Impact of Perceived Safety and Barriers on Physical Activity Levels in Community-Dwelling Older Adults During the COVID-19 Pandemic in Singapore: A Cross-Sectional Mixed Methods Study.

This descriptive cross-sectional mixed methods study conducted in Singapore aimed to describe community-dwelling older adults' differences in physical activity (PA) based on perceived safety to exercise, barriers to PA, and preferred modes of PA during a pandemic. Out of 268 older adults, 25.4% felt unsafe to exercise during the pandemic. More participants who felt unsafe were aged 75 years and older (72.1% vs. 57.0%, p = .028) and lacked formal education (54.4% vs. 37.0%, p = .040). Barriers included difficulties exercising with masks, family concerns, and exercise center closures. Those who felt unsafe were significantly more likely to exercise at home and had significantly shorter duration of exercise and walks per week (2.72 vs. 4.50 hr, p = .002). Perceived barriers and exercise preferences should be considered when developing programs to improve older adults' PA during pandemics.

Factors influencing fear of falling in community-dwelling older adults in Singapore: a cross-sectional study.

BACKGROUND: Fear of falling (FoF) has far-reaching implications including activity restriction, functional decline and reduced quality of life. It is a common consequence of falls but may be present even in non-fallers. This study aimed to determine the factors associated with FoF in a segment of Singapore's community-dwelling older adults. METHODS: This descriptive cross-sectional study recruited a convenience sample of adults aged 65 and above from 4 primary care clinics from September 2020 to March 2021. Data were collected on demographic factors, clinical factors such as multi-morbidity, falls characteristics such as history of falls, injuries, and reasons for falls and frailty as determined by the Clinical Frailty Scale (CFS). FoF was measured using the Short Falls Efficacy Scale-International (Short FES-I), cut-off score of 14 and above indicated high FoF. Logistic regression was used to determine factors associated with high FoF. RESULTS: Out of 360 older adults, 78.1% were Chinese and 59.7% females. The mean age was 78.3 years and 76 (21.1%) had a history of falls in the past six months. Almost half (43.1%) were mildly to moderately frail and most (80.6%) had multi-morbidity. The mean FoF score was 15.5 (SD 5.97) and 60.8% reported high FoF. There were statistically significant differences in age, gender, ethnicity, marital status, educational level, use of walking aid, multi-morbidity, frailty status, history of falls within six months and reason for falls between patients who had high FoF versus those who had moderate or low FoF. Logistic regression found that Malay ethnicity (OR = 5.81, 95% CI 1.77-19.13), marital status, use of walking aids (OR = 3.67, 95% CI = 1.54-8.77) and frailty were significant factors associated with high FoF. Compared to those who were never married, the odds of high FoF were significantly higher in married older adults (OR = 6.75, 95% CI 1.39 to 32.76), those who were separated or divorced (OR 10.40, 95% CI 1.13 to 95.76) and those who were widowed (OR = 7.41, 95% CI 1.51 to 36.41). Compared to well older adults, the odds of high FoF were significantly higher in pre frail older adults (OR = 6.87, 95% CI = 2.66-17.37), mildly frail older adults (OR = 18.58, 95% CI = 4.88-70.34) and moderately frail older adults (OR = 144.78, 95% CI = 13.86-1512.60). CONCLUSIONS: The study found that pre frail to moderately frail older adults as determined by CFS have significantly higher risk of high FoF. The demographic factors such as marital status and ethnicity and falls characteristics associated with FoF in this study will be helpful to develop targeted and tailored interventions for FoF.

Factors Associated with Healing Outcomes in Primary Care Patients with Diabetic Foot Ulcers: A Retrospective Study in a Multiethnic Sample.

OBJECTIVE: To identify and determine patient- and ulcer-related factors associated with healing outcomes within 3 months for patients with diabetic foot ulcer (DFU) in a multiethnic primary care sample. METHODS: Retrospective data were collected over 3 months from 520 primary care patients with a DFU between April 1, 2016 and March 31, 2017. Multivariable prevalence ratios (PRs) were calculated using Poisson regression to find associations between patient- and ulcer-related factors and healing outcomes. RESULTS: Most patients were male (66%) and Chinese (49.8%) and had a diabetes mellitus duration longer than 5 years (81.8%). Toe ulcers (64%) were most common. Healing occurred for 33.9% of participants; 19.1% and 1.5% underwent minor and major amputation, respectively. Wound sizes between 1 and 10 cm2 (PR, 0.61; 95% confidence interval [CI], 0.46-0.76; P < .001) and over 10 cm2 (PR, 0.55; 95% CI, 0.33-0.76; P = .003), ulcer duration 6 months or longer (PR, 0.36; 95% CI, 0.19-0.53; P < .001), ischemic ulcers (PR, 0.54; 95% CI, 0.22-0.86; P = .044), and neuroischemic ulcers (PR, 0.73; 95% CI, 0.53-0.93; P = .027) were negatively associated with healing outcomes. Women were more likely to experience healing (PR, 1.18; 95% CI, 0.91-1.45; P = .157). CONCLUSIONS: Ulcer healing varied by sex and was affected by wound size, wound duration, and ischemic etiology, regardless of ethnicity. Prompt attention to these risk factors may reduce healing time. Further studies are warranted to elucidate the mechanism underlying sex differences in association with DFU healing.

Description and Utilization of Telewound Monitoring Services in Primary Care Patients with Acute Wounds in Singapore: A Retrospective Study.

OBJECTIVE: To describe an inaugural telewound monitoring service (TMS) designed for the remote monitoring of acute wounds to empower primary care patients, and identify factors associated with the utilization of the TMS. METHODS: Retrospective data were collected from 204 patients who participated in the TMS between June 19, 2016 and August 31, 2017 and analyzed using both descriptive and multiple regression analysis. RESULTS: The mean patient age was 27.9 years (SD, 12.4); wound area was 7.8 cm2 (SD, 21.2); and duration of healing was 11.7 days (SD, 6.9). A multiple regression model based on patients' demographics and wound factors predicted which patients were likely to have more telewound sessions than face-to-face sessions. The model was statistically significant (F = 2.093 (11, 124), P = .025) with 15.7% of variance explained by the variables. An increase in age (P = .043) and increased days to healing (P = .043) were associated with a reduction in the number of telewound sessions. CONCLUSIONS: The TMS is a valuable alternative to face-to-face wound care that enables patients with acute wounds to assume the roles of both patient and carer simultaneously. Age and healing duration are predictors for utilization of this service. Prompt attention to these predictors may improve service allocation and utilization.

Understanding nurse preceptors' experiences in a primary health care setting: A descriptive qualitative study.

AIM: This study sought to understand primary health care nurse preceptors' experiences of precepting junior nurses. BACKGROUND: Nurse preceptors provide clinical teaching to nurses and pre-registration nurses and play a supervisory role in their work. The demand for preceptors in the primary health care setting is on the rise, and there is a huge responsibility placed on them on top of their routine workload. METHODS: A descriptive qualitative approach was adopted, and purposive sampling was used to select the participants. 14 nursing preceptors across six polyclinics were interviewed. Thematic analysis was used to analyse the data. RESULTS: The analysis revealed three themes: (1) a vessel for transferring knowledge; (2) building a therapeutic relationship; and (3) overcoming organisational barriers. CONCLUSION: In light of the study's findings, strategies to address the insufficient knowledge of nurse preceptors, lack of recognition and preceptorship opportunities must be developed. IMPLICATIONS FOR NURSING MANAGEMENT: More attention and opportunities for nurse preceptors' professional development such as courses to enhance their knowledge on educational and research developments as well as teaching seminars to maintain and build effective relationships with their preceptees. In addition, recognizing the role of nurse preceptors as a pillar of guiding the future generation of nurses and research to support nurse preceptors in their training cannot be undermined.

"When nothing happens, nobody is afraid!" beliefs and perceptions around self-care and health-seeking behaviours: Voices of patients living with diabetic lower extremity amputation in primary care.

Self-management and self-care are the cornerstone of diabetes care and an essential part of successfully preventing or delaying diabetes complications. Yet, despite being armed with the required information and guidance for self-management, self-care and adherence to foot self-care recommendations and compliance to medication among patients with diabetic foot ulcer and diabetic lower extremity amputations remain low and suboptimal. This study reveals in-depth account of nine such patients' beliefs and perceptions around their illness, their self-care, and their health-seeking behaviours. Patients living with diabetic lower extremity amputation displayed profound lack of knowledge of self-care of diabetes and foot and passive health-related behaviours. The overarching sense that "when nothing happens, nobody is afraid," points to a lack of motivation in taking charge of one's own health, whether this is with reference to treatment or care adherence, following recommended self-care advice, or seeking timely treatment. The Health Beliefs Model provides the theoretical framework for probing into the factors for the participants' suboptimal self-care and passive health-seeking behaviours. Two themes emerged from data analysis: profound knowledge deficit and passive health-related behaviours. The beliefs and perceptions around self-care and health-seeking behaviours for patients with lower extremity amputation are interpreted as the "ignorant self" with passive health-seeking behaviours. Patients with diabetes and diabetic foot diseases may benefit from personalized education, motivational interviewing, and family support.

Exploring Patient and Caregiver Perceptions of Primary Healthcare Sector Home Care for Simple Acute Wounds.

GENERAL PURPOSE: To provide information about a study exploring patient and caregiver perceptions of home wound care for patients with simple acute wounds in Singapore. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be able to:1. Assess benefits and barriers to home wound care management.2. Analyze the methodology, results, and implications of the study. ABSTRACT: To control healthcare expenditure, patients with simple, acute, low-risk wounds are encouraged to perform self-wound care at home. However, patient perception of this care is not known. OBJECTIVE: To explore patient and caregiver perceptions of home wound care for patients with simple acute wounds in the primary healthcare sector in Singapore. METHODS: This study used the constructivist grounded theory approach. Nine participants from 2 polyclinics were interviewed. In vivo codes were extracted, and the constant comparative technique was applied throughout the analytical process. RESULTS: Fear, lack of knowledge, and the difficulty in performing care resulted in many patients avoiding self-wound care. Age, educational level, and cost did not have much impact. Participants with some first aid knowledge and those who appreciated the flexibility of self-wound care were more likely to embrace this concept. Participants also suggested that telecommunications and mobile nurses could assist in this concept. CONCLUSIONS: Generally, patients are willing to accept this self-wound care concept. To ensure successful implementation, nurses should encourage eligible patients to attend educational programs to prepare them to perform wound care at home.

Which Aspect of Patient-Provider Relationship Affects Acceptance and Adherence of Insulin Therapy in Type 2 Diabetes Mellitus? A Qualitative Study in Primary Care.

PURPOSE: In type 2 diabetes mellitus (T2DM), insulin therapy is often recommended to achieve the optimal control of disease, thereby preventing the onset and progression of diabetes-related complications. Despite knowing about the benefits, it has been reported that 71% of patients refuse insulin and the adherence rate ranges from 30 to 80%. Patient-provider relationship (PPR) may affect such insulin-related behaviours, but little is known about which aspect of PPR affects this. This study aimed to explore the key aspect of the patient-provider relationship that affects the initial insulin acceptance and continued adherence. PATIENTS AND METHODS: We used the grounded theory approach in this qualitative research. The study was conducted at two primary care clinics between September 2019 and January 2021. Patients with T2DM on basal or premixed insulin were recruited using maximum variation sampling. Data were collected using semi-structured in-depth interviews and transcribed verbatim for analysis using constant comparison and synthesis. RESULTS: Twenty-one participants with different levels of diabetes control and adherence were recruited. Four themes that emerged were 1) patient-provider interaction, 2) addressing the psychological fears, 3) gaining confidence in handling insulin equipment and 4) follow-up after insulin initiation. Among the subthemes, trust in doctors, provider's communication skills, patient-centred decision-making and continuity of care positively influenced insulin acceptance and adherence. Conversely, fear of being judged by the provider hindered open communication around non-adherence. Various aspects of interaction with nurses helped in alleviating patient's fear of injection and gaining confidence with the insulin equipment. CONCLUSION: Many aspects of PPR affect insulin acceptance and adherence. Among these, gaining patients' trust, effective patient-provider communication, patient-centred decision-making, and ensuring continuity of care improve both insulin acceptance and treatment adherence. Various interactions with nurses help in addressing fears surrounding injection and gaining acceptance towards insulin therapy. Patients' fear of being blamed or judged by the provider negatively affects open communication around non-adherence.

Struggling for normality: experiences of patients with diabetic lower extremity amputations and post-amputation wounds in primary care.

AIM: To explore the experiences of patients living with diabetic lower extremity amputation (DLEA) and its post-amputation wound in primary care. BACKGROUND: DLEA, including both minor and major amputation, is a life-altering condition that brings numerous challenges to an individual's life. Post-amputation physical wound healing is complicated and challenging because of wound dehiscence and prolonged healing times. Understanding patients' experiences after DLEA with a post-amputation wound will enable healthcare professionals to develop interventions to assist patients in physical healing and psychosocial recovery. METHODS: This study employs a qualitative design using interpretative phenomenological analysis (IPA). A purposive maximum variation sample of nine patients who had had lower extremity amputations and post-amputation wound attributed to diabetes in the previous 12 months was recruited from a primary care setting in Singapore. Semi-structured audio recorded one-to-one interviews with a duration of 45-60 min each were conducted between September 2018 and January 2019. The interviews were transcribed verbatim and analysed using IPA. FINDINGS: The essential meaning of the phenomenon 'the lived experiences for patients with DLEA and post-amputated wound' can be interpreted as 'struggling for "normality"' which encompasses four domains of sense making: physical loss disrupted normality, emotional impact aggravated the disrupted normality, social challenges further provoked the disrupted normality, and attempt to regain normality. The study highlights the complex physical and psychosocial transition facing patients after DLEA before post-amputation wound closure. In primary care, an amputation, whether minor or major, is a life-altering experience that requires physical healing, emotional recovery, and social adaptation to regain normality. Patients living with DLEA and a post-amputation wound may benefit from an interdisciplinary team care model to assist them with physical and psychosocial adjustment and resume normality.