Exploring the implementation of the Community for Successful Ageing (ComSA)program in Singapore: lessons learnt on program delivery for improving BioPsychoSocial health.

BACKGROUND: The Community for Successful Ageing (ComSA) program has implemented overlapping BioPsychoSocial (BPS) components as part of a Community Development (CD) grassroots and volunteer-led initiative. Implementation of such multi-component programming is influenced by known program characteristics including novelty, complexity and observability as well as related organizational factors. As such, we explored ComSA CD's implementation from the organizational perspective, seeking to inform program improvements. METHODS: We conducted four focus groups with program staff, partners and trainers (total N = 21 participants). Findings were analysed using an interpretative approach and synthesized into a line of argument informing lessons learnt. RESULTS: An implementation framework was identified. It is guided by considering the influence of known program characteristics across major themes, representing three core implementation stages. These and supporting sub-themes are elaborated in turn: 1) Creating commitment toward the program was challenged by novelty and at times a lack of shared understanding of ComSA CD, particularly relating to the S component. Overall, cohesion within organizational contexts and having a strong rapport with the community (ability to engage) were needed to persuade volunteers and participants to commit to the program. 2) Coordination and resource allocation were influenced by the complexity of interconnecting BPS components - requiring aligning communication between partners and adapting the BPS sequence, given the separated management structure of program trainers. Efficiency of resource utilization was constrained by the ability to pool and match resources given the limited manpower and community partners who worked-in-silo due to a KPI-centric culture. 3) Collaborative program monitoring and appraisal increased observability of the program's benefits, but depended on partners' prior commitment. Despite appreciating its holistic BPS programming, dropout rate was used as a way to gauge program success, which has limited interpretability. Occasional uncertainty about the program value contributed to concerns about duplicating existing ageing programs, particularly those related to the B component. CONCLUSION: Lessons learnt for improving BPS programming include (1) eliciting better participants' buy-in and shared program vision, (2) increasing adaptability of BPS sequence and building a culture of shared values for working together (3) and developing comprehensive monitoring systems for program appraisal.

Theory and Design of the Community for successful ageing (ComSA) program in Singapore: connecting BioPsychoSocial health and quality of life experiences of older adults.

BACKGROUND: Despite the emphasis on holistic health promotion in community programs for older people, few studies explicitly consider how BioPsychoSocial (BPS) health elements are interconnected and function to improve Quality of Life (QoL). The Community for Successful Ageing (ComSA) program in Singapore focuses on Community Development (CD) initiatives for older people, accounting for BPS theory in its design and content. Biological (B) health is conceived as physiological and cognitive functioning and related biological self-care; Psychological (P) health as feelings of life satisfaction, and Social health (S) as perceived social support and civic engagement. Furthermore, three overlapping sub-constructs are theorized to connect these elements. Namely Bio-Psychological (BP) health in terms of self-perceptions of ageing; the Psycho-Social (PS) aspects of interpersonal communication; and the Socio-Communal (SC) health in terms of civic engagement. BPS health is conceived as distinct from QoL, defined as composed of control, autonomy, self-realisation and pleasure (measured by CASP-19) of the older person. We examined 1) interconnections of BPS constructs and related sub-constructs and 2) their associations with QoL to inform a practical, applied program theory. METHODS: A baseline survey (n = 321) of program participants (Mean = 70 years, SD = 8.73). All continuous variables were binarized as 'high' if the scores were above the median. Multivariate logistic regression was used to assess 1) the adjusted effect of each BPS construct on CASP-19, and 2) the odds of scoring high on one BPS construct with the odds of scoring high on a related sub-construct (e.g. B and BP health). RESULTS: The strongest relationship with QoL was markedly with BP self-perceptions of ageing (OR = 4.07, 95%CI = 2.21-7.49), followed by P life satisfaction (OR = 3.66, 95%CI = 2.04-6.57), PS interpersonal communication (OR = 2.42, 95%CI = 1.23-4.77), SC civic engagement (OR = 1.94, 95%CI = 1.05-3.57), and S social support (OR = 1.89, 95%CI = 1.06-3.38). Core B, P and S health were closely associated with their sub-constructs. CONCLUSION: ComSA CD is tightly coupled to its proposed program theory. It offers classes to improve B self-care and BP self-perceptions of ageing, group-based guided autobiography to improve P life-satisfaction and PS interpersonal communication, and community initiatives that encourage seniors to solve community issues. This holistic approach is likely to enhance ageing experiences and QoL.

The theoretical and empirical basis of a BioPsychoSocial (BPS) risk screener for detection of older people's health related needs, planning of community programs, and targeted care interventions.

BACKGROUND: This study introduces the conceptual basis and operational measure, of BioPyschoSocial (BPS) health and related risk to better understand how well older people are managing and to screen for risk status. The BPS Risk Screener is constructed to detect vulnerability at older ages, and seeks to measure dynamic processes that place equal emphasis on Psycho-emotional and Socio-interpersonal risks, as Bio-functional ones. We validate the proposed measure and describe its application to programming. METHODS: We undertook a quantitative cross-sectional, psychometric study with n = 1325 older Singaporeans, aged 60 and over. We adapted the EASYCare 2010 and Lubben Social Network Scale questionnaires to help determine the BPS domains using factor analysis from which we derive the BPS Risk Screener items. We then confirm its structure, and test the scoring system. The score is initially validated against self-reported general health then modelled against: number of falls; cognitive impairment; longstanding diseases; and further tested against service utilization (linked administrative data). RESULTS: Three B, P and S clusters are defined and identified and a BPS managing score ('doing' well, or 'some', 'many', and 'overwhelming problems') calculated such that the risk of problematic additive BPS effects, what we term health 'loads', are accounted for. Thirty-five items (factor loadings over 0.5) clustered into three distinct B, P, S domains and were found to be independently associated with self-reported health: B: 1.99 (1.64 to 2.41), P: 1.59 (1.28 to 1.98), S: 1.33 (1.10 to 1.60). The fit improved when combined into the managing score 2.33 (1.92 to 2.83, < 0.01). The score was associated with mounting risk for all outcomes. CONCLUSIONS: BPS domain structures, and the novel scoring system capturing dynamic BPS additive effects, which can combine to engender vulnerability, are validated through this analysis. The resulting tool helps render clients' risk status and related intervention needs transparent. Given its explicit and empirically supported attention to P and S risks, which have the potential to be more malleable than B ones, especially in the older old, this tool is designed to be change sensitive.

Comparing patient and healthcare worker experiences during a dengue outbreak in Singapore: understanding the patient journey and the introduction of a point-of-care test (POCT) toward better care delivery.

BACKGROUND: In the aftermath of an upsurge in the number of dengue cases in 2013 and 2014, the SD BIOLINE Dengue Duo rapid diagnostic Point-of-Care Test (POCT) kit was introduced in Tan Tock Seng Hospital, Singapore in June 2013. It is known that the success of POCT usage is contingent on its implementation within the health system. We evaluated health services delivery and the Dengue Duo rapid diagnostic test kit application in Singapore from healthcare workers' perspectives and patient experiences of dengue at surge times. METHODS: Focus group discussions were conducted with dengue patients, from before and after the POCT implementation period. In-depth interviews with semi-structured components with healthcare workers were carried out. A patient centred process mapping technique was used for evaluation, which mapped the patient's journey and was mirrored from the healthcare worker's perspective. RESULTS: Patients and healthcare workers confirmed a wide range of symptoms in adults, making it challenging to determine diagnosis. There were multiple routes to help seeking, and no 'typical patient journey', with patients either presenting directly to the hospital emergency department, or being referred there by a primary care provider. Patients groups diagnosed before and after POCT implementation expressed some differences between speed of diagnoses and attitudes of doctors, yet shared negative feelings about waiting times and a lack of communication and poor information delivery. However, the POCT did not in its current implementation do much to help waiting times. Healthcare workers expressed that public perceptions of dengue in recent years was a major factor in changing patient management, and that the POCT kit was helpful in improving the speed and accuracy of diagnoses. CONCLUSIONS: Health service delivery for dengue patients in Singapore was overall perceived to be of an acceptable clinical standard, which was enhanced by the introduction of the POCT. However, improvements can be focused on Adapting to outbreaks by reducing and rendering Waiting experiences more comfortable; Advancing education about symptom recognition, while also Recognising better communication strategies; and Expanding follow-up care options. This is presented as the Dengue AWARE model of care delivery.

Factors and experiences associated with unscheduled 30-day hospital readmission: A mixed method study.

INTRODUCTION: Analysis of risk factors can pave the way for reducing unscheduled hospital readmissions and improve resource utilisation. METHODS: This was a concurrent nested, mixed method study. Factors associated with patients readmitted within 30 days between 2011 and 2015 at the National University Hospital, Singapore (N=104,496) were examined. Fifty patients were sampled in 2016 to inform an embedded qualitative study. Narrative interviews explored the periods of readmissions and related experiences, contrasted against those of non-readmitted patients. RESULTS: Neoplastic disease (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.70-2.15), number of discharged medications (5 to 10 medications OR 1.21, 95% CI 1.14-1.29; ≥11 medications OR 1.80, 95% CI 1.66-1.95) and length of stay >7 days (OR 1.46, 95% CI 1.36-1.58) were most significantly associated with readmissions. Other factors including number of surgical operations, subvention class, number of emergency department visits in the previous year, hospital bill size, gender, age, Charlson comorbidity index and ethnicity were also independently associated with hospital readmissions. Although readmitted and non-readmitted patients shared some common experiences, they reported different psychological reactions to their illnesses and viewed hospital care differently. Negative emotions, feeling of being left out by the healthcare team and perception of ineffective or inappropriate treatment were expressed by readmitted patients. CONCLUSION: Patient, hospital and system-related factors were associated with readmissions, which may allow early identification of at-risk patients. Qualitative analysis suggested several areas of improvement in care including greater empowerment and involvement of patients in care and decision making.

Promoting BioPsychoSocial health of older adults using a Community for Successful Ageing program (ComSA) in Singapore: A mixed-methods evaluation.

BioPsychoSocial health promotion is increasingly emphasized for Successful Ageing. Few programs are known to target BioPsychoSocial health of older adults and their community. The Community for Successful Ageing: Community Development program (ComSA CD) was developed in Singapore for this purpose. This study assessed program effects on BioPsychoSocial health and civic engagement behaviours of participants. ComSA CD offered self-care healthy lifestyle education (Bio-physical), guided autobiography (Psychological) and a civic engagement component which galvanized participants to solve community issues (Social). Recruitment occurred through self-care or guided autobiography; following which participants were funnelled into the civic engagement component. A mixed-methods quasi-experimental evaluation was conducted, using a pre-post one-year survey (N=232) with those exposed and unexposed (rejected) to ComSA CD. Using a generalized linear model, associations between post one-year BioPsychoSocial outcomes and exposure group were quantified using percentage change, adjusting for baseline outcome and group differences. Concurrently, program effects were explored through six focus groups with program implementers and participants using thematic analysis. The program had multiple positive effects. Participants recruited via self-care also taking part in civic engagement reported 31% higher frequency of self-care (95% CI=21% to 68%) post one-year compared to unexposed participants. Qualitative findings illustrated how the civic engagement component stimulated agency of participants to push for neighborhood changes and civic engagement initiatives. The quantitative survey highlighted that this effect was strongest among those funnelled from guided-autobiography (92% higher frequency of civic engagement at post one-year than unexposed; 95%CI=41% to 178%) compared to those funnelled from self-care (53% higher than unexposed, 95%CI=17% to 114%). It was found qualitatively that guided-autobiography enabled more meaningful bonding and communication than the self-care component, explaining quantitative effects on social support only present among guided autobiography participants (36% higher than unexposed; 95%CI=11% to 68%). Findings highlighted the importance of improving group dynamics for collective action.

Explaining the continuum of social participation among older adults in Singapore: from 'closed doors' to active ageing in multi-ethnic community settings.

OBJECTIVES: This study aims to identify and explain the continuum in which older people in Singapore participate in community and social life, highlighting the influence of culture and policy context on social participation. METHODS: Using an ethnographic approach in a neighbourhood (n=109), we conducted focus groups with older adults of different ethnicities, exploring experiences of social participation. Next, participants took 50 photographs relating to 'lives of elders', showcasing the socio-ecological context that influenced social participation. Lastly, go-along interviews were conducted in various precincts with community leaders. RESULTS: A continuum of social participation emerged among older adults, ranging from (1) marginalization and exclusion, to (2) 'comfort-zoning' alone (3) seeking consistent social interactions, (4) expansion of social network, and (5) giving back to society. Seeking consistent social interactions was shaped by a preference for cultural grouping and ethnic values, but also a desire for emotional safety. Attitudes about expanding one's social network depended on the psychosocial adjustment of the older person to the prospect of gossip and 'trouble' of managing social relations. Despite the societal desirability of an active ageing lifestyle, cultural scripts emphasizing family meant older adults organized participation in social and community life, around family responsibilities. Institutionalizing family reliance in Singapore's welfare approach penalized lower-income older adults with little family support from accessing subsidies, and left some living on the margins. DISCUSSION: To promote inclusiveness, ageing programs should address preferences for social participation, overcoming barriers at the individual, ethnic culture and policy level.