Multi-level determinants of breast cancer screening among Malay-Muslim women in Singapore: a sequential mixed-methods study.

OBJECTIVE: Ethnic disparity persists despite equal access to health care in Singapore, with Malay-Muslim women having the lowest mammogram uptake rate and highest breast cancer mortality rate. We sought to understand barriers to and facilitators for mammogram uptake in this community. METHODS: We used a sequential mixed-methods design to first explore reasons for screening and not screening for breast cancer, then determine factors associated with screening and regular screening in a survey. We used maximum variation sampling for semi-structured in-depth interviews to select screeners and non-screeners of diverse ages and educational levels. Twenty-three Malay-Muslim women aged 40-69 years old were interviewed. Themes were categorized using thematic analysis. For the survey, we applied the Health Belief Model, Social Ecological Model, as well as themes from the interviews and findings from previous studies on factors influencing screening in Muslim women to guide questionnaire design. We surveyed 271 Malay-Muslim women aged 50-69 years old in a nationally representative sample. Multivariable logistic regression was used to determine factors associated with ever gone for mammogram and regular mammogram uptake. RESULTS: Through in-depth-interviews, we found perceived benefits of saving lives and breasts from early detection, reminders from doctors and husbands, symptoms, perceived test from God, and personal responsibility to care for one's health facilitated screening. Barriers were perceived low susceptibility, inconvenience, cost, negative psychological effects, misinformation on mammogram triggering cancer cells, religious beliefs, perceived negative outcomes from mammography and distrust of doctor. From the survey, we found cues from health care professionals and needing symptoms before deciding to go for mammogram to be significantly associated with ever gone for mammogram and regular mammogram. Factors associated with ever gone for mammogram only included age, perceived benefits of saving lives from early detection, perceived importance of mammogram, Punishing Allah Reappraisal, and modesty. Factors associated with regular mammogram only included household income, perceived structural barriers to screening and perceived susceptibility to breast cancer. CONCLUSIONS: Mammogram uptake is affected by multiple levels of influence. Interventions to promote screening should be designed with multiple stakeholders including doctors, religious leaders and women who had attended screening.

Screening is not always healthy: an ethical analysis of health screening packages in Singapore.

BACKGROUND: Health screening is undertaken to identify individuals who are deemed at higher risk of disease for further diagnostic testing so that they may possibly benefit from interventions to modify the natural course of disease. In Singapore, screening tests are widely available in the form of a package, which bundles multiple tests in one session and commonly includes non-recommended tests. There are various ethical issues associated with such testing as they may not be clinically appropriate and can result in more harm than benefit. This article describes the practice of health screening packages, identifies the ethical issues arising from such packages and discusses the implications of these ethical issues on policy and practice of screening in Singapore. METHODS: A content analysis of the websites of providers offering general health screening packages to individuals was conducted. A total of 14 health screening package providers were analysed for how packages were conducted and promoted, how clinically appropriate screening tests were, and the price range and composition of screening packages. A normative ethical analysis based on the four principles approach of beneficence, non-maleficence, autonomy and justice in biomedical ethics was used. RESULTS: Twelve of the 14 providers included non-recommended tests such as tumour markers, treadmill stress tests and MRI scans in their general health screening packages. Package prices ranged from S$26 to S$10,561, with providers charging higher when more tests were included. Health screening packages were broadly conducted in three stages: (1) the offer and selection of a health screening package; (2) medical assessment and performance of screening tests; (3) a post-screening review. While material provided by all providers was factual, there was no information on the potential risks or harms of screening. CONCLUSION: Several ethical issues were identified that should be addressed with regard to health screening packages in Singapore. A key issue was the information gap between providers and patients, which may result in patients undergoing inappropriate testing that may be more harmful than beneficial. Health screening packages can stimulate unnecessary demand for healthcare and contribute to an inequitable distribution of healthcare resources.

Colorectal cancer patients advocating screening to their siblings: a randomized behavioral intervention.

BACKGROUND AND AIMS: Siblings of colorectal cancer (CRC) patients are at increased risk of developing CRC, but screening rates remain low. Through a randomized behavioral intervention, this study aimed to determine whether patients can advocate screening to their siblings using a tailored educational package. METHODS: CRC survivors were recruited and randomized into relaying either tailored materials (intervention group) or existing national screening guidelines (control group) to their siblings. Siblings could respond to the study team if they were interested in learning about CRC screening. Study outcomes were patient advocacy rates (number of patients who had successfully contacted at least 1 eligible sibling) between groups and the proportion of eligible siblings who responded. RESULTS: Between May 2017 and March 2021, 219 CRC patients were randomized to the intervention (n = 110) and control (n = 109) groups. Patient advocacy rates were high and did not differ significantly between groups. However, only 14.3% of eligible siblings (n = 85) responded to the study team. Siblings of patients from the intervention group were more likely to respond (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0; P < .05). Moreover, after controlling for potential confounders, siblings aged ≥60 years were significantly less likely to respond (adjusted odds ratio, .3; 95% confidence interval, .1-.7; P < .01). CONCLUSIONS: CRC patients are willing advocates of screening, and siblings contacted by patients from the intervention group were also more likely to reach out to the study team. However, overall sibling response rates were low despite advocacy, suggesting that patient-led advocacy should at best be used as an adjunct to other, multipronged CRC screening promotion modalities.

Factors predicting improved compliance towards colonoscopy in individuals with positive faecal immunochemical test (FIT).

OBJECTIVES: Follow-up colonoscopy after a positive faecal immunochemical test (FIT) in any colorectal cancer (CRC) screening programme is integral. However, many individuals who had a positive FIT declined colonoscopy subsequently. This study aims to uncover the predictors on completion of colonoscopy using the Health Belief Model (HBM) between individuals who complete and those who did not after a positive FIT. METHODS: A mixed-method study comprising qualitative semi-structured interviews followed by a locally validated questionnaire in Singapore was prospectively administered via telephone interview to average risk individuals with positive FIT results from a cohort of the national FIT screening database referred for follow-up colonoscopic evaluation. RESULTS: A total of 394 individuals, with a median age of 66 years (range, 46-89 years), were recruited. Fifty percent completed follow-up colonoscopic evaluation and formed the "doers" group. All participants demonstrated high knowledge of symptoms of CRC and awareness and qualitative responses were aligned to the various HBM domains. Using multi-variable analysis, doers felt that medical recommendations (odds ratio [OR], 2.39, 95% confidence interval [CI]: 1.23-4.63, p = 0.01) and mainstream media publicity (OR, 2.16, 95% CI: 1.09-4.26, p = 0.026) were important. Non-doers showed positive association with perceived barriers such as cost (OR, 2.15, 95% CI: 1.10-4.20, p = 0.026) and inconvenience (OR, 3.44, 95% CI: 1.50-7.89, p = 0.004). CONCLUSIONS: Identified factors such as tackling perceived barriers, public health education and active promotion by medical physicians, family and friends could help guide subsequent interventions to improve compliance of individuals with positive FIT to undergo follow-up colonoscopy.

Association between sexual orientation acceptance and suicidal ideation, substance use, and internalised homophobia amongst the pink carpet Y cohort study of young gay, bisexual, and queer men in Singapore.

BACKGROUND: Gay, bisexual and queer (GBQ) men are frequently subjected to minority stressors that have negative impacts on their health. Milestones that include the acceptance and disclosure of sexual identity amongst GBQ men are hence key instruments in understanding the prevalence of internalised homophobia and predicting health outcomes. As such, this work takes a novel approach to deduce the correlates of delayed acceptance of sexual orientation in young GBQ men as a measure of internalised homophobia through retrospective self-reporting and age-based analysis. METHODS: Participants were recruited as part of a cohort study exploring the syndemic risks associated with HIV acquisition among young GBQ men in Singapore. We examined their levels of internalised, perceived, experienced homophobia, as well as their health behaviours and suicidal tendencies. Two separate variables were also self-reported by the participants - the age of questioning of sexual orientation and the age of acceptance of sexual orientation. We subsequently recoded a new variable, delayed acceptance of sexual orientation, by taking the difference between these two variables, regressing it as an independent and dependent variable to deduce its psychosocial correlates, as well as its association with other measured instruments of health. RESULTS: As a dependent variable, delayed acceptance of sexual orientation is positively associated with an increase of age and internalised homophobia, while being negatively associated with reporting as being gay, compared to being bisexual or queer. As an independent variable, delayed acceptance of sexual orientation was associated with a delayed age of coming out to siblings and parents, suicide ideation, historical use of substances including smoking tobacco cigarettes and consuming marijuana, as well as reporting higher levels of experienced, internalised and perceived homophobia. CONCLUSION: Greater levels of early intervention and efforts are required to reduce the heightened experience of minority stress resulting from communal and institutional hostilities. Areas of improvement may include community-based counselling and psychological support for GBQ men, while not forsaking greater education of the social and healthcare sectors. Most importantly, disrupting the stigma narrative of a GBQ 'lifestyle' is paramount in establishing an accepting social environment that reduces the health disparity faced by GBQ men.

Perceptions of an HIV self-testing intervention and its potential role in addressing the barriers to HIV testing among at-risk heterosexual men: a qualitative analysis.

OBJECTIVES: Voluntary HIV testing rates are still low in several Asian countries including Singapore. HIV self-testing (HIVST) has the potential to increase testing, leading to earlier diagnosis and better prognosis. However, the views of at-risk individuals, especially heterosexual men (HSM), who are not coming forward for testing are still poorly understood. In this study, we examined the barriers and facilitators to and delivery preferences for HIVST in order to implement an effective intervention in Singapore. METHODS: From May 2017 to June 2018, 48 in-depth interviews were conducted with HSM aged 21-66 years and at risk of HIV infection. Participants were purposively sampled based on ethnicity, age and testing behaviour. Recruitment was done mainly at brothels and entertainment establishments in Singapore. Participants gave their views on HIV testing, factors affecting HIVST use and their preferred HIVST service delivery model. RESULTS: Most participants preferred HIVST over conventional testing for its convenience, privacy, anonymity and autonomy, but older men still preferred conventional testing. Low self-perceived risk, low awareness and self-efficacy for HIVST, and non-comprehensive test for other STIs were reported as barriers to HIVST. There were mixed opinions on kit preference. A blood-based kit was favoured for higher accuracy, while the oral-fluid-based kit was favoured for ease of use. Participants wanted a human touch for post-test counselling and linkage to care only if they self-tested positive. Traditional media, internet and social media, and venue-based outreach were potential advertising platforms mentioned. CONCLUSIONS: A locally acceptable and feasible HIVST intervention must address the barriers and facilitators of using HIVST in order to improve HIV testing rates among this at-risk population who might otherwise delay or fail to present for testing.

Tobacco use patterns and attitudes in Singapore young male adults serving military national service: a qualitative study.

OBJECTIVES: To explore tobacco use patterns and factors influencing tobacco use in young Singaporean men serving military national service. METHODS: A qualitative study using in-depth telephone interviews and maximum variation sampling was conducted with 29 Singaporean men who have completed their national service in 2017-2018. Data were analysed using thematic analysis. RESULTS: More than half (51.7%) of the participants started smoking before age 18, with a mean age of smoking initiation at 16 years. At the individual level, the two main contributing factors to tobacco use were smoking as a coping mechanism, and physical or psychological addiction. Financial concern was reported as the key motivation to quit smoking. At the interpersonal level, peers and superiors played an influential role in the smoking habits of the participants. When superiors took additional measures against smoking behaviours, it contributed to their decision to smoke less. At the organisation level, some unintended consequences were reported as a result of the strict tobacco control measures implemented by the military, such as the designated smoking areas within the camps become regarded as an area for socialisation. CONCLUSION: Informed by the Socio-Ecological Model, this study has provided insights into the multifaceted and interactive effect of individual, interpersonal and organisational factors that influence tobacco use in young men serving military national service in the Singapore and Asian context. The study insights provided an understanding of the local context before designing programmes or changing regulations to further discourage tobacco usage in the military.

Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach.

AIMS: To assess factors associated with ever receiving prediabetes education, and to explore the health education and communication needs among primary care patients with prediabetes in Singapore. METHODS: A mixed methods study, consisting of a cross-sectional survey involving 433 patients with prediabetes aged 21-79, and in-depth interviews (IDIs) with 48. Multivariable regression was used to analyse the survey results, while thematic analysis was used to analyse the IDIs. RESULTS: The prevalence of ever receiving prediabetes education was 26.6%. This was positively associated with school education, impaired glucose tolerance, number of co-morbidities, having family or peer with diabetes, having support to reduce diabetes risk, confidence to self-manage prediabetes, and negatively associated with age. A common reason among those not receiving such education was not being referred by doctors. The preferred content of health communication messages were to focus on risk and prevention of diabetes, health and family, and to avoid the term 'prediabetes' in messages. The top 2 preferred education components were healthy eating and physical activity, and the most desired setting was the community centre. CONCLUSIONS: More efforts are needed to increase the take-up rate of prediabetes education. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources.

Uncovering the barriers to undergoing screening among first degree relatives of colorectal cancer patients: a review of qualitative literature.

First degree relatives (FDRs) of colorectal cancer (CRC) patients are at higher risks of developing the disease, but screening rates amongst this group remains dismal. We undertook a systematic review of qualitative studies to identify the barriers surrounding CRC screening among FDRs from both the FDRs' and the healthcare professionals' perspectives. A comprehensive search of major bibliographic databases from January 2000 till February 2017 was performed to answer the above research questions. Pre-determined inclusion and exclusion criteria were applied. Thematic analysis was used to derive the commonalities across the studies. COREQ checklist was used to evaluate the quality of the included studies. Eight qualitative studies were included. Some of the barriers reported by FDRs included the fear of diagnosis of cancer and socio-cultural barriers. The most important barrier was the FDRs' negative perceptions towards screening test such as discomfort, embarrassment, cost of procedure and accessibility to healthcare resources. Likewise, the lack of awareness amongst FDRs that they are at increased risk of developing CRC was also found to be a barrier. On the other hand, healthcare providers are keen for patients themselves to be advocates for CRC screening of their family members as constraints posed by their daily workload impede their time to advocate screening. Lack of knowledge of the physicians on CRC screening guidelines is another notable barrier. A lack of awareness of being at higher risk of developing CRC coupled with negative attitude towards colonoscopy are the main barriers faced by the FDRs of CRC patients. Healthcare providers are more comfortable with patients being the advocates of screening among their family members.

Screening in spouses of colorectal cancer patients: a missed opportunity.

BACKGROUND: Spouses of colorectal cancer (CRC) patients could be at increased risk of developing CRC due to shared lifestyle habits with the patients which is a notable risk factor. This study explores the various issues surrounding CRC screening among these spouses. METHODS: A mixed method study comprising in-depth qualitative semi-structured interviews followed by structured quantitative questionnaire was administered to spouses who accompanied CRC patients during their appointments, from January 2016 to February 2017. RESULTS: Fifty spouses of CRC patients, median age of 60 (range, 41-82) years, were qualitatively interviewed but 5 of them did not complete the questionnaire. Only 26 (57.8%) of them were current with CRC screening. Data saturation was reached at the 48th participant. Four main themes emerged from the qualitative interviews. These included (i) adequacy of knowledge and attitudes about CRC screening, (ii) suboptimal public health promotion efforts of CRC screening, (iii) barriers of CRC screening, and (iv) need for mutual spousal support. From the questionnaires, spouses who were not current with CRC screening were more likely to report more barriers and have different cues to actions than those who are current. The majority of the spouses demonstrated high levels of knowledge on CRC, understood its severity and their susceptibility. CONCLUSION: Spouses exhibit high levels of knowledge and awareness of the implications of CRC. Apart from addressing psychological issues during the acute phases, targeted interventions should be considered to improve their screening rates and to use them as advocates for CRC screening among family and community.

Getting the first degree relatives to screen for colorectal cancer is harder than it seems-patients' and their first degree relatives' perspectives.

INTRODUCTION: First degree relatives (FDR) of colorectal cancer (CRC) patients are at increased risk of CRC compared to the general population. However, screening colonoscopy rates amongst the FDRs remain dismal. The aim of the study was to explore the various issues amongst the patients and their FDR precluding their adoption of screening colonoscopy. METHODS: A qualitative study of CRC patients and their FDRs was performed. Semi-structured interviews were conducted with participants using open-ended questions until data saturation was achieved. These qualitative data were then thematically analysed. RESULTS: Fifty CRC patients and thirty-one FDRs were recruited between June 2015 and December 2015. For the patients, three main themes emerged, which include (i) poor understanding of the CRC screening guidelines for their FDRs, (ii) recommendations are lacking amongst medical professionals and (iii) numerous barriers are hindering patients from being advocates for screening colonoscopy for their FDRs. For the FDRs, three main themes emerged. These include (i) poor understanding of the exact CRC screening guidelines amongst the FDRs, (ii) the lack of health promotion efforts amongst medical professionals and (iii) barriers to the uptake of screening colonoscopy such as fear of colonoscopy, high cost of the procedure, its associated inconvenience and perceived invulnerability of the individual. CONCLUSIONS: Patients and FDRs are not aware of the increased risks of developing CRC amongst the family members. Guidelines regarding screening are also not clearly understood. The numerous barriers that are present amongst the CRC patients and their FDRs can be addressed.

What are the factors associated with human immunodeficiency virus/sexually transmitted infection screening behaviour among heterosexual men patronising entertainment establishments who engaged in casual or paid sex? - Results from a cross-sectional survey in an Asian urban setting.

BACKGROUND: Late presentation of human immunodeficiency virus (HIV) is associated with heterosexual transmission, particularly among heterosexual men in Asia. Although data on HIV/sexually transmitted infection (STI) testing behaviour is increasing, information is still lacking among heterosexual men who receive far lesser attention and are generally invisible in HIV/ STI prevention, particularly in the Asian urban setting. The aim of this study was to assess the prevalence of HIV/STI testing among heterosexual men patronising entertainment establishments (EEs) who engaged in casual or paid sex in Singapore, and the factors associated with this behaviour. METHODS: This was a cross-sectional survey involving 604 participants using time location sampling between March and May 2015. For multivariable analysis, we used a mixed effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratio (aPR) for the association of various factors with HIV/STI testing. RESULTS: Among 604 at-risk participants, only 163 (27.0%) had gone for HIV or STI testing in the past 6 months. Of this, 83.4% of them specifically underwent HIV testing. In multivariable analysis, HIV/STI testing increased with being non-Chinese (aPR 1.50; 95% CI: 1.08-2.06), having engaged in anal sex with casual or paid partner in the past 6 months (aPR 1.80; 95% CI: 1.27-2.57), number of partners in the past 6 months (aPR 1.03; 95% CI: 1.01-1.05) and HIV knowledge score (aPR 1.11; 95% CI: 1.05-1.16). Among those who reported non-consistent condom use with casual or paid partner, almost half of them (47.9%) perceived that they were at low risk for HIV/STI. Sigmatisation and discrimination was another common barrier for non-testing. CONCLUSIONS: Despite being at risk of HIV/STI, the low prevalence of testing coupled with a high prevalence of risky sexual behaviour among this group of heterosexual men in Singapore calls for a need for HIV/STI prevention interventions in the EE setting. Other than promoting testing and safer sex, the interventions should address the discordance between perceived risk and actual sexual behaviour, in addition to the stigma and discrimination associated with testing for this group.

Prevalence of overweight/obesity and its associated factors among university students from 22 countries.

Obesity among young people increases lifetime cardiovascular risk. This study assesses the prevalence of overweight/obesity and its associated factors among a random sample of university students from 22 universities in 22 low, middle income and emerging economy countries. This cross-sectional survey comprised of a self-administered questionnaire and collected anthropometric measurements. The study population was 6773 (43.2%) males and 8913 (56.8%) females, aged 16 to 30 years (mean 20.8 years, SD = 2.6). Body mass index (BMI) was used for weight status. Among men, the prevalence of underweight was 10.8%, normal weight 64.4%, overweight 18.9% and obesity 5.8%, while among women, the prevalence of underweight was 17.6%, normal weight 62.1%, overweight 14.1% and obesity 5.2%. Overall, 22% were overweight or obese (24.7% men and 19.3% women). In multivariate regression among men, younger age, coming from a higher income country, consciously avoiding fat and cholesterol, physically inactivity, current tobacco use and childhood physical abuse, and among women older age, coming from a higher income country, frequent organized religious activity, avoiding fat and cholesterol, posttraumatic stress symptoms and physical childhood abuse were associated overweight or obesity. Several gender specific risk factors identified can be utilized in health promotion programmes.

Overcoming Barriers to Mammography Screening: A Quasi-randomised Pragmatic Trial in a Community-based Primary Care Setting.

INTRODUCTION: Breast cancer is the leading cancer among women in Singapore. Five years after a population-wide breast cancer screening programme was introduced, screening rates remained relatively low at 41%. Studies have shown decreased screening propensity among medically underserved women typically of minority or socioeconomically disadvantaged status. We conducted a quasi-randomised pragmatic trial aimed at encouraging mammography screening among underscreened or unscreened women in a publicly funded primary care facility in Singapore. MATERIALS AND METHODS: The study was conducted from May to August 2010. Components of intervention included (1) tailored education, (2) doctor's reminder, and (3) cost reduction. Researchers administered a structured questionnaire to eligible female polyclinic attendees and patient companions aged 40 to 69 years. Individual knowledge, attitudes, beliefs, and barriers towards mammography screening were identified and educational messages tailored. Doctor's reminder and cost reduction were implemented additively. RESULTS: Overall, out of 448 participants, 87 (19.4%, 95% confidence interval (CI), 15.8% to 23.1%) completed mammography screening across 3 arms of study. Participants who received a cost reduction were more likely to attend screening compared to participants in other intervention arms (adjusted odds ratio (OR) 2.4, 95% CI, 1.2 to 4.5, P = 0.009). Cost of screening, ethnicity, prior screening history, and attitudes towards mammography screening were identified as significant factors predicting mammogram attendance. CONCLUSION: Including a cost reduction component was the most effective intervention that increased mammography screening rates. Women's underlying beliefs, attitudes, and other predisposing factors should also be considered for integration into existing breast cancer screening programmes.

Gender differences in predictors of colorectal cancer screening uptake: a national cross sectional study based on the health belief model.

BACKGROUND: Colorectal Cancer (CRC) is rapidly rising in Asia, but screening uptake remains poor. Although studies have reported gender differences in screening rates, there have been few studies assessing gender specific perceptions and barriers towards CRC screening, based on behavioral frameworks. We applied the Health Belief Model to identify gender-specific predictors of CRC screening in an Asian population. METHODS: A nationwide representative household survey was conducted on 2000 subjects aged 50 years and above in Singapore from 2007 to 2008. Screening behaviour, knowledge and beliefs on CRC screening were assessed by face-to-face structured interviews. The response rate was 88.2%. RESULTS: 26.7 percent had undergone current CRC screening with no gender difference in rates. Almost all agreed that CRC would lead to suffering (89.8%), death (84.6%) and would pose significant treatment cost and expense (83.1%). The majority (88.5%) agreed that screening aids early detection and cure but only 35.4% felt susceptible to CRC. Nearly three-quarters (74.3%) of the respondents recalled reading or hearing information on CRC in the print or broadcast media. However, only 22.6% were advised by their physicians to undergo screening. Significantly more women than men had feared a positive diagnosis, held embarrassment, pain and risk concerns about colonoscopy and had friends and family members who encouraged screening. On multivariate analysis, screening uptake showed a positive association with worry about contracting CRC and a physician's recommendation and a negative association with perceived pain about colonoscopy for both genders. For women only, screening was positively associated with having attended a public talk on CRC and having a family member with CRC, and was negatively associated with Malay race and perceived danger of colonoscopy. CONCLUSIONS: CRC screening remains poor despite high levels of awareness of its benefits in this Asian population. Race, worry about contracting cancer, psychological barriers, and cues from the doctor and a public talk on CRC were associated with screening with gender specific differences. Strategies to increase CRC screening uptake should consider gender specific approaches to address psychological barriers and increase disease susceptibility through public health education and active promotion by physicians.

Sex work and risky sexual behaviors among foreign entertainment workers in urban Singapore: findings from Mystery Client Survey.

Globalization has led to a rapid influx of female workers from Asian countries with high prevalence of HIV to Singapore, with many entering the entertainment industry. We assessed the prevalence of sexual services, condom use, and self-initiated screening for sexually transmitted infections (STIs) and associated variables among foreign female entertainment workers in Singapore. A cross-sectional survey of 317 female entertainment workers, using mystery clients, was conducted on a two-stage proportional cluster sample of 93 entertainment establishments stratified by geographical zone in Singapore. We found a high prevalence (71 %) of sexual services in entertainment establishments with 53 % of the female entertainment workers reporting selling sex. Consistent condom use for sex with paying clients in a usual week in the past 3 months was low, ranging from 37.9 % for oral sex, 46.9 % for anal sex, to 51.9 % for vaginal sex. On multivariate logistic regression, consistent condom use for vaginal sex with clients showed a significant independent association with the entertainment worker's behavior of asking clients to use condoms and a borderline association with entertainment worker being a Chinese national. Less than half (48.9 %) of the sex workers had ever been screened for STIs either locally or in their home country. The only independent factor significantly associated with STI screening was having to support one's family. In summary, a high percentage of foreign female entertainment workers in Singapore reported selling sex. Condom use and STI screening were low among them. Access to STI screening, treatment, and education services should be enhanced for foreign female entertainment workers in Singapore.

Human immunodeficiency virus (HIV) prevention education in Singapore: challenges for the future.

We reviewed the current human immunodeficiency virus (HIV) prevention education programmes in Singapore, discussed the challenges faced and proposed prevention education interventions for the future. Education programmes on HIV prevention have shown some success as seen by reduced visits to sex workers among the general adult population and a marked increase in condom use among brothel-based sex workers. However, we still face many challenges such as low awareness of HIV preventive strategies and high prevalence of HIV stigma in the general population. Voluntary HIV testing and condom use remain low among the priority groups such as men who have sex with men (MSM) and heterosexual men who buy sex. Casual sex has increased markedly from 1.1% in 1989 to 17.4% in 2007 among heterosexuals in Singapore, with the majority (84%) practising unprotected sex. Sex workers have moved from brothels to entertainment venues where sex work is mostly hidden with lack of access to sexually transmitted infections (STIs)/ HIV prevention education and treatment programmes. Education programmes promoting early voluntary testing is hampered because of poor access, high cost and stigma towards people living with HIV. It remains a challenge to promote abstinence and consistent condom use in casual and steady sexual relationships among heterosexuals and MSM. New ways to promote condom use by using a positive appeal about its pleasure enhancing effects rather than the traditional disease-oriented approach should be explored. Education programmes promoting early voluntary testing and acceptance of HIV-infected persons should be scaled up and integrated into the general preventive health services.

Assessing knowledge of human papillomavirus and collecting data on sexual behavior: computer assisted telephone versus face to face interviews.

BACKGROUND: Education campaigns seeking to raise awareness of human papillomavirus (HPV) and promoting HPV vaccination depend on accurate surveys of public awareness and knowledge of HPV and related sexual behavior. However, the most recent population-based studies have relied largely on computer-assisted telephone interviews (CATI) as opposed to face to face interviews (FTFI). It is currently unknown how these survey modes differ, and in particular whether they attract similar demographics and therefore lead to similar overall findings. METHODS: A comprehensive survey of HPV awareness and knowledge, including sexual behavior, was conducted among 3,045 Singaporean men and women, half of whom participated via CATI, the other half via FTFI. RESULTS: Overall levels of awareness and knowledge of HPV differed between CATI and FTFI, attributable in part to demographic variations between these survey modes. Although disclosure of sexual behavior was greater when using CATI, few differences between survey modes were found in the actual information disclosed. CONCLUSION: Although CATI is a cheaper, faster alternative to FTFI and people appear more willing to provide information about sexual behavior when surveyed using CATI, thorough assessments of HPV awareness and knowledge depend on multiple survey modes.

Singaporean women's knowledge of human papillomavirus (HPV) and attitudes toward HPV vaccination.

With a vaccination program currently planned to protect Singaporean women from human papillomavirus, a need arises for assessing Singaporean women's knowledge of human papillomavirus and attitudes toward human papillomavirus vaccination to identify barriers to a successful program and to help inform health education campaigns. A representative sample of 2,145 women aged between 18 and 49 years were randomly selected from households throughout Singapore and interviewed with a similar questionnaire to that used in a recent study of Australian women. Although Singaporean women's knowledge of human papillomavirus was poor, with only 20% having heard of it, attitudes toward human papillomavirus vaccination were generally positive. The most trusted sources of information about human papillomavirus and vaccination were gynecologists and general practitioners. Based on our findings, an urgent need exists in Singapore for accurate and accessible information about human papillomavirus and the benefits of vaccination.

Premarital sexual intercourse among adolescents in an Asian country: multilevel ecological factors.

OBJECTIVE: The goal was to assess personal and environmental factors associated with premarital sex among adolescents. METHODS: We conducted a case-control study. Between 2006 and 2008, we recruited 500 adolescents who reported having engaged in voluntary sex for most recent sex. Five hundred control subjects were matched for age, gender, and ethnicity. RESULTS: Independently significant factors for premarital sex among boys were pornography viewing (adjusted odds ratio [OR]: 5.82 [95% confidence interval [CI]: 2.34-14.43]), lack of confidence to resist peer pressure (OR: 3.84 [95% CI: 2.27-6.50]), perception that more than one half of their friends had engaged in sex (OR: 3.37 [95% CI: 1.92-5.92]), permissiveness regarding premarital sex (OR: 3.41 [95% CI: 2.10-5.55]), involvement in gang activities (OR: 3.45 [95% CI: 1.66-7.15]), drinking (OR: 1.77 [95% CI: 1.07-2.94]), smoking (OR: 1.91 [95% CI: 1.14-3.20]), and living in low-cost housing (OR: 3.25 [95% CI: 1.64-6.43]). For girls, additional factors were previous sexual abuse (OR: 7.81 [95% CI: 2.50-24.41]) and dropping out of school (OR: 2.72 [95% CI: 1.32-5.61]), and stronger associations were found for lack of confidence to resist peer pressure (OR: 5.56 [95% CI: 2.94-10.53]) and permissiveness regarding premarital sex (OR: 6.25 [95% CI: 3.30-11.83]). Exposure to persons with HIV/AIDS or sexually transmitted infections in the media was negatively associated with sex for boys (OR: 0.27 [95% CI: 0.16-0.45]) and girls (OR: 0.24 [95% CI: 0.13-0.47]). CONCLUSION: Sex education programs for adolescents must address social, media, and pornographic influences and incorporate skills to negotiate sexual abstinence.