Slow art plus: developing and piloting a single session art gallery-based intervention for mental health promotion via a mixed method waitlist randomized control trial.

Introduction: The current study builds on the expertise of National Gallery Singapore and Nanyang Technological University Singapore (NTU) in developing and piloting an enhanced version of the Slow Art program, namely "Slow Art Plus" for mental health promotion. Methods: A single-site, open-label, waitlist Randomized Control Trial (RCT) design comprising of a treatment group and waitlist control group was adopted (ClinicalTrials.gov ID: NCT05803226). Participants (N = 196) completed three online questionnaires at three timepoints: baseline [T1], immediately post-intervention/s baseline [T2], post-intervention follow-up/immediately post-intervention [T3]. Qualitative focus groups were conducted to evaluate program acceptability. Results: A mixed model ANOVA was performed to understand intervention effectiveness between the immediate intervention group and waitlist control group. The analyses revealed a significant interaction effect where intervention group participants reported an improvement in spiritual well-being (p = 0.001), describing their thoughts and experiences (p = 0.02), and nonreacting to inner experiences (p = 0.01) immediately after Slow Art Plus as compared to the control group. Additionally, one-way repeated measure ANOVAs were conducted for the intervention group to evaluate maintenance effects of the intervention. The analyses indicated significant improvements in perceived stress (p < 0.001), mindfulness (p < 0.001) as well as multiple mindfulness subscales, active engagement with the world (p = 0.003), and self-compassion (p = 0.02) 1 day after the completion of Slow Art Plus. Results from framework analysis of focus group data revealed a total of two themes (1: Experiences of Slow Art Plus, 2: Insights to Effective Implementation) and six subthemes (1a: Peaceful relaxation, 1b: Self-Compassion, 1c: Widened Perspective, 2a: Valuable Components, 2b: Execution Requisites, 2c: Suggested Enhancements), providing valuable insights to the overall experience and implementation of the intervention. Discussion: Slow Art Plus represents a unique approach, offering a standardized, multimodal, single-session program that integrates mindfulness and self-compassion practices, as well as reflective and creative expressions with Southeast Asian art. It demonstrates potential in meeting the mental health needs of a wide range of individuals and could be readily incorporated into social prescribing initiatives for diverse populations.

Prevalence and correlates of depressive symptoms among matriculated university students in Singapore during Covid-19 pandemic: findings from a repeated cross-sectional analysis.

BACKGROUND: Depression is a common issue among university students and has been particularly exacerbated during the COVID-19 pandemic. However, limited research has specifically focused on depression among university entrants. OBJECTIVES: This study aimed to determine the prevalence of depression severity and identify associated factors during different phases of the COVID-19 pandemic using health screening questionnaires completed by matriculated university students in Singapore. METHODS: A repeated cross-sectional study was conducted at a public university in Singapore. Data from health screening questionnaires administered in 2020 and 2021, involving 15,630 newly enrolled university students, were analyzed. The questionnaires covered students' sociodemographic information, physical health status, own and family medical history, lifestyle behaviours, and the Patient Health Questionnaire (PHQ-9). The PHQ-9 was used to measure the severity of depressive symptoms, categorizing into moderate to severe depressive symptoms (MSDS), mild depressive symptoms (MDS), or no depressive symptom (NDS). Multinomial logistic regression was used to assess the sociodemographic, physical and behavioural correlates of depression. RESULTS: The prevalence of MSDS was 1% in both 2020 and 2021, while the rates for MDS were 1.93% in 2020 and 1.64% in 2021. In the 2020 cohort, male freshmen who reported better health had a lower likelihood of experiencing depression. Conversely, students of Malay ethnicity, those majoring in Engineering, those with multiple chronic diseases, monthly alcohol consumers, current smokers, and those with a family history of mental disorder had a higher likelihood of experiencing depression. Moreover, students who lived on-campus in the 2021 cohort were less likely to experience depression than those living off-campus. However, the associations between academic majors, alcohol consumption, and smoking with depression were not significant in the 2021 cohort. CONCLUSIONS: This study reported a low prevalence of both MSDS and MDS among university entrants in Singapore. The study further identified three categories of factors associated with depression: sociodemographic, physical, and behavioural. This study suggests policy interventions to enhance targeted social support that address each student group's specific requirements and susceptibilities. A more extensive and comprehensive study is warranted to assess the changes in student mental health status post-COVID-19 pandemic.

The gift of here and now at the end of life: Mindful living and dignified dying among Asian terminally ill patients.

OBJECTIVES: In Chochinov's dignity model, living in the here and now (mindful living) is explicitly stated as a dignity-conserving practice. However, what facilitates mindful living remain unclear. This study aims to investigate the mechanisms of mindful living among Asian terminally ill patients. METHODS: This interpretative phenomenological analysis comprised patients aged 50 and above with a prognosis of less than 12 months. Fifty interview transcripts from a larger Family Dignity Intervention study conducted in Singapore were used for the analysis. RESULTS: Findings revealed 12 themes that were organized into 3 axioms of mindful living for dignified dying: (a) purposive self-awareness, (b) family-centered attention, and (c) attitudes of mortality acceptance. Through purposive self-awareness, patients introspected their lived experience with illness and anticipated death to find resilience and contentment. Patients' conscious family-centered attention revolved around their relationships, achievements, and legacy within the family, leading to a deepened sense of interconnectedness with self and beloved others at life's end. Lastly, patients adopted nonjudgmental attitudes of mortality acceptance as they made necessary arrangements in preparation for their death, allowing them to treasure every living moment and obtain a closure in life. An empirical model of mindful living for dignified dying was developed based on these emerging themes, illustrating the interweaving of intention, attention, and attitude for facilitating meaningful living in the face of mortality. SIGNIFICANCE OF RESULTS: Mindful living is a dignity-preserving practice, which helps terminally ill patients to find tranquility in each present moment despite their impending death. The identified mechanisms of mindful living lay important groundwork for a new understanding and possible directions for culture-specific, mindfulness-based, family-centered interventions suited to terminally ill patients in the Asian context.

The effect of 3 commonly used surgical approaches for total hip arthroplasty on mid- to long-term patient-reported outcome measures.

INTRODUCTION: The most effective surgical approach for total hip arthroplasty (THA) remains controversial. Comparisons of surgical approach based on patient-reported outcome measures (PROMs) have been limited to short- to mid-term outcomes or the comparison of only 2 approaches. The aim of this study was to compare PROMs for the 3 main approaches for THA with up to 10 years follow-up. METHODS: A total of 906 patients who underwent primary THA at a single hospital between 2009 and 2020 through an anterior (312), lateral (211) or posterior (383) approach were evaluated using the Oxford Hip Score (OHS), EuroQoL-5-Dimension (EQ-5D-5L) and visual analogue scale/verbal rating scale for pain (VAS/VRS). PROMs were prospectively collected before surgery and routinely at 6 weeks, 6 months and 1, 2, 5 and 10 years after surgery. RESULTS: There was no significant difference in demographics or comorbidities between the 3 groups. All 3 approaches resulted in a significant improvement in overall PROMs after THA, and plateaued after 6 months postoperatively, with no difference between the approaches (OHS, p < 0.01;EQ-5D-5L Index, p < 0.01;VAS/VRS, p < 0.01). The EQ-5D-5L mobility dimension showed that the lateral approach resulted in 20% more patients reporting problems with mobility than the posterior and anterior approaches at the 6-week, 6-month, 2-year and 10-year follow-up. CONCLUSIONS: This study shows that all 3 common THA approaches substantially and similarly improve the OHS, EQ-5D-5L Index and VRS between 6 months and 10 years postoperatively. However, patient-reported mobility was poorer after a lateral approach and continued to be so at long-term follow-up.

Recovery needs and psychosocial rehabilitation trajectory of stroke survivors (PReTS): A qualitative systematic review of systematic reviews.

OBJECTIVE: Stroke has a major impact on a person's life. While much research exists on stroke prevention and treatment, explorations into psychosocial recovery needs are lacking. This review critically consolidates the challenges and needs of stroke survivors and develops a trajectory that encapsulates their journey from illness to recovery. DATA SOURCES: Six major databases were searched, including Academic Search Premier, CINAHL, Global Health, Medline, PsycArticles, and PsycINFO. METHODS: This review adhered to the PRISMA guidelines and employed the PICo (population, phenomena of interest, context) framework to screen for relevant qualitative reviews published between 1 January 2010 and 31 August 2023. Following full-text screening and the assessment of methodological quality using a modified version of the Assessment of Multiple Systematic Reviews scale, a total of 17 reviews were included for thematic synthesis. RESULTS: Included reviews referenced 400 qualitative primary studies involving more than 5623 stroke survivors. Data synthesis revealed 18 themes that were further organized into six conceptual categories: (1) The unfamiliar body, (2) compassionate healthcare system, (3) holistic rehabilitation, (4) intrapersonal strength, (5) interpersonal relations, and (6) thriving forward to form the psychosocial rehabilitation trajectory of stroke survivor (PReTS) model. The model recognizes the losses that can occur after a stroke and emphasizes the essentiality of addressing psycho-socio-emotional and spiritual needs alongside physical impairments. CONCLUSION: The PReTS model is the first to highlight stroke survivors' losses, recovery journeys, and psychosocial needs. The conceptualization serves to inform and advance stroke rehabilitation practices with holistic and wellness recovery research.

Empowering Foot Care Literacy Among People Living With Diabetes and Their Carers With an mHealth App: Protocol for a Feasibility Study.

BACKGROUND: Diabetic foot ulcers (DFUs) cause significant morbidity affecting 19% to 34% of people living with diabetes mellitus. DFUs not only impair quality of life but may also result in limb loss and mortality. Patient education has been advocated to raise awareness of proper foot self-care and the necessity of seeking assistance when a foot wound occurs. Modern technologies, including mobile health (mHealth) interventions such as health apps, bring the potential for more cost-effective and scalable interventions. OBJECTIVE: This study aims to examine the feasibility and usability of a newly developed mHealth app called Well Feet, which is a diabetes and foot care education app for individuals at risk of developing DFU. METHODS: Well Feet was developed using an evidence-based and expert panel cocreation approach to deliver educational content available in 3 languages (ie, English, Chinese, and Malay) via animation videos and a range of additional features, including adaptive learning. A nonrandomized, single-arm feasibility study using a mixed methods approach with a series of validated questionnaires and focus group discussions will be conducted. In total, 40 patients and carers will be recruited from a tertiary hospital diabetes clinic to receive a 1-month mHealth intervention. The primary outcomes are the usability of the app and a qualitative perspective on user experience. Secondary outcomes include changes in foot care knowledge, self-management behaviors, and quality of life. RESULTS: Patient recruitment began in July 2023, and the intervention and data collection will be completed by the end of September 2023. This study has been approved by National Healthcare Group Domain Specific Review Board (2022/00614) on February 10, 2023. The expected results will be published in spring 2024. CONCLUSIONS: Through this feasibility study, the Well Feet DFU education app will undergo a comprehensive quantitative and qualitative evaluation of its usability and acceptance for future improvement in its design. With local contextualization, cultural adaptation, and its multilingual functionality, the app addresses a critical aspect of DFU health education and self-management in a multiethnic population. Findings from this study will refine and enhance the features of the app based on user feedback and shape the procedural framework for a subsequent randomized controlled trial to assess the effectiveness of Well Feet. TRIAL REGISTRATION: ClinicalTrials.gov NCT05564728; https://clinicaltrials.gov/study/NCT05564728. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52036.

Scope, Characteristics, Behavior Change Techniques, and Quality of Conversational Agents for Mental Health and Well-Being: Systematic Assessment of Apps.

BACKGROUND: Mental disorders cause substantial health-related burden worldwide. Mobile health interventions are increasingly being used to promote mental health and well-being, as they could improve access to treatment and reduce associated costs. Behavior change is an important feature of interventions aimed at improving mental health and well-being. There is a need to discern the active components that can promote behavior change in such interventions and ultimately improve users' mental health. OBJECTIVE: This study systematically identified mental health conversational agents (CAs) currently available in app stores and assessed the behavior change techniques (BCTs) used. We further described their main features, technical aspects, and quality in terms of engagement, functionality, esthetics, and information using the Mobile Application Rating Scale. METHODS: The search, selection, and assessment of apps were adapted from a systematic review methodology and included a search, 2 rounds of selection, and an evaluation following predefined criteria. We conducted a systematic app search of Apple's App Store and Google Play using 42matters. Apps with CAs in English that uploaded or updated from January 2020 and provided interventions aimed at improving mental health and well-being and the assessment or management of mental disorders were tested by at least 2 reviewers. The BCT taxonomy v1, a comprehensive list of 93 BCTs, was used to identify the specific behavior change components in CAs. RESULTS: We found 18 app-based mental health CAs. Most CAs had <1000 user ratings on both app stores (12/18, 67%) and targeted several conditions such as stress, anxiety, and depression (13/18, 72%). All CAs addressed >1 mental disorder. Most CAs (14/18, 78%) used cognitive behavioral therapy (CBT). Half (9/18, 50%) of the CAs identified were rule based (ie, only offered predetermined answers) and the other half (9/18, 50%) were artificial intelligence enhanced (ie, included open-ended questions). CAs used 48 different BCTs and included on average 15 (SD 8.77; range 4-30) BCTs. The most common BCTs were 3.3 "Social support (emotional)," 4.1 "Instructions for how to perform a behavior," 11.2 "Reduce negative emotions," and 6.1 "Demonstration of the behavior." One-third (5/14, 36%) of the CAs claiming to be CBT based did not include core CBT concepts. CONCLUSIONS: Mental health CAs mostly targeted various mental health issues such as stress, anxiety, and depression, reflecting a broad intervention focus. The most common BCTs identified serve to promote the self-management of mental disorders with few therapeutic elements. CA developers should consider the quality of information, user confidentiality, access, and emergency management when designing mental health CAs. Future research should assess the role of artificial intelligence in promoting behavior change within CAs and determine the choice of BCTs in evidence-based psychotherapies to enable systematic, consistent, and transparent development and evaluation of effective digital mental health interventions.

A Systematic Review of Microwave Ablation for Colorectal Pulmonary Metastases.

BACKGROUND/AIM: Pulmonary metastases are the second most common site of metastasis in colorectal cancer after the liver, and microwave ablation (MWA) for its treatment has grown in popularity in patients who are not suitable for pulmonary metastatectomy. However, its long-term efficacy remains unknown. MATERIALS AND METHODS: A systematic review was conducted in July 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using PubMed, EMBASE, Scopus, and Cochrane databases. Studies adopting MWA for colorectal cancer pulmonary metastases were included. RESULTS: A total of 488 lesions were ablated in 230 patients across eight studies. The median duration of ablation was 10 minutes. The mean length of stay in hospital was 2.3 days. Complications included pneumothorax in 128 (52%) patients; pneumonia, which occurred in 4 (1.7%) patients, and pulmonary haemorrhage in 23 (10.0%) patients. Complete remission was achieved in 85 (37.0%) patients, local control was achieved in 103 (44.8%) patients, and residual or progressive disease remained in 85 (37.0%). Survival post ablation at 1 year was 89.2% and at 3 years was 40.3%. Post-ablation disease-free survival was 43.2% at 3 years. CONCLUSION: MWA is an alternative treatment for pulmonary metastases of colorectal cancer. It has competitive theoretical properties and local recurrence rate compared to radiofrequency ablation.

The systemic challenges of non-palliative care professionals caring for end-of-life patients: A lived experience study.

OBJECTIVES: The aims of this study are to identify the challenges faced by non-palliative care professionals (NPCPs) in caring for end-of-life patients; determine how these challenges interact with and influence each other systemically; and advance the theories and practices for supporting NPCPs in the provision of quality end-of-life care beyond the boundaries of palliative medicine. METHODS: A constructivist phenomenological research design with an Interpretive-Systemic Framework of inquiry was adopted. Thirty-five physicians, 35 nurses, and 35 Medical Social Workers who play critical roles in caring for end-of-life patients and belonging to the 9 major medical disciplines of Cardiology, Geriatric, Intensive Care Medicine, Internal Medicine, Nephrology, Neurology, Oncology, Respiratory Medicine, and Surgery were recruited through purposive snowball sampling from 3 major public hospitals. RESULTS: Framework analysis revealed 5 themes and 17 subthemes that illuminate the individual, relational, cultural, institutional, and structural challenges that NPCPs faced in rendering end-of-life care. These challenges influence each other within the health-care ecosystem, serving to perpetuate or heighten care obstacles. SIGNIFICANCE OF RESULTS: This is the first known study exploring the systemic challenges of NPCPs spanning 9 major medical disciplines and encompassing 3 professional stakeholders responsible for the care for end-of-life patients, thus ensuring perspective inclusivity across the health-care system. Recommendations that consider the complexity of the interactions between these systemic challenges are presented in detail.

Do Certain Patient Cohorts Benefit From Different Surgical Approaches in Total Hip Arthroplasty?

BACKGROUND: Unfortunately, an important minority of total hip arthroplasty (THA) patients report unsatisfactory outcomes. We aimed to compare the patient-reported outcome measures (PROMs) for three main THA approaches and evaluate the effect of sex and body mass index (BMI) on PROMs over a 10-year period. METHODS: A total of 906 patients (535 women, mean BMI 30.7 [range, 15 to 58]; 371 men, mean BMI 31.2 [range, 17 to 56]) who underwent primary THA by an anterior (AA) (312), lateral (LA) (211), or posterior (383) approach between 2009 and 2020 at a single institution were evaluated using the Oxford Hip Score (OHS). PROMs were prospectively collected before surgery and routinely at 6 weeks, 6 months, and 1, 2, 5, and 10 years after surgery. RESULTS: All three approaches resulted in significant postoperative OHS improvement. Overall, women experienced significantly lower OHS than men (P < .01). A significant negative relationship between BMI and OHS was identified and this relationship was exacerbated with an AA (P < .01). Women who had a BMI ≤ 25 reported OHS with a difference more than 5 points in favor of the AA, while women who had a BMI ≥ 42 reported an OHS with a difference more than 5 in favor of the LA. The BMI ranges were wider when comparing the anterior and posterior approaches, 22 to 46 for women and > 50 for men. For men, an OHS difference more than 5 was only seen with BMI ≥ 45 in favor of the LA. CONCLUSION: This study demonstrated that no single THA approach is superior to another but rather that certain patient cohorts may benefit more from specific approaches. We suggest that women who have a BMI ≤ 25 should consider undergoing an anterior approach for THA, while for women who have a BMI ≥ 42, a lateral approach or for a BMI ≥ 46, a posterior approach is advised.

Living losses in stroke caregiving: A qualitative systematic review of systematic reviews on psycho-socio-emotional challenges and coping mechanisms.

BACKGROUND: Stroke compromises the quality of life and wellbeing of stroke survivors and families as a whole. The unexpected caregiving responsibilities often cause psychological distress, overwhelming emotions, living losses and grief, and relational conflicts with stroke survivors. Despite the increasing research to better understand their needs, empirically sound and holistic psychosocial interventions for stroke caregivers are lacking. AIMS: This study aims to consolidate psycho-socio-emotional needs and challenges in the existing systematic reviews and offer potential directions for psychosocial interventions to better support caregivers at a psycho-socio-emotional level. METHODS: This systematic review adhered to the PRISMA guideline and employed the PICo (population, phenomena of interest, context) framework to screen for relevant systematic reviews for analysis. Six major databases were searched, including Academic Search Premier, CINAHL, Global Health, Medline, PsycArticles, and PsycInfo between 2010 and 2020. Ten systematic reviews were selected for full-text analysis using thematic synthesis. SUMMARY OF REVIEW: Data synthesis revealed eight themes with sixteen sub-themes, all together organized into two main theme categories. The psycho-socio-emotional challenges included disruptions to (1) psychological homeostasis, (2) role equilibrium, (3) familial connection, and (4) caregiving empowerment. The psycho-socio-emotional coping mechanisms, which could be adopted to buffer against the identified challenges, involved (1) recalibration of normality and balance, (2) psychosocial support and caregiver relief, (3) relational reorientation and dyadic coping, and (4) institutional holistic care and support. CONCLUSION: The findings accentuate the importance of addressing living losses and grief emerging from the caregiving journey, as well as facilitating meaning reconstruction to safeguard caregivers' wellbeing. Clinical implications and future research directions are discussed.

Continuity of Care Advocate Model (CCAM): Healthcare Workers' Perspectives on Quality Stroke Care at an Acute Unit, Rehabilitation Center and Community Rehabilitation Program in Singapore.

Physicians, nurses, social workers, and allied health professionals including physiotherapists and occupational therapists play important roles as they work closely with stroke survivors to improve functional independence in daily activities and quality of life. Yet, in Singapore little is known about their perspectives on what constitute quality stroke care based on their clinical experiences. In this project, our qualitative interviews with 15 healthcare workers at a major stroke center in the country yielded a Continuity of Care Advocate Model (CCAM) to help us better understand our participants' experience-based perspectives on quality stroke care. We found that CCAM, constructed based on the perspectives of HCWs across a stroke care continuum, is a holistic model of quality stroke care which prioritizes support for patients and their families throughout the patient's health trajectory. We conclude by discussing how this model is aligned with and differs from current research on definitions of care continuity.

Effects of participatory 'A'rt-Based Activity On 'Health' of Older Community-Dwellers: results from a randomized control trial of the Singapore A-Health Intervention.

Introduction: The practice of participatory art has been found to support the promotion, prevention, and management of health across the lifespan. However, clinical trials investigating the benefits of creative activities curated with and conducted in museums among older adults in East Asia remains limited. Methods: The current research utilized a single-site, open-label randomized control trial (RCT) to evaluate a standardized Participatory 'A'rt-Based Activity On 'Health' of Older Community-Dwellers - the Singapore A-Health Intervention. Outcome measures include frailty as assessed by the Centre of Excellence on Longevity Self-administered Questionnaire, wellbeing as assessed by the Warwick-Edinburgh Mental Wellbeing Scales, and quality of life as assessed by the EuroQol-5D. 112 participants aged 60 and above were randomized into the intervention group (n = 56) or an inactive control group (n = 56). Participants completed four standardized online self-administered assessments at baseline, 5-week, 9-week and 12-week follow-up during the intervention period. Results: Linear mixed model analyses revealed no statistically significant differences between the intervention group and control group for all outcome measures. However, within the intervention group, a consistent significant reduction in frailty was observed across time from baseline to 9 weeks (MD -0.44, 95% CI -0.85 to -0.039, p = 0.032), 5-weeks to 9-weeks (MD -0.64, 95% CI -1.03 to -0.24, p = 0.002), and 5-weeks to 12-weeks (MD -0.51, 95% CI -0.91 to -0.10, p = 0.014). Moreover, the post-test mean wellbeing score in the intervention group significantly improved over time at 9-weeks (MD 1.65, 95% CI 0.09 to 3.22, p = 0.039) and 12-week (MD 2.42, 95% CI 0.67 to 4.16, p = 0.006) as compared to baseline scores. Discussion: The findings demonstrate the potential of a structured art and museum-based intervention as a resource for promoting health among aging populations. Such benefits transcend social, cultural, and societal contexts. Clinical trial registration: ClinicalTrial.gov, NCT05945589.

A qualitative examination on the implementation of participatory "A"rt-based activity on "Health" of older community-dwellers: what worked for the Singapore A-Health Intervention?

Introduction: Art and museum-based interventions are gaining increasing recognition for their potential as low-risk activities for older adults, offering numerous physical, cognitive, and emotional benefits. However, there remains a dearth of knowledge regarding the science of implementation as well as the factors and processes that contribute to their effectiveness from the perspectives of intervention participants. Methods: The current research draws on the qualitative evaluation data obtained from a larger mixed-method randomized control trial that evaluated a standardized Participatory "A"rt-Based Activity On "Health" of Older Community-Dwellers-the Singapore A-Health Intervention. Adopting a participatory action research approach, the primary objective is to critically examine the lived experiences and health impact of the Singapore A-Health Intervention with a secondary objective to uncover strategies for optimized implementation outcomes. All 56 participants who completed the intervention filled out a program evaluation survey and a nested sample of 30 participants completed a series of acceptability focus groups. Results: Descriptive analyses of the program evaluation survey data revealed that 96.2% of participants were satisfied with the overall experience of the Singapore A-Health intervention (M = 9.00, SD = 1.76), reported that the intervention positively impacted their quality of life (M = 8.90, SD = 1.43), and social wellbeing (M = 8.92, SD = 1.43). Thematic analysis with a grounded theory approach on the qualitative focus group data revealed three interrelated themes detailing how the Singapore A-Health Intervention contributed to positive health and wellbeing outcomes (1. A-Health Experience, 2. Wellbeing Outcomes, 3. Enabling Factors) and nine subthemes (1a. Intellectual Stimulation, 1b. Positive Stress, 1c. Peer Interaction, 2a. Interpersonal Bonds, 2b. Personal Growth, 2c. Mindful Living, 3a. Integrated Support, 3b. Session Design, 3c. Mode of Engagement). Discussion: This investigation provides important insights to the Singapore A-Health intervention's effectiveness for enhancing wellbeing among older adults, as well as the factors that enable successful program implementation. These findings offer a culturally unique perspective on the benefits of art and museum interventions, while underscoring the imperative need for strong partnership and collaborations among community stakeholders in supporting the health and wellbeing of ageing populations.

Acceptability and feasibility of a pilot randomized controlled trial of Narrative e-Writing Intervention (NeW-I) for parent-caregivers of children with chronic life-threatening illnesses in Singapore.

BACKGROUND: Narrative e-Writing Intervention (NeW-I) is a novel psycho-socio-spiritual intervention which aims to bridge gaps in paediatric palliative care by providing anticipatory grief support to parent-caregivers who are looking after their child with a chronic life-threatening illness in Singapore. This is done via a therapist-facilitated smartphone app that focuses on strengths and meaning derived from parents' caregiving journey. NeW-I is empirically informed by an international systematic review and a Singapore-based qualitative inquiry on the lived experience of parental bereavement and supported by anticipatory grief interventions literature for improving the holistic well-being for parent-caregivers of seriously ill children. NeW-I is implemented in Singapore as an open-label two-armed randomized controlled trial comprising an intervention and control group. METHODS: This study examined the acceptability (via analysis of participants' post-intervention qualitative feedback and responses to a post-intervention evaluation survey) and feasibility (via records and memos of therapists' experience of delivering the intervention) of NeW-I among 26 intervention participants drawn from the larger trial. RESULTS: Framework analysis of participants' post-intervention feedback revealed four themes, namely: (i) Meaningful opportunity for reflection, (ii) Congruity with parent-caregivers' needs, (iii) Compatibility of online narrative writing and (iv) Sustainability and enhancement recommendations. The post-intervention evaluation survey showed that participants were overall satisfied with their NeW-I experience with a large number of participants acknowledging that NeW-I had improved their spiritual well-being, hopefulness about the future and perception of social support that was available to them, as well as lessened their feelings of sadness and depression, caregiver burden and fear and anxiety about their child's illness. The research team found it feasible to deliver the intervention in the current setting. CONCLUSION: NeW-I is an innovative e-health tool that could immeasurably value-add to paediatric palliative care services for Asian families in Singapore and around the world. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03684382 , Verified: September 2018.

Predicting neuropsychiatric symptoms of persons with dementia in a day care center using a facial expression recognition system.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) affect 90% of persons with dementia (PwD), resulting in various adverse outcomes and aggravating care burdens among their caretakers. This study aimed to explore the potential of artificial intelligence-based facial expression recognition systems (FERS) in predicting BPSDs among PwD. METHODS: A hybrid of human labeling and a preconstructed deep learning model was used to differentiate basic facial expressions of individuals to predict the results of Neuropsychiatric Inventory (NPI) assessments by stepwise linear regression (LR), random forest (RF) with importance ranking, and ensemble method (EM) of equal importance, while the accuracy was determined by mean absolute error (MAE) and root-mean-square error (RMSE) methods. RESULTS: Twenty-three PwD from an adult day care center were enrolled with ≥ 11,500 FERS data series and 38 comparative NPI scores. The overall accuracy was 86% on facial expression recognition. Negative facial expressions and variance in emotional switches were important features of BPSDs. A strong positive correlation was identified in each model (EM: r = 0.834, LR: r = 0.821, RF: r = 0.798 by the patientwise method; EM: r = 0.891, LR: r = 0.870, RF: r = 0.886 by the MinimPy method), and EM exhibited the lowest MAE and RMSE. CONCLUSIONS: FERS successfully predicted the BPSD of PwD by negative emotions and the variance in emotional switches. This finding enables early detection and management of BPSDs, thus improving the quality of dementia care.

Competing expectations: Advance care planning from the perspectives of doctors and nurses in the South-East Asian context.

This study qualitatively examines the perspectives of doctors and nurses on the implementation of the Advance Care Planning program in Singapore. Findings suggest that a combination of structural and conceptual factors hindered the performance of ACP. Themes on structural factors indicated that low awareness of ACP among senior staff resulted overall lack of buy-in and incorrect implementation of the program due to misconceptions. Conceptual factors pointed to lack of clarity on intended outcomes or roles. Consequently, participants drew meaning through the prism of their profession, resulting in competing expectations and tensions on possible outcomes of the program.

Resolving anticipatory grief and enhancing dignity at the end-of life: A systematic review of palliative interventions.

Anticipatory grief is the experience of grief symptomatology prior to loss. This study is a systematic review of empirical interventions or interventional components that were observed to lessen or adaptively direct the experience of anticipatory grief for patients at the end of life and their family members. A search of 5 major databases found 13,718 articles, of which 10 high-quality randomized controlled trials were included for final review. Lebow's "adaptational tasks of anticipatory mourning" was employed as a working model on the efficacy of the interventions. The interventions exhibited some positive outcomes but none addressed anticipatory grief directly. Recommendations for future research are discussed.

A Novel Mindful-Compassion Art-Based Therapy for Reducing Burnout and Promoting Resilience Among Healthcare Workers: Findings From a Waitlist Randomized Control Trial.

Protecting the mental health of healthcare workers is an urgent global public health priority. Healthcare workers, especially those immersed in palliative care, are prone to burnout due to the intense emotions associated with end-of-life caregiving. This study examines the efficacy of a novel, multimodal, and group-based Mindful-Compassion Art-based Therapy (MCAT) that integrates reflective self-awareness with creative emotional expression for protecting healthcare workers' mental health. A dual-arm open-label waitlist randomized controlled trial was conducted. A total of 56 healthcare workers were recruited from the largest homecare hospice in Singapore and randomized to the immediate-treatment condition of a standardized 6-week, 18-hours MCAT intervention (n=29), or the waitlist-control condition (n=27). Self-administered outcome measures on burnout, resilience, emotional regulation, self-compassion, death attitudes, and quality of life were collected at baseline, post-intervention/second-baseline at 6weeks, and follow-up/post-intervention at 12weeks. Results from mixed model ANOVAs reveal that treatment group participants experienced significant reduction in mental exhaustion, as well as significant improvements in overall emotional regulation, nonreactivity to intrusive thoughts, approach acceptance of death, and afterlife belief as compared to waitlist-control immediately after MCAT completion. Effect sizes of these impacts ranged from medium to large (η 2=0.65 to 0.170). Results from one-way ANOVAs further reveal that the treatment gains of reduced mental exhaustion and increased emotional regulation were maintained among treatment group participants at 12-weeks follow-up compared to baseline, with new benefits identified. These include increased ability to observe and describe one's experiences, elevated overall self-compassion, greater mindful awareness, enhanced common humanity, and better quality of life. Effect sizes of these impacts were large (η 2=0.128 to 0.298). These findings reflect the robust effectiveness and positive residual effects of MCAT for reducing burnout, building resilience, nurturing compassion, fostering collegial support, and promoting mental wellness among healthcare workers. The clinical model and applicability of MCAT in larger and more diverse caregiving contexts, such as family dementia care, are discussed. Clinical Trial Registration: ClinicalTrials.gov # NCT03440606, #NCT04548089.