Personalised care and support planning in Singapore: qualitative interviews with people living with diabetes.

BACKGROUND: Personalised care and support planning (CSP) is a person-centred approach for the care of people living with long-term conditions. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) adapts the Year of Care Partnerships (YOCP) approach to CSP in the UK for people living with diabetes at Singapore polyclinics. Polyclinics are multi-storey primary care hubs that provide affordable, multidisciplinary, comprehensive, and high-throughput public health care for the multi-ethnic, multilingual Singapore population. AIM: To explore the experience of PACE-D-enrolled people living with diabetes with personalised CSP at Singapore polyclinics. DESIGN & SETTING: Qualitative interviews of people living with diabetes who experienced personalised CSP at National University Polyclinics (NUP) in Singapore between July 2020 and November 2021. METHOD: PACE-D-enrolled people living with diabetes who experienced personalised CSP were purposively sampled. In-depth semi-structured interviews were recorded, transcribed, and analysed using Braun and Clarke's reflexive thematic analysis. RESULTS: Fifty-two patients participated in the study. Four main themes were identified. Theme 1 was the importance of the care-planning letter. Patients reported that the CPL prompted reflection and patient preparation for CSP conversations. Theme 2 was the role of the programme coordinator. PACE-D programme coordinators amplified self-management by playing advocate and confidant beyond administrative duties. Theme 3 was the value of the personalised CSP conversation. CSP providers were perceived as partners in care, with more time to listen compared with usual consultations. Patient engagement was affected by language confidence. Theme 4 was agency in self-management. With adequate time and support, patients increased in confidence and agency both in CSP engagement and diabetes self-management. CONCLUSION: While language confidence may affect patient engagement, personalised CSP shows promise for strengthening patient engagement and self-management among people living with diabetes at Singapore polyclinics.

Lockdown! Learning public health of infectious diseases through gameplay.

The COVID-19 pandemic has demonstrated the detrimental effects of a lack of understanding of public health measures. During the pandemic, lockdowns, social distancing, and mask mandates introduced by governments were met with skepticism, doubt, and an unwillingness to comply, increasing the extent of negative outcomes as a result. Albeit devastating, the pandemic has offered an invaluable opportunity to observe the correlation between the prevalence of public health education and compliance with public health measures during critical times. In this article, we describe a card game that was developed during the COVID-19 pandemic to educate the public (including children) about how specific public health measures address the pandemic and how global cooperation is essential in addressing even one country's problems. The game can be used in primary, secondary, or tertiary education classrooms, initiating conversations about the topic and providing a basic understanding before more in-depth learning.

Implementing and evaluating care and support planning: a qualitative study of health professionals' experiences in public polyclinics in Singapore.

BACKGROUND: Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals' perspectives on CSP to inform future developments. METHODS: Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them. RESULTS: Both polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP 'going well' all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals' accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers' person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals' ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP. CONCLUSION: Health professionals' interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Antibiotic treatment failure of uncomplicated urinary tract infections in primary care.

BACKGROUND: Higher resistance rates of > 20% have been noted in Enterobacteriaceae urinary isolates towards ciprofloxacin and co-trimoxazole (C + C) in Singapore, compared with amoxicillin-clavulanate and nitrofurantoin (AC + N). This study examined if treatment failure varied between different antibiotics, given different resistant rates, for uncomplicated urinary tract infections (UTIs) managed in primary care. We also aimed to identify gaps for improvement in diagnosis, investigations, and management. METHODS: A retrospective cohort study was conducted from 2019 to 2021 on female patients aged 18-50 with uncomplicated UTIs at 6 primary care clinics in Singapore. ORENUC classification was used to exclude complicated UTIs. Patients with uncomplicated UTIs empirically treated with amoxicillin-clavulanate, nitrofurantoin, ciprofloxacin or co-trimoxazole were followed-up for 28 days. Treatment failure was defined as re-attendance for symptoms and antibiotic re-prescription, or hospitalisation for UTI complications. After 2:1 propensity score matching in each group, modified Poisson regression and Cox proportional hazard regression accounting for matched data were used to determine risk and time to treatment failure. RESULTS: 3194 of 4253 (75.1%) UTIs seen were uncomplicated, of which only 26% were diagnosed clinically. Urine cultures were conducted for 1094 (34.3%) uncomplicated UTIs, of which only 410 (37.5%) had bacterial growth. The most common organism found to cause uncomplicated UTIs was Escherichia coli (64.6%), with 92.6% and 99.4% of isolates sensitive to amoxicillin-clavulanate and nitrofurantoin respectively. Treatment failure occurred in 146 patients (4.57%). Among 1894 patients treated with AC + N matched to 947 patients treated with C + C, patients treated with C + C were 50% more likely to fail treatment (RR 1.49, 95% CI 1.10-2.01), with significantly higher risk of experiencing shorter time to failure (HR 1.61, 95% CI 1.12-2.33), compared to patients treated with AC + N. CONCLUSION: Treatment failure rate was lower for antibiotics with lower reported resistance rates (AC + N). We recommend treating uncomplicated UTIs in Singapore with amoxicillin-clavulanate or nitrofurantoin, based on current local antibiograms. Diagnosis, investigations and management of UTIs remained sub-optimal. Future studies should be based on updating antibiograms, highlighting its importance in guideline development.

Risk and protective factors associated with adolescent depression in Singapore: a systematic review.

Introduction: Adolescent depression is prevalent, and teen suicide rates are on the rise locally. A systemic review to understand associated risk and protective factors is important to strengthen measures for the prevention and early detection of adolescent depression and suicide in Singapore. This systematic review aims to identify the factors associated with adolescent depression in Singapore. Methods: A systematic search on the following databases was performed on 21 May 2020: PubMed, EMBASE and PsycINFO. Full texts were reviewed for eligibility, and the included studies were appraised for quality using the Newcastle Ottawa Scale. Narrative synthesis of the finalised articles was performed through thematic analysis. Results: In total, eight studies were included in this review. The four factors associated with adolescent depression identified were: (1) sociodemographic factors (gender, ethnicity); (2) psychological factors, including childhood maltreatment exposure and psychological constructs (hope, optimism); (3) coexisting chronic medical conditions (asthma); and (4) lifestyle factors (sleep inadequacy, excessive internet use and pathological gaming). Conclusion: The identified factors were largely similar to those reported in the global literature, except for sleep inadequacy along with conspicuously absent factors such as academic stress and strict parenting, which should prompt further research in these areas. Further research should focus on current and prospective interventions to improve mental health literacy, targeting sleep duration, internet use and gaming, and mitigating the risk of depression in patients with chronic disease in the primary care and community setting.

Prescribing Antibiotics in Public Primary Care Clinics in Singapore: A Retrospective Cohort Study.

BACKGROUND: Antibiotic prescription practices in primary care in Singapore have received little scholarly attention. In this study, we ascertained prescription prevalence and identified care gaps and predisposing factors. METHODS: A retrospective study was conducted on adults (>21 years old) at six public primary care clinics in Singapore. Prescriptions >14 days were excluded. Descriptive statistics were used to showcase the prevalence data. We used chi-square and logistic regression analyses to identify the factors affecting care gaps. RESULTS: A total of 141,944 (4.33%) oral and 108,357 (3.31%) topical antibiotics were prescribed for 3,278,562 visits from 2018 to 2021. There was a significant reduction in prescriptions (p < 0.01) before and after the pandemic, which was attributed to the 84% reduction in prescriptions for respiratory conditions. In 2020 to 2021, oral antibiotics were most prescribed for skin (37.7%), genitourinary (20.2%), and respiratory conditions (10.8%). Antibiotic use in the "Access" group (WHO AWaRe classification) improved from 85.6% (2018) to 92.1% (2021). Areas of improvement included a lack of documentation of reasons for antibiotic use, as well as inappropriate antibiotic prescription for skin conditions. CONCLUSION: There was a marked reduction in antibiotic prescriptions associated with the onset of the COVID-19 pandemic. Further studies could address the gaps identified here and evaluate private-sector primary care to inform antibiotic guidelines and the local development of stewardship programs.

COVID-19 vaccine acceptance and hesitancy among primary healthcare workers in Singapore.

BACKGROUND: Factors affecting COVID-19 vaccine acceptance and hesitancy among primary healthcare workers (HCW) remain poorly understood. This study aims to identify factors associated with vaccine acceptance and hesitancy among HCW. METHODS: A multi-centre online cross-sectional survey was performed across 6 primary care clinics from May to June 2021, after completion of staff vaccination exercise. Demographics, profession, years working in healthcare, residential status, presence of chronic medical conditions, self-perceived risk of acquiring COVID-19 and previous influenza vaccination were collected. HCW who accepted vaccine were then asked to rank their top 5 reasons for vaccine acceptance; HCW who were vaccine hesitant had to complete the 15-item 5C scale on psychological antecedents of vaccination. RESULTS: Five hundred fifty seven out of 1182 eligible HCW responded (47.1%). Twenty nine were excluded due to contraindications. Among 528 respondents, vaccine acceptance rate was 94.9% (n = 501). There were no statistically significant differences in COVID-19 vaccine acceptance between sex, age, ethnicity, profession, number of years in healthcare, living alone, presence of chronic diseases, self-perceived risk or previous influenza vaccination. The top 3 reasons for COVID-19 vaccine acceptance ranked by 501 HCW were to protect their family and friends, protect themselves from COVID-19 and due to high risk of acquiring COVID-19 because of their jobs. HCW with suspected or confirmed COVID-19 exposure were 3.4 times more likely to rank 'high risk at work' as one of the top reasons for vaccine acceptance (χ2 = 41.9, p < 0.001, OR = 3.38, 95%C.I. 2.32-4.93). High mean scores of 'Calculation' (5.79) and low scores for 'Constraint' (2.85) for 5C components among vaccine hesitant HCW (n = 27) highlighted that accessibility was not a concern; HCW took time to weigh vaccine benefits and consequences. CONCLUSION: COVID-19 vaccine hesitancy is a minute issue among Singapore primary HCW, having achieved close to 95% acceptance rate. COVID-19 exposure risk influences vaccine acceptance; time is required for HCW to weigh benefits against the risks. Future studies can focus on settings with higher hesitancy rates, and acceptance of booster vaccinations with the emergence of delta and omicron variants.

Exploring antibiotic prescribing in public and private primary care settings in Singapore: a qualitative analysis informing theory and evidence-based planning for value-driven intervention design.

BACKGROUND: Singapore's healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems. AIM: To explore processes underpinning decision-making for antibiotic prescribing, by considering doctors' experiences in different primary care settings. METHODS: Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing. RESULTS: Given Singapore's lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices. These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change. CONCLUSIONS: These VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly.

The Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) protocol: a non-randomised controlled trial of personalised care and support planning for persons living with diabetes.

BACKGROUND: Personalised care and support planning (CSP) has been shown to improve diabetes outcomes, patient experience and provider morale in the care of persons living with diabetes. However, this has not been confirmed in controlled studies. Patient Activation through Community Empowerment/Engagement for Diabetes Management (PACE-D) is a pragmatic controlled trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in the public primary care setting in Singapore. METHODS: Teamlet-empanelled patients with diabetes at four polyclinics are recruited for this study. Participants who attend either of the two Intervention clinics are sent their investigation results in a care planning letter (CPL) to prepare them for the CSP conversation. This conversation is facilitated by a trained CSP practitioner who engages them in discussion of concerns, goals and action plans, and documents their plans for subsequent review. Participants in the two Control clinics will receive standard diabetes care. Participants will complete two or more CSP conversations (Intervention) or regular consultations (Control) at the annual review visits within the 18 months of the study. The sample size is calculated at 1620 participants, with glycated haemoglobin (HbA1c) as the primary outcome measure. Secondary outcome measures include patient activation (as measured by PAM-13) and changes in healthcare utilisation and cost. DISCUSSION: This study is a pragmatic trial that evaluates the effectiveness of personalised CSP in persons living with diabetes in a real world setting. It promises to provide insights with regard to the implementation of this model of care in Singapore and the region. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04288362. Retrospectively registered on 28 February 2020.

The adult patient with headache.

Headaches are common in primary care. For safe assessment and management of the patient with headache, a focused history and physical examination are important to identify secondary headache, and find out whether an immediate referral to the emergency department or a non-emergent referral to the neurologist is warranted. The majority of patients with primary headache may be safely managed in the outpatient setting. Key steps include proper categorisation of the primary headache, attention to lifestyle and psychosocial factors, prescription of analgesics for acute pain relief, and the use of preventive medication when indicated. The patient with a cluster headache, a headache of uncertain diagnosis and/or poor response to preventive strategies or a migraine with persistent aura, or a headache with associated motor weakness, should be referred to a neurologist. Secondary headache and the diagnosis of medication overuse headache should be considered in a patient on long-term analgesics with unremitting headache.

Outpatient management of knee osteoarthritis.

Osteoarthritis of the knee is a common disease that causes significant disability. Most patients can be managed conservatively in the outpatient setting. A small minority require surgery. The cornerstones of treatment are weight loss, exercise and analgesia. Walking aids, medial patellar taping, acupuncture and transcutaneous electrical nerve stimulation are useful management adjuncts. Current evidence does not support routine prescription of glucosamine and chondroitin supplements. Early consultation with an orthopaedic surgeon should be made when conservative measures fail.

Results from a Patient-Based Health Education Intervention in Reducing Antibiotic Use for Acute Upper Respiratory Tract Infections in the Private Sector Primary Care Setting in Singapore.

We investigated the efficacy of patient-targeted education in reducing antibiotic prescriptions for upper respiratory tract infections (URTIs) among adults in the private primary care setting in Singapore. Our randomized controlled trial enrolled patients aged 21 years and above presenting at general practitioner (GP) clinics with URTI symptoms for 7 days or less. Intervention arm patients were verbally educated via pamphlets about the etiology of URTIs, the role of antibiotics in treating URTIs, and the consequences of inappropriate antibiotic use. Control arm patients were educated on influenza vaccinations. Both arms were compared regarding the proportions prescribed antibiotics and the patients' postconsultation views. A total of 914 patients consulting 35 doctors from 24 clinics completed the study (457 in each arm). The demographics of patients in both arms were similar, and 19.1% were prescribed an antibiotic, but this varied from 0% to 70% for individual GPs. The intervention did not significantly reduce antibiotic prescriptions (odds ratio [OR], 1.20; 95% confidence interval [CI], 0.83-1.73) except in patients of Indian ethnicity (OR, 0.28; 95% CI, 0.09-0.93). Positive associations between the intervention and the view that antibiotics were not needed most of the time for URTIs (P = 0.047) and on being worried about the side effects of antibiotics (P = 0.018) were restricted to the Indian subgroup. GPs in limited liability partnerships or clinic chains prescribed less (OR, 0.36; 95% CI, 0.14 to 0.92), while certain inappropriate patient responses were associated with the receipt of antibiotics. Follow-up studies to investigate differences in responses to educational programs between ethnicities and to explore GP-targeted interventions are recommended.

Outpatient management of transient ischaemic attack.

Stroke is a significant cause of death and disability in Singapore; in 2014, it was the fourth most common cause of death. Transient ischaemic attack (TIA) is defined as a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without evidence of acute infarction. The diagnosis of TIA/acute stroke needs to be considered in all patients who present with sudden focal neurological dysfunction. Prompt referral for assessment, neuroimaging and intervention provides the best chance for neurological recovery and/or minimising further neurological damage. Primary care physicians have a crucial role in TIA/stroke prevention and management. This includes referring patients with suspected acute TIA/stroke to hospitals with stroke treatment facilities immediately; managing the modifiable risk factors of cerebral ischaemia; continuing prescription of antiplatelet agents and/or anticoagulation where indicated; and teaching patients to recognise and respond to suspected cerebral ischaemia using the FAST (face, arm, speech, time) acronym.

Knowledge, attitudes and practices towards antibiotic use in upper respiratory tract infections among patients seeking primary health care in Singapore.

BACKGROUND: Patients' expectations can influence antibiotic prescription by primary healthcare physicians. We assessed knowledge, attitude and practices towards antibiotic use for upper respiratory tract infections (URTIs), and whether knowledge is associated with increased expectations for antibiotics among patients visiting primary healthcare services in Singapore. METHODS: Data was collected through a cross-sectional interviewer-assisted survey of patients aged ≥21 years waiting to see primary healthcare practitioners for one or more symptoms suggestive of URTI (cough, sore throat, runny nose or blocked nose) for 7 days or less, covering the demographics, presenting symptoms, knowledge, attitudes, beliefs and practices of URTI and associated antibiotic use. Univariate and multivariate logistic regression was used to assess independent factors associated with patients' expectations for antibiotics. RESULTS: Nine hundred fourteen out of 987 eligible patients consulting 35 doctors were recruited from 24 private sector primary care clinics in Singapore. A third (307/907) expected antibiotics, of which a substantial proportion would ask the doctor for antibiotics (121/304, 40 %) and/or see another doctor (31/304, 10 %) if antibiotics were not prescribed. The majority agreed "antibiotics are effective against viruses" (715/914, 78 %) and that "antibiotics cure URTI faster" (594/912, 65 %). Inappropriate antibiotic practices include "keeping antibiotics stock at home" (125/913, 12 %), "taking leftover antibiotics" (114/913, 14 %) and giving antibiotics to family members (62/913, 7 %). On multivariate regression, the following factors were independently associated with wanting antibiotics (odds ratio; 95 % confidence interval): Malay ethnicity (1.67; 1.00-2.79), living in private housing (1.69; 1.13-2.51), presence of sore throat (1.50; 1.07-2.10) or fever (1.46; 1.01-2.12), perception that illness is serious (1.70; 1.27-2.27), belief that antibiotics cure URTI faster (5.35; 3.76-7.62) and not knowing URTI resolves on its own (2.18; 1.08-2.06), while post-secondary education (0.67; 0.48-0.94) was inversely associated. Those with lower educational levels were significantly more likely to have multiple misconceptions about antibiotics. CONCLUSION: Majority of patients seeking primary health care in Singapore are misinformed about the role of antibiotics in URTI. Agreeing with the statement that antibiotics cure URTI faster was most strongly associated with wanting antibiotics. Those with higher educational levels were less likely to want antibiotics, while those with lower educational levels more likely to have incorrect knowledge.