Maternal distress and parenting during COVID-19: differential effects related to pre-pandemic distress?

BACKGROUND: Distinguishing whether and how pre-existing characteristics impact maternal responses to adversity is difficult: Does prior well-being decrease the likelihood of encountering stressful experiences? Does it protect against adversity's negative effects? We examine whether the interaction between relatively uniformly experienced adversity (due to COVID-19 experience) and individual variation in pre-existing (i.e., pre-pandemic onset) distress predicted mothers' pandemic levels of distress and insensitive caregiving within a country reporting low COVID-19 death rates, and strict nationwide regulations. METHOD: Fifty-one Singaporean mothers and their preschool-aged children provided data across two waves. Pre- pandemic onset maternal distress (i.e., psychological distress, anxiety, and parenting stress) was captured via self-reports and maternal sensitivity was coded from videos. Measures were repeated after the pandemic's onset along with questionnaires concerning perceived COVID-19 adversity (e.g., COVID-19's impact upon stress caring for children, housework, job demands, etc.) and pandemic-related objective experiences (e.g., income, COVID-19 diagnoses, etc.). Regression analyses (SPSS v28) considered pre-pandemic onset maternal distress, COVID-19 stress, and their interaction upon post-pandemic onset maternal distress. Models were re-run with appropriate covariates (e.g., objective experience) when significant findings were observed. To rule out alternative models, follow up analyses (PROCESS Model) considered whether COVID-19 stress mediated pre- and post-pandemic onset associations. Models involving maternal sensitivity followed a similar data analytic plan. RESULTS: Pre-pandemic maternal distress moderated the association between COVID-19 perceived stress and pandemic levels of maternal distress (ß = 0.22, p < 0.01) but not pandemic assessed maternal sensitivity. Perceived COVID-19 stress significantly contributed to post-pandemic onset maternal distress for mothers with pre-pandemic onset distress scores above (ß = 0.30, p = 0.05), but not below (ß = 0.25, p = 0.24), the median. Objective COVID-19 adversity did not account for findings. Post-hoc analyses did not suggest mediation via COVID-19 stress from pre-pandemic to pandemic maternal distress. CONCLUSIONS: Pre-existing risk may interact with subsequent perceptions of adversity to impact well-being. In combination with existing research, this small study suggests prevention programs should focus upon managing concurrent mental health and may highlight the importance of enhanced screening and proactive coping programs for people entering high stress fields and/or phases of life.

Resilience and coping behaviour among adolescents in a high-income city-state during the COVID-19 pandemic.

The study aimed to determine the resilience of multi-ethnic, multi-cultural adolescent students in cosmopolitan Singapore, their coping abilities, and the impact on their social and physical activities during the COVID-19 pandemic and its association with their resilience. A total of 582 adolescents in post-secondary education institutes completed an online survey from June to November 2021. The survey assessed their sociodemographic status, resilience level using the Brief Resilience Scale (BRS) and Hardy-Gill Resilience Scale (HGRS), the impact of the COVID-19 pandemic on their daily activities, life settings, social life, social interactions, and coping ability in these aspects of life. Poor ability to cope with school life (adjusted beta = - 0.163, 95% CI - 1.928 to 0.639, p < 0.001), staying home (adjusted beta = - 0.108, 95% CI = - 1.611 to - 0.126, p = 0.022), sports (adjusted beta = - 0.116, 95% CI - 1.691 to - 0.197, p = 0.013) and friends (adjusted beta = - 0.143, 95% CI - 1.904 to - 0.363, p = 0.004) were associated with statistically significant low resilience level measured with HGRS. About half and a third of the participants reported normal and low resilience, respectively, based on BRS (59.6%/32.7%) and HGRS (49.0%/29.0%) scores. Adolescents of Chinese ethnicity and low socioeconomic status had comparatively lower resilience scores. Approximately half of the adolescents in this study had normal resilience despite the COVID-19 pandemic. Adolescents with lower resilience tended to have lower coping abilities. The study did not compare changes in the social life and coping behaviour of the adolescents due to COVID-19, as data on these aspects prior to the pandemic was unavailable.

A qualitative research study of primary care physicians' views of telehealth in delivering postnatal care to women.

BACKGROUND: The postpartum period is a critical time for women to optimise their physical and mental health. Primary care physicians (PCP) often manage postpartum women in the community setting after uneventful births. However, women encounter difficulties accessing care before and after their conventional 6-week physical review. Telehealth-based interventional studies have demonstrated their successful applications in several areas of postpartum care but is not widely adopted. The study aimed to explore the PCPs' views on their acceptability and perceived barriers of telehealth in delivering postpartum care to women in primary care. METHODS: Twenty-nine PCPs participated in eleven in-depth interviews and four focus group discussions for this qualitative study conducted in Singapore. The purposively sampled PCPs had varied demographic background and medical training. Two investigators independently coded the audited transcripts. Thematic content analysis was performed using the codes to identify issues in the pertaining to the perceived usefulness, ease of use and attitudes towards telehealth in postpartum care as described in the "Telehealth Acceptance Model" framework. RESULTS: Most PCPs perceived usefulness and ease of use of video consultation in delivering postpartum care. They recognised telehealth service to complement and support the current face-to-face postpartum care amidst the pandemic. However, training, leadership support, organizational infrastructure, healthcare financial policy and personal demographic profile influence their acceptance of a new care model for postnatal mothers. CONCLUSION: Addressing the barriers and strengthening the facilitators will enhance PCPs' acceptance and utilisation of the proposed hybrid (telehealth and in-person) postnatal care model for mothers.

Awareness, Barriers and Concerns of Adolescents Toward the COVID-19 Vaccine: A Cross-Sectional Study in Singapore.

Background: COVID-19 vaccination is a key public health measure to mitigate the crippling effects of the pandemic. COVID-19 vaccination began in adults and targeted adolescents at a later stage. However, medical decision-making on its uptake among the latter was unknown, which could be affected by their literacy and concerns about the vaccine. The study aimed to elucidate the awareness, concerns and barriers of adolescents toward the COVID-19 vaccine. Methods: A cross-sectional online survey using a self-developed questionnaire was conducted between June to November 2021. The adolescent participants were students from institutes of post-secondary education who were recruited via convenience sampling. The data were collated from an officially approved electronic platform, audited and analyzed. Continuous and categorical variables were expressed as mean (standard deviation) and percentages, respectively. Results: A total of 460 adolescents participated in the study (mean age: 16.99 ± 0.99; 73% female). Most of them (91.5%) were aware of the COVID-19 vaccines. The main barriers to vaccination were uncertainty about long-term health risks (38.6%) and vaccine efficacy (37.3%). Regarding the potential vaccine side effects, they were concerned about: anaphylactic shock (73.2%), low blood pressure (58.3%) and fast heartbeat (58.0%). Only 58% expressed willingness for repeated COVID-19 vaccination. Conclusion: Despite high COVID-19 vaccine awareness, the adolescents were concerned about the potentially severe but rare side-effects. The study identified apprehension regarding vaccine efficacy and the potential long-term health impact as the main barriers to vaccination. Future studies should address these concerns to scale vaccination programs among adolescents.

Longitudinal study on the progression of muscle status among community-dwelling ambulatory older multiethnic Asians with type 2 diabetes mellitus.

BACKGROUND: Muscle health decline with age, but its deterioration in older persons with type-2 diabetes mellitus (T2DM) over time is not well-established. This study aimed to determine the change in muscle mass, handgrip strength and gait speed over time among community-dwelling ambulatory older multi-ethnic Asian patients with T2DM and their associated factors. METHODS: Among 387 eligible patients aged 60-89 years who were recruited at baseline, 348 (89.9%) were reviewed at a public primary care clinic in Singapore in the subsequent 9 to 34 months. The change in their clinical and functional status, levels of physical activity and muscle status (mass, grip strength and gait speed based on the Asian Working Group for Sarcopenia criteria) were recorded and compared. Their physical activity levels were assessed using the Physical Activity Scale for the Elderly (PASE) and International Physical Activity Questionnaire (IPAQ). Their quality of life was evaluated based on the World Health Organization Quality of Life (WHOQOL) domains. Linear regression analysis was used to identify the factors associated with muscle health change. RESULTS: The study population comprised men (52.9%), Chinese (69.3%), mean age of 68.4 ± SD5.6 years and had at least secondary education (76.4%). Their mean muscle mass significantly decreased by 0.03 ± SD0.06 kg/m2/month, mean handgrip strength by 0.06 ± SD0.26 kg/month and negligible change in gait speed of 0.002 ± SD0.01 m/sec/month. Their mean weight significantly decreased by 0.5 ± SD3.9 kg, waist and hip circumferences by 2.5 ± SD6cm and 3.2 ± SD5.1 cm respectively, with no change in BMI. Linear regression shows significant associations between muscle mass change and education level (ß = 0.36,p = 0.012, 95% CI = 0.08-0.64), BMI (ß = 0.11,p = < 0.001, 95% CI = 0.05-0.17), change in medication class (ß = 0.39,p = < 0.001, 95% CI = 0.06-0.71) and review interval (ß = - 0.003, p < 0.001, 95% CI = -0.004--0.002). Gait speed change was associated with singlehood (ß = - 0.13,p = 0.029, 95% CI = -0.25--0.01) and WHOQOL physical health (ß = 0.01,p = 0.024, 95% CI = 0.00-0.02) domain. No factor was associated with handgrip strength change. CONCLUSIONS: The study population with T2DM showed significant decline in their mean weight, waist and hip circumferences, mean muscle mass and mean grip strength but gait speed was unaffected. Muscle mass change was associated with education level, BMI and length of review interval. Handgrip strength change was not significantly correlated with any factor. Gait speed change was associated with singlehood and physical health.

Self-administered oral glucose tolerance test with capillary glucose measurements for the screening of diabetes mellitus in high-risk adults: a feasibility study.

INTRODUCTION: Early diagnosis of prediabetes based on blood sampling for the oral glucose tolerance test (OGTT) is crucial for intervention but multiple barriers hinder its uptake. This study aimed to assess the feasibility and precision of a self-administered capillary OGTT for type-2 diabetes mellitus (T2DM) in high-risk individuals. RESEARCH DESIGN AND METHODS: Participants with history of gestational diabetes or prediabetes were recruited in primary care. Due to their prediabetic status and previous diagnosis of gestational diabetes mellitus, a proportion of participants had previous experience doing OGTT. They self-administered the capillary OGTT and concurrently their venous glucose samples were obtained. They filled a questionnaire to collect their demographic information, views of their capillary OGTT, and their preferred site of the test. RESULTS: Among 30 participants enrolled in this feasibility study, 93.3% of them felt confident of performing the capillary OGTT themselves, and 70.0% preferred the test at home. Older, less educated participants found it less acceptable. Mean capillary glucose values were significantly higher than venous glucose values, with mean difference at 0.31 mmol/L (95% CI 0.13 to 0.49) at fasting, and 0.47 mmol/L (95% CI 0.12 to 0.92) 2 hours post-OGTT. Capillary and venous glucose measurements were correlated for fasting (r=0.95; p<0.001) and 2-hour-post-OGTT (r=0.95;p<0.001). The Fleiss-Kappa Score (0.79, p<0.0001) indicated fair agreement between the two methods. The capillary OGTT had excellent sensitivity (94.1%) and negative predictive value (NPV=91.7%) in identifying prediabetes or T2DM status, vis-a-vis to venous glucose samples. CONCLUSION: Self-administered capillary OGTT is feasible and acceptable, especially among younger adults, with excellent sensitivity and NPV compared with plasma-based OGTT.

Experiences of primary care physicians managing postpartum care: a qualitative research study.

BACKGROUND: The postpartum period is redefined as 12 weeks following childbirth. Primary care physicians (PCP) often manage postpartum women in the community after uneventful childbirths. Postpartum care significantly impacts on the maternal and neonatal physical and mental health. However, evidence has revealed unmet needs in postpartum maternal care. AIM: The study aimed to explore the experiences of PCPs in managing postpartum mothers. METHODS: Four focus group discussions and eleven in-depth interviews with twenty-nine PCPs were conducted in this qualitative research study in urban Singapore. PCPs of both gender and variable postgraduate training background were purposively enrolled. Audited transcripts were independently coded by two investigators. Thematic content analysis was performed using the codes to identify issues in the "clinician", "mother", "postpartum care" and "healthcare system & policy" domains stipulated in "The Generalists' Wheel of Knowledge, Understanding and Inquiry" framework. FINDINGS: PCPs' personal attributes such as gender and knowledge influenced their postpartum care delivery. Prior training, child caring experience and access to resource materials contributed to their information mastery of postpartum care. Their professional relationship with local multi-ethic and multi-lingual Asian mothers was impacted by their mutual communication, language compatibility and understanding of local confinement practices. Consultation time constraint, awareness of community postnatal services and inadequate handover of care from the specialists hindered PCPs in the healthcare system. DISCUSSION: Personal, maternal and healthcare system barriers currently prevent PCPs from delivering optimal postpartum care. CONCLUSION: Interventions to overcome the barriers to improve postpartum care will likely be multi-faceted across domains discussed.

Patient similarity analytics for explainable clinical risk prediction.

BACKGROUND: Clinical risk prediction models (CRPMs) use patient characteristics to estimate the probability of having or developing a particular disease and/or outcome. While CRPMs are gaining in popularity, they have yet to be widely adopted in clinical practice. The lack of explainability and interpretability has limited their utility. Explainability is the extent of which a model's prediction process can be described. Interpretability is the degree to which a user can understand the predictions made by a model. METHODS: The study aimed to demonstrate utility of patient similarity analytics in developing an explainable and interpretable CRPM. Data was extracted from the electronic medical records of patients with type-2 diabetes mellitus, hypertension and dyslipidaemia in a Singapore public primary care clinic. We used modified K-nearest neighbour which incorporated expert input, to develop a patient similarity model on this real-world training dataset (n = 7,041) and validated it on a testing dataset (n = 3,018). The results were compared using logistic regression, random forest (RF) and support vector machine (SVM) models from the same dataset. The patient similarity model was then implemented in a prototype system to demonstrate the identification, explainability and interpretability of similar patients and the prediction process. RESULTS: The patient similarity model (AUROC = 0.718) was comparable to the logistic regression (AUROC = 0.695), RF (AUROC = 0.764) and SVM models (AUROC = 0.766). We packaged the patient similarity model in a prototype web application. A proof of concept demonstrated how the application provided both quantitative and qualitative information, in the form of patient narratives. This information was used to better inform and influence clinical decision-making, such as getting a patient to agree to start insulin therapy. CONCLUSIONS: Patient similarity analytics is a feasible approach to develop an explainable and interpretable CRPM. While the approach is generalizable, it can be used to develop locally relevant information, based on the database it searches. Ultimately, such an approach can generate a more informative CRPMs which can be deployed as part of clinical decision support tools to better facilitate shared decision-making in clinical practice.

What are the measures taken to prevent COVID-19 infection among healthcare workers? A retrospective study in a cluster of primary care clinics in Singapore.

OBJECTIVE: To examine factors contributing to the low COVID-19 infectivity rate among healthcare workers in SingHealth Polyclinics (SHP), Singapore, from February to July 2020. DESIGN: Retrospective description, analysis and discussion of the factors and their contribution. SETTING: Single-institution study. METHODS: We describe and discuss the healthcare policies, infrastructure, people and processes contributing to the low COVID-19 infectivity rate in SHP.There were 1212 full-time and 198 contract staff. Of these, 171 SHP employees also supported the work in dormitories, isolation and community care facilities. During the review period, healthcare workers (HCWs) in SHP managed about 867 076 patient attendances, including 63 503 for upper respiratory tract infections, across its cluster of eight polyclinics. 29 642 swabs for COVID-19 were performed in SHP, with 126 positive results. 395 swabs were carried out in the dormitories and 59 were positive. Despite the high exposure, only two SHP staff were infected with COVID-19. Both have recovered well. RESULTS: Provision of adequate personal protection equipment, zonal segregation of high-risk patients, reduction in physical patient visits, effective staff communication, implementation of self-declared temperature monitoring and the maintenance of sustainable workload and work hours of HCWs contributed to the mitigation of COVID-19 infection risk among our staff. CONCLUSIONS: Until the widespread uptake of safe and effective vaccines against COVID-19, these measures are important in protecting HCWs. They are also important when managing future pandemics of similar nature to COVID-19.

The impact of COVID-19 pandemic on the health-seeking behaviour of an Asian population with acute respiratory infections in a densely populated community.

BACKGROUND: The COVID-19 pandemic led to the implementation of various non-pharmaceutical interventions (NPI) as the Singapore government escalated containment efforts from DORSCON Orange to Circuit Breaker. NPI include mandatory mask wearing, hand hygiene, social distancing, and closure of schools and workplaces. Considering the similar mode of transmission of COVID-19 and other pathogens related to acute respiratory infections (ARI), the effects of NPI could possibly lead to decreased ARI attendances in the community. This study aims to determine the year-on-year and weekly changes of ARI attendances across a cluster of polyclinics following the implementation of NPI. METHODS: The effect of the nation-wide measures on the health-seeking behaviour of the study population was examined over three periods: (1) 9 weeks prior to the start of Circuit Breaker (DORSCON Orange period), (2) 8 weeks during the Circuit Breaker, and (3) 9 weeks after easing of Circuit Breaker. Data on ARI attendances for the corresponding periods in 2019 were also extracted for comparison and to assess the seasonal variations of ARI. The average weekly workday ARI attendances were compared with those of the preceding week using Wilcoxon signed rank test. RESULTS: ARI attendances dropped steadily throughout the study period and were 50-80% lower than in 2019 since Circuit Breaker. They remained low even after Circuit Breaker ended. Positivity rate for influenza-like illnesses samples in the community was 0.0% from the last week of Circuit Breaker to end of study period. CONCLUSIONS: NPI and public education measures during DORSCON Orange and Circuit Breaker periods appear to be associated with the health-seeking behaviour of the public. Changing levels of perceived susceptibility, severity, benefits and barriers, and widespread visual cues based on the Health Belief Model may account for this change. Understanding the impact of NPI and shifts in the public's health-seeking behaviour will be relevant and helpful in the planning of future pandemic responses.