Involvement Projects (OCIPs). Little is known about the learning outcomes of an OCIP and how this complements their medical education back home. Understanding this can help the medical educators structure the OCIP to optimise its learning value. Objectives This study aims to gain an in-depth understanding of the experiences and learning outcomes of the medical students who participated in the OCIP. Methods This was a qualitative study involving Singaporean students from one medical school travelling to Nepal. Data was collected from reflective journals, overall group reflections and two focus group discussions. The data was thematically analysed using the Accreditation Council for Graduate Medical (ACGME) core competencies for medical professionals. Results The data could be classified under various themes within the six domains of the ACGME framework. The study revealed themes of: humanism, socioeconomic and cultural determinants of health under the domain of patient care, application of medical knowledge, investigating and evaluating the needs of a population and feedback to drive improvement under the domain of practice-based learning and improvement, use of non-verbal cues and communicating across language barriers under the domain of interpersonal and communication skills, healthcare systems and delivery, resourcefulness and adaptability, health equity and accessibility under the domain of systems-based practice, ethics, role-modelling, teamwork and leadership skills, interprofessional skills and resilience under the domain of professionalism. Understanding the students’ motivations, utilising reflections, and following the patients’ journey facilitated attainment of these outcomes. Conclusions This OCIP experience translated to learning outcomes aligned with the ACGME framework. There is great potential for the experiential learning from a well-structured OCIP to help with personal and professional development and global health education.

Livestock farms are recognized sources of ammonia emissions, impacting nearby regions’ fine dust particle concentrations, though the full extent of this impact remains uncertain. Air dispersion models, commonly employed to estimate particulate matter (PM) levels, are heavily reliant on data quality, resulting in varying levels of accuracy. This study compares the performance of both air dispersion models and spatiotemporal deep learning models in estimating PM concentrations in Republic of Korea’s livestock-farming areas. Hourly PM concentration data, alongside temperature, humidity, and air pressure, were collected from seven monitoring stations across the study area. Using a 200 m × 200 m prediction grid, forecasts were generated for both 1 h and 24 h intervals using the Graz Lagrangian model (GRAL) and a one-dimensional convolutional neural network combined with the long short-term memory algorithm (1DCNN-LSTM). Results highlight the potential of the deep learning model to enhance PM prediction, indicating its promise as an effective alternative or supplement to conventional air dispersion models, particularly in data-scarce areas such as those surrounding livestock farms. Gaining a comprehensive understanding and evaluating the advantages and disadvantages of each approach would offer valuable scientific insights for monitoring atmospheric pollution levels within a specific area.

Background The working population encounters unique work-related stressors. Despite these challenges, accessibility to mental healthcare remains limited. Digital technology-enabled mental wellness tools can offer much-needed access to mental healthcare. However, existing literature has given limited attention to their relevance and user engagement, particularly for the working population.Aim This study aims to assess user perceptions and feature utilisation of mindline at work, a nationally developed AI-enabled digital platform designed to improve mental wellness in the working population.Methods This study adopted a mixed-methods design comprising a survey (n=399) and semistructured interviews (n=40) with office-based working adults. Participants were asked to use mindline at work for 4 weeks. We collected data about utilisation of the platform features, intention for sustained use and perceptions of specific features.Results Participants under 5 years of work experience reported lower utilisation of multimedia resources but higher utilisation of emotion self-assessment tools and the AI chatbot compared with their counterparts (p

BackgroundThe clinical management of type 2 diabetes mellitus (T2DM) presents a significant challenge due to the constantly evolving clinical practice guidelines and growing array of drug classes available. Evidence suggests that artificial intelligence (AI)–enabled clinical decision support systems (CDSSs) have proven to be effective in assisting clinicians with informed decision-making. Despite the merits of AI-driven CDSSs, a significant research gap exists concerning the early-stage implementation and adoption of AI-enabled CDSSs in T2DM management. ObjectiveThis study aimed to explore the perspectives of clinicians on the use and impact of the AI-enabled Prescription Advisory (APA) tool, developed using a multi-institution diabetes registry and implemented in specialist endocrinology clinics, and the challenges to its adoption and application. MethodsWe conducted focus group discussions using a semistructured interview guide with purposively selected endocrinologists from a tertiary hospital. The focus group discussions were audio-recorded and transcribed verbatim. Data were thematically analyzed. ResultsA total of 13 clinicians participated in 4 focus group discussions. Our findings suggest that the APA tool offered several useful features to assist clinicians in effectively managing T2DM. Specifically, clinicians viewed the AI-generated medication alterations as a good knowledge resource in supporting the clinician’s decision-making on drug modifications at the point of care, particularly for patients with comorbidities. The complication risk prediction was seen as positively impacting patient care by facilitating early doctor-patient communication and initiating prompt clinical responses. However, the interpretability of the risk scores, concerns about overreliance and automation bias, and issues surrounding accountability and liability hindered the adoption of the APA tool in clinical practice. ConclusionsAlthough the APA tool holds great potential as a valuable resource for improving patient care, further efforts are required to address clinicians’ concerns and improve the tool’s acceptance and applicability in relevant contexts.

Abstract Early detection of undiagnosed diabetes, hypertension or hyperlipidemia through screening could reduce healthcare costs resulting from disease complications. To date, despite ample research on the factors linked to the uptake of community health screening programs, little attention has been directed at delayed or incomplete follow-up after positive outcomes are identified in community screening tests. This study aimed to investigate the socioeconomic and behavioral factors that influence non-compliance with recommendations for primary care physician referrals, following community-based screening for diabetes, hypertension and hyperlipidemia. A parallel mixed-methods study was conducted. For quantitative data, we performed multivariable analysis on community-based chronic disease screening data. The qualitative component involved semi-structured interviews with individuals with both non-compliance and compliance with referral recommendations. Thematic data analysis was undertaken using the Theoretical Domains Framework (TDF). The quantitative analysis showed that older age (OR = 0.92, 95%CI [0.89–0.96]), non-Chinese ethnicity (OR = 0.24; 95% CI [0.08–0.44]) and residing in 5-room public/ private housing (OR = 0.40; 95% CI [0.14–0.74]) were associated with lower odds of non-compliance with referral recommendations. Thematic analysis identified multiple behavioral-level determinants acting as enablers or barriers within 7 TDF domains: awareness of health risks after receiving screening results, self-management orientation and behavioral control, fear of formal diagnosis and concerns about healthcare cost, optimistic belief driven by the lack of symptoms, interpersonal relationship and social obligations, aversion to medication, communication at the result collection and sense of uncertainty regarding self-scheduling of appointment. Findings provide valuable implications for the development of interventions aimed at improving adherence to referral recommendation. Future endeavors should include culturally sensitive outreach, evidence-based information dissemination, family-centered education, positive public health messaging, brief counseling during result collection and an opt-out appointment system to enhance follow-up care.

BackgroundAn emerging focus on person-centered care has prompted the need to understand how shared decision-making (SDM) and health coaching could support self-management of diabetes and hypertension. ObjectiveThis study aims to explore preferences for the scope of involvement of health coaches and health care professionals (HCPs) in SDM and the factors that may influence optimal implementation of SDM from the perspectives of patients and HCPs. MethodsWe conducted focus group discussions with 39 patients with diabetes and hypertension and 45 HCPs involved in their care. The main topics discussed included the roles of health coaches and HCPs in self-management, views toward health coaching and SDM, and factors that should be considered for optimal implementation of SDM that involves health coaches. All focus group discussions were audio recorded, transcribed verbatim, and analyzed using thematic analysis. ResultsParticipants agreed that the main responsibility of HCPs should be identifying the patient’s stage of change and medication education, while health coaches should focus on lifestyle education, monitoring, and motivational conversation. The health coach was seen to be more effective in engaging patients in lifestyle education and designing goal management plans as health coaches have more time available to spend with patients. The importance of a health coach’s personal attributes (eg, sufficient knowledge of both medical and psychosocial management of disease conditions) and credentials (eg, openness, patience, and empathy) was commonly emphasized. Participants viewed that addressing the following five elements would be necessary for the optimal implementation of SDM: (1) target population (newly diagnosed and less stable patients), (2) commitment of all stakeholders (discrepancy on targeted times and modality), (3) continuity of care (familiar faces), (4) philosophy of care (person-centered communication), and (5) faces of legitimacy (physician as the ultimate authority). ConclusionsThe findings shed light on the appropriate roles of health coaches vis-à-vis HCPs in SDM as perceived by patients and HCPs. Findings from this study also contribute to the understanding of SDM on self-management strategies for patients with diabetes and hypertension and highlight potential opportunities for integrating health coaches into the routine care process.

BackgroundOlder adults worldwide experienced heightened risks of depression, anxiety, loneliness, and poor mental well-being during the COVID-19 pandemic. During this period, digital technology emerged as a means to mitigate social isolation and enhance social connectedness among older adults. However, older adults’ behaviors and attitudes toward the adoption and use of digital technology are heterogeneous and shaped by factors such as age, income, and education. Few empirical studies have examined how older adults experiencing social and economic disadvantages perceive the learning of digital tools. ObjectiveThis study aims to examine the motivations, experiences, and perceptions toward a community-based digital intervention among older adults residing in public rental flats in a low-income neighborhood. Specifically, we explored how their attitudes and behaviors toward learning the use of smartphones are shaped by their experiences related to age and socioeconomic challenges. MethodsThis study adopted a qualitative methodology. Between December 2020 and March 2021, we conducted semistructured in-depth interviews with 19 participants aged ≥60 years who had completed the community-based digital intervention. We asked participants questions about the challenges encountered amid the pandemic, their perceived benefits of and difficulties with smartphone use, and their experiences with participating in the intervention. All interviews were audio recorded and analyzed using a reflexive thematic approach. ResultsAlthough older learners stated varying levels of motivation to learn, most expressed ambivalence about the perceived utility and relevance of the smartphone to their current needs and priorities. While participants valued the social interaction with volunteers and the personalized learning model of the digital intervention, they also articulated barriers such as age-related cognitive and physical limitations and language and illiteracy that hindered their sustained use of these digital devices. Most importantly, the internalization of ageist stereotypes of being less worthy learners and the perception of smartphone use as being in the realm of the privileged other further reduced self-efficacy and interest in learning. ConclusionsTo improve learning and sustained use of smartphones for older adults with low income, it is essential to explore avenues that render digital tools pertinent to their daily lives, such as creating opportunities for social connections and relationship building. Future studies should investigate the relationships between older adults’ social, economic, and health marginality and their ability to access digital technologies. We recommend that the design and implementation of digital interventions should prioritize catering to the needs and preferences of various segments of older adults, while working to bridge rather than perpetuate the digital divide.

BackgroundPatients with type 2 diabetes mellitus (T2DM) experience multiple barriers to improving self-management. Evidence suggests that motivational interviewing (MI), a patient-centered communication method, can address patient barriers and promote healthy behavior. Despite the value of MI, existing MI studies predominantly used face-to-face or phone-based interventions. With the growing adoption of smartphones, automated MI techniques powered by artificial intelligence on mobile devices may offer effective motivational support to patients with T2DM. ObjectiveThis study aimed to explore the perspectives of patients with T2DM on the acceptability of app-based MI in routine health care and collect their feedback on specific MI module features to inform our future intervention. MethodsWe conducted semistructured interviews with patients with T2DM, recruited from public primary care clinics. All interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted using NVivo. ResultsIn total, 33 patients with T2DM participated in the study. Participants saw MI as a mental reminder to increase motivation and a complementary care model conducive to self-reflection and behavior change. Yet, there was a sense of reluctance, mainly stemming from potential compromise of autonomy in self-care by the introduction of MI. Some participants felt confident in their ability to manage conditions independently, while others reported already making changes and preferred self-management at their own pace. Compared with in-person MI, app-based MI was viewed as offering a more relaxed atmosphere for open sharing without being judged by health care providers. However, participants questioned the lack of human touch, which could potentially undermine a patient-provider therapeutic relationship. To sustain motivation, participants suggested more features of an ongoing supportive nature such as the visualization of milestones, gamified challenges and incremental rewards according to achievements, tailored multimedia resources based on goals, and conversational tools that are interactive and empathic. ConclusionsOur findings suggest the need for a hybrid model of intervention involving both app-based automated MI and human coaching. Patient feedback on specific app features will be incorporated into the module development and tested in a randomized controlled trial.

Background: Screening patients with patient-reported outcome measures allows identification of palliative care concerns. The Integrated Palliative Care Outcome Scale (IPOS) was developed in the United Kingdom for this purpose. Tools developed in another setting might not be readily usable locally. We previously evaluated the validity and reliability of the IPOS in our cardiology setting. However, it remains uncertain what factors would influence the subsequent implementation of IPOS for routine screening of patients with advanced heart failure in future practice. Objectives: This study aimed to identify the factors that could affect the IPOS implementation for patients with advanced heart failure. Design: This was a qualitative study conducted at the National Heart Centre Singapore. Methods: Patients with advanced heart failure who participated in our previous IPOS validation study were purposively recruited for semi-structured interviews. Healthcare workers caring for these patients and involved in the testing of the IPOS tool were also invited for interviews. The interviews were analyzed thematically and mapped to the Consolidated Framework for Implementation Research (CFIR). Results: Our analysis identified six potential facilitators and six potential barriers to implementation across five major domains of the CFIR (intervention characteristics, inner setting, outer setting, individual characteristics, and process). Facilitators include: (i) perception of utility, (ii) perception of minimal complexity, (iii) perception of relatability, (iv) conducive culture, (v) dedicated resources, and (vi) advocates for implementation. Barriers include: (i) need for adaptation, (ii) mindsets/role strains, (iii) resource constraints, (iv) cultural concerns, (v) individual needs, and (vi) change process. Conclusion: Institutions could focus on cultivating appropriate perceptions and conducive cultures, providing dedicated resources for implementation and introducing facilitators to advocate for implementation. Adaptation of IPOS to suit workflows and individual needs, consideration of change processes, and systemic changes to alleviate cultural, resource, and staff role strains would improve IPOS uptake during actual implementation in clinical services. Trial registration: Not applicable.

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

Objective: We aimed to provide an up-to-date synthesis of the effectiveness of patient reported outcome measures (PROMs) use to self-monitor symptoms compared to conventional follow-up care in patients with rheumatic diseases. We also compared the effect of providing feedback via PROMs to a control group in which PROMs feedback was not provided. Methods: This review was guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. Articles published before October 2023 were retrieved from PubMed[Formula: see text], Cochrane Library[Formula: see text], Embase[Formula: see text], and PsycINFO[Formula: see text](Ovid). Studies were included if (1) they compared PROMs use compared against not using PROMs, (2) used PROMs as an intervention with feedback provided to healthcare professionals/patients to compare against PROMs use but no feedback was provided. Methodological quality and level of evidence were evaluated according to the Risk of Bias tool and the Risk of Bias in Non-randomized Studies of Interventions tool. Results: A total of 15, 571 articles were screened, 5 articles met the inclusion criteria, and 3 additional articles were identified from handsearching. Most studies reported positive results on symptom control, health-related quality of life, patient perception, shared decision making, and a reduction in clinic visits. No studies reported on survival/mortality. In general, we found conflicting evidence regarding whether feedback from physicians improved patient satisfaction in clinical care. Conclusion: We identified 8 articles through a systematic review and synthesised evidence on their effectiveness. There is a lack of studies comparing PROMs use to conventional care in rheumatic diseases. Future studies should explore the implications of using PROMs in clinical care.

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

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

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

Introduction During the COVID-19 pandemic, safe-distancing measures resulted in many community-dwelling older adults being socially isolated and lonely, with its attending negative impact on wellbeing and quality of life. While digital technology may have mitigated this, older adults of low socioeconomic status (SES) are more likely to be digitally excluded and hence susceptible to the adverse effects of social isolation and loneliness. This study aims to understand the factors that affect digital literacy, smartphone ownership, and willingness to participate in a digital literacy program (DLP), and to test the hypothesized relations between digital literacy, social connectedness, loneliness, wellbeing, and quality of life amongst community dwelling older adults of low SES. Materials and methods A questionnaire assessing digital literacy, social connectedness, wellbeing and quality of life was administered. Socio-demographic variables, pre-existing internet-enabled, and willingness to participate in a home-based DLP was also collected. Logistic regression was used to identify demographic factors associated with digital literacy, smartphone ownership, and willingness to enroll in a DLP. Serial mediation analysis was also performed using a structural equation model framework. Results A total of 302 participants were recruited. Female gender, older age, lower education levels were associated with lower digital literacy. Those who owned a smartphone tended to be younger and better educated. Older adults who were better educated, of Chinese descent (the ethnic majority in Singapore), and who had lower digital literacy, were most willing to enroll in the digital literacy education program. Social-use digital literacy had a positive indirect effect on well-being ( Discussion The results suggest there are demographic barriers to participation in DLPs and highlight the benefit of focusing on enhancing social-use digital literacy. Further study is needed to evaluate how well specific interventions to improve social-use digital literacy help to reduce social isolation and loneliness, and ultimately improve wellbeing and quality of life.

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

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

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

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

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

Objectives Poor symptom appraisal (detection, interpretation and response to symptoms) plays a major role in prolonged prediagnosis interval in various health conditions. Theories and models have been proposed to study the symptom appraisal process but how they could be employed to improve symptom appraisal remains unclear. We therefore aimed to review approaches to improving symptom appraisal in the literature and to develop a theoretical framework that could guide the development of approaches to improving symptom appraisal among individuals in the general population.Design Systematic review.Data sources Medline, Web of Science, PsycINFO, Embase, CINAHL and Scopus were searched from inception to 30 March 2021.Eligibility criteria We included original articles in English in which approaches to improve the detection, interpretation or response to symptoms for symptomatic individuals were described. We excluded articles in which approaches were developed to improve symptom appraisal among healthcare professionals.Data extraction and synthesis A predefined data extraction form was used to extract the development, characteristics and evaluation of approaches to improving symptom appraisal. This formed the basis for the narrative synthesis.Results Of 19 046 publications identified from the literature search, 112 were selected for full-text review and 29 approaches comprising provision of knowledge of symptoms/signs and additional components (eg, symptom self-examination and comparison) for symptom appraisal were included in the synthesis. Less than half (41.4%) of these approaches were developed based on theories/models. Interestingly, despite the variety of theories/models adopted in developing these approaches, the components of these approaches were similar.Conclusion Symptom appraisal is an essential process in a patient’s journey that can be targeted to facilitate early diagnosis but is largely unstudied. Building on the literature, we proposed a theoretical framework and approaches to improving symptom appraisal. This could facilitate early identification of a variety of health conditions in the general population.Trial registration number CRD42021279500.

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

Abstract Background Medical professionalism is important for establishing public trust in doctors. Its definition is culture-sensitive. However, no research has explored medical professionalism in Traditional Chinese Medicine (TCM) practitioners. This study aims to (a) establish the domains of professionalism in TCM practitioners in Singapore, and to (b) compare the domains of professionalism of practitioners trained in TCM and practitioners trained in conventional medicine. Methods Data for this qualitative study was collected through in-depth interviews (IDIs) with TCM practitioners. IDIs were audio-recorded and transcribed verbatim. Thematic analysis was conducted by two independent coders using the Professionalism Mini-Evaluation Exercise (P-MEX) as a framework. The domains of professionalism in TCM and conventional medicine were then compared, using data from a similar study on professionalism in practitioners trained in conventional medicine. Results A total of 27 TCM practitioners (40.7% male) participated in this study. The four domains of professionalism in the P-MEX, namely doctor-patient relationship skills, reflective skills, time management and inter-professional relationship skills, and two new sub-domains, “communicated effectively with patient” and “demonstrated understanding and integrated with conventional medicine”, were relevant to TCM practitioners. This is largely similar to that of practitioners trained in conventional medicine, with a few differences, including “ensured continuity of care” and “used health resources appropriately”. Conclusion The domains of professionalism in TCM practitioners were established and they are similar to that of practitioners trained in conventional medicine. This study is the first to define medical professionalism in TCM practitioners. Findings will provide guidance on the education of professionalism in TCM practitioners.

Abstract Background Since the beginning of the COVID-19 outbreak in December 2019, a substantial body of COVID-19 medical literature has been generated. As of June 2020, gaps and longitudinal trends in the COVID-19 medical literature remain unidentified, despite potential benefits for research prioritisation and policy setting in both the COVID-19 pandemic and future large-scale public health crises. Methods In this paper, we searched PubMed and Embase for medical literature on COVID-19 between 1 January and 24 March 2020. We characterised the growth of the early COVID-19 medical literature using evidence maps and bibliometric analyses to elicit cross-sectional and longitudinal trends and systematically identify gaps. Results The early COVID-19 medical literature originated primarily from Asia and focused mainly on clinical features and diagnosis of the disease. Many areas of potential research remain underexplored, such as mental health, the use of novel technologies and artificial intelligence, pathophysiology of COVID-19 within different body systems, and indirect effects of COVID-19 on the care of non-COVID-19 patients. Few articles involved research collaboration at the international level (24.7%). The median submission-to-publication duration was 8 days (interquartile range: 4–16). Conclusions Although in its early phase, COVID-19 research has generated a large volume of publications. However, there are still knowledge gaps yet to be filled and areas for improvement for the global research community. Our analysis of early COVID-19 research may be valuable in informing research prioritisation and policy planning both in the current COVID-19 pandemic and similar global health crises.

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

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

Introduction: The COVID-19 pandemic affects the process of care transition for patients with underlying chronic conditions. This study aims to explore the impact of the pandemic measures on discharge planning and continuum of care for vulnerable older patients from multi-stakeholder perspectives. Methods: We conducted focus group discussions and individual interviews with healthcare workers, community partners, government officials and family caregivers in Singapore. All interviews were audio-recorded, transcribed verbatim and thematically analysed. Results: A total of 53 individuals participated in the study. Discharge planning and care continuity in the community were affected primarily by the limited step-down care options and remote assessment of discharge needs. Participants felt a need to revisit the decision of ‘essential’ community services through engagement of all stakeholders to enhance care community. To improve better care transition, participants suggested the need for clearer communication of guidelines, improved intersectoral collaboration, shared responsibility of patient care through community engagement and employment of novel models of care. Conclusion: The pandemic measures generated challenges of safe discharge of patients and care continuity in the community. Findings shed light on the need to proactively assess care pathways and catalyse novel models to improve care transition beyond the pandemic.

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

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

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

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

Abstract Background Various population segmentation tools have been developed to inform the design of interventions that improve population health. However, there has been little consensus on the core indicators and purposes of population segmentation. The existing frameworks were further limited by their applicability in different practice settings involving stakeholders at all levels. The aim of this study was to generate a comprehensive set of indicators and purposes of population segmentation based on the experience and perspectives of key stakeholders involved in population health. Methods We conducted in-depth semi-structured interviews using purposive sampling with key stakeholders (e.g. government officials, healthcare professionals, social service providers, researchers) involved in population health at three distinct levels (micro, meso, macro) in Singapore. The interviews were audio-recorded and transcribed verbatim. Thematic content analysis was undertaken using NVivo 12. Results A total of 25 interviews were conducted. Eight core indicators (demographic characteristics, economic characteristics, behavioural characteristics, disease state, functional status, organisation of care, psychosocial factors and service needs of patients) and 21 sub-indicators were identified. Age and financial status were commonly stated as important indicators that could potentially be used for population segmentation across three levels of participants. Six intended purposes for population segmentation included improving health outcomes, planning for resource allocation, optimising healthcare utilisation, enhancing psychosocial and behavioural outcomes, strengthening preventive efforts and driving policy changes. There was consensus that planning for resource allocation and improving health outcomes were considered two of the most important purposes for population segmentation. Conclusions Our findings shed light on the need for a more person-centric population segmentation framework that incorporates upstream and holistic indicators to be able to measure population health outcomes and to plan for appropriate resource allocation. Core elements of the framework may apply to other healthcare settings and systems responsible for improving population health. Trial registration The study was approved by the SingHealth Institutional Review Board (CIRB Reference number: 2017/2597).

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

The growing interest regarding the role of the living environment in healthy ageing highlights the need to investigate place-related urban features contributing to health and socio-emotional wellbeing. This study aimed to use a participatory methodology to explore the determinants of an age-friendly neighbourhood built environment that promotes or limits healthy ageing in place among seniors residing in a low-income urban community in Singapore. The study utilised photovoice and semi-structured interviews with 25 community-dwelling seniors aged 65 and above, residing in government-built public housing. Analysis of the photographs and interviews was guided by the World Health Organisation (WHO) Global Age-friendly Cities Framework to assess the age-friendliness of places. Our findings generally corresponded to the WHO framework, and our analysis identified a total of 8 facilitators and 4 barriers affecting the neighbourhood age-friendliness. A safe and pleasant outdoor environment that is connected to essential services, amenities and transport to key destinations encourages higher activity in seniors and enables them to fulfil their daily living needs. However, the lack of wheelchair accessible features in some areas deterred the mobility of seniors in the neighbourhood. Interestingly, there was also a high level of civic participation in the form of senior volunteerism observed among the participants as they took ownership to continuously improve the liveability of their neighbourhood. Additionally, there is a sufficient range of aged care services in their neighbourhood available to support seniors to age in their homes and community. The determinants that emerged from our findings are important for guiding future national policies and initiatives to improve the living environment that supports healthy ageing in place. [ABSTRACT FROM AUTHOR]

BackgroundThe management of diabetes is complex. There is growing recognition of the use of patient-reported outcome measures (PROMs) as a standardized method of obtaining an outlook on patients’ functional status and well-being. However, no systematic reviews have summarized the studies that investigate the measurement properties of diabetes PROMs. ObjectiveOur aims were to conduct a systematic review of studies investigating the measurement properties of diabetes PROMs by evaluating the methodological quality and overall level of evidence of these PROMs and to categorize them based on the outcome measures assessed. MethodsThis study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the Embase, PubMed, and PsychINFO databases. The PROMs were evaluated with the COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) guidelines. ResultsA total of 363 articles evaluating the measurement properties of PROMs for diabetes in the adult population were identified, of which 238 unique PROMs from 248 studies reported in 209 articles were validated in the type 2 diabetes population. PROMs with at least a moderate level of evidence for ≥5 of 9 measurement properties include the Chinese version of the Personal Diabetes Questionnaire (C-PDQ), Diabetes Self-Management Instrument Short Form (DSMI-20), and Insulin Treatment Appraisal Scale in Hong Kong primary care patients (C-ITAS-HK), of which the C-PDQ has a “sufficient (+)” rating for >4 measurement properties. A total of 43 PROMs meet the COSMIN guidelines for recommendation for use. ConclusionsThis study identified and synthesized evidence for the measurement properties of 238 unique PROMs for patients with type 2 diabetes and categorized the PROMs according to their outcome measures. These findings may assist clinicians and researchers in selecting appropriate high-quality PROMs for clinical practice and research. Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42020180978; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020180978.

IntroductionCardiovascular diseases (CVDs) are the leading cause of mortality worldwide. Hyperlipidemia is one of the important modifiable risk factors for CVDs. Raising public awareness of CVD risks is an important step in reducing CVD burdens. In this study, we aimed to assess public awareness and knowledge of cholesterol and its management in a multiethnic Asian population.MethodsWe recruited 1000 participants from three major ethnic groups for this nationwide population-based survey. A structured questionnaire was used to collect socio-demographics, knowledge of cholesterol and cholesterol-lowering medications. Univariate and multivariate analyses were conducted to identify factors associated with good knowledge on cholesterol and its management.ResultsOf the participants, 65% thought that high cholesterol produces symptoms and that lifestyle modification would be as effective as medication at lowering cholesterol. Nearly 70% believed that long term statin could lead to kidney or liver damage, and 56% thought that statin was associated with higher risk of cancer. A third saw herbal medicine or supplements as healthier and safer. About 45% believed that statin therapy should not be taken long term and that one could stop taking cholesterol medication when cholesterol is under control. Malays were more likely to have poor knowledge (adjusted OR 0.68; 95% CI 0.47-0.98; P = 0.039) compared to Chinese. Participants with intermediate education were more likely to have good knowledge of cholesterol and its management (adjusted OR 1.67; 95% CI 1.11-2.51; P = 0.013) compared to those with primary education.ConclusionPublic knowledge and awareness of high cholesterol and its management remains poor in Asian multi-ethnic population. Understanding gaps in public knowledge can inform the implementation of health promotion programs to effectively raise awareness of cholesterol and its management.

Objective To outline the facilitators and barriers to patients’ self-management of predialysis chronic kidney disease (CKD).Design Qualitative.Setting Three polyclinics in a public primary care institution in Singapore.Participants 20 patients entered and completed the study. Inclusion criteria were: (1) English speaking, (2) aged 40 years and above, (3) identified by clinical coding as ‘DM (diabetes mellitus) nephropathy-overt’ and ‘DM nephropathy-incipient’, by their physicians in the polyclinic, with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 (based on electronic health records) and (4) aware of their CKD illness. Exclusion criteria were: (1) receiving dialysis or had received a kidney transplant, (2) suffered from any visual, auditory or cognitive impairment which could hinder their ability to participate in the study or (3) pregnant.Results We found that the major barriers to CKD management were a lack of knowledge and awareness of CKD, a passive attitude toward self-management and insufficient patient-physician communication. Major facilitators included patient trust and satisfaction with the physician and family support. Many patients reported that there was an overload of information and too little guidance on how to manage their condition, especially regarding dietary recommendations.Conclusion We identified several barriers and facilitators to the management of predialysis CKD among patients. A multi-pronged approach for raising CKD awareness is required: improving patient-physician communication, implementing CKD workshops and home-visits and disseminating accurate online information about CKD. Strategies should also focus on increasing patient engagement and optimising family support by involving family members in patients’ care. Furthermore, clear dietary recommendations and patient-specific advice are needed to empower patients to manage their own condition.

The objective of this study was to establish a test method for assessing radon exhalation rates from building materials considering radon related environmental policy and research in Korea. This method was established in consideration of cost-effectiveness based on the International Standards Organization (ISO) method and the closed chamber method, which is an evaluation method for the emission of hazardous chemical substances from building materials in Korea. The assessment of radon exhalation rates from five types each of granite and marble used in the construction industry in Korea gave mean radon exhalation rates of 0.497 ± 0.467 Bq/m2∙h from granite and 0.193 ± 0.113 Bq/m2∙h from marble, indicating higher radon exhalation rates from granite. These results are consistent with those of a previous study, indicating that granites are more likely to show higher radon exhalation rates than marbles.