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Digital health technology has been adopted rapidly by countries as tools to promote good public health outcomes over the last decade. The COVID-19 pandemic that occurred since November 2019 has further accelerated the salience and relevance of digital health technology in tackling public health issues as countries start to implement movement restriction policies that pose a challenge to the physical delivery of healthcare services. Unarguably, the pandemic has elevated the significances of digital solutions to public health issues, which include improving access to an increased range of health services and the potential of cost-saving, maximizing population-wide health impacts through behavioral modifications, and controlling and managing public health emergencies. In general, digital technology in public health has three major applications—monitoring, decision support, and education. Monitoring is especially relevant in the context of effective disease screening and pandemic surveillance, decision support applies to the promotion of behavior modifications and resource optimization, while education serves to improve population-level health awareness and knowledge. Despite the promises of digital solutions to address various public health issues, there are unintended consequences that could arise consequent to their widespread applications, resulting in governance challenges and ethical issues in their applications, such as data privacy and erosion of trust, safety, cybersecurity, algorithmic bias, liability, autonomy, and social justice. To reap tangible benefits and positive impacts from large-scale deployment of various digital health solutions, countries need to anchor their national digital health policies or strategies by considering not only their benefits and applications, but also various governance challenges and ethical issues that could ensue during their implementations.

The high tertiary healthcare utilisation in Singapore due to an ageing population and increasing chronic disease load has resulted in the establishment of primary care networks (PCNs) for private general practitioners (GPs) to provide team-based, community care for chronic diseases. A total of 22 PCN leaders and programme managers from 10 PCNs participated in online group discussions and a survey. Outcome harvesting was used to retrospectively link the intended and unintended outcomes to the programme initiatives and intermediate results (IRs). The outcomes were generated, refined and verified before shortlisting for analysis. About 134 positive and 22 negative PCN outcomes were observed since inception in 2018. By establishing PCN headquarters and entrusting PCN leaders with the autonomy to run these, as well as focusing policy direction on GP onboarding, GP engagements and clinical governance, the programme successfully harnessed the collective capabilities of GPs. Developments in the organisation (IR1) and monitoring and evaluation (IR4) were the top two contributors for positive and negative outcomes. Sustainable practice and policy changes represented 46% and 20% of the positive outcomes respectively. Sustainable positive outcomes were predominantly contributed by funding, clear programme policy direction and oversight. Conversely, most negative outcomes were due to the limited programme oversight especially in areas not covered by the programme policy.

The International Health Regulations—State Party Annual Reporting (IHR-SPAR) index and the Global Health Security Index (GHSI) have been developed to aid in strengthening national capacities for pandemic preparedness. We examined the relationship between country-level rankings on these two indices, along with two additional indices (the Universal Health Coverage Service Coverage Index and World Bank Worldwide Governance Indicator (n = 195)) and compared them to the country-level reported coronavirus disease (COVID-19) cases and deaths (Johns Hopkins University COVID-19 Dashboard) through 17 June 2020. Ordinary least squares regression models were used to compare weekly reported COVID-19 cases and death rates per million in the first 12 weeks of the pandemic between countries classified as low, middle and high ranking on each index while controlling for country socio-demographic information. Countries with higher GHSI and IHR-SPAR index scores experienced fewer reported COVID-19 cases and deaths but only for the first 8 weeks after the country’s first case. For the GHSI, this association was further limited to countries with populations below 69.4 million. For both the GHSI and IHR-SPAR, countries with a higher sub-index score in human resources for pandemic preparedness reported fewer COVID-19 cases and deaths in the first 8 weeks after the country’s first reported case. The Universal Health Coverage Service Coverage Index and Worldwide Governance Indicator country-level rankings were not associated with COVID-19 outcomes. The associations between GHSI and IHR-SPAR scores and COVID-19 outcomes observed in this study demonstrate that these two indices, although imperfect, may have value, especially in countries with a population under 69.4 million people for the GHSI. Preparedness indices may have value; however, they should continue to be evaluated as policy makers seek to better prepare for future global public health crises.

Accessibility to effective cancer treatments is a goal of Universal Health Coverage; yet, achieving this in the context of escalating costs in a diversity of Asian nations with different socioeconomic development is extremely challenging. Value-based assessments within the context of each health care system, financing infrastructure that will facilitate appropriate prioritization of high-cost medications, transparency in international pricing and reducing out-of-pocket costs through national insurance programs are measures that Asian countries should take toward Universal Health Coverage for cancer care. Encouraging sharing data on pricing through the World Health Organization, sharing expertise in health technology assessments and regulatory approvals, and exploring bulk negotiations would also strengthen the process of price control. For each individual country, rational selection of national cancer formulary, aiming at price reduction and sound procurement strategies for each drug, is important toward ensuring affordable access to quality cancer medications.

Objectives: To assess the effect of health check-ups on health among the elderly Chinese.Methods: The first dataset was panel data extracted from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Health Longevity Survey (CLHLS). The second dataset was cross-sectional data come from CLHLS 2018 linked with the lagged term of health check-ups in CLHLS 2011. Health check-ups were measured by a binary variable annual health check-up (AHC). Health was assessed by a binary variable self-rated health (SRH). A coarsened exact matching method and individual fixed-effects models, as well as logistic regressions were employed.Results: AHC attendance among the elderly increased from 2011 to 2018, with higher utilization of AHC also detected in the rural group. AHC had positive effects on SRH among rural respondents (short-term effect: OR = 1.567, p < 0.05; long-term effect: OR = 3.385, p < 0.001).Conclusion: This study highlights a higher utilization of AHC in rural area, and the effectiveness of AHC in SRH improvement among rural participants. It indicates enhanced access to public healthcare services in rural area and underlying implications of health check-ups for reducing urban–rural health inequalities.

Assisted living (AL) is an emerging model of care in countries where long-term care needs are escalating, with emphasis given to promoting independence and autonomy among the residents to achieve active and healthy ageing. Unlike established nursing homes, the governance of AL is nebulous due to its novelty and diverse nature of operations in many jurisdictions. A comprehensive understanding of how AL is governed globally is important to inform regulatory policies as the adoption of AL increases. A systematic literature review was undertaken to understand the different levels of regulations that need to be instituted to govern AL effectively. A total of 65 studies, conducted between 1990 to 2020, identified from three major databases (PubMed, Medline, and Scopus), were included. Using a thematic synthesis analytical approach, we identified macro-level regulations (operational authorisation, care quality assessment and infrastructural requirements), meso-level regulations (operational management, staff management and distribution, service provision and care monitoring, and crisis management), and micro-level regulations (clear criteria for resident admission and staff hiring) that are important in the governance of AL. Large-scale adoption of AL without compromising the quality, equity and affordability would require clear provisions of micro-, meso- and macro-level regulations.

Background Singapore and Malaysia are neighbouring countries with similar ethnic make-up: Chinese, Indian, and Malays. However, Singapore is a high-income economy while Malaysia is a middle-income economy. Such a difference has resulted in some levels of dichotomy in diet and lifestyles. In this study, we sought to investigate the gut-ethnic variation across the two neighbouring countries with varying levels of economic development. Methods A total of 439 relatively healthy Malaysian (n=190) and Singaporean (n=249) adults (>18) were included, comprising Chinese (n=240), Indian (n=74), Malay (n=40), and the indigenous Jakun community (n=85). The sequences were processed with DADA2 and annotated using the SILVA database. Results Country of origin explained the most variation in the gut microbiota (PERMANOVA, Pseudo-F=80.798, R2=0.156, p=0.001; IDDF2021-ABS-0150 Figure 1. Ordination). Importantly, ethnicity was still significantly associated with the gut microbiota even after adjusting for the country, age and sex (PERMANOVA, Pseudo-F=4.206, R2=0.019, p=0.001). Several taxa were found to be differentially abundant across ethnicity (ANCOM-BC, q Conclusions Gut-ethnic differences persist across geographical regions, which was likely due to similar lifestyle and cultural practices by individuals sharing similar ancestry. These signals provide potential biomarkers on the role of the gut microbiota in the aetiology of the unequal disease burdens affecting the different ethnic groups in this multicultural region.

Background Psychological stress, which is associated with poor sleep quality, has a profound effect on the gut microbiome. To better elucidate the gut microbiome changes associated with psychological stress, we measured levels of stress and sleep quality among the healthy stool donors recruited through a national campaign, and further assessed their relationship with the gut microbiome. Methods The gut microbial composition of 272 adults residing in Singapore was determined by 16S rRNA V3-V4 amplicon sequencing. Stress and distress levels of participants were assessed using the Perceived Stress Scale (PSS) and Kessler Psychological Distress Scale (K10) respectively, while sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Multivariate statistical data analyses were conducted to explore the link between the gut microbiome, stress, distress and sleep quality. Results A significant proportion of stool donors exhibited low distress (84.2%) levels. However, nearly one-third of participants reported high-stress levels (33.5%) and poor sleep quality (44.8%) (IDDF2021-ABS-0165 Figure A. Stacked bar plot showing the number of participants under each category of (i) K10 , (ii) PSS and (iii) PSQI). The overall variation in the gut microbiome composition amongst stool donors was predominantly dependent on age and body mass index (BMI), rather than psychosocial stress and sleep quality (IDDF2021-ABS-0165 Figure B. PERMANOVA results of main factors in this study). However, four microbial features (i.e., Streptococcus, Erysipelotrichaceae UCG-003, Sutterella and Parabacteroides) were found to be positively associated with severe distress, of which Erysipelotrichaceae UCG-003 was more abundant in both distressed and stressed donors (DESeq2, p Conclusions One-third of the participants exhibited high stress/distress levels and almost half poor sleep. In this study, we identified several bacterial genera that are significantly altered in the gut microbiome of stressed individuals, with Erysipelotrichaceae UCG-003 being consistently increased across people with high stress and severe distress levels. Erysipelotrichaceae UCG-003 was previously reported to be elevated in individuals with sleep deprivation. Our findings also suggest the need to factor for stress and sleep quality when studying the gut microbiome of healthy individuals.

Background The gut microbiome plays an instrumental role in cardiovascular, metabolic and gastrointestinal health (Valdes et al. 2018). In Traditional Chinese Medicine (TCM), one’s health status can be described by nine body constitutions (BCs) which are broadly classified as ‘Neutral’, indicating optimal health, or ‘Unbalanced’, indicating suboptimal health. Similar to the gut microbiome, BCs are strongly influenced by lifestyle and diet. We evaluated the gut microbial composition of Neutral, Qi-Deficiency (QD), Phlegm-dampness (PD) and Damp Heat (DH) subjects. The latter three are unbalanced BCs, with QD associated with heart disease (Zhu et al. 2017), PD with obesity and metabolic syndrome (Wang et al. 2013), and DH with gastrointestinal disease (Liang et al. 2020). Methods Stool samples were collected from 211 healthy subjects and gut microbial composition was profiled using 16S rRNA amplicon sequencing of the V3-V4 regions. BCs were determined using the Constitution in Chinese Medicine Questionnaire (Wang, 2005). Alpha diversity of QD, PD and DH was inferred and compared against that of Neutral using the Kruskal-Wallis test. Differentially abundant bacterial phyla, family and species were identified by calculating Log2FoldChange of taxa in the unbalanced BCs compared to Neutral. Results There were 135 Neutral, 59 QD, 24 PD and 12 DH subjects. 16 participants exhibited two or more unbalanced BCs. PD exhibited significantly lower alpha diversity (Shannon, Simpson) than Neutral (p Conclusions Varying TCM BCs exhibit unique microbiota signatures. Participants with unbalanced BCs are associated with greater dysbiosis compared to participants with Neutral BC. The lower alpha diversity in PD is consistent with that in obese and metabolic syndrome patients (Stanislawski et al. 2019; Oh et al. 2021). Streptococcus gallolyticus, a species associated with gastrointestinal malignancy (Chand et al. 2016), was significantly higher in all three unbalanced BCs and thus may serve as a potential biomarker for identifying patients with unbalanced BCs.

Background The impact of non-dietary lifestyle factors on the gut microbiota, such as physical activity, has not been frequently reported. Recent studies have suggested that exercise can increase the number of beneficial microbial species which enhance short-chain fatty acid synthesis and carbohydrate metabolism. Therefore, we investigated the relationship between physical activity and gut microbiome composition within a cohort of multi-ethnic healthy Singaporeans. Methods 257 individuals completed the Global Physical Activity Questionnaire (GPAQ) (Armstrong et al. 2006) and Food Frequency Questionnaire (FFQ) (Whitton et al. 2017), to obtain quantitative measures of their physical activity, nutrition and dietary habits, respectively. They also provided paired stool samples, which underwent 16S rRNA V3-4 amplicon sequencing. Community and individual microbial features associated with physical activity were assessed using microbial ecology measures such as α-diversity and principal coordinate analysis (PCA), as well as, multivariate sparse Partial Least Squares analyses, whilst confounding for nutritional and dietary habits. Results Using the GPAQ, 57% of the individuals were deemed to have an active lifestyle. Active individuals have increased microbial α-diversity, although not statistically significant. Unsupervised PCA analysis identified a subset of active individuals with distinct microbiome signatures, whereby these individuals, compared to those with sedentary lifestyles, have increased abundances of Prevotella spp., which is in keeping with their increased fibre intake. Sedentary lifestyle individuals were found to have increased abundance of Lachnoclostridium spp., whereby phylogenetic similar microbial features (such as Roseburia and Subdoligranulum spp.) were significantly correlated with more frequent eating out at hawker stalls and fast-food establishments (IDDF2021-ABS-0169 Figure 1. Correlation between gut microbiome with (a) nutrient intake; and (b) food habit). Studying the metabolic potential of the microbiome, active individuals had increased abundances of gene content related to energy production, whereby sedentary individuals had increased abundances of gene content related to degradation of aromatic compounds. Conclusions Our study reaffirms that increased physical activity is associated with increased microbial diversity and beneficial microbial features. However, the differences in gut microbiota associated with physical activity may be due to differences in dietary intake and practices, rather than the exercise itself. Further studies investigating the link of gut microbiome and physical activity should control and standardize the dietary intake of participants.

Background Low-wage dormitory-dwelling migrant workers in Singapore were disproportionately affected by coronavirus disease 2019 (COVID-19) infection. This was attributed to communal living in high-density and unhygienic dormitory settings and a lack of inclusive protection systems. However, little is known about the roles of social and geospatial networks in COVID-19 transmission. The study examined the networks of non-work–related activities among migrant workers to inform the development of lockdown exit strategies and future pandemic preparedness. Methods A population-based survey was conducted with 509 migrant workers across the nation, and it assessed dormitory attributes, social ties, physical and mental health status, COVID-19-related variables and mobility patterns using a grid-based network questionnaire. Mobility paths from dormitories were presented based on purposes of visit. Two-mode social networks examined the structures and positions of networks between workers and visit areas with individual attributes. Results COVID-19 risk exposure was associated with the density of dormitory, social ties and visit areas. The migrant worker hub in the city centre was the most frequently visited for essential services of grocery shopping and remittance, followed by south central areas mainly for social gathering. The hub was positioned as the core with the highest degree of centrality with a cluster of workers exposed to COVID-19. Conclusions Social and geospatial networks of migrant workers should be considered in the implementation of lockdown exit strategies while addressing the improvement of living conditions and monitoring systems. Essential services, like remittance and grocery shopping at affordable prices, need to be provided near to dormitories to minimize excess gatherings.

Low-wage migrant workers in Singapore are legally entitled to healthcare provided by their employers and supported by private insurance, separate from the national UHC (universal health coverage) system. In practice, they face multiple barriers to access. In this article, we describe this policy-practice gap from the perspective of HealthServe, a non-profit organisation that assists low-wage migrant workers. We outline the healthcare financing system for migrant workers, describe commonly encountered barriers, and comment on their implications for the global UHC movement’s key ethical concepts of fairness, equity, and solidarity.

Colorectal cancer (CRC) is the most common cancer in Singapore. We sought to evaluate the long-term cost-effectiveness of targeted genetic testing and surveillance programs in individuals at high risk of hereditary non-polyposis colorectal cancer (HNPCC), as compared to an unselective clinical surveillance program alone in Singapore. A Markov model analysis from the healthcare service provider's perspective was developed to follow over a lifetime a cohort of cancer-free 21-year-old individuals, who were first-degree relatives of HNPCC patients with a known mutation. Genetic testing strategy provided a lifetime saving of Singapore dollars (SGD) 13,588 per person and gained additional life years of 0.01, as compared to clinical surveillance alone, by sparing non-mutation carriers from unnecessary and invasive intensive clinical surveillance (assuming 100% compliance with recommended surveillance programs in both strategies). Sensitivity analyses showed that as long as the compliance rate in mutation carriers was not lower than that for individuals without genetic testing, pursuing a genetic testing strategy would either be a more favorable option with discounted incremental cost-effectiveness ratios ranging from SGD 6,961 to 17,289 per life year gained or a dominant status achieved (more life year gained and less costly). Genetic testing for individuals at high risk of HNPCC allows targeted clinical surveillance to be directed at mutation carriers, ensuring efficient use of healthcare resources and reduces CRC-related mortality. It can be regarded as a cost-effective strategy in Singapore, if an improved compliance with recommended surveillance protocol is achieved in proven mutation carriers.

Sternoclavicular joint infection is rare and tends to present insidiously in debilitated and immunocompromised patients. Between August 1996 and July 1998, we managed 7 patients with 8 sternoclavicular joint infections. Three were women. Their age ranged from 42 to 63 years. Five of the patients had significant associated medical conditions. Six patients, including 1 with bilateral involvement, underwent surgical resection, which consisted of radical excision of the involved joint, medial third of the clavicle, first and second ribs and adjacent muscular wall, and part of the manubrium. All of them underwent delayed reconstruction with either pectoralis major or latissimus dorsi flaps. There was 1 operative mortality from continuing sepsis from another source. All the surviving patients showed no sign of local recurrent infection and no functional deficits at follow-up. We conclude that infection of the sternoclavicular joint often presents late in debilitated patients. Medical therapy often fails in these cases. Radical excision is effective in eradicating the septic focus, and functional results after reconstruction are excellent.

The ability to successfully recruit and retain research participants is an important precursor to conducting a successful clinical trial. With respect to participant recruitment, we discuss potential strategies used in well-known and successful research studies to reach out to the targeted populations, including public education on the importance of clinical trials and the use of new media in reaching out to a wider population. The measures used by research studies to engage their participants and their healthcare providers to optimise participant retention are also examined. We conclude by discussing how these strategies may be adapted for use in Singapore.

Delayed pseudoaneurysm of the abdominal aorta is an exceedingly rare but potentially fatal complication following blunt abdominal trauma. A 25-year-old male presented 3 months after a road traffic accident with central abdominal pain. A 4-cm pseudoaneurysm of the infrarenal aorta was detected by computed tomography. Successful surgical repair was performed with an interposition graft and reimplantation of the inferior mesenteric artery.

Background Kidney disease is the 9th leading cause of death in Singapore. While preventive effects have focused on early detection and education, little is known about the knowledge level of chronic kidney disease (CKD) locally. We seek to evaluate the knowledge of CKD among primary care patients. Methods We conducted a cross-sectional survey of a convenience sample of 1520 patients from 3 primary care centers. Those with existing CKD or on dialysis were excluded. Knowledge was assessed based on 7 questions on CKD in the self-administered questionnaire. One point was given for each correct answer with a maximum of 7 points. Results 1435 completed all 7 questions on CKD. Mean age was 48.9 ±15.0 (SD) years. 50.9% were male. 62.3% had a secondary and below education and 52.4% had a monthly household income of ≤ $2000. 43.7% had chronic diseases. Mean score was 3.44 ± 1.53 (out of a maximum of 7). Median score was 4. In multivariate logistic regression, being older {>60 years [Odds Ratio (OR) 0.50, 95% Confidence Interval (CI) 0.32-0.79]; 40–60 years (OR 0.62, 95% CI 0.43,0.89)}, less educated [up to primary education (OR 0.33, 95% CI 0.22-0.49)], having a lower monthly household income [ Conclusion This suggests that CKD education should be targeted at older patients with lower education and lower socioeconomic status.