Exploring the Implementation of Shared Decision-Making Involving Health Coaches for Diabetes and Hypertension Self-Management: Qualitative Study.

BACKGROUND: An emerging focus on person-centered care has prompted the need to understand how shared decision-making (SDM) and health coaching could support self-management of diabetes and hypertension. OBJECTIVE: This study aims to explore preferences for the scope of involvement of health coaches and health care professionals (HCPs) in SDM and the factors that may influence optimal implementation of SDM from the perspectives of patients and HCPs. METHODS: We conducted focus group discussions with 39 patients with diabetes and hypertension and 45 HCPs involved in their care. The main topics discussed included the roles of health coaches and HCPs in self-management, views toward health coaching and SDM, and factors that should be considered for optimal implementation of SDM that involves health coaches. All focus group discussions were audio recorded, transcribed verbatim, and analyzed using thematic analysis. RESULTS: Participants agreed that the main responsibility of HCPs should be identifying the patient's stage of change and medication education, while health coaches should focus on lifestyle education, monitoring, and motivational conversation. The health coach was seen to be more effective in engaging patients in lifestyle education and designing goal management plans as health coaches have more time available to spend with patients. The importance of a health coach's personal attributes (eg, sufficient knowledge of both medical and psychosocial management of disease conditions) and credentials (eg, openness, patience, and empathy) was commonly emphasized. Participants viewed that addressing the following five elements would be necessary for the optimal implementation of SDM: (1) target population (newly diagnosed and less stable patients), (2) commitment of all stakeholders (discrepancy on targeted times and modality), (3) continuity of care (familiar faces), (4) philosophy of care (person-centered communication), and (5) faces of legitimacy (physician as the ultimate authority). CONCLUSIONS: The findings shed light on the appropriate roles of health coaches vis-à-vis HCPs in SDM as perceived by patients and HCPs. Findings from this study also contribute to the understanding of SDM on self-management strategies for patients with diabetes and hypertension and highlight potential opportunities for integrating health coaches into the routine care process.

Experiences of a Community-Based Digital Intervention Among Older People Living in a Low-Income Neighborhood: Qualitative Study.

BACKGROUND: Older adults worldwide experienced heightened risks of depression, anxiety, loneliness, and poor mental well-being during the COVID-19 pandemic. During this period, digital technology emerged as a means to mitigate social isolation and enhance social connectedness among older adults. However, older adults' behaviors and attitudes toward the adoption and use of digital technology are heterogeneous and shaped by factors such as age, income, and education. Few empirical studies have examined how older adults experiencing social and economic disadvantages perceive the learning of digital tools. OBJECTIVE: This study aims to examine the motivations, experiences, and perceptions toward a community-based digital intervention among older adults residing in public rental flats in a low-income neighborhood. Specifically, we explored how their attitudes and behaviors toward learning the use of smartphones are shaped by their experiences related to age and socioeconomic challenges. METHODS: This study adopted a qualitative methodology. Between December 2020 and March 2021, we conducted semistructured in-depth interviews with 19 participants aged ≥60 years who had completed the community-based digital intervention. We asked participants questions about the challenges encountered amid the pandemic, their perceived benefits of and difficulties with smartphone use, and their experiences with participating in the intervention. All interviews were audio recorded and analyzed using a reflexive thematic approach. RESULTS: Although older learners stated varying levels of motivation to learn, most expressed ambivalence about the perceived utility and relevance of the smartphone to their current needs and priorities. While participants valued the social interaction with volunteers and the personalized learning model of the digital intervention, they also articulated barriers such as age-related cognitive and physical limitations and language and illiteracy that hindered their sustained use of these digital devices. Most importantly, the internalization of ageist stereotypes of being less worthy learners and the perception of smartphone use as being in the realm of the privileged other further reduced self-efficacy and interest in learning. CONCLUSIONS: To improve learning and sustained use of smartphones for older adults with low income, it is essential to explore avenues that render digital tools pertinent to their daily lives, such as creating opportunities for social connections and relationship building. Future studies should investigate the relationships between older adults' social, economic, and health marginality and their ability to access digital technologies. We recommend that the design and implementation of digital interventions should prioritize catering to the needs and preferences of various segments of older adults, while working to bridge rather than perpetuate the digital divide.

Acceptability of Mobile App-Based Motivational Interviewing and Preferences for App Features to Support Self-Management in Patients With Type 2 Diabetes: Qualitative Study.

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) experience multiple barriers to improving self-management. Evidence suggests that motivational interviewing (MI), a patient-centered communication method, can address patient barriers and promote healthy behavior. Despite the value of MI, existing MI studies predominantly used face-to-face or phone-based interventions. With the growing adoption of smartphones, automated MI techniques powered by artificial intelligence on mobile devices may offer effective motivational support to patients with T2DM. OBJECTIVE: This study aimed to explore the perspectives of patients with T2DM on the acceptability of app-based MI in routine health care and collect their feedback on specific MI module features to inform our future intervention. METHODS: We conducted semistructured interviews with patients with T2DM, recruited from public primary care clinics. All interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted using NVivo. RESULTS: In total, 33 patients with T2DM participated in the study. Participants saw MI as a mental reminder to increase motivation and a complementary care model conducive to self-reflection and behavior change. Yet, there was a sense of reluctance, mainly stemming from potential compromise of autonomy in self-care by the introduction of MI. Some participants felt confident in their ability to manage conditions independently, while others reported already making changes and preferred self-management at their own pace. Compared with in-person MI, app-based MI was viewed as offering a more relaxed atmosphere for open sharing without being judged by health care providers. However, participants questioned the lack of human touch, which could potentially undermine a patient-provider therapeutic relationship. To sustain motivation, participants suggested more features of an ongoing supportive nature such as the visualization of milestones, gamified challenges and incremental rewards according to achievements, tailored multimedia resources based on goals, and conversational tools that are interactive and empathic. CONCLUSIONS: Our findings suggest the need for a hybrid model of intervention involving both app-based automated MI and human coaching. Patient feedback on specific app features will be incorporated into the module development and tested in a randomized controlled trial.

Empowering patients with comorbid diabetes and hypertension through a multi-component intervention of mobile app, health coaching and shared decision-making: Protocol for an effectiveness-implementation of randomised controlled trial.

INTRODUCTION: Diabetes and hypertension are prevalent and costly to the health system. We have developed a mobile app (EMPOWER app) which enables remote monitoring and education through personalised nudges. We aim to study the effectiveness of a multi-component intervention comprising the EMPOWER mobile app with health coaching and shared decision-making for diabetes and hypertension. METHODS: We will conduct a two-arm, open-label, pragmatic randomised controlled trial (RCT). Participants with comorbid diabetes and hypertension enrolled from public primary care clinics will be randomised to either intervention or control in a 1:1 ratio. The intervention group participants will have access to health coaching with shared decision-making interventions in addition to the EMPOWER app and their usual primary care. The control group participants will continue to receive usual primary care and will neither receive the EMPOWER app nor health coaching and shared decision-making interventions. Our primary outcome is change in HbA1c level over 9 months. Secondary outcomes include change in systolic blood pressure, quality of life, patient activation, medication adherence, physical activity level, diet, and healthcare cost (direct and indirect) over 9 months. DISCUSSION: Our trial will provide key insights into clinical- and cost-effectiveness of a multi-component intervention comprising EMPOWER mobile app, health coaching and shared decision-making in diabetes and hypertension management. This trial will also offer evidence on cost-effective and sustainable methods for promoting behavioural changes among patients with comorbid diabetes and hypertension. TRIAL REGISTRATION: This study was registered on clintrials.gov on August 3, 2022, with the trial registration number: NCT05486390.

Frameworks for measuring population health: A scoping review.

INTRODUCTION: Many regions in the world are using the population health approach and require a means to measure the health of their population of interest. Population health frameworks provide a theoretical grounding for conceptualization of population health and therefore a logical basis for selection of indicators. The aim of this scoping review was to provide an overview and summary of the characteristics of existing population health frameworks that have been used to conceptualize the measurement of population health. METHODS: We used the Population, Concept and Context (PCC) framework to define eligibility criteria of frameworks. We were interested in frameworks applicable for general populations, that contained components of measurement of health with or without its antecedents and applied at the population level or used a population health approach. Eligible reports of eligible frameworks should include at least domains and subdomains, purpose, or indicators. We searched 5 databases (Pubmed, EMBASE, Web of Science, NYAM Grey Literature Report, and OpenGrey), governmental and organizational sites on Google and websites of selected organizations using keywords from the PCC framework. Characteristics of the frameworks were summarized descriptively and narratively. RESULTS: Fifty-seven frameworks were included. The majority originated from the US (46%), Europe (23%) and Canada (19%). Apart from 1 framework developed for rural populations and 2 for indigenous populations, the rest were for general urban populations. The numbers of domains, subdomains and indicators were highly variable. Health status and social determinants of health were the most common domains across all frameworks. Different frameworks had different priorities and therefore focus on different domains. CONCLUSION: Key domains common across frameworks other than health status were social determinants of health, health behaviours and healthcare system performance. The results in this review serve as a useful resource for governments and healthcare organizations for informing their population health measurement efforts.

Artificial intelligence, ChatGPT, and other large language models for social determinants of health: Current state and future directions.

This perspective highlights the importance of addressing social determinants of health (SDOH) in patient health outcomes and health inequity, a global problem exacerbated by the COVID-19 pandemic. We provide a broad discussion on current developments in digital health and artificial intelligence (AI), including large language models (LLMs), as transformative tools in addressing SDOH factors, offering new capabilities for disease surveillance and patient care. Simultaneously, we bring attention to challenges, such as data standardization, infrastructure limitations, digital literacy, and algorithmic bias, that could hinder equitable access to AI benefits. For LLMs, we highlight potential unique challenges and risks including environmental impact, unfair labor practices, inadvertent disinformation or "hallucinations," proliferation of bias, and infringement of copyrights. We propose the need for a multitiered approach to digital inclusion as an SDOH and the development of ethical and responsible AI practice frameworks globally and provide suggestions on bridging the gap from development to implementation of equitable AI technologies.

Prevalence and factors associated with sarcopenia among older adults in a post-acute hospital in Singapore.

BACKGROUND: Sarcopenia is common in older adults worldwide, but its prevalence varies widely owing to differences in diagnostic criteria, population sampled, and care setting. We aimed to determine the prevalence and factors associated with sarcopenia in patients aged 65 and above admitted to a post-acute hospital in Singapore. METHODS: This was a cross-sectional study of 400 patients recruited from a community hospital in Singapore. Data including socio-demographics, physical activity, nutritional status, cognition, clinical and functional status, as well as anthropometric measurements were collected. Sarcopenia was defined using the Asian Working Group for Sarcopenia 2019 criteria [AWGS2019]. RESULTS: Of the 383 patients with complete datasets, overall prevalence of sarcopenia was 54% while prevalence of severe sarcopenia was 38.9%. Participants with increased age, male gender and a low physical activity level were more likely to be sarcopenic, while those with higher hip circumference and higher BMI of ≥27.5m/kg2 were less likely to be sarcopenic. Other than the above-mentioned variables, cognitive impairment was also associated with severe sarcopenia. CONCLUSIONS: More than 1 in 2 older adults admitted to a post-acute hospital in Singapore are sarcopenic. There is an urgent need to address this important clinical syndrome burden and to identify patients at risk of sarcopenia in post-acute settings in Singapore for early intervention.

Socioeconomic and behavioral determinants of non-compliance with physician referrals following community screening for diabetes, hypertension and hyperlipidemia: a mixed-methods study.

Early detection of undiagnosed diabetes, hypertension or hyperlipidemia through screening could reduce healthcare costs resulting from disease complications. To date, despite ample research on the factors linked to the uptake of community health screening programs, little attention has been directed at delayed or incomplete follow-up after positive outcomes are identified in community screening tests. This study aimed to investigate the socioeconomic and behavioral factors that influence non-compliance with recommendations for primary care physician referrals, following community-based screening for diabetes, hypertension and hyperlipidemia. A parallel mixed-methods study was conducted. For quantitative data, we performed multivariable analysis on community-based chronic disease screening data. The qualitative component involved semi-structured interviews with individuals with both non-compliance and compliance with referral recommendations. Thematic data analysis was undertaken using the Theoretical Domains Framework (TDF). The quantitative analysis showed that older age (OR = 0.92, 95%CI [0.89-0.96]), non-Chinese ethnicity (OR = 0.24; 95% CI [0.08-0.44]) and residing in 5-room public/ private housing (OR = 0.40; 95% CI [0.14-0.74]) were associated with lower odds of non-compliance with referral recommendations. Thematic analysis identified multiple behavioral-level determinants acting as enablers or barriers within 7 TDF domains: awareness of health risks after receiving screening results, self-management orientation and behavioral control, fear of formal diagnosis and concerns about healthcare cost, optimistic belief driven by the lack of symptoms, interpersonal relationship and social obligations, aversion to medication, communication at the result collection and sense of uncertainty regarding self-scheduling of appointment. Findings provide valuable implications for the development of interventions aimed at improving adherence to referral recommendation. Future endeavors should include culturally sensitive outreach, evidence-based information dissemination, family-centered education, positive public health messaging, brief counseling during result collection and an opt-out appointment system to enhance follow-up care.

Evaluating the association of COVID-19 restrictions on discharge planning and post-discharge outcomes in the community hospital and Singapore regional health system.

Objectives: The COVID-19 is a global health issue with widespread impact around the world, and many countries initiated lockdowns as part of their preventive measures. We aim to quantify the duration of delay in discharge to community from Community Hospitals, as well as quantify adverse patient outcomes post discharge pre and during lockdown period. Design and methods: We conducted a before-after study comparing the length of stay in Community Hospitals, unscheduled readmissions or Emergency Department attendance, patients' quality of life using EQ5D-5l, number and severity of falls, in patients admitted and discharged before and during lockdown period. Results: The average length of stay in the lockdown group (27.77 days) were significantly longer than that of the pre-lockdown group (23.76 days), p = 0.003. There were similar proportions of patients with self-reported falls post discharge between both groups. Patients in the pre-lockdown group had slightly better EQ-5D-5l Index score at 0.55, compared to the lockdown study group at 0.49. Half of the patients in both groups were referred to Community Care Services on discharge. Conclusion: Our study would help in developing a future systematic preparedness guideline and contingency plans in times of disease outbreak and other similar public health emergencies.

A policy ethnography study of a Singapore regional health system on its governance adaptations and associated challenges as a project organisation to implement Healthier Singapore.

Objectives: Project organisations reflect a modern and non-bureaucratic form of organising public-sector activities, which promises innovation, entrepreneurship, and order and control to bring about change. This study seeks to investigate the project organisation Singapore Health Services (SingHealth) Region Health System (RHS)'s approach to implementing the Healthier Singapore (HSG) strategy, including models of governance and perceptions of RHS leads, identify the challenges facing the RHS, and to draw insights into the conditions necessary for using project organisation as a policy tool in policy implementation. Study design: We adopted a policy ethnography approach to answering the research question. Methods: The approach involved: (1) non-participant observation with fieldnotes taken during meetings, events, programme activities, and conferences concerning SingHealth and HSG implementation; (2) analysis of 52 organisational documents; and (3) interviews with 21 senior SingHealth leaders from the RHS Executive Committee, involved in envisioning and overseeing the production of RHS projects to align with the HSG strategy (March to September 2022). Results: Evidence demonstrates the presence of multiple governance and interactive governance in HSG implementation, including legitimising the RHS as the project organisation; engaging the private corporations; incorporating the citizens; and working with non-governmental organisations. However, the RHS faced many challenges, ranging from governance, workforce, financing, IT infrastructure and care models, problem definition, primary care and legacy issues, knowledge management, and being pandemic-informed in its delivery. Conclusion: The RHS will need to address these challenges through the necessary constitutive, directive, and operational actions, and interactive governance to enhance its institutional capacity to implement the HSG Strategy.

Role of Caregivers in Remote Management of Patients With Type 2 Diabetes Mellitus: Systematic Review of Literature.

BACKGROUND: With the growing use of remote monitoring technologies in the management of patients with type 2 diabetes mellitus (T2DM), caregivers are becoming important resources that can be tapped into to improve patient care. OBJECTIVE: This review aims to summarize the role of caregivers in the remote monitoring of patients with T2DM. METHODS: We performed a systematic review in MEDLINE, Embase, Scopus, PsycINFO, and Web of Science up to 2022. Studies that evaluated the role of caregivers in remote management of adult patients with T2DM were included. Outcomes such as diabetes control, adherence to medication, quality of life, frequency of home glucose monitoring, and health care use were evaluated. RESULTS: Of the 1198 identified citations, 11 articles were included. The majority of studies were conducted in North America (7/11, 64%) and South America (2/11, 18%). The main types of caregivers studied were family or friends (10/11, 91%), while the most common remote monitoring modalities evaluated were interactive voice response (5/11, 45%) and phone consultations (4/11, 36%). With regard to diabetes control, 3 of 6 studies showed improvement in diabetes-related laboratory parameters. A total of 2 studies showed improvements in patients' medication adherence rates and frequency of home glucose monitoring. Studies that evaluated patients' quality of life showed mixed evidence. In 1 study, increased hospitalization rates were noted in the intervention group. CONCLUSIONS: Caregivers may play a role in improving clinical outcomes among patients with T2DM under remote monitoring. Studies on mobile health technologies are lacking to understand their impact on Asian populations and long-term patient outcomes.

Smartphone ownership, digital literacy, and the mediating role of social connectedness and loneliness in improving the wellbeing of community-dwelling older adults of low socio-economic status in Singapore.

INTRODUCTION: During the COVID-19 pandemic, safe-distancing measures resulted in many community-dwelling older adults being socially isolated and lonely, with its attending negative impact on wellbeing and quality of life. While digital technology may have mitigated this, older adults of low socioeconomic status (SES) are more likely to be digitally excluded and hence susceptible to the adverse effects of social isolation and loneliness. This study aims to understand the factors that affect digital literacy, smartphone ownership, and willingness to participate in a digital literacy program (DLP), and to test the hypothesized relations between digital literacy, social connectedness, loneliness, wellbeing, and quality of life amongst community dwelling older adults of low SES. MATERIALS AND METHODS: A questionnaire assessing digital literacy, social connectedness, wellbeing and quality of life was administered. Socio-demographic variables, pre-existing internet-enabled, and willingness to participate in a home-based DLP was also collected. Logistic regression was used to identify demographic factors associated with digital literacy, smartphone ownership, and willingness to enroll in a DLP. Serial mediation analysis was also performed using a structural equation model framework. RESULTS: A total of 302 participants were recruited. Female gender, older age, lower education levels were associated with lower digital literacy. Those who owned a smartphone tended to be younger and better educated. Older adults who were better educated, of Chinese descent (the ethnic majority in Singapore), and who had lower digital literacy, were most willing to enroll in the digital literacy education program. Social-use digital literacy had a positive indirect effect on well-being ([Formula: see text]) and Quality of life ([Formula: see text]), mediated by social connectedness and loneliness. In contrast, instrumental-use digital literacy had a negative indirect effect on well-being ([Formula: see text]) and Quality of life ([Formula: see text]), mediated by social connectedness and loneliness. DISCUSSION: The results suggest there are demographic barriers to participation in DLPs and highlight the benefit of focusing on enhancing social-use digital literacy. Further study is needed to evaluate how well specific interventions to improve social-use digital literacy help to reduce social isolation and loneliness, and ultimately improve wellbeing and quality of life.

Implementation of social prescribing: lessons learnt from contextualising an intervention in a community hospital in Singapore.

The need to develop holistic public health approaches that go beyond treating the biological causes of ill health, to addressing the social determinants of health, have been highlighted in the global health agenda. Social prescribing, where care professionals link individuals to community resources that tackle social needs have gained increasing traction worldwide. In Singapore, SingHealth Community Hospitals introduced social prescribing in July 2019 to manage the complex health and social needs of the aging populace. Faced with the paucity of evidence on the effectiveness of social prescribing and its implementation, implementers had to contextualise the theory of social prescribing to patients' needs and setting of practice. Using an iterative approach, the implementation team constantly reviewed and adapted practices, work processes and outcome measurement tools based on data and stakeholder feedback to address implementation challenges. As social prescribing continues to scale in Singapore and take root in the Western Pacific region, agile implementation and continued evaluation of programmes to build an evidence pool will help to guide best practices. The aim of this paper is to review the implementation of a social prescribing programme from the exploratory phase to full implementation, and draw lessons learned in the process.

Pandemic-related health literacy: a systematic review of literature in COVID-19, SARS and MERS pandemics.

Introduction: Health literacy plays an essential role in one's ability to acquire and understand critical medical information in the coronavirus disease 2019 (COVID-19) infodemic and in other pandemics. We aimed to summarise the assessment, levels and determinants of pandemic-related health literacy and its associated clinical outcomes. Methods: A systematic review was performed in Medline®, Embase®, PsycINFO®, CINAHL® and four major preprint servers. Observational and interventional studies that evaluated health literacy related to the novel COVID-19, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were included. Items used in health literacy instruments were grouped under the themes of knowledge, attitudes and practices. Determinants of health literacy were grouped into five domains: sociodemographic, medical, psychological/psychiatric, health systems-related and others. Results: Of the 2,065 articles screened, 70 articles were included. Of these, 21, 17 and 32 studies evaluated health literacy related to COVID-19, SARS and MERS, respectively. The rates of low pandemic health literacy ranged from 4.3% to 57.9% among medical-related populations and from 4.0% to 82.5% among nonmedical populations. Knowledge about the symptoms and transmission of infection, worry about infection, and practices related to mask usage and hand hygiene were most frequently evaluated. Sociodemographic determinants of health literacy were most frequently studied, among which higher education level, older age and female gender were found to be associated with better health literacy. No studies evaluated the outcomes associated with health literacy. Conclusion: The level of pandemic-related health literacy is suboptimal. Healthcare administrators need to be aware of health literacy determinants when formulating policies in pandemics.

Association of Social Support with Rehabilitation Outcome among Older Adults with Hip Fracture Surgery: A Prospective Cohort Study at Post-Acute Care Facility in Asia.

OBJECTIVES: There is growing interest in the role of social support during the recovery after hip fractures. The research to date has been mainly focused on structural support, with few studies concerned with functional support. This study examined the effects of both functional and structural aspects of social support on rehabilitation outcomes among older adults with hip fracture surgery. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: Consecutive older adults (≥60 years) with hip fracture surgery who underwent inpatient rehabilitation in a post-acute care facility in Singapore between January 11, 2021, and October 30, 2021 (n = 112). METHODS: We administered the Medical Outcome Study-Social Support Survey (MOS-SSS) to assess perceived functional support of patients and used living arrangement as an indicator for structural support. Participants were followed up over the inpatient stay at the post-acute care facility until discharge; thereafter, rehabilitation efficiency (REy) and rehabilitation effectiveness (REs) were evaluated. Multiple linear regressions were performed to examine the associations of MOS-SSS score and living arrangement with REy and REs, respectively, adjusting for age, gender, ethnicity, comorbidity, body mass index, prefracture function, type of fracture, and length of stay. RESULTS: Perceived functional support had positive associations with rehabilitation outcomes. A 1-unit increase in MOS-SSS total score was associated with 0.15 units (95% CI 0.03-0.3, P = .029) greater gain in physical function after a typical 1-month stay, and 0.21 units (95% CI 0.01-0.41, P = .040) higher achievement in potential functional improvement upon discharge. In contrast, no association was observed between structural support and rehabilitation outcomes. CONCLUSIONS AND IMPLICATIONS: Perceived functional support may significantly impact the recovery of older adults with hip fracture during the inpatient rehabilitation process, independent of structural support. Our findings suggest the potential of incorporating interventions enhancing perceived functional support of patients into the post-acute care model for hip fracture.

Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials.

BACKGROUND: Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient's recovery. OBJECTIVES: We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures. METHODS: We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non-English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included "good quality" RCTs with Jadad score ≥ 3 for data extraction and synthesis. RESULTS: Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported. CONCLUSIONS: The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.

Factors Influencing the Uptake of Seasonal Influenza Vaccination among Community-Dwelling Older Adults during COVID-19: A Mixed Methods Study.

Background: Despite making the influenza vaccine accessible and affordable, vaccination rates remained low among community-dwelling older adults. Therefore, this study aimed to explore the factors influencing vaccine uptake and the impact of COVID-19 on vaccine uptake among community-dwelling older adults in Singapore. Methods: A mixed methods study involving a survey and semi-structured interviews were conducted between September 2020 and July 2021. Community-dwelling older adults aged ≥ 65 years were recruited from 27 Community Nurse Posts. Data on participants' demographics, health condition(s), vaccination status, attitudes towards influenza infections and vaccinations, willingness to pay, intention for future vaccination and source of information were collected via the survey. Semi-structured interviews were conducted to understand vaccination experiences, key enablers and barriers, and the impact of COVID-19 on vaccine uptake. All interviews were analysed using Braun and Clarke's thematic analysis. Quantitative data were analysed using descriptive statistics, chi-square tests and multinomial logistic regressions. Results: A total of 235 participants completed the survey. Living arrangement was a statistically significant contributing factor for influenza vaccine uptake (ꭓ2= -0.139; p = 0.03). Participants who lived alone were 2.5 times more likely to be vaccinated than those living with others (OR = 2.504, 95% CI: 1.294-4.842, p = 0.006). Avoidance of getting infected (82.5%), avoidance of transmission to others (84.7%), and advice from healthcare professionals to receive vaccination (83.4%) were key enablers, while concerns about possible side effects (41.2%), the effectiveness of the vaccine (42.6%), and not having enough information (48.1%) were barriers. Twenty participants were interviewed. The findings were congruent with the survey results. Five themes were identified as follows: (1) Perceived importance of influenza vaccination, (2) Sphere of influence, (3) Healthcare schemes and medical subsidies, (4) Psychological impediments, and (5) Inconsistent emphases at various touch points. Conclusions: Greater public health efforts are needed to reach out to the larger population of older adults of different living arrangements and those concerned about the possible side effects and effectiveness of the influenza vaccine. Healthcare professionals need to provide more information to address these concerns, especially during COVID-19, to encourage vaccine uptake.

Factors influencing medication adherence in multi-ethnic Asian patients with chronic diseases in Singapore: A qualitative study.

Background: Poor medication adherence can lead to adverse health outcomes and increased healthcare costs. Although reasons for medication adherence have been widely studied, less is explored about factors affecting medication adherence for patients in non-Western healthcare setting and from Asian cultures. This study aimed to explore cultural perspectives on factors influencing medication adherence among patients with chronic diseases in a multi-ethnic Asian healthcare setting. Methods: We conducted a qualitative study involving in-depth interviews with patients with chronic conditions purposively recruited from a community hospital in Singapore until data saturation was achieved. A total of 25 patients participated in this study. Interviews were transcribed and thematically analyzed. Themes were subsequently mapped into the World Health Organization (WHO) Framework of Medication Adherence. Results: Participants commonly perceived that sides effects (therapy-related dimension), poor understanding of medication (patient-related dimension), limited knowledge of condition (patient-related dimension), forgetfulness (patient-related dimension) and language issues within a multi-ethnic healthcare context (healthcare team and system-related dimension) as the main factors contributing to medication adherence. Importantly, medication adherence was influenced by cultural beliefs such as the notion of modern medicines as harms and fatalistic orientations towards escalation of doses and polypharmacy (patient-related dimension). Participants made various suggestions to foster adherence, including improved patient-physician communication, enhanced care coordination across providers, use of language familiar to patients, patient education and empowerment on the benefits of medication and medication adjustment. Conclusion: A wide range of factors influenced medication adherence, with therapy- and patient-related dimensions more pronounced compared to other dimensions. Findings demonstrated the importance of cultural beliefs that may influence medication adherence. Future efforts to improve medication adherence should consider a person-centered approach to foster more positive health expectations and self-efficacy on medication adherence, supplemented with routine reviews, development of pictograms and cultural competence training for healthcare professionals.

A Mobile Application to Improve Diabetes Self-Management Using Rapid Prototyping: Iterative Co-Design Approach in Asian Settings.

Background: Diabetes is a global public health issue, causing burden on healthcare system and increasing risk of mortality. Mobile applications (apps) can be a promising approach to facilitate diabetes self-management. An increasingly utilized approach to facilitate engagement with mobile health (mHealth) technology is to involve potential users in the creation of the technology. Objective: The aim of this study was to use co-design for type 2 diabetes mellitus (T2DM) self-management mHealth development. Methods: Three rounds of iterative rapid prototyping panel sessions were conducted with a total of 9 T2DM participants in an Asian setting between Oct 2020 and April 2021. The participants were recruited through convenience sampling. For each round, feedback was gathered through qualitative interviews, and the feedback was used as a reference by the development team to develop and test a more refined version of the app in the next round. Transcribed semi-structured interview data was analyzed thematically using an inductive approach. Results: Participants' ages ranged from 40 to 69 years. Data saturation was reached, with no new themes emerging from the data. During the sessions, the participants expressed a variety of concerns and feedback on T2DM self-management using EMPOWER app and raised suggestions on the features of ideal T2DM self-management app. Important features include 1) reminders and notifications for medications, 2) Bluetooth integration with glucometers and blood pressure machines to minimize manual entry, 3) enlarged local food database including information on sugar content and recommendations for healthier options, 4) one touch for logging of routine medications and favorite foods, 5) export function for data sharing with physicians. Overall inputs concerned aspects such as user-friendliness of the app, customization possibilities, and educational content for the features in the mobile app. Conclusion: In this study, we explored users' opinions on a T2DM self-management mobile app using co-design approach. This study adds to the growing body of literature on co-designing behavioral mHealth interventions and can potentially guide researchers in mobile app design for other chronic conditions.

mHealth App to Facilitate Remote Care for Patients With COVID-19: Rapid Development of the DrCovid+ App.

BACKGROUND: The 2019 novel COVID-19 has severely burdened the health care system through its rapid transmission. Mobile health (mHealth) is a viable solution to facilitate remote monitoring and continuity of care for patients with COVID-19 in a home environment. However, the conceptualization and development of mHealth apps are often time and labor-intensive and are laden with concerns relating to data security and privacy. Implementing mHealth apps is also a challenging feat as language-related barriers limit adoption, whereas its perceived lack of benefits affects sustained use. The rapid development of an mHealth app that is cost-effective, secure, and user-friendly will be a timely enabler. OBJECTIVE: This project aimed to develop an mHealth app, DrCovid+, to facilitate remote monitoring and continuity of care for patients with COVID-19 by using the rapid development approach. It also aimed to address the challenges of mHealth app adoption and sustained use. METHODS: The Rapid Application Development approach was adopted. Stakeholders including decision makers, physicians, nurses, health care administrators, and research engineers were engaged. The process began with requirements gathering to define and finalize the project scope, followed by an iterative process of developing a working prototype, conducting User Acceptance Tests, and improving the prototype before implementation. Co-designing principles were applied to ensure equal collaborative efforts and collective agreement among stakeholders. RESULTS: DrCovid+ was developed on Telegram Messenger and hosted on a cloud server. It features a secure patient enrollment and data interface, a multilingual communication channel, and both automatic and personalized push messaging. A back-end dashboard was also developed to collect patients' vital signs for remote monitoring and continuity of care. To date, 400 patients have been enrolled into the system, amounting to 2822 hospital bed-days saved. CONCLUSIONS: The rapid development and implementation of DrCovid+ allowed for timely clinical care management for patients with COVID-19. It facilitated early patient hospital discharge and continuity of care while addressing issues relating to data security and labor-, time-, and cost-effectiveness. The use case for DrCovid+ may be extended to other medical conditions to advance patient care and empowerment within the community, thereby meeting existing and rising population health challenges.