"The Menthol One Is More Friendly": Young Singaporeans' Perspectives on Flavored Cigarettes.

Over half of the cigarettes sold in Singapore contain added flavors such as menthol. We conducted nine focus group discussions (n = 46) with young (aged 20-25) current smokers in Singapore to understand the role of flavors in smoking initiation. We found that flavors triggered the curiosity to experiment with tobacco and e-cigarette products and played an important role in the formation of early cigarette preferences. Menthol-flavored cigarettes were the most appealing to participants due to their smoothness and cooling sensation, described as pleasant against Singapore's hot and humid climate. While some participants believed that flavored and nonflavored cigarettes were equally harmful, others believed that flavored variants had a lower nicotine content and were therefore less harmful, or that the added chemicals in flavored cigarettes could result in higher toxicant exposures. Thus, among young people in Singapore, flavors appear to play an important role in smoking initiation and there appear to be various misperceptions regarding their harmfulness.

The Influence of Normative Perceptions on the Uptake of the COVID-19 TraceTogether Digital Contact Tracing System: Cross-sectional Study.

BACKGROUND: In 2020, the Singapore government rolled out the TraceTogether program, a digital system to facilitate contact tracing efforts in response to the COVID-19 pandemic. This system is available as a smartphone app and Bluetooth-enabled token to help identify close contacts. As of February 1, 2021, more than 80% of the population has either downloaded the mobile app or received the token in Singapore. Despite the high adoption rate of the TraceTogether mobile app and token (ie, device), it is crucial to understand the role of social and normative perceptions in uptake and usage by the public, given the collective efforts for contact tracing. OBJECTIVE: This study aimed to examine normative influences (descriptive and injunctive norms) on TraceTogether device use for contact tracing purposes, informed by the theory of normative social behavior, a theoretical framework to explain how perceived social norms are related to behaviors. METHODS: From January to February 2021, cross-sectional data were collected by a local research company through emailing their panel members who were (1) Singapore citizens or permanent residents aged 21 years or above; (2) able to read English; and (3) internet users with access to a personal email account. The study sample (n=1137) was restricted to those who had either downloaded the TraceTogether mobile app or received the token. RESULTS: Multivariate (linear and ordinal logistic) regression analyses were carried out to assess the relationships of the behavioral outcome variables (TraceTogether device usage and intention of TraceTogether device usage) with potential correlates, including perceived social norms, perceived community, and interpersonal communication. Multivariate regression analyses indicated that descriptive norms (unstandardized regression coefficient ß=0.31, SE=0.05; P<.001) and injunctive norms (unstandardized regression coefficient ß=0.16, SE=0.04; P<.001) were significantly positively associated with the intention to use the TraceTogether device. It was also found that descriptive norms were a significant correlate of TraceTogether device use frequency (adjusted odds ratio [aOR] 2.08, 95% CI 1.66-2.61; P<.001). Though not significantly related to TraceTogether device use frequency, injunctive norms moderated the relationship between descriptive norms and the outcome variable (aOR 1.12, 95% CI 1.03-1.21; P=.005). CONCLUSIONS: This study provides useful implications for the design of effective intervention strategies to promote the uptake and usage of digital methods for contact tracing in a multiethnic Asian population. Our findings highlight that influence from social networks plays an important role in developing normative perceptions in relation to TraceTogether device use for contact tracing. To promote the uptake of the TraceTogether device and other preventive behaviors for COVID-19, it would be useful to devise norm-based interventions that address these normative perceptions by presenting high prevalence and approval of important social referents, such as family and close friends.

Breast Cancer Information Behaviours and Needs among Singapore Women: A Qualitative Study.

BACKGROUND: There is growing evidence on cancer communication and its impact on cancer-related health outcomes; however, little is known about how women gain access to and use breast cancer information in the multi-ethnic Asian context. This paper aimed to explore the breast cancer information acquisition behaviours and needs among Singapore women who attended a community-based health organisation for mammography screening. Methods, design and setting: Qualitative data were collected through semi-structured interviews with 37 racially diverse, aged 50 and above women, who have received mammography screening within the past two years. The interviews were conducted at either the Singapore Cancer Society Clinic or participant's home. RESULTS: Although cancer information scanning was more prevalent than information seeking (91.9% vs. 62.2%), those who purposively seek information exhibited a higher knowledge level of breast cancer. The most commonly cited sources for information scanning were friends, television and family, and for information seeking were the Internet, pamphlets from a healthcare organisation/ public authority, and healthcare providers. Singapore women were well-informed about the benefits of mammogram; however, specific knowledge, such as modifiable risk factors, reasons for different screening options and the trade-off between harm and benefit, was still lacking which led to confusion about screening. CONCLUSION: Breast cancer health educational materials should provide clear and balanced information to give women a more accurate or realistic expectation about mammography screening. Study findings provide important implications for breast cancer education and programs to move beyond simply raising awareness and craft specific informative messages addressing the needs of the target group.  
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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.

Social Capital and Health Communication in Singapore: An Examination of the Relationships between Community Participation, Perceived Neighborliness and Health Communication Behaviors.

Social capital is a collective characteristic of communities that determines the health and well-being of populations. There is ample evidence supporting the link between social capital and health; however, less is known about the relationship between social capital and health communication behaviors. Our study aimed to investigate the relationships between social capital and health communication in Singaporean adults aged 21 years and above. Cross-sectional data (N = 1,012) were collected from the Singapore Population Health Studies (SPHS) Online Panel. Three main outcome variables assessing health communication behaviors in the past 12 months were (1) health information-seeking; health information-sharing (2) with family members and (3) with friends and coworkers. Two components of social capital were assessed: structural component (i.e., community participation) and cognitive component (i.e., perceived neighborliness). Regression analyses found that community participation and perceived neighborliness were significantly associated with health information-seeking. The analyses also found that perceived cohesion was a significant correlate of health information-sharing with family members. Finally, moderation tests indicated that perceived neighborliness moderated the relationships between trust in information sources and health communication (health information-seeking and health information-sharing with friends/coworkers). Findings have implications for community-based health interventions and social policies to strengthen community participation and cohesion.

Investigating the relationships between social capital, chronic health conditions and health status among Australian adults: findings from an Australian national cohort survey.

BACKGROUND: Social capital is a collective attribute of communities that determines health and well-being of populations. The collective resources in a high social capital community have been reported to result in better health outcomes. While evidence supports the links between social capital and various health outcomes, it is not clear about underlying mechanisms connecting multiple dimensions of social capital to health. METHODS: Using the two-wave data from a nationally representative cohort study of Australian adults (N = 16,637), this study examined the effects of two dimensions of social capital (i.e., structural and cognitive social capital) on physical and mental health in the Australian adult population. Based on prior literature and theoretical reasoning, it was anticipated that the structural and cognitive social capital would influence self-assessed health status (physical and mental health). Additionally, these two dimensions of social capital were hypothesized to moderate the relationships between chronic health conditions and these two aspects of health status. RESULTS: Analyses showed that the effects of chronic health conditions on mental health status were moderated by the structural social capital (ß = .652, SE = .249, p = .009). Additionally, it was found that perceived community cohesion was predictive of mental health (ß = .295, SE = .103, p = .004). Our analysis also indicated that perceptions of disadvantaged neighbourhood environment contributed to poorer mental health status (ß = -.461, SE = .144, p = .001). However, none of the social capital variables significantly predicted physical health status. CONCLUSIONS: Findings suggest that the structural dimension of social capital would function as a buffer against the malicious effects of chronic health conditions, impairments and disabilities. Specifically, community participation (structural social capital) is indispensable to develop an effective community-based program to improve health and well-being of those with chronic health conditions or disabilities, as increasing active participation may generate beneficial effects in this vulnerable population. Subjective perceptions about communities can also play an important role in improving better health outcomes. Further research is needed to examine underlying mechanisms linking the multiple dimensions of social capital to health outcomes among individuals who are vulnerable to external stressors.

Prevalence of pole dance injuries from a global online survey.

BACKGROUND: Pole dancing is a physically demanding sport which combines acrobatics and aerial stunts which could potentially lead to be severely debilitating injuries. However, there is a paucity of medical research data on the injuries that can be sustained. The objective of this study aimed to determine the prevalence of pole injuries, the severity of injuries that can be sustained from this activity, and to help to determine safety protocols. The results will also aid physiotherapists in prescribing exercises when treating pole dancers. METHODS: Cross sectional data was collected from an online web-based survey via social media platforms over 2 weeks in March in 2019. RESULTS: The most commonly reported injuries were shoulder related (54.5%) injuries, wrist (34.2%) and back (24.7%) injuries. 75.5% of injuries were acutely sustained. Pole dancers who were 40 and above were 3.7 times more likely (95% CI: 1.14 to 11.76, P=0.030) to need more than 3 months to recover from their pole injuries than those who were aged from 19 to 29 years. Participants with 3 to 6 years of pole sport experience were at 3.9 times (95% CI: 1.24, 12.39, P=0.020) higher risk for moderate/severe injuries, than those who had less experience. CONCLUSIONS: Our study shows that the most common injuries are sustained in the shoulder and wrist. We also found a relation with age and experience. More studies on this sport is needed to create injury prevention programs and safety protocols.

National Tobacco Control Policies from the Perspectives of Singapore Young Male Adults.

Between 2016 and 2018, tobacco control legislation has undergone several amendments to further restrict tobacco use in Singapore. This study explored the attitudes toward these policy changes and the perceived effectiveness of legislations from the perspectives of young male adults in Singapore. Twenty-nine semi-structured telephone interviews were conducted among young male adults who have completed their National Service in 2017/18 and self-reported as a smoker at pre-enlistment screening. Young male smoker perspectives on Singapore tobacco policies including taxation, smoke-free environment, point-of-sale display ban on tobacco products, graphic health warnings, and raising the minimum legal age of smoking to 21, were evaluated. Participants held the view that cigarette pricing was a highly effective approach to control their smoking behavior because it has a direct impact on tobacco affordability, and they shared that the least effective approaches were point-of-sale display bans and graphic health warnings. Results demonstrate that participants were well aware of tobacco control policies in Singapore, but they did not always fully accept them or understand the rationale behind them. Tobacco control measures should be implemented along with public education to correct misperceptions and increase public support for tobacco control measures in Singapore.

Change in Provider Beliefs Regarding Cervical Cancer Screening Intervals After an Educational Intervention.

BACKGROUND: Current cervical cancer screening guidelines include the option of lengthening the screening interval to 5 years for average-risk women aged 30-65 years when screened with Pap and human papillomavirus (HPV) test (co-test). Because many providers are reluctant to extend screening intervals, we launched an educational intervention to promote recommended screening practices. The study objective was to assess changes in provider attitudes and beliefs to extending screening intervals among low-income women. METHODS: The study was conducted in 15 clinics in Federally Qualified Health Centers in Illinois. Providers in the intervention arm received a multicomponent educational intervention. Fifty-six providers (n = 29 intervention and n = 27 control) completed baseline and 12-month follow-up surveys assessing beliefs and intentions about extending screening intervals. RESULTS: The 12-month assessment showed providers in the intervention arm were significantly more likely than those in the control arm to recommend a 3-year screening interval (guideline recommendation at time of study) with a normal co-test result. Providers who received the intervention were significantly more likely to agree that routine co-testing is the best way to screen for cervical cancer, that extending the screening interval would be good, easy, and beneficial, and to disagree that the increased screening interval would cause patients to lose contact with the medical system. CONCLUSION: Educating providers on the natural history of HPV infection and cervical cancer and the benefits of extended intervals increased their willingness to follow guidelines. This study provides evidence that an educational intervention delivered with HPV testing materials may be effective in encouraging appropriate cervical screening intervals.

Changes in Knowledge and Beliefs About Human Papillomavirus and Cervical Cancer Screening Intervals in Low-Income Women After an Educational Intervention.

INTRODUCTION: Women have been reluctant to adopt longer than annual intervals for cervical cancer screening, despite guidelines recommending screening every 3 to 5 years. Our study assessed patient knowledge and beliefs about human papillomavirus (HPV) and cervical cancer screening after exposure to an educational intervention, and whether there was a change in time regarding knowledge and beliefs among all study participants in an underserved population. METHOD: The study was conducted in 15 clinics associated with 6 Federally Qualified Health Centers in Illinois, USA. Cervical cancer screening patients (n = 644) completed a baseline and postintervention follow-up survey. The intervention included an HPV test and an educational pamphlet. Significance testing of changes in knowledge and beliefs was conducted with multilevel, mixed-effects models adjusting for repeated measures of patients and clustering within clinics. RESULTS: No significant differences in study outcomes were found between the intervention and control groups. Among all women, knowledge of HPV significantly improved over time. At follow-up, fewer women reported that having a co-test is good, wise, will give you peace of mind, will tell you whether you need to worry if Pap is abnormal, is something your doctor thinks you should have, and will give you the best care available. More women said it would be bad, useless, or worrying to wait 3 years for a Pap test at follow-up. CONCLUSION: HPV knowledge improved over time, but the educational intervention utilized in this study was not successful in improving attitudes and beliefs about co-testing and longer screening intervals, and beliefs about HPV co-testing and 3-year screening intervals were less favorable. Having health care providers discuss the consequences of overscreening and the natural history of HPV and cervical cancer with their patients may help increase adherence to longer screening intervals. Further examination of the essential components for educational intervention in this population is warranted.

Overcoming barriers to health-care access: A qualitative study among African migrants in Guangzhou, China.

Guangzhou is China's third most populous city, and the region's burgeoning manufacturing economy has attracted many young African businessmen and entrepreneurs to the city. The aims of this study were to examine strategies that African migrants in Guangzhou have adopted in response to health-care barriers, and explore their perceptions of how to address their needs. Twenty-five semi-structured interviews and two focus groups were conducted among African migrants residing in Guangzhou, China. Facing multiple barriers to care, African migrants have adopted a number of suboptimal and unsustainable approaches to access health care. These included: using their Chinese friends or partners as interpreters, self-medicating, using personal connections to medical doctors, and travelling to home countries or countries that offer English-speaking doctors for health care. Health-care providers and health organisations in Guangzhou have not yet acquired sufficient cultural competence to address the needs of African migrants residing in the city. Introducing linguistically and culturally competent health-care services in communities concentrated with African migrants may better serve the population. With the growing international migration to China, it is essential to develop sustainable approaches to improving health-care access for international migrants, particularly those who are marginalised.

Racial and ethnic differences in human papillomavirus positivity and risk factors among low-income women in Federally Qualified Health Centers in the United States.

Reasons for racial/ethnic disparities in HPV infection are unclear. This study assessed racial/ethnic differences in and risk factors for HPV positivity among low-income women. Data were collected from 984 low-income women visiting Federally Qualified Health Centers across Illinois (2009-2011). Pearson chi square and Logistic regression analyses were used to examine associations with HPV positivity. Our results showed Mexican-born Hispanics had the lowest HPV positivity (16%), followed by non-Hispanic whites (29%), US-born Hispanics (35%), and non-Hispanic blacks (39%). Mexican-born Hispanics reported fewer risk behaviors for HPV positivity, including first sexual intercourse before age 16 years (9% versus 27%), multiple sexual partners in lifetime (48% versus 90%), and current cigarette smoking status (10% versus 35%) when compared to non-Hispanic whites (p<0.001). In multivariate-adjusted logistic regression, being non-Hispanic black, first sexual intercourse before age 16 years, increasing numbers of recent or lifetime sexual partners and current cigarette smoking status were associated with a higher likelihood of HPV positivity. Our findings highlight racial/ethnic differences in HPV positivity and risk factors in a population of women with similar socioeconomic characteristics. When measuring HPV risk factors within the Hispanic population, foreign-born status and other mediating factors, such as social norms and cultural characteristics, may be relevant to assess the intragroup heterogeneity.

Communication practices about HPV testing among providers in Federally Qualified Health Centers.

OBJECTIVE: Little is known about the information providers share with patients when ordering a co-test, or combined human papillomavirus (HPV) and Papanicolaou (Pap) test, for cervical cancer screening. We assessed provider perceptions of such communication practices with female patients aged 30-60 years. METHODS: We analyzed data from 98 providers in 15 Federally Qualified Health Center clinics across Illinois (2009-2010). RESULTS: About 70% of the providers reported that when ordering a co-test, they would usually or always communicate information about the HPV test to their patients, explain the test detects a sexually transmitted infection, and discuss how the test results may determine their next screening interval. Most (>85%) reported that they were comfortable discussing co-test results. Compared with concordant positive results (HPV positive/Pap positive), providers were more likely to perceive that discordant results (HPV positive/Pap negative) would be too complex for patients to understand (25% vs. 15%, p = 0.006), and make patients feel less assured that they were getting the best standard of care (67% vs. 88%, p < 0.001). CONCLUSION: As HPV testing plays a more prominent role in cervical cancer screening, more attention should be given to communications between providers and patients about the benefits and harms of different screening options.

Provider beliefs associated with cervical cancer screening interval recommendations: A pilot study in Federally Qualified Health Centers.

BACKGROUND: Among providers who serve low-income and uninsured women, resistance to extending the cervical cancer screening interval following normal Pap and co-test results has been documented. Our objective was to examine provider characteristics and beliefs associated with guideline-consistent screening interval recommendations. METHOD: We collected cross-sectional survey data between 2009 and 2010 from 82 primary care providers in six Federally Qualified Health Centers in Illinois, USA. The relationships between characteristics, beliefs, and screening interval recommendations (1 year vs. 3 years) were tested with Pearson chi-square, negative binomial and ordered logistic regression. RESULTS: Compared to providers who recommended annual intervals after a normal co-test, providers who recommended a guideline-consistent (i.e., 3 years) screening interval were significantly more likely to report the goodness, ease, and benefit of their recommendation and perceived encouragement for a 3-year interval from professional organizations and journals (p < .05). Providers who recommended a 3-year interval were also less likely to report that longer intervals increase patient risk for cervical cancer (p < .05). Interval recommendations were not associated with provider specialty, gender, or years in practice. CONCLUSION: Messages that promote the benefits of longer screening intervals after a normal co-test, the natural history of human papillomavirus and cervical cancer, and low risk of developing cancer with a longer interval may be useful to promote evidence-based screening in this population of Federally Qualified Health Center providers. Dissemination of targeted messages through professional journals and specialty organizations should be considered.

Provider management of equivocal cervical cancer screening results among underserved women, 2009-2011: follow-up of atypical squamous cells of undetermined significance.

PURPOSE: Reflex human papillomavirus (HPV) testing is the preferred triage option for most women diagnosed with atypical squamous cells of undetermined significance (ASC-US). This study was conducted to describe follow-up results of women with ASC-US Pap test results in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), focusing on HPV test use. METHODS: We examined the follow-up of 45,049 women in the NBCCEDP with ASC-US Pap tests during 2009-2011. Data on demographic characteristics, diagnostic procedures, and clinical outcomes were analyzed. RESULTS: NBCCEDP providers diagnosed 45,049 women (4.5 % of all Pap tests) with an ASC-US result. Of those, 28,271 (62.8 %) were followed with an HPV test, 3,883 (8.6 %) with a repeat Pap test, 6,592 (14.6 %) with colposcopy, and 6,303 were lost to follow-up (14.0 %). Women aged 40 and older were followed more often with an HPV test. White, black, and Asian/Pacific Islander women were followed more often with an HPV test after an ASC-US Pap compared to Hispanic and American Indian/Alaska Native (AI/AN) women. Among women with a positive HPV test on follow-up, almost 90 % continued with colposcopy as recommended. AI/AN women had the highest rates of HPV positivity (55.2 %) and of no follow-up (25.0 %). CONCLUSION: This is the first analysis describing follow-up of ASC-US Pap test results in the NBCCEDP, providing a window into current management of ASC-US results. Findings raise concerns about persistent disparities among AI/AN women. During 2009-2011, nearly two-thirds of women with an ASC-US Pap test result were followed with an HPV reflex test.

Substance Use among a National Sample of Asian/Pacific Islander Men Who Have Sex with Men in the U.S.

The objectives of this study were to describe drug use among Asian/Pacific Islander (API) men who have sex with men (MSM) and to examine how nativity (and acculturation as a secondary correlate) predicted such use. A total of 445 self-identified API MSM from seven metropolitan cities participated in a national HIV serological testing and psychosocial and behavioral assessment study. Results indicate clubbing was significantly associated with higher levels of substance use. Additionally, participants who were U.S.-born were more likely to have reported marijuana use and those with higher levels of acculturation reported less marijuana use. Our bivariate findings suggest that foreign-born status and acculturation experience may provide a protective effect against marijuana use among API MSM. These associations largely did not hold in our multivariate models. Future research should more fully examine the role of acculturation and nativity in substance use behaviors.

Health Care Experiences and Perceived Barriers to Health Care Access: A Qualitative Study Among African Migrants in Guangzhou, Guangdong Province, China.

Guangzhou, one of China's largest cities and a main trading port in South China, has attracted many African businessmen and traders migrating to the city for financial gains. Previous research has explored the cultural and economic roles of this newly emerging population; however, little is known about their health care experiences while in China. Semi-structured interviews and focus groups were used to assess health care experiences and perceived barriers to health care access among African migrants in Guangzhou, China. Overall, African migrants experienced various barriers to accessing health care and were dissatisfied with local health services. The principal barriers to care reported included affordability, legal issues, language barriers, and cultural differences. Facing multiple barriers, African migrants have limited access to care in Guangzhou. Local health settings are not accustomed to the African migrant population, suggesting that providing linguistically and culturally appropriate services may improve access to care for the migrants.