Implementing a community-based shared care breast cancer survivorship model in Singapore: a qualitative study among primary care practitioners.

BACKGROUND: The adaptability of existing recommendations on shared care implementation to Asian settings is unknown. This qualitative study aims to elicit public- and private-sectors primary care practitioners' (PCPs) perspectives on the sustainable implementation of a shared care model among breast cancer survivors in Singapore. METHODS: Purposive sampling was employed to engage 70 PCPs from SingHealth Polyclinics, National University Polyclinics, National Healthcare Group Polyclinics, and private practice. Eleven focus groups and six in-depth interviews were conducted between June to November 2018. All sessions were audio-recorded and transcribed verbatim. Guided by the RE-AIM framework, we performed deductive thematic analysis in QSR NVivo 12. RESULTS: PCPs identified low-risk breast cancer survivors who demonstrated clear acceptability of PCPs' involvement in follow-up as suitable candidates for shared care. Engagement with institution stakeholders as early adopters is crucial with adequate support through PCP training, return pathways to oncologists, and survivorship care plans as communication tools. Implementation considerations differed across practices. Selection of participating PCPs could consider seniority and interest for public and private practice, respectively. Proposed adoption incentives included increased renumeration for private PCPs and work recognition for public PCPs. Public PCPs further proposed integrating shared care elements to their existing family medicine clinics. CONCLUSIONS: PCPs perceived shared care favorably as it echoed principles of primary care to provide holistic and well-coordinated care. Contextual factors should be considered when adapting implementation recommendations to Asian settings like Singapore. With limited competitive pressure, the government is then pivotal in empowering primary care participation in survivorship shared care delivery.

Relationship between Perceived Peer and Adolescents' Sexual Behaviors: The Moderating Role of Gender.

In Malaysia, sexual health risks such as unprotected sex, teenage pregnancies, abandoned babies, abortion, and sexually transmitted diseases are on the rise because adolescents are increasingly engaging in such sexual behaviors. The present study aimed to investigate the relationship between perceived peer sexual behaviors and sexual behaviors among adolescents as well as to examine the interacting role of gender in such a relationship. This cross-sectional study recruited a sample of 338 school-going adolescents (Mage = 16.7; SDage = 1.53) using the purposive sampling method. Participants were required to complete questionnaires consisting of the modified Human Sexuality Questionnaire-Orgasmic Experience Scale and the Peer Norms Scale. Results indicated that adolescents who perceived their peers to be actively engaging in sexual behaviors were more prone to being sexually active themselves. The results also showed gender as a significant moderator in the relationship between adolescents' perceived peers' sexual behaviors and sexual behaviors. Besides, the impact of perceived peer sexual behaviors on sexual behaviors was found to be stronger in male than female adolescents. Overall, the findings from this study hinted at the importance of peers and gender differences during the planning and implementation of sexual and health education.

Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study.

BACKGROUND: Breast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so. OBJECTIVE: To explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists. METHODS: Eleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12. RESULTS: Majority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme. CONCLUSIONS: PCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation.

Are migrant workers in Singapore receiving adequate healthcare? A survey of doctors working in public tertiary healthcare institutions.

INTRODUCTION: Migrant workers comprise about one-fifth of Singapore's resident population and form a substantial and vital component of the nation's workforce. However, limited data is available regarding the barriers that migrant workers face in accessing healthcare from the healthcare providers' perspective. METHODS: We conducted a survey on doctors working in four restructured hospitals in Singapore, to assess what they perceived to be barriers faced by migrant workers in accessing healthcare. We also assessed the doctors' understanding of migrant-health-related policies in Singapore. RESULTS: A total of 427 survey responses were collected. Most respondents were senior doctors (senior residents or consultants) who had been practising medicine for a median of ten years. Among doctors, the most common perceived barriers to migrant workers accessing healthcare were related to culture/language (92.3%) and finances (healthcare cost) (81.0%). Of the six questions asked pertaining to migrant healthcare policy in Singapore, the respondents achieved a median of four correctly answered questions (interquartile range 3-5), and about 55% were unaware or unsure of available resources for migrant workers. CONCLUSION: Our study identified healthcare providers' perceived barriers to the delivery of healthcare to migrant workers, which corroborate previously published data reported by migrant workers themselves. Further efforts should be directed towards diminishing these barriers and increasing the literacy of migrant health among healthcare workers.

Reducing Follow-Up Appointments in a Mental Health Institute in Singapore: Family Medicine-Psychiatry Collaboration.

BACKGROUND: The Institute of Mental Health (IMH), the leading tertiary psychiatric hospital in Singapore, has managed patients' psychiatric issues for decades. However, these patients' existing medical conditions often require care in subspeciality outpatient clinics of restructured hospitals. Given the need to reduce follow-up appointments in subspeciality outpatient clinics for conditions that can be managed by family physicians, a novel family medicine-psychiatry collaborative initiative between Sengkang General Hospital and IMH was implemented to address this issue. METHODS: Data were retrospectively collected on patients with upcoming appointments who were seen by family physicians at IMH from January 2 to May 14, 2017. Patients with upcoming appointments in the subspeciality outpatient clinics were scheduled for review by family physicians. Continuous data were summarized as median (range) and count (percentage). RESULTS: At 4.5 months, 272 patients with 426 preexisting specialty appointments had been seen by family physicians. Of the specialty appointments, 150 (35.2%) were cancelled, as the conditions could be managed by family physicians. In 64 (15.0%) cases, a memo requesting transfer of care was given to the subspecialty consultant to ensure a consensus regarding the patient's management. CONCLUSIONS: Family physicians embedded in mental health institutions can reduce the need to transfer patients out of the hospital to receive care for nonpsychiatric conditions.

Attitudes, perceptions and practice patterns of primary care practitioners towards house calls.

INTRODUCTION Historically, doctors routinely delivered medical care to sick patients in their homes, with house calls accounting for 40% of all doctor-patient encounters in the 1940s. This proportion has dwindled to less than 1% today. Advantages of house calls include decreased mortality rates, admissions to long-term care in the general elderly population and increased patient appreciation. Therefore, we asked 'Why do some primary care practitioners do house calls and what are the reasons that others do not?'. AIM This review aims to understand the attitudes, perceptions of Primary Care Practitioners (PCPs) towards house calls and their practice patterns. METHODS A search of PubMed and Embase was conducted for articles published before 31 December 2017. A total of 531 articles with 44 duplicates was generated. Of these, 13 were shortlisted along with three hand-searched articles for a total of 16 articles included in this review. RESULTS Primary care providers were aware of the role of house calls and their advantages in enabling comprehensive care for a patient. They saw making house calls as a responsibility with rewards that enhanced the doctor-patient relationship. However, opportunity cost, time, medical liability and miscellaneous reasons such as the lack of training precluded some PCPs from making more house calls. DISCUSSION Primary care practitioners recognise the importance of house calls, especially in the care of elderly patients, but there are many unaddressed issues such as opportunity cost and clinical inadequacy in the home setting that have caused a decline in house calls over the years.