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Abstract Background Experiential learning through service provides opportunities to nurture and practice empathy. Of growing concern, studies showed significantly decreased empathy scores as students progress through medical school. Additionally, peer-to-peer learning provides an effective way for students to learn. Constructing Care Collaboration (CCC) is a student initiated, structured-service-learning-program that promotes the development of empathy and peer-to-peer teaching. CCC is conducted in cycles of 6 sessions. This is a mixed methods study that explores the effectiveness of CCC as a service learning platform in developing student participants’ empathy, social and cultural competencies, communication skills and peer-to-peer teaching skills, ultimately aiming to promote a culture of serving the underprivileged. Methods The study comprised of a self-administered quantitative questionnaire and qualitative interviews. Both evaluated if CCC participation developed volunteers’ social-awareness, cultural competency, communication, confidence and motivation to teach their peers. Results Quantitative data were collated from 38 completed student volunteers’ questionnaires. Volunteers generally agreed CCC improved social-awareness and cultural competency. It increased confidence of participants in approaching migrant-workers, communicating with people from different social backgrounds, and promoted a culture of peer-to-peer teaching. Thematic analysis of 17 interviews was conducted. Themes identified include: increased empathy towards migrant-workers, improved communication skills, and identifying benefits and challenges in peer-to-peer teaching. Conclusion From the quantitative and qualitative information gathered, CCC has been shown to be effective in nurturing participants’ self-reported empathy, cultural competence, communication skills and improved attitude towards peer-to-peer teaching. Given its effectiveness, CCC can be adopted as a model for structured service-learning.

Objective: Telemonitoring (TM) remotely monitors individuals' health. Awareness of personal clinical data has resulted in improved glycaemic control in adults with type-2 diabetes mellitus (T2DM). However, its effects on their health-seeking behaviour remain unclear. This study aims to explore and understand the effects of a multicomponent TM system on self-efficacy in adults with T2DM., Design: A qualitative study using semistructured interviews., Setting: A public primary care clinic which is located at an estate in north-eastern Singapore with a population of about 300 000 multiethnic Asian residents., Participants: 21 participants who completed 6 months of TM intervention which included immediate feedback on glucose and blood pressure readings, educational videos on exercise and nutrition, and personalised support with TM nurse when clinical parameters met high glucose or blood pressure thresholds., Results: The health belief model was used to explain the participants' behaviour change, including (1) immediate feedback from TM clinical parameters (blood pressure and glucose), raised their awareness of their health status and disease control to motivate behaviour change; (2) notification of higher glucose through TM allowed patients to reflect on their recent food consumption and nudged them to select healthier food options; (3) App teleeducation improved health literacy and supported lifestyle changes; (4) cues for action through personalised engagement with TM nurse and via automated reminders and (5) the TM system enhanced self-efficacy by modifying their multifaceted self-care behaviours., Conclusion: TM heightened understanding among adults with T2DM of their potential for health complications and increased awareness of the benefits of proper diabetes management. It also helped lower the barriers to self-management and further enhanced their self-efficacy in self-care. The system and care team provided users with cues for health which was perceived to lead to adapting their lifestyle in order to achieve better health outcomes., Clinical Trials Registration Number: NCT04306770., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Population ageing and increased care needs lead to adults making consequential medical decisions for others, potentially impacting treatment and end of life. We aim to describe the prevalence of medical decision-making by proxy among the national population and associated demographic and care factors., Methods: We designed a cross-sectional online survey with a nationally representative adult cohort with an 80% participation rate. 311 Singapore residents completed the survey., Results: 73% of respondents reported having ever assisted others with medical decisions, while 58% have ever assisted with activities of daily living (ADLs), and 88% with instrumental ADLs (IADLs). Having a digital caregiver account, having a lasting power of attorney as a donee and assisting with ADLs and IADLs are significantly associated with proxy medical decision-making. Gender, ethnicity, income and age did not appear to have a significant impact., Conclusions: A majority of Singapore adults assist others with caregiving tasks and medical decision-making. These helping behaviours are often performed informally, which may increase decisional burden for caregivers and potential abuse of power., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Dental caries is one of the most prevalent chronic diseases of childhood. Early childhood caries (ECC), defined as onset of dental caries before 6 years of age, is preventable and reversible in the early stages with proper interventions. The purpose of the study is to assess the clinical effectiveness and cost-effectiveness of technology-enabled anticipatory guidance and peer support in empowering parents to establish good diets, feeding and oral hygiene practices to prevent ECC., Methods and Analysis: Mother-child dyads will be recruited from pre-natal clinics and post-natal wards of a tertiary care hospital in Singapore. The control group will receive conventional oral health education materials while the intervention group will join four rounds of online parent empowerment sessions focusing on anticipatory guidance and peer-support. Mothers will complete a questionnaire and food frequency checklist when their child turns 12, 24 and 36 months; each child will undergo an oral examination at the age of 24 and 36 months. Chi-square tests and two-sample t-tests, or their non-parametric equivalents will be used to compare proportions of children with caries by decayed, missing and filled teeth (dmft) and decayed, missing and filled surfaces (dmfs) scores between groups. Effect sizes and their confidence intervals will be calculated along with number needed to treat. Multivariable analyses will be carried out to assess the effect of the intervention on primary outcomes (caries incidence at 24 and 36 months) and secondary outcomes (including parental efficacy, child's oral health behaviours and oral hygiene status, quality of life). Cost-effectiveness analyses will also be carried out., Ethics and Dissemination: The study was approved by Domain Specific Review Board (DSRB 2024/00244). Results will be published in international peer-reviewed journals., Trial Registration Number: The trial was retrospectively registered on ClinicialTrials.gov (NCT06558955) around the time of the commencement of patient recruitment, but prior to the commencement of any intervention., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Continuous glucose monitoring (CGM) is increasingly popular for managing Type 2 Diabetes Mellitus (T2DM). Many systematic reviews have reported on CGM's effectiveness, but with heterogeneous methodologies and objectives. We aim to conduct an umbrella review (UR) to consolidate a most contemporaneous and comprehensive evidence base comparing CGM with self-monitoring of blood glucose or usual care (SMBG/UC)., Methods: Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, Epistemonikos, SCOPUS, Web of Science and PubMed were searched from their dates of inception to 28th June 2024. Systematic reviews (SR) with or without meta-analyses comparing the use of CGM with SMBG or usual care (UC) for T2DM management in patients treated with or without insulin were included. Narrative synthesis of HbA1c, glycemic variability metrics and other physical measurements were done. Corrected covered area (CCA) was calculated to assess suitability of meta-meta-analysis., Results: 31 SRs were included in this UR. There was high overlap within meta-analyses of HbA1c, time-in-range (TIR), time-above-range (TAR) and time-below-range (TBR). A primary study-level meta-analysis demonstrated that compared to SMBG/UC, CGM was associated with significantly greater HbA1c decrease (n = 11,494, MD = -0.40% [95% CI: -0.54 to -0.25]), TIR increase (n = 1452, MD = 6.00% [95%CI: 3.13 to 8.88]) and TAR decrease (n = 1113, MD = -4.33% [95%CI: -8.37 to -0.28]).These findings were invariant with CGM modality, study funding, pre-existing insulin treatment and risk-of-bias. Meta-analysis of patient reported outcome measures (PROMs) demonstrated insignificant differences in PROMs with CGM use compared to SMBG/UC., Conclusion: CGM could lead to better clinical outcomes than SMBG/UC and was of moderate evidence certainty (GRADE), while its effect on PROMs remains inconclusive. We recommend the introduction of CGM into standard care alongside SMBG for T2DM and further research exploring patient experience and acceptability of CGM use., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Meta-analysis shows that home tele-monitoring (HTM) improves glycaemic control in patients with type-2 diabetes mellitus (T2DM) up to 12 months, but their health outcomes after HTM cessation remains unclear. This study aimed to determine the health outcomes of these patients 18 months after completing 6 months of HTM, compared to standard care., Methods: Patients with T2DM were enrolled in an open-labelled randomised controlled trial, aged 26 to 65 years, and suboptimal glycaemic control (HbA1c = 7.5%-10%). Patients in the intervention group ( n  = 165) undertook HTM using the OPTIMUM (Optimising care of Patients via Telemedicine In Monitoring and aUgmenting their control of diabetes Mellitus) HTM system for 6 months followed by usual care for another 18 months, while control group ( n  = 165) had usual care for 24 months. The OPTIMUM HTM system includes in-app video-based tele-education, tele-monitoring of the blood pressure (BP), capillary glucose and weight via Bluetooth devices and mobile applications, followed by algorithm-based telecare by the investigators. They were assessed using the Self-Care Inventory Scale (SCIR) and medication adherence (Medication Adherence Report Scale 5) at baseline, 6-month and 24-month time-points., Results: The data from 146 (intervention) and 152 (control) patients, with comparable baseline demographic profiles were eventually analysed. The decrease in HbA1c over 24 months was comparable between intervention and control group. Those in the intervention group were more likely to maintain their glycemic control (HbA1c ≤ 8%) (adjusted odds ratio (AOR) = 1.9, 95%confidence interval (CI) = 1.1-3.2; p  = 0.028), had higher SCIR score ( p  = 0.004), and less likely to "never forget" ( p  = 0.022), or "stop medications" ( p  = 0.048), at 24-month time-point as compared to subjects in the control group., Conclusion: The glycaemic control of patients with T2DM continued to be maintained for another 18 months after 6 months of HTM, which were attributed to sustained self-care behaviour and medication adherence., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: As numerous studies highlighted the importance of maintaining proper foot care (FC) behaviours among individuals with diabetes to prevent complications, we sought to assess FC behaviours among patients with diabetes and to identify the factors associated with the practice of diabetic FC., Methods: We used a cross-sectional design and collected data through self-reported questionnaires administered to a sample of 586 patients from five medical centres. We conducted descriptive and inferential analyses to explore the relationships between potential risk and protective factors and FC behaviours., Results: Overall, 429 individuals (73.2%) had good FC behaviours, while 157 (26.8%) displayed poor FC behaviours. Furthermore, we identified eight influencing factors on FC behaviours, including smoking status, the availability of a caregiver, the presence of diabetic foot ulcers, amputation history, FC knowledge, subjective norms in diabetes self-care behaviour, diabetes-related stress, and quality of life index values. The logistic regression analysis showed that current smokers were 60% less likely to practice good FC compared to non-smokers (odds ratio (OR) = 0.40; 95%; confidence interval (CI) =  0.22-0.73). Having a caregiver decreased the likelihood of practicing good FC by 50% (OR = 0.52; 95% CI = 0.33-0.84), while having diabetic foot ulcers doubled it (OR = 2.65; 95% CI = 1.26-5.54). Additionally, more FC knowledge increased the likelihood by 20% (OR = 1.21; 95% CI = 1.10-1.33), and higher diabetes-related stress increased it by 1.03 times (OR = 1.03; 95% CI = 1.02-1.05)., Conclusions: Our findings underscore the interplay of various factors influencing FC behaviours among individuals with diabetes and call for targeted interventions and tailored strategies to improve FC practices in this vulnerable population., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

Background: Telemonitoring programs have been found to be effective in improving diabetic control by promoting patients' self-management of diabetes through medication adherence, dietary modifications, and exercise. Nonetheless, few studies have assessed the cost-effectiveness of telemonitoring for the self-management of diabetes based on real-world data. Methods: A randomized controlled trial entitled Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus was conducted among adults with Type 2 Diabetes Mellitus in Singapore. Individuals in the intervention group ( n = 159) underwent a telemonitoring program comprising of remote patient monitoring, education, individualized health coaching, and teleconsultations, whereas individuals in the control group ( n = 160) received regular care. Economic evaluation was conducted from health care system and societal perspectives in 2020 in Singapore dollars, using health outcomes and costs documented at baseline and at 6 month follow-up. One-way sensitivity analyses and bootstrapping to generate scatter plot on cost-effectiveness planes were done. Results: The adjusted reduction in HbA1c scores was greater in the intervention group by -0.41 (95% confidence interval [CI], -0.65 to -0.17), while the change in utility scores was higher in the intervention group by 0.011 (95% CI, -0.016 to 0.0378). From a health care perspective, the incremental cost-effectiveness ratio (ICER) of the telemonitoring program per unit improvement in HbA1c, per additional case of well-controlled diabetes, and per unit improvement in quality adjusted life years was SGD 580.44, SGD 9100.15, and SGD 21,476.36, respectively. From a societal perspective, the ICERs were SGD 817.20, SGD 12,812.02, and SGD 30,236.36, respectively. Conclusions: The Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus telemonitoring program was effective and potentially cost-effective for the management and control of diabetes among patients in primary care.

Background: Rare diseases pose immense challenges for healthcare systems due to their low prevalence, associated disabilities, and attendant treatment costs. Advancements in gene therapy, such as treatments for Spinal Muscular Atrophy (SMA), have introduced novel therapeutic options, but the high costs, exemplified by Zolgensma® at US$2.1 million, present significant financial barriers. This scoping review aimed to compare the funding approaches for rare disease treatments across high-performing health systems in Australia, Singapore, South Korea, the United Kingdom (UK), and the United States (US), aiming to identify best practices and areas for future research., Methods: In accordance with the PRISMA-ScR guidelines and the methodological framework by Arksey and O'Malley and ensuing recommendations, a comprehensive search of electronic databases (Medline, EMBASE, and Cochrane) and grey literature from health department websites and leading national organizations dedicated to rare diseases in these countries was conducted. Countries selected for comparison were high-income countries with advanced economies and high-performing health systems: Australia, Singapore, South Korea, the UK, and the US. The inclusion criteria focused on studies detailing drug approval processes, reimbursement decisions and funding mechanisms, and published from 2010 to 2024., Results: Based on a thorough review of 18 published papers and grey literature, various strategies are employed by countries to balance budgetary constraints and access to rare disease treatments. Australia utilizes the Life Saving Drugs Program and risk-sharing agreements. Singapore depends on the Rare Disease Fund, which matches public donations. South Korea's National Health Insurance Service covers specific orphan drugs through risk-sharing agreements. The UK relies on the National Institute for Health and Care Excellence (NICE) to evaluate treatments for cost-effectiveness, supported by the Innovative Medicines Fund. In the US, a combination of federal and state programs, private insurance and non-profit support is used., Conclusion: Outcome-based risk-sharing agreements present a practical solution for managing the financial strain of costly treatments. These agreements tie payment to actual treatment efficacy, thereby distributing financial risk and promoting ongoing data collection. Countries should consider adopting and expanding these agreements to balance immediate expenses with long-term benefits, ultimately ensuring equitable access to crucial treatments for patients afflicted by rare diseases., (© 2024. The Author(s).)

Background: While health care and societal costs are routinely modelled for most diseases, there is a paucity of comprehensive data and cost-of-illness (COI) studies for inherited retinal diseases (IRDs). This lack of data can lead to underfunding or misallocation of resources. A comprehensive understanding of the COI of IRDs would assist governmental and healthcare leaders in determining optimal resource allocation, prioritizing funding for research, treatment, and support services for these patients., Methods: Following PRISMA guidelines, a literature search was conducted using Medline, EMBASE and Cochrane databases, from database inception up to 30 Jun 2023, to identify COI studies related to IRD. Original studies in English, primarily including patients with IRDs, and whose main study objective was the estimation of the costs of IRDs and had sufficiently detailed methodology to assess study quality were eligible for inclusion. To enable comparison across countries and studies, all annual costs were standardized to US dollars, adjusted for inflation to reflect their current value and recalculated on a "per patient" basis wherever possible. The review protocol was registered in PROSPERO (registration number CRD42023452986)., Results: A total of nine studies were included in the final stage of systematic review and they consistently demonstrated a significant disease burden associated with IRDs. In Singapore, the mean total cost per patient was roughly US$6926/year. In Japan, the mean total cost per patient was US$20,833/year. In the UK, the mean total cost per patient with IRD ranged from US$21,658 to US$36,549/year. In contrast, in the US, the mean total per-patient costs for IRDs ranged from about US$33,017 to US$186,051 per year. In Canada, these mean total per-patient costs varied between US$16,470 and US$275,045/year. Non-health costs constituted the overwhelming majority of costs as compared to healthcare costs; 87-98% of the total costs were due to non-health costs, which could be attributed to diminished quality of life, poverty, and increased informal caregiving needs for affected individuals., Conclusion: IRDs impose a disproportionate societal burden outside health systems. It is vital for continued funding into IRD research, and governments should incorporate societal costs in the evaluation of cost-effectiveness for forthcoming IRD interventions, including genomic testing and targeted therapies., (© 2024. The Author(s).)

Introduction: This scoping review examined the number, types and characteristics of journal publications on ageing in Singapore from 2008 to 2018 to determine how ageing research in medical and social domains in Singapore has transformed over time., Methods: Using relevant search terms, articles were extracted from multiple databases and then screened and reviewed for eligibility and inclusion by independent reviewers. Data such as article title, authors, year of publication, name of journal, type of journal, study design and the kind of data used were charted from the included articles for evidence synthesis., Results: Since 2008, there has been a steady increase in the number of publications on ageing in medical and social domains in Singapore. In the medical domain, publications on Ophthalmology (22%) made up the largest proportion of the existing medical literature on ageing in Singapore, followed by Physical Functioning (17%), which involved physiological measurements of physical well-being, and Geriatrics (16%). Non-medical publications comprised 38% of all the included publications, with publications on the social aspects of ageing (43%) forming the largest group in this cluster, followed by publications on Prevention (19%) and Healthcare services (18%). The study design was mostly observational (82%), with only 3% of interventional studies., Conclusion: While ageing research had expanded in Singapore in the last decade, it was predominantly discipline specific and observational in design. As ageing issues are complex, with biology intersecting with psychology and sociology, we call for greater interdisciplinary collaboration, the conduct of more interventional studies, as well as more research in understudied and emerging areas., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

This study aimed to elicit the preferences and willingness-to-pay for blood pressure (BP) telemonitoring programs. This study also investigated the different factors or participant characteristics that could influence preferences and choice behaviors. Participants with hypertension were identified from an online survey panel demographically representative of Singapore's general population. Participants completed a discrete choice experiment (DCE) with 12 choice sets, selecting their preferred BP monitoring program differing on five attributes: mode of consultation, BP machine type (with Bluetooth or not), BP machine price, monthly fee, and program duration. The base reference population (male, married, higher income, more formal education years, full-time worker, aged 55 to <65 years, and digital skills score of 36) preferred teleconsultation over in-person consultation, Bluetooth feature, lower machine price, lower monthly fee, and shorter program duration. A subgroup of participants can be considered teleconsultation-resistant, and three demographic factors were associated with lower preference for teleconsultation: female, fewer formal education years, and lower income. Considering the reference population and Bluetooth attribute, participants were willing to pay 66 SGD (~49 USD) additional for the machine to obtain the Bluetooth feature. Considering the reference population and teleconsultation attribute, participants were willing to pay 6.80 SGD (~5.10 USD) extra monthly fee for a program using teleconsultation. Here we report that amongst participants with hypertension, there is strong preference for the use of teleconsultation and a BP machine with Bluetooth feature in a BP monitoring program. However, a subgroup of participants are teleconsultation-resistant and would prefer in-person consultation., (© 2023. Springer Nature Limited.)

Background: Telemedicine is becoming integral in primary care hypertension management, and is associated with improved blood pressure control, self-management and cost-effectiveness. This study explored the experiences of patients and healthcare professionals and their perceived barriers and facilitators in implementing and using a technology-enabled blood pressure monitoring intervention with teleconsultation in the Singapore primary care setting., Methods: This was a qualitative study embedded within the Primary Technology-Enhanced Care Hypertension pilot trial. Patients were selected purposively and invited to participate by telephone; healthcare professionals involved in the trial were invited to participate by email. Individual semi-structured interviews were conducted in English or Mandarin with thirteen patients and eight healthcare professionals. Each interview was audio-recorded and transcribed verbatim. Data were analyzed inductively to identify emergent themes which were then grouped into the dimensions of the socio-technical systems model to study the interactions between the technical, individual and organizational factors involved in the process., Results: Several emergent themes were identified. The factors involved in the implementation and use of the intervention are complex and interdependent. Patients and healthcare professionals liked the convenience resulting from the intervention and saw an improvement in the patient-provider relationship. Patients appreciated that the intervention helped form a habit of regular blood pressure monitoring, improved their self-management, and provided reassurance that they were being monitored by the care team. Healthcare professionals found that the intervention helped to manage workload by freeing up time for other urgent matters. Nevertheless, participants highlighted challenges with usability of the equipment and management portal, data access, and some expressed technology anxiety. Participants suggested patient segmentation for the intervention to be more targeted, wished for a more user-friendly equipment and proposed allocating more resources to the intervention., Conclusions: The implementation and use of telemedicine for hypertension management can engender various benefits and challenges to patients, healthcare professionals and the healthcare system. Stakeholder feedback gathered on the sociotechnical aspects of the technology should be taken into consideration to guide the design, implementation and evaluation of future telemedicine interventions in primary care., Trial Registration: This study was registered on ClinicalTrials.gov on October 9, 2018. ID: NCT03698890., (© 2023. The Author(s).)

Background: Chronic obstructive pulmonary disease (COPD) is a growing epidemic, with a heavy associated economic burden. Education, physical activity, and pulmonary rehabilitation programs are important aspects of the management of COPD. These interventions are commonly delivered remotely as part of telemedicine interventions. Several systematic reviews and meta-analyses have been conducted to assess the effectiveness of these interventions. However, these reviews often have conflicting conclusions., Objective: We aim to conduct an umbrella review to critically appraise and summarize the available evidence on telemedicine interventions for the management of COPD., Methods: In this umbrella review, the MEDLINE, Embase, PsycINFO, and Cochrane databases were searched from inception to May 2022 for systematic reviews and meta-analyses relating to telemedicine interventions for the management of COPD. We compared odds ratios, measures of quality, and heterogeneity across different outcomes., Results: We identified 7 systematic reviews that met the inclusion criteria. Telemedicine interventions used in these reviews were teletreatment, telemonitoring, and telesupport. Telesupport interventions significantly reduced the number of inpatient days and quality of life. Telemonitoring interventions were associated with significant reductions in respiratory exacerbations and hospitalization rates. Teletreatment showed significant effectiveness in reducing respiratory exacerbations, hospitalization rate, compliance (acceptance and dropout rate), and physical activity. Among studies that used integrated telemedicine interventions, there was a significant improvement in physical activity., Conclusions: Telemedicine interventions showed noninferiority or superiority over the standard of care for the management of COPD. Telemedicine interventions should be considered as a supplement to usual methods of care for the outpatient management of COPD, with the aim of reducing the burden on health care systems., (©Jin Hean Koh, Lydia Ching Yee Chong, Gerald Choon Huat Koh, Shilpa Tyagi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.02.2023.)

Background: Trust is of fundamental importance to the adoption of technologies in health care. The increasing use of telemedicine worldwide makes it important to consider user views and experiences. In particular, we ask how the mediation of a technological platform alters the trust relationship between patient and health care provider., Objective: To date, few qualitative studies have focused on trust in the use of remote health care technologies. This study examined the perspectives of patients and clinical staff who participated in a remote blood pressure monitoring program, focusing on their experiences of trust and uncertainty in the use of technology and how this telehealth intervention may have affected the patient-provider relationship., Methods: A secondary qualitative analysis using inductive thematic analysis was conducted on interview data from 13 patients and 8 staff members who participated in a remote blood pressure monitoring program to elicit themes related to trust., Results: In total, 4 themes were elicited that showed increased trust (patients felt reassured, patients trusted the telehealth program, staff felt that the data were trustworthy, and a better patient-provider partnership based on the mutually trusted data), and 4 themes were elicited that reflected decreased trust (patients' distrust of technology, clinicians' concerns about the limitations of technologically mediated interactions, experiences of uncertainty, and institutional risk)., Conclusions: Managing trust relationships plays an important role in the successful implementation of telemedicine. Ensuring that trust building is incorporated in the design of telehealth interventions can contribute to improved effectiveness and quality of care., (©Evelyn Chew, Sok Huang Teo, Wern Ee Tang, David Wei Liang Ng, Gerald Choon Huat Koh, Valerie Hui Ying Teo. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 05.01.2023.)

Background: Integrating healthcare services across and between the different health system levels can be achieved in a few ways; however, examining the social side of integration is essential and challenging. This paper explores the concept of integration perceived by general practitioners (GPs) and primary care network (PCN) representatives from the regional health systems (RHS) in a GP-RHS PCN and their perceived partnership success., Methods: In this study, we explored three GP-RHS PCNs in Singapore. We used a qualitative research design and, overall, performed 17 semi-structured in-depth interviews with GPs (n = 11) and PCN representatives (n = 6) from the RHS. All interviews were audiotaped and transcribed verbatim. We conducted thematic analysis to inductively identify themes from the data. Singer's conceptual model of integration types was used as guiding principles to derive relevant and salient themes for integration., Results: GPs and the RHS perceived the concept of integration through a series of interrelated strategies. Within the normative dimension, a sense of urgency motivated GPs to integrate improvements into their general practice. Participants perceived teamwork and relational climate as appropriate enablers for achieving interpersonal integration in a primary care partnership. While developing a trusted relationship was a perceived success of this partnership across the network, developing camaraderie and gaining knowledge in chronic disease management through the components of functional integration was a perceived success at an individual general practice level. The data also revealed some operational challenges within the structural dimension and some inabilities of the PCN to achieve complete process integration., Conclusions: Our study points to multi-faceted integration, comprising various forms that need to be manifested at all levels of care to achieve coordinated, seamless, and comprehensive care for patients suffering from chronic conditions. The present iteration of the PCN has been shown to offer integration at a level that warrants praise but still requires structural and process integration improvement., (© 2022. The Author(s).)

Background: The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health. However, their broad definitions have led to variations in their assessment, in the innovations implemented to improve these functions and ultimately in their performance., Objectives: To update and operationalise the 4Cs' definitions by using a literature review and analysis of enhancement strategies, and to identify innovations that may lead to their enhancement., Methods: Narrative, descriptive analysis of the 4Cs definitions, coming from PC international reports and organisations, to identify measurable features for each of these functions. Additionally, we performed an electronic search and analysis of enhancement strategies to improve these four Cs, to explore how the 4Cs inter-relate., Results: Specific operational elements for first contact include modality of contact, and conditions for which PC should be approached; for comprehensiveness, scope of services and spectrum of population needs; for coordination, links between PC and higher levels of care and social/community-based services, and workforce managing transitions and for continuity, type, level and context of continuity. Several innovations like enrolment, digital health technologies and new or enhanced PC provider's roles, simultaneously influenced two or more of the 4Cs., Conclusion: Providing clear, well-defined operational elements for these 4Cs to measure their achievement and improve the way they function, and identifying the complex network of interactions among them, should contribute to the field in a way that supports efforts at practice innovation to optimise the processes and outcomes in PC.

Objectives: To identify and describe caregiver profiles based on their psychosocial health characteristics over a 12-month period and transitions among these profiles, to determine if stroke rehabilitation use at 12 months post-stroke differed by caregiver profile transition patterns, and to investigate if caregiver profiles at 3 months post-stroke moderate the association of stroke rehabilitation use at 3 months and 12 months post-stroke after accounting for covariates., Design: Latent profile transition analysis of caregiver psychosocial health with stroke rehabilitation use at 12 month post-stroke as outcome., Setting and Participants: A total of 149 stroke patient-caregiver dyads from the Singapore Stroke Study., Methods: Cross-sectional latent profile analyses were conducted on caregiver psychosocial health indicators of burden, depression, health status, quality of relationship with patient, and social support. Changes in latent profile classification over 3 time points (baseline, 3 months, and 12 months post-stroke) were analyzed using latent transition analysis. A transition model with stroke rehabilitation use at 12 months post-stroke as the outcome was tested after accounting for covariates., Results: Two distinct caregiver psychosocial health latent profiles were found across time: nondistressed and distressed. Most caregivers were classified as nondistressed and remained nondistressed over time. Distressed caregivers at baseline were 76% likely to become nondistressed at 12 month post-stroke. Regardless of profile transition patterns, nondistressed caregivers at 12 months post-stroke tended to have cared for stroke rehabilitation nonusers at 12 months post-stroke. Patient depression explained profile classification at 3 months and 12 months post-stroke. After accounting for covariates, rehabilitation users at 3 months post-stroke tended to continue using rehabilitation at 12 months post-stroke only when they had nondistressed caregivers at 3 months post-stroke., Conclusions and Implications: Whether caregiver adaptation explains the associations between the latent profile transition patterns and rehabilitation use at 12 months post-stroke should be examined. Early psychosocial health assessment and sustained support should be made available to stroke caregivers to enhance their well-being and subsequent patient rehabilitation participation., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated patient-reported roles of families, physicians, and patients themselves in treatment decision making and whether discordance between perceived and preferred roles is associated with psychological distress and perceived quality of care among patients with cancer., Methods: We analyzed cross-sectional survey data from 599 adults with stage IV solid malignancy in Singapore. Stuart-Maxwell tests were used to compare patients' perceived and preferred roles in decision making. Types of discordance were categorized as follows: involvement at a lesser level than preferred, involvement at a greater level than preferred, and no change in patient involvement. Ordinary least squares regressions examined the associations between types of discordance and patient outcomes, controlling for patient characteristics., Results: Discordance between perceived and preferred roles was observed in 16% of patients. Amongst patients with discordance, 33% reported being involved at a lesser level than they preferred, 47% reported being involved at a greater level than they preferred, and 19% reported discordance where level of patient involvement did not change. Multivariable analyses showed that lesser involvement than preferred and discordance with no change in patient involvement were associated with poorer quality of physician communication (β = - 9.478 [95% confidence interval {CI} - 16.303 to - 2.653] and β = - 9.184 [95% CI - 18.066 to - 0.301]) and poorer care coordination (β = - 11.658 [95% CI - 17.718 to - 5.597] and β = - 8.856 [95% CI - 16.744 to - 0.968]) compared with concordance., Conclusions: Most patients reported participating at their desired level. Despite this finding, our results suggest that involving patients at a lesser level than they prefer can lead to poorer perceived quality of physician communication and care coordination and that encouraging patient participation is a safe approach to minimizing poor outcomes., (© 2021. Springer Nature Switzerland AG.)

The prevalence of gestational diabetes mellitus (GDM) is increasing, and only a few mobile health (mHealth) applications are specifically designed to manage GDM. In this mixed-methods study, a follow-up study of a randomized controlled trial (RCT) analyzed a largely automated mHealth application-based lifestyle coaching program to (a) measure the application's usage behavior and (b) explore users' perceptions of its usefulness in GDM management. Quantitative data were collected from the 170 application users who had participated in the intervention arm of the RCT. Semi-structured interviews (n = 14) captured users' experiences when using the application. Data were collected from June 2019 to January 2020. Quantitative data were analyzed descriptively, and interviews were analyzed thematically. Only 57/170 users (34%) logged at least one meal, and only 35 meals on average were logged for eight weeks because of the incorrectly worded food items and limited food database. On the contrary, an average of 1.85 (SD = 1.60) weight values were logged per week since the weight tracking component was easy to use. Many users (6/14 (43%)) mentioned that the automatic coach messages created an immediate sense of self-awareness in food choices and motivated behavior. The findings suggest that for GDM management, a largely automated mHealth application has the potential to promote self-awareness of healthy lifestyle choices, reducing the need for intensive human resources. Additionally, several gaps in the application's design were identified which need to be addressed in future works.

Objective: The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN., Design: We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved., Setting: Singapore., Results: Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions., Conclusion: PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The primary care network (PCN) was implemented as a healthcare delivery model which organises private general practitioners (GPs) into groups and furnished with a certain level of resources for chronic disease management. A secondary qualitative analysis was conducted with data from an earlier study exploring facilitators and barriers GPs enrolled in PCN's face in chronic disease management. The objective of this study is to map features of PCN to Starfield's "4Cs" framework. The "4Cs" of primary care-comprehensiveness, first contact access, coordination and continuity-offer high-quality design options for chronic disease management. Interview transcripts of GPs (n = 30) from the original study were purposefully selected. Provision of ancillary services, manpower, a chronic disease registry and extended operating hours of GP practices demonstrated PCN's empowering features that fulfil the "4Cs". On the contrary, operational challenges such as the lack of an integrated electronic medical record and disproportionate GP payment structures limit PCNs from maximising the "4Cs". However, the enabling features mentioned above outweighs the shortfalls in all important aspects of delivering optimal chronic disease care. Therefore, even though PCN is in its early stage of development, it has shown to be well poised to steer GPs towards enhanced chronic disease management.

In recent years, there is growing interest internationally to implement patient-centered medical homes (PCMHs), and Singapore is no exception. However, studies understanding the influence of contextual policy factors on the implementation of PCMHs are limited. We conducted 10 semi-structured in-depth interviews with general practitioners working in seven out of the nine PCMHs. Audio recordings were transcribed and analyzed by two study team members in NVivo 12 Software using grounded theory techniques. Power dynamics between the stakeholders and lack of shared decision-making among them in selecting the locale of the PCMH and formulating the practice fee and pharmacy structure were the key factors which negatively affected the implementation of PCMHs on a larger scale. Over time, lack of funding to hire dedicated staff to transfer patients and misalignment of various stakeholders' interest to other right-siting programs also resulted in low number of patients with chronic conditions and revenue. Countries seeking to implement a successful PCMH may benefit from building trust and relationship between stakeholders, engaging in shared decision-making, ongoing cost-efficiency efforts, and formulating a clear delineation of responsibilities between stakeholders. For a healthcare delivery model to succeed in the primary care landscape, policies should be developed keeping mind the realities of primary care practice.

Background: Self-sampling for SARS-CoV-2 would significantly raise testing capacity and reduce healthcare worker (HCW) exposure to infectious droplets personal, and protective equipment (PPE) use., Methods: We conducted a diagnostic accuracy study where subjects with a confirmed diagnosis of COVID-19 (n = 401) and healthy volunteers (n = 100) were asked to self-swab from their oropharynx and mid-turbinate (OPMT), and self-collect saliva. The results of these samples were compared to an OPMT performed by a HCW in the same patient at the same session., Results: In subjects confirmed to have COVID-19, the sensitivities of the HCW-swab, self-swab, saliva, and combined self-swab plus saliva samples were 82.8%, 75.1%, 74.3% and 86.5% respectively. All samples obtained from healthy volunteers were tested negative. Compared to HCW-swab, the sensitivities of a self-swab sample and saliva sample were inferior by 8.7% (95%CI: 2.4% to 15.0%, p = 0.006) and 9.5% (95%CI: 3.1% to 15.8%, p = 0.003) respectively. The combined detection rate of self-swab and saliva had a sensitivity of 2.7% (95%CI: -2.6% to 8.0%, p = 0.321). The sensitivity of both the self-collection methods are higher when the Ct value of the HCW swab is less than 30. The specificity of both the self-swab and saliva testing was 100% (95% CI 96.4% to 100%)., Conclusion: Our study provides evidence that sensitivities of self-collected OPMT swab and saliva samples were inferior to a HCW swab, but they could still be useful testing tools in the appropriate clinical settings., Competing Interests: Author CXT is employed by Temasek International Pte Ltd, and was acting on behalf of Sheares Healthcare Group Pte Ltd for the study. This commercial affiliation does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Family caregivers of patients with advanced cancer have been reported to provide long hours of care and be at risk for poor psychological outcomes. Although research has focused on the nature of caregiving burden, little attention has been paid to identifying protective factors that improve caregiver psychological outcomes., Aim: We examined the relationship between caregivers' time spent caregiving and the following psychological outcomes: anxiety, depression and caregiving esteem. Subsequently, we explored the main and moderating effects of caregiver-perceived self-competency and sense of meaning on caregiver psychological outcomes., Design/participants: Cross-sectional analysis was conducted using the baseline data from an ongoing cohort study. Family caregivers of advanced cancer patients (n=287) were recruited from two tertiary hospitals in Singapore., Results: Time spent caregiving was not significantly associated with caregiver anxiety, depression or caregiving esteem. However, significant main effects of self-competency on anxiety and caregiving esteem; and sense of meaning on anxiety, depression and caregiving esteem were observed. Moderator analyses further indicated that self-competency attenuated the positive relationship between time spent caregiving and anxiety, while sense of meaning attenuated the negative relationship between time spent caregiving and caregiving esteem., Conclusion: Greater perceived self-competency and sense of meaning are related to better caregiver psychological outcomes, and protect caregivers from worsening outcomes as caregiving hours increase. Our findings suggest that screening caregivers for distress is an important part of care, and that supportive interventions for caregivers should aim to enhance their perceived caregiving competencies and the ability to make meaning of their caregiving role., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

BioPsychoSocial health promotion is increasingly emphasized for Successful Ageing. Few programs are known to target BioPsychoSocial health of older adults and their community. The Community for Successful Ageing: Community Development program (ComSA CD) was developed in Singapore for this purpose. This study assessed program effects on BioPsychoSocial health and civic engagement behaviours of participants. ComSA CD offered self-care healthy lifestyle education (Bio-physical), guided autobiography (Psychological) and a civic engagement component which galvanized participants to solve community issues (Social). Recruitment occurred through self-care or guided autobiography; following which participants were funnelled into the civic engagement component. A mixed-methods quasi-experimental evaluation was conducted, using a pre-post one-year survey (N=232) with those exposed and unexposed (rejected) to ComSA CD. Using a generalized linear model, associations between post one-year BioPsychoSocial outcomes and exposure group were quantified using percentage change, adjusting for baseline outcome and group differences. Concurrently, program effects were explored through six focus groups with program implementers and participants using thematic analysis. The program had multiple positive effects. Participants recruited via self-care also taking part in civic engagement reported 31% higher frequency of self-care (95% CI=21% to 68%) post one-year compared to unexposed participants. Qualitative findings illustrated how the civic engagement component stimulated agency of participants to push for neighborhood changes and civic engagement initiatives. The quantitative survey highlighted that this effect was strongest among those funnelled from guided-autobiography (92% higher frequency of civic engagement at post one-year than unexposed; 95%CI=41% to 178%) compared to those funnelled from self-care (53% higher than unexposed, 95%CI=17% to 114%). It was found qualitatively that guided-autobiography enabled more meaningful bonding and communication than the self-care component, explaining quantitative effects on social support only present among guided autobiography participants (36% higher than unexposed; 95%CI=11% to 68%). Findings highlighted the importance of improving group dynamics for collective action., Competing Interests: Declaration of competing interest We declare that no conflict of interest was encountered with our community partners, co-authors or stakeholders in the process of this study., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The Universal Health Coverage goals call for access to affordable palliative care to reduce inequities in "total pain" and suffering. To achieve this, a patient-centred understanding of these inequities is required., Aim: To assess association of total pain and suffering (i.e. physical, psychological, social, and spiritual health outcomes) and perceived health care quality with financial difficulties among stage IV solid malignancy patients., Design: Using baseline data from the COMPASS cohort study, we assessed total pain and suffering including physical (physical and functional well-being, pain, symptom burden), psychological (anxiety, depression, emotional well-being), social (social well-being), and spiritual (spiritual well-being, hope) outcomes and perceived health care quality (physician communication, nursing care, and coordination/responsiveness). Financial difficulties were scored by assessing patient perception of the extent to which their resources were meeting expenses for their treatments, daily living, and other obligations. We used multivariable linear/logistic regression to test association between financial difficulties and each patient-reported outcome., Setting/participants: Six hundred stage IV solid malignancy patients in Singapore., Results: Thirty-five percent reported difficulty in meeting expenses. A higher financial difficulties score was associated with worse physical, psychological, social, spiritual outcomes, and lower perceived quality of health care coordination and responsiveness (i.e. greater total pain and suffering) (all p < 0.05). These associations persisted after adjustment for socio-economic indicators., Conclusion: Results identify advanced cancer patients with financial difficulties to be a vulnerable group with greater reported total pain and suffering. A holistic patient-centred approach to care at end-of-life may help meet goals for Universal Health Coverage.

Background: Community involvement is an important component of health programme development and implementation, including those focused on chronic condition treatment and management. Yet, few studies explore the manifestations of community involvement in chronic care programmes. Our review aims to examine the evidence on how communities are involved in planning and implementing chronic condition programmes in high and upper-middle income countries., Methods: Eligible studies included those that involved the community in the planning, implementation, monitoring and evaluation of health services, policy or health interventions. We searched Medline, Embase, Global Health, Scopus, and LILACs from 2000 to 2016, independently screened articles for inclusion, conducted data extraction, and assessed studies for risk of bias., Results: 27,232 records were identified and after screening, 32 met inclusion criteria. We conducted a narrative synthesis to report on the forms and processes of community involvement used across mental health programmes and contrast this with the paucity of evidence on comparable programmes addressing other chronic conditions. Challenges reported included user factors, organisational factors, and social challenges such as stigma., Conclusion: Our review adds to the evidence supporting community involvement in chronic condition management and the processes that contribute to successful and sustainable involvement. We report on a model, derived from inductive analysis, that considers social and cultural components, organisational factors and stakeholder relationships as underpinning the development of community interventions across the care continuum., (Copyright © 2019. Published by Elsevier B.V.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Aims/hypothesis: The aim of this study was to test the effectiveness of a structured strength and balance training intervention in improving health-related quality of life (HRQoL) and functional status in individuals with diabetic peripheral neuropathy (DPN)., Methods: The study was a single-blind parallel-group randomised controlled trial comparing 2 months of once-weekly home-based strength and balance training against standard medical therapy. Participants were patients with physician-diagnosed type 2 diabetes and neuropathy recruited from five public sector institutions in Singapore between July 2014 and October 2017. Participants were block-randomised to intervention or control arms. Outcomes were assessed at baseline, 2 months and 6 months by a trained assessor blinded to group assignment. Primary outcomes were change in physical component summary (PCS) score of SF-36v2 (a 36-item generic HRQoL instrument that has been validated for use in Singapore) and EQ-5D-5L index score (derived from a five-item generic HRQoL instrument [EQ-5D-5L]) over 6 months. Secondary outcomes were change in functional status (timed up-and-go [TUG], five times sit-to-stand [FTSTS], functional reach, static balance, ankle muscle strength and knee range of motion) and balance confidence over 6 months. Mean differences in scores between groups were compared using mixed models., Results: Of the 143 participants randomised (intervention, n = 70; control, n = 73), 67 participants were included in each arm for the final intention-to-treat analysis. The two groups were similar, except in terms of sex. There were no significant differences between groups on the primary outcomes of PCS score (mean difference [MD] 1.56 [95% CI -1.75, 4.87]; p = 0.355) and EQ-5D-5L index score (MD 0.02 [95% CI -0.01, 0.06]; p = 0.175). There were significant improvements in TUG test performance (MD -1.14 [95% CI -2.18, -0.1] s; p = 0.032), FTSTS test performance (MD -1.31 [95% CI -2.12, -0.51] s; p = 0.001), ankle muscle strength (MD 4.18 [95% CI 0.4, 7.92] N; p = 0.031), knee range of motion (MD 6.82 [95% CI 2.87, 10.78]°; p = 0.001) and balance confidence score (MD 6.17 [95% CI 1.89, 10.44]; p = 0.005). No adverse events due to study participation or study intervention were reported., Conclusions/interpretation: Short-term structured strength and balance training did not influence HRQoL but produced sustained improvements in functional status and balance confidence at 6 months. More intensive interventions may be needed to influence HRQoL in these individuals. However, this intervention may be a useful treatment option for individuals with DPN to reduce the risk of falls and injuries., Trial Registration: ClinicalTrials.gov NCT02115932 FUNDING: This work was supported by the National Medical Research Council, Singapore.

Purpose: To map the Shah-modified Barthel Index (SBI) to the Health Utility Index Mark III (HUI-3) in stroke patients, and to compare the performance of a recently developed method called the Mean Rank Method (MRM) against a popular method, the Ordinary Least Squares (OLS) method., Methods: A cohort of 473 patients who had their first clinical stroke diagnosis and hospital admission and were assessed using the SBI and HUI-3 at 3 months and/or 12 months post-admission. Observations were split to form a training dataset (N = 473) and a validation dataset (N = 245)., Results: In the training dataset, the MRM using SBI total score as the predictor produced a mapped utility distribution that closely resembled the observed utility distribution. It had almost no shrinkage of the standard deviation (P = 0.542), whereas the OLS using SBI total score and SBI item scores under-estimated the standard deviation by 28% and 26%, respectively (each P < 0.001). The MRM mapping gave better fit in terms of smaller mean absolute error and larger intra-class correlation than the two versions of OLS mapping, whereas the OLS gave smaller mean-squared errors than the MRM. Multivariate regression analysis showed that the use of OLS-mapped utilities tended to under-estimate both the mean utility of people who had no comorbidity and the utility-comorbidity association as compared to the observed utility-comorbidity pattern although the differences did not reach statistical significance (each P > 0.05). The MRM-mapped utility showed utility-comorbidity pattern more similar to the observed. Similar findings were obtained from the validation dataset., Conclusions: The MRM performed well. Mapping functions are available to map the SBI to the HUI-3 Utility Index.

Aim: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore., Methods: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome., Results: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization., Conclusion: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

Background: The Community for Successful Ageing (ComSA) program has implemented overlapping BioPsychoSocial (BPS) components as part of a Community Development (CD) grassroots and volunteer-led initiative. Implementation of such multi-component programming is influenced by known program characteristics including novelty, complexity and observability as well as related organizational factors. As such, we explored ComSA CD's implementation from the organizational perspective, seeking to inform program improvements., Methods: We conducted four focus groups with program staff, partners and trainers (total N = 21 participants). Findings were analysed using an interpretative approach and synthesized into a line of argument informing lessons learnt., Results: An implementation framework was identified. It is guided by considering the influence of known program characteristics across major themes, representing three core implementation stages. These and supporting sub-themes are elaborated in turn: 1) Creating commitment toward the program was challenged by novelty and at times a lack of shared understanding of ComSA CD, particularly relating to the S component. Overall, cohesion within organizational contexts and having a strong rapport with the community (ability to engage) were needed to persuade volunteers and participants to commit to the program. 2) Coordination and resource allocation were influenced by the complexity of interconnecting BPS components - requiring aligning communication between partners and adapting the BPS sequence, given the separated management structure of program trainers. Efficiency of resource utilization was constrained by the ability to pool and match resources given the limited manpower and community partners who worked-in-silo due to a KPI-centric culture. 3) Collaborative program monitoring and appraisal increased observability of the program's benefits, but depended on partners' prior commitment. Despite appreciating its holistic BPS programming, dropout rate was used as a way to gauge program success, which has limited interpretability. Occasional uncertainty about the program value contributed to concerns about duplicating existing ageing programs, particularly those related to the B component., Conclusion: Lessons learnt for improving BPS programming include (1) eliciting better participants' buy-in and shared program vision, (2) increasing adaptability of BPS sequence and building a culture of shared values for working together (3) and developing comprehensive monitoring systems for program appraisal.

Background: Despite the emphasis on holistic health promotion in community programs for older people, few studies explicitly consider how BioPsychoSocial (BPS) health elements are interconnected and function to improve Quality of Life (QoL). The Community for Successful Ageing (ComSA) program in Singapore focuses on Community Development (CD) initiatives for older people, accounting for BPS theory in its design and content. Biological (B) health is conceived as physiological and cognitive functioning and related biological self-care; Psychological (P) health as feelings of life satisfaction, and Social health (S) as perceived social support and civic engagement. Furthermore, three overlapping sub-constructs are theorized to connect these elements. Namely Bio-Psychological (BP) health in terms of self-perceptions of ageing; the Psycho-Social (PS) aspects of interpersonal communication; and the Socio-Communal (SC) health in terms of civic engagement. BPS health is conceived as distinct from QoL, defined as composed of control, autonomy, self-realisation and pleasure (measured by CASP-19) of the older person. We examined 1) interconnections of BPS constructs and related sub-constructs and 2) their associations with QoL to inform a practical, applied program theory., Methods: A baseline survey (n = 321) of program participants (Mean = 70 years, SD = 8.73). All continuous variables were binarized as 'high' if the scores were above the median. Multivariate logistic regression was used to assess 1) the adjusted effect of each BPS construct on CASP-19, and 2) the odds of scoring high on one BPS construct with the odds of scoring high on a related sub-construct (e.g. B and BP health)., Results: The strongest relationship with QoL was markedly with BP self-perceptions of ageing (OR = 4.07, 95%CI = 2.21-7.49), followed by P life satisfaction (OR = 3.66, 95%CI = 2.04-6.57), PS interpersonal communication (OR = 2.42, 95%CI = 1.23-4.77), SC civic engagement (OR = 1.94, 95%CI = 1.05-3.57), and S social support (OR = 1.89, 95%CI = 1.06-3.38). Core B, P and S health were closely associated with their sub-constructs., Conclusion: ComSA CD is tightly coupled to its proposed program theory. It offers classes to improve B self-care and BP self-perceptions of ageing, group-based guided autobiography to improve P life-satisfaction and PS interpersonal communication, and community initiatives that encourage seniors to solve community issues. This holistic approach is likely to enhance ageing experiences and QoL.

Background: In recent years, there has been a rising demand for home hospice care in Singapore and globally. Studies have shown that polypharmacy and the use of potentially inappropriate medications (PIMs) remain prevalent in palliative care patients. This is commonly associated with increased adverse drug reactions and hospitalization. However, research on medication use in hospice care and its appropriateness is lacking in Asian settings. Objective: (1) To describe the medication use among cancer and non-cancer patients in home hospice care settings in Singapore at two time points, on the day of referral and at death. (2) To describe the discontinuation patterns of medications and assess their appropriateness. Design: This retrospective study analyzed 6158 cancer and 780 non-cancer cases referred to HCA Hospice Care (HCA), Singapore. Sociodemographic, clinical, and medication data were extracted from electronic medical records. The OncPal Deprescribing Guideline (OncPal) was utilized to assess the appropriateness of discontinuation of medications. Results: Non-cancer patients had a higher mean number of medications at admission and death, with 7.84 and 7.07 medications, respectively ( p  < 0.05), compared with cancer patients, with 5.65 and 5.69 medications, respectively ( p  = 0.372). The top medications for all patients were laxatives, opioids, and proton pump inhibitors (PPIs). These were mainly used for symptom control. PPI was the main PIM identified by OncPal. Conclusion: Despite being close to end of life and on hospice care, majority of patients still experienced significant medication burden. Continuous assessment of PIMs for their appropriateness based on clinical indications is imperative to reduce polypharmacy.

The juxtaposition of a young city-state showing relative maturity as a rapidly aging society suffuses the population aging narrative in Singapore and places the "little red dot" on the spotlight of international aging. We first describe population aging in Singapore, including the characteristic events that shaped this demographic transition. We then detail the health care and socioeconomic ramifications of the rapid and significant shift to an aging society, followed by an overview of the main aging research areas in Singapore, including selected population-based data sets and the main thrust of leading aging research centers/institutes. After presenting established aging policies and programs, we also discuss current and emerging policy issues surrounding population aging in Singapore. We aim to contribute to the international aging literature by describing Singapore's position and extensive experience in managing the challenges and maximizing the potential of an aging population. We hope that similar graying populations in the region will find the material as a rich source of information and learning opportunities. Ultimately, we aspire to encourage transformative collaborations-locally, regionally, and internationally-and provide valuable insights for policy and practice., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Community participation is widely believed to be beneficial to the development, implementation and evaluation of health services. However, many challenges to successful and sustainable community involvement remain. Importantly, there is little evidence on the effect of community participation in terms of outcomes at both the community and individual level. Our systematic review seeks to examine the evidence on outcomes of community participation in high and upper-middle income countries., Methods and Findings: This review was developed according to PRISMA guidelines. Eligible studies included those that involved the community, service users, consumers, households, patients, public and their representatives in the development, implementation, and evaluation of health services, policy or interventions. We searched the following databases from January 2000 to September 2016: Medline, Embase, Global Health, Scopus, and LILACs. We independently screened articles for inclusion, conducted data extraction, and assessed studies for risk of bias. No language restrictions were made. 27,232 records were identified, with 23,468 after removal of duplicates. Following titles and abstracts screening, 49 met the inclusion criteria for this review. A narrative synthesis of the findings was conducted. Outcomes were categorised as process outcomes, community outcomes, health outcomes, empowerment and stakeholder perspectives. Our review reports a breadth of evidence that community involvement has a positive impact on health, particularly when substantiated by strong organisational and community processes. This is in line with the notion that participatory approaches and positive outcomes including community empowerment and health improvements do not occur in a linear progression, but instead consists of complex processes influenced by an array of social and cultural factors., Conclusion: This review adds to the evidence base supporting the effectiveness of community participation in yielding positive outcomes at the organizational, community and individual level., Trial Registration: Prospero record number: CRD42016048244., Competing Interests: The authors have declared that no competing interests exist.

In Singapore, a densely urbanised Asian city state, more than 80% of the population stays in public housing estates and the majority (90%) own their own homes. For the needy who cannot afford home ownership, public rental flats are available. We were interested in exploring social-environmental factors that are associated with loneliness among elderly residents of public rental housing in Singapore. We surveyed residents aged ≥60 in two Singapore public housing precincts in 2016. Loneliness was measured using a three-item scale. Sociodemographic information was obtained via standardised questionnaires. We used chi-square to identify associations between loneliness and sociodemographic characteristics, as well as neighbourhood perceptions (safety, convenience and the physical environment), on univariate analysis; and logistic regression for multivariate analysis. The response rate was 62.1% (528/800). On multivariate analysis, staying in a rental flat block was independently associated with loneliness (adjusted odds ratio, aOR = 2.10, 95% confidence interval (CI) = 1.32⁻3.36), as was staying in a poorer physical environment (aOR = 1.92, 95% CI = 1.15⁻3.22). Although needy Singapore residents share the same built environment as more well-to-do neighbours, differences in the impact of loneliness do exist.

Purpose: To map the Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory (ADCS-ADL) to the Health Utility Index Mark III (HUI3) in people living with dementia (PWD) and to compare the performance of five methods for mapping., Methods: A cross-sectional study of 346 dyads of community-dwelling PWD and family caregiver was carried out in Singapore. ADCS-ADL and HUI3 were rated by the family caregivers. Disease severity ratings and Mini Mental State Examination (MMSE) results were retrieved from medical records. A recently proposed mapping method called the Mean Rank Method (MRM) was described and applied, and the results were compared with regression-based mapping, including ordinary least squares, censored least absolute deviation (CLAD), Tobit and response mapping., Results: The MRM produced a mapped utility distribution that closely resembled the observed utility distribution. The standard deviations (SDs) of the observed and MRM-mapped utility were both 0.340, whereas the SDs of the other mapped utilities ranged from 0.243 (response mapping) to 0.283 (CLAD). Regressing the MRM- and CLAD-mapped and observed utility values upon disease severity and MMSE gave similar regression lines (each P > 0.05). Regressing the other mapped utility values upon the covariates under- (over-) estimated the utility of good (poor) clinical states. However, regression-based mapping methods gave a better fit at the individual level, as measured by root mean square error, mean absolute error and R 2 . K fold cross-validation gave similar results., Conclusions: The MRM is accurate at the group level. The regression-based mapping methods are more accurate for making individual-level prediction. In addition, CLAD also performed reasonably well at the group level.

Objective: To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting., Design: Qualitative study involving semi-structured in-depth interviews and focus group discussions., Setting: General community., Participants: Participants (N=37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling., Interventions: Singapore Tele-technology Aided Rehabilitation in Stroke trial., Main Outcome Measures: Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists., Results: Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled hypertension. Barriers identified by patients were equipment setup-related difficulties and limited scope of exercises; barriers identified by tele-therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation., Conclusions: Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment methods suitable for virtual platforms., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Involvement of clinicians in biomedical research is imperative for the future of healthcare. Several factors influence clinicians' inclination towards research: the medical school experience, exposure to research article reading and writing, and knowledge of research. This cohort study follows up medical students at time of graduation to explore changes in their inclination towards research and pursuing a research career compared to their inclination at time of entry into medical school., Methods: Students from medical schools in six different countries were enrolled in their first year of school and followed-up upon graduation in their final year. Students answered the same self-administered questionnaire at both time points. Changes in inclination towards research and pursuing a research career were assessed. Factors correlated with these changes were analysed., Results: Of the 777 medical students who responded to the study questionnaire at entry into medical school, 332 (42.7%) completed the follow-up survey. Among these 332 students, there was no significant increase in inclination towards research or pursuing a research career over the course of their medical schooling. Students from a United States based school, in contrast to those from schools other countries, were more likely to report having research role models to guide them (51.5% vs. 0%-26.4%) and to have published in a peer-reviewed journal (75.7% vs. 8.9%-45%). Absence of a role model was significantly associated with a decrease in inclination towards research, while an increased desire to learn more about statistics was significantly associated with an increase in inclination towards pursuing a research career., Conclusion: Most medical students did not experience changes in their inclination towards research or pursuing a research career over the course of their medical schooling. Factors that increased their inclination to undertaking research or pursuing a research career were availability of a good role model, and a good knowledge of both the research process and the analytical tools required.