Colorectal cancer patients advocating screening to their siblings: a randomized behavioral intervention.

BACKGROUND AND AIMS: Siblings of colorectal cancer (CRC) patients are at increased risk of developing CRC, but screening rates remain low. Through a randomized behavioral intervention, this study aimed to determine whether patients can advocate screening to their siblings using a tailored educational package. METHODS: CRC survivors were recruited and randomized into relaying either tailored materials (intervention group) or existing national screening guidelines (control group) to their siblings. Siblings could respond to the study team if they were interested in learning about CRC screening. Study outcomes were patient advocacy rates (number of patients who had successfully contacted at least 1 eligible sibling) between groups and the proportion of eligible siblings who responded. RESULTS: Between May 2017 and March 2021, 219 CRC patients were randomized to the intervention (n = 110) and control (n = 109) groups. Patient advocacy rates were high and did not differ significantly between groups. However, only 14.3% of eligible siblings (n = 85) responded to the study team. Siblings of patients from the intervention group were more likely to respond (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-3.0; P < .05). Moreover, after controlling for potential confounders, siblings aged ≥60 years were significantly less likely to respond (adjusted odds ratio, .3; 95% confidence interval, .1-.7; P < .01). CONCLUSIONS: CRC patients are willing advocates of screening, and siblings contacted by patients from the intervention group were also more likely to reach out to the study team. However, overall sibling response rates were low despite advocacy, suggesting that patient-led advocacy should at best be used as an adjunct to other, multipronged CRC screening promotion modalities.

Multi-level determinants of breast cancer screening among Malay-Muslim women in Singapore: a sequential mixed-methods study.

OBJECTIVE: Ethnic disparity persists despite equal access to health care in Singapore, with Malay-Muslim women having the lowest mammogram uptake rate and highest breast cancer mortality rate. We sought to understand barriers to and facilitators for mammogram uptake in this community. METHODS: We used a sequential mixed-methods design to first explore reasons for screening and not screening for breast cancer, then determine factors associated with screening and regular screening in a survey. We used maximum variation sampling for semi-structured in-depth interviews to select screeners and non-screeners of diverse ages and educational levels. Twenty-three Malay-Muslim women aged 40-69 years old were interviewed. Themes were categorized using thematic analysis. For the survey, we applied the Health Belief Model, Social Ecological Model, as well as themes from the interviews and findings from previous studies on factors influencing screening in Muslim women to guide questionnaire design. We surveyed 271 Malay-Muslim women aged 50-69 years old in a nationally representative sample. Multivariable logistic regression was used to determine factors associated with ever gone for mammogram and regular mammogram uptake. RESULTS: Through in-depth-interviews, we found perceived benefits of saving lives and breasts from early detection, reminders from doctors and husbands, symptoms, perceived test from God, and personal responsibility to care for one's health facilitated screening. Barriers were perceived low susceptibility, inconvenience, cost, negative psychological effects, misinformation on mammogram triggering cancer cells, religious beliefs, perceived negative outcomes from mammography and distrust of doctor. From the survey, we found cues from health care professionals and needing symptoms before deciding to go for mammogram to be significantly associated with ever gone for mammogram and regular mammogram. Factors associated with ever gone for mammogram only included age, perceived benefits of saving lives from early detection, perceived importance of mammogram, Punishing Allah Reappraisal, and modesty. Factors associated with regular mammogram only included household income, perceived structural barriers to screening and perceived susceptibility to breast cancer. CONCLUSIONS: Mammogram uptake is affected by multiple levels of influence. Interventions to promote screening should be designed with multiple stakeholders including doctors, religious leaders and women who had attended screening.

Screening is not always healthy: an ethical analysis of health screening packages in Singapore.

BACKGROUND: Health screening is undertaken to identify individuals who are deemed at higher risk of disease for further diagnostic testing so that they may possibly benefit from interventions to modify the natural course of disease. In Singapore, screening tests are widely available in the form of a package, which bundles multiple tests in one session and commonly includes non-recommended tests. There are various ethical issues associated with such testing as they may not be clinically appropriate and can result in more harm than benefit. This article describes the practice of health screening packages, identifies the ethical issues arising from such packages and discusses the implications of these ethical issues on policy and practice of screening in Singapore. METHODS: A content analysis of the websites of providers offering general health screening packages to individuals was conducted. A total of 14 health screening package providers were analysed for how packages were conducted and promoted, how clinically appropriate screening tests were, and the price range and composition of screening packages. A normative ethical analysis based on the four principles approach of beneficence, non-maleficence, autonomy and justice in biomedical ethics was used. RESULTS: Twelve of the 14 providers included non-recommended tests such as tumour markers, treadmill stress tests and MRI scans in their general health screening packages. Package prices ranged from S$26 to S$10,561, with providers charging higher when more tests were included. Health screening packages were broadly conducted in three stages: (1) the offer and selection of a health screening package; (2) medical assessment and performance of screening tests; (3) a post-screening review. While material provided by all providers was factual, there was no information on the potential risks or harms of screening. CONCLUSION: Several ethical issues were identified that should be addressed with regard to health screening packages in Singapore. A key issue was the information gap between providers and patients, which may result in patients undergoing inappropriate testing that may be more harmful than beneficial. Health screening packages can stimulate unnecessary demand for healthcare and contribute to an inequitable distribution of healthcare resources.

Effect of a Popular Web Drama Video Series on HIV and Other Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men in Singapore: Community-Based, Pragmatic, Randomized Controlled Trial.

BACKGROUND: Gay, bisexual, and other men who have sex with men (GBMSM) are at disproportionately higher risk of acquiring HIV and other sexually transmitted infections (STI). While HIV/STI testing rates among GBMSM are increasing worldwide, they remain suboptimal in a variety of settings. While many studies have attempted to evaluate the efficacy of a variety of community-based campaigns, including peer and reminder-based interventions on HIV/STI testing, however few have attempted to do so for a web drama series. OBJECTIVE: This study evaluates the effectiveness of a popular web drama video series developed by a community-based organization in Singapore for GBMSM on HIV and other STI testing behaviors. METHODS: The study is a pragmatic, randomized controlled trial to evaluate a popular web drama video series developed by a community-based organization in Singapore for GBMSM. A total of 300 HIV-negative, GBMSM men in Singapore aged 18 to 29 years old were recruited and block-randomized into the intervention (n=150) and control arms (n=150). Primary outcomes included changes in self-reported intention to test for, actual testing for, and regularity of testing for HIV, syphilis, chlamydia or gonorrhea, while secondary outcomes include changes in a variety of other knowledge-based and psychosocial measures at the end of the study period. RESULTS: Overall, 83.3% (125/150) of participants in the intervention arm completed the proof of completion survey, compared to 88.7% (133/150) in the control arm. We found improvements in self-reporting as a regular (at least yearly) tester for HIV (15.9% difference, 95% CI, 3.2% to 28.6%; P=.02), as well as chlamydia or gonorrhea (15.5% difference, 95% CI, 4.2% to 26.9%; P=.009), indicating that the intervention had positively impacted these outcomes compared to the control condition. We also found improvements in participants' intentions to test for HIV (16.6% difference, 95% CI, 4.3% to 28.9%; P=.009), syphilis (14.8% difference, 95% CI, 3.2% to 26.4%; P=.01), as well as chlamydia or gonorrhea (15.4% difference, 95% CI, 4.2% to 26.6%; P=.008), in the next 3 months, indicating that the intervention was effective in positively impacting intention for HIV and other STI testing among participants. CONCLUSIONS: There are clear benefits for promoting intentions to test regularly and prospectively on a broad scale through this intervention. This intervention also has potential to reach GBMSM who may not have access to conventional HIV and other STI prevention messaging, which have typically been implemented at sex-on-premises venues, bars, clubs, and in sexual health settings frequented by GBMSM. When coupled with community or population-wide structural interventions, the overall impact on testing will likely be significant. TRIAL REGISTRATION: ClinicalTrials.gov NCT04021953; https://clinicaltrials.gov/ct2/show/NCT04021953. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2019-033855.

COVID-19 and the shifting organisation of sex work markets in Singapore.

While past studies have sought to capture how the COVID-19 pandemic has impacted on the health and sexual lives of sex workers internationally, less attention has been paid to the reorganisation of sex markets as a result of COVID-19. We conducted a sequential exploratory mixed methods study using in-depth interviews, cyber ethnography and surveyor-administered structured surveys among sex workers. We report two key findings on how the pandemic has impacted sex markets in Singapore. First, the organisation of sex markets shifted as a result of lockdown and associated movement control measures. This shift was characterised by the out-migration of sex workers, the reduction in supply and demand for in-person sex work, and a shift towards online spaces. Second, we found that sex workers experienced greater economic hardship as a result of such changes. Given the potential shifts in sex markets as a result of the pandemic, we adopt a World Health Organisation Health Workplace Framework and Model to identify interventions to improve the occupational safety and health of sex workers in a post-COVID-19 era.

Perceptions of an HIV self-testing intervention and its potential role in addressing the barriers to HIV testing among at-risk heterosexual men: a qualitative analysis.

OBJECTIVES: Voluntary HIV testing rates are still low in several Asian countries including Singapore. HIV self-testing (HIVST) has the potential to increase testing, leading to earlier diagnosis and better prognosis. However, the views of at-risk individuals, especially heterosexual men (HSM), who are not coming forward for testing are still poorly understood. In this study, we examined the barriers and facilitators to and delivery preferences for HIVST in order to implement an effective intervention in Singapore. METHODS: From May 2017 to June 2018, 48 in-depth interviews were conducted with HSM aged 21-66 years and at risk of HIV infection. Participants were purposively sampled based on ethnicity, age and testing behaviour. Recruitment was done mainly at brothels and entertainment establishments in Singapore. Participants gave their views on HIV testing, factors affecting HIVST use and their preferred HIVST service delivery model. RESULTS: Most participants preferred HIVST over conventional testing for its convenience, privacy, anonymity and autonomy, but older men still preferred conventional testing. Low self-perceived risk, low awareness and self-efficacy for HIVST, and non-comprehensive test for other STIs were reported as barriers to HIVST. There were mixed opinions on kit preference. A blood-based kit was favoured for higher accuracy, while the oral-fluid-based kit was favoured for ease of use. Participants wanted a human touch for post-test counselling and linkage to care only if they self-tested positive. Traditional media, internet and social media, and venue-based outreach were potential advertising platforms mentioned. CONCLUSIONS: A locally acceptable and feasible HIVST intervention must address the barriers and facilitators of using HIVST in order to improve HIV testing rates among this at-risk population who might otherwise delay or fail to present for testing.

The Impact of the Coronavirus Disease (COVID-19) on the Health and Social Needs of Sex Workers in Singapore.

We evaluated the impact of the coronavirus disease (COVID-19) on the sex work industry and assessed how it has impacted the health and social conditions of sex workers in Singapore. We conducted a sequential exploratory mixed methods study amidst the COVID-19 pandemic from April to October 2020, including in-depth interviews with 24 stakeholders from the sex work industry and surveyor-administered structured surveys with 171 sex workers. COVID-19 had a substantial impact on sex workers' income. The illegality of sex work, stigma, and the lack of work documentation were cited as exclusionary factors for access to alternative jobs or government relief. Sex workers had experienced an increase in food insecurity (57.3%), housing insecurity (32.8%), and sexual compromise (8.2%), as well as a decrease in access to medical services (16.4%). Being transgender female was positively associated with increased food insecurity (aPR = 1.23, 95% CI [1.08, 1.41]), housing insecurity (aPR = 1.28, 95% CI [1.03, 1.60]), and decreased access to medical services (aPR = 1.74, 95% CI [1.23, 2.46]); being a venue-based sex worker was positively associated with increased food insecurity (aPR = 1.46, 95% CI [1.00, 2.13]), and being a non-Singaporean citizen or permanent resident was positively associated with increased housing insecurity (aPR = 2.59, 95% CI [1.73, 3.85]). Our findings suggest that COVID-19 has led to a loss of income for sex workers, greater food and housing insecurity, increased sexual compromise, and reduced access to medical services for sex workers. A lack of access to government relief among sex workers exacerbated such conditions. Efforts to address such population health inequities should be implemented.

Association between sexual orientation acceptance and suicidal ideation, substance use, and internalised homophobia amongst the pink carpet Y cohort study of young gay, bisexual, and queer men in Singapore.

BACKGROUND: Gay, bisexual and queer (GBQ) men are frequently subjected to minority stressors that have negative impacts on their health. Milestones that include the acceptance and disclosure of sexual identity amongst GBQ men are hence key instruments in understanding the prevalence of internalised homophobia and predicting health outcomes. As such, this work takes a novel approach to deduce the correlates of delayed acceptance of sexual orientation in young GBQ men as a measure of internalised homophobia through retrospective self-reporting and age-based analysis. METHODS: Participants were recruited as part of a cohort study exploring the syndemic risks associated with HIV acquisition among young GBQ men in Singapore. We examined their levels of internalised, perceived, experienced homophobia, as well as their health behaviours and suicidal tendencies. Two separate variables were also self-reported by the participants - the age of questioning of sexual orientation and the age of acceptance of sexual orientation. We subsequently recoded a new variable, delayed acceptance of sexual orientation, by taking the difference between these two variables, regressing it as an independent and dependent variable to deduce its psychosocial correlates, as well as its association with other measured instruments of health. RESULTS: As a dependent variable, delayed acceptance of sexual orientation is positively associated with an increase of age and internalised homophobia, while being negatively associated with reporting as being gay, compared to being bisexual or queer. As an independent variable, delayed acceptance of sexual orientation was associated with a delayed age of coming out to siblings and parents, suicide ideation, historical use of substances including smoking tobacco cigarettes and consuming marijuana, as well as reporting higher levels of experienced, internalised and perceived homophobia. CONCLUSION: Greater levels of early intervention and efforts are required to reduce the heightened experience of minority stress resulting from communal and institutional hostilities. Areas of improvement may include community-based counselling and psychological support for GBQ men, while not forsaking greater education of the social and healthcare sectors. Most importantly, disrupting the stigma narrative of a GBQ 'lifestyle' is paramount in establishing an accepting social environment that reduces the health disparity faced by GBQ men.

Delineating patterns of sexualized substance use and its association with sexual and mental health outcomes among young gay, bisexual and other men who have sex with men in Singapore: a latent class analysis.

BACKGROUND: Young gay, bisexual, and other men who have sex with men (YMSM) are vulnerable to the risks associated with sexualized substance use. This is a novel study in Singapore that aims to classify patterns of sexualized substance use among YMSM, and investigate its association with sexual and mental health outcomes. METHODS: In this cross-sectional study among 570 YMSM aged 18 to 25 years old, latent class analysis (LCA) conducted to identify classes with similar patterns of sexualized substance use, across which measures of inconsistent condom use, recent STI diagnoses, past suicide ideation and depression severity were compared. RESULTS: LCA revealed three classes of YMSM based on types of substances ever used in sexualized contexts, which we labelled as 'substance-naive', 'substance-novice', and 'chemsex'. Substance-naive participants (n = 404) had only ever used alcohol, while substance-novice participants (n = 143) were primarily amyl nitrite users with a small proportion who reported using chemsex-related drugs. Chemsex participants (n = 23) comprised individuals who had mostly used such drugs. Those in the chemsex group were more likely to report recent unprotected anal sex with casual partners (aPR = 3.28, 95%CI [1.85, 5.79]), depression severity (aß = 3.69, 95%CI [0.87, 6.51]) and a history of suicide ideation (aPR = 1.64, 95%CI [1.33, 2.03]). CONCLUSIONS: Findings of this study highlight how the use of varying substances in sexualized contexts may be classified and characterized by different sexual and mental health outcomes. Health promotion efforts should be differentiated accordingly to address the risks associated with sexualized substance use among YMSM.

Correlates, facilitators and barriers of physical activity among primary care patients with prediabetes in Singapore - a mixed methods approach.

BACKGROUND: Primary care patients with prediabetes is a priority group in the clinical, organisational and policy contexts. Engaging in regular physical activity is crucial to prevent diabetes for this group. The objectives of the study were to assess factors associated with meeting the recommendation of at least 150 min of moderate/vigorous physical activity weekly, and to explore facilitators and barriers related to the behaviour among primary care patients with prediabetes in Singapore. METHODS: This was a mixed methods study, consisting of a cross-sectional survey involving 433 participants from 8 polyclinics, and in-depth interviews with 48 of them. Adjusted prevalence ratios (aPR) were obtained by mixed effects Poisson regression model. The socio-ecological model (SEM) was applied, and thematic analysis performed. RESULTS: The prevalence of meeting the recommendation was 65.8%. This was positively associated with being male (aPR 1.21, 95%CI 1.09-1.34), living in 4-5 room public housing (aPR 1.19, 95%CI 1.07-1.31), living in executive flat/private housing (aPR 1.26, 95%CI 1.06-1.50), having family members/friends to exercise with (aPR 1.57, 95%CI 1.38-1.78); and negatively associated with a personal history of osteoarthritis (aPR 0.75, 95%CI 0.59-0.96), as well as time spent sitting or reclining daily (aPR 0.96, 95%CI 0.94-0.98). The recurrent themes for not meeting the recommendation included lacking companionship from family members/friends, medical conditions hindering physical activity (particularly osteoarthritis), lacking knowledge/skills to exercise properly, "no time" to exercise and barriers pertaining to exercise facilities in the neighbourhood. The recurrent themes for meeting the recommendation included family/peer influence, health/well-being concerns and education by healthcare professionals. CONCLUSIONS: Much more remains to be done to promote physical activity among primary care patients with prediabetes in Singapore. Participants reported facilitators and barriers to physical activity at different levels of the SEM. Apart from the individual and interpersonal levels, practitioners and policy makers need to work together to address the organisational, community and policy barriers to physical activity.

Estimating the size of key populations for HIV in Singapore using the network scale-up method.

OBJECTIVES: To develop a localised instrument and Bayesian statistical method to generate size estimates-adjusted for transmission error and barrier effects-of at-risk populations in Singapore. METHODS: We conducted indepth interviews and focus group to guide the development of the survey questionnaire. The questionnaire was administered between July and August 2017 in Singapore. Using the network scale-up method (NSUM), we developed a Bayesian hierarchical model to estimate the number of individuals in four hidden populations at risk of HIV. The method accounted for both transmission error and barrier effects using social acceptance measures and demographics. RESULTS: The adjusted size estimate of the population of male clients of female sex workers was 72 000 (95% CI 51 000 to 100 000), of female sex workers 4200 (95% CI 1600 to 10 000), of men who have sex with men 210 000 (95% CI 140 000 to 300 000) and of intravenous drug users 11 000 (95% CI 6500 to 17 000). CONCLUSIONS: The NSUM with adjustment for attitudes and demographics allows national-level estimates of multiple priority populations to be determined from simple surveys of the general population, even in relatively conservative societies.

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.

Risky sexual behaviors among Malay adolescents: a comparison with Chinese adolescents in Singapore.

OBJECTIVE: Malays, with majority of the individuals being Muslim, form the largest ethnic group in Southeast Asia. This region is experiencing a rising incidence of HIV infections. Due to circumcision and prohibition of sex outside marriage, being Muslim was argued to be a protective factor against sexually transmitted infections (STI) and Human Immunodeficiency Virus (HIV). However, Malay adolescents were found to be more likely to contract chlamydia and gonorrhea than non-Malay adolescents in Singapore. DESIGN: Using a cross-sectional survey, we examined and compared safer sex knowledge, attitudes and self-efficacy, and sexual behaviors of 248 sexually active Malay adolescents with 384 Chinese adolescents aged 16-19 years in Singapore. Poisson regression, adjusted for socio-demographic characteristics, was used for modeling each dependent variable. Adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were obtained. RESULTS: On multivariate analysis, Malay adolescents were more likely to report marginally unfavorable attitude towards condom use (aPR 1.21 CI 1.00-1.48) and significantly lower confidence in using condoms correctly (aPR 1.24 CI 1.05-1.47) than Chinese adolescents. They were also more likely to report significantly younger first sex age (aPR 0.98 CI 0.96-1.00), never use of condoms for vaginal sex (aPR 1.32 CI 1.16-1.49) and anal sex (aPR 1.75 CI 1.11-2.76) and non-use of contraceptives at last sex (aPR 1.30 CI 1.17-1.45) than Chinese respondents. Malay males were less likely to buy sex (aPR 0.56 CI 0.37-0.85), but they reported higher likelihood of inconsistent condom use with female sex workers (aPR 2.24 CI 1.30-3.87). CONCLUSION: Malay ethnicity was associated with unfavorable condom use attitude and lower self-efficacy in using condoms, which was consistent with risky sexual behaviors such as non-use of condoms. Future research should use mixed methods to explore and identify cultural influences to these behaviors.

A Public Health Communication Intervention Using Edutainment and Communication Technology to Promote Safer Sex among Heterosexual Men Patronizing Entertainment Establishments.

It is a challenge to reach out, develop and implement a communication intervention for heterosexual men (HSM) patronizing entertainment establishments (EEs) to promote safer sex. We described the theoretical basis and process from assessment to implementation where edutainment (talk shows) and communication technology (interactive web portal) was implemented. A female comedian hosted the talk shows. The portal contained an HIV risk profile calculator with individually tailored strategies to lower risk; two videos on real-life stories of unsafe sex and exit strategies to avoid casual or paid sex; as well as online support. We integrated edutainment, social cognitive theory (SCT) and the elaboration likelihood model (ELM). Edutainment techniques like humor through jokes, fun through games, and narrative persuasion through real-life accounts were applied. The SCT focused on modifying attitudes and social norm on sexual well-being, increasing self-perceived HIV/STI risk as well as building self-efficacy and skills in condom use. We applied the ELM to guide communication strategies and message development. For peripheral processing, we used cues like comedian delivery and charisma. For central processing, we focused on argument framing, issue involvement, argument quality, and modeling. The intervention was effective in promoting condom use with casual partners among the target group in Singapore.

Efficacy of multicomponent culturally tailored HIV/ STI prevention interventions targeting foreign female entertainment workers: a quasi-experimental trial.

OBJECTIVES: We assessed the efficacy of a multicomponent culturally tailored HIV/STI prevention intervention programme on consistent condom use and STI incidence among foreign Thai and Vietnamese female entertainment workers (FEWs) in Singapore. METHODS: We conducted a quasi-experimental pretest and post-test intervention trial with a comparison group. We recruited 220 participants (115 Vietnamese and 105 Thai) for the comparison group, followed by the intervention group (same number) from the same sites which were purposively selected after a 3-month interval period. Both groups completed a self-administered anonymous questionnaire and STI testing for cervical gonorrhoea and Chlamydia, as well as pharyngeal gonorrhoea at baseline and 6-week follow-up. The peer-led intervention consisted of behavioural (HIV/STI education and condom negotiation skills), biomedical (STI screening and treatment services) and structural components (access to free condoms). We used the mixed effects Poisson regression model accounting for clustering by establishment venue to compute the adjusted risk ratio (aRR) of the outcomes at follow-up. RESULTS: At follow-up, the intervention group was more likely than the comparison group to report consistent condom use for vaginal sex with paid (aRR 1.77; 95% CI 1.71 to 1.83) and casual (aRR 1.81; 95% CI 1.71 to 1.91) partners. For consistent condom use for oral sex, this was aRR 1.50; 95% CI 1.23 to 1.82 with paid and aRR 1.54; 95% CI 1.22 to 1.95 with casual partners. STI incidence at follow-up was significantly lower in the intervention (6.8 per 100 FEWs) than the comparison (14.8 per 100 FEWs) group (aRR 0.42; 95% CI 0.32 to 0.55). CONCLUSIONS: This trial was effective in promoting consistent condom use for vaginal and oral sex as well as reducing STI incidence among the foreign Thai and Vietnamese FEWs in Singapore. The feasibility of scaling up the interventions to all entertainment establishments in Singapore should be assessed.

Screening in spouses of colorectal cancer patients: a missed opportunity.

BACKGROUND: Spouses of colorectal cancer (CRC) patients could be at increased risk of developing CRC due to shared lifestyle habits with the patients which is a notable risk factor. This study explores the various issues surrounding CRC screening among these spouses. METHODS: A mixed method study comprising in-depth qualitative semi-structured interviews followed by structured quantitative questionnaire was administered to spouses who accompanied CRC patients during their appointments, from January 2016 to February 2017. RESULTS: Fifty spouses of CRC patients, median age of 60 (range, 41-82) years, were qualitatively interviewed but 5 of them did not complete the questionnaire. Only 26 (57.8%) of them were current with CRC screening. Data saturation was reached at the 48th participant. Four main themes emerged from the qualitative interviews. These included (i) adequacy of knowledge and attitudes about CRC screening, (ii) suboptimal public health promotion efforts of CRC screening, (iii) barriers of CRC screening, and (iv) need for mutual spousal support. From the questionnaires, spouses who were not current with CRC screening were more likely to report more barriers and have different cues to actions than those who are current. The majority of the spouses demonstrated high levels of knowledge on CRC, understood its severity and their susceptibility. CONCLUSION: Spouses exhibit high levels of knowledge and awareness of the implications of CRC. Apart from addressing psychological issues during the acute phases, targeted interventions should be considered to improve their screening rates and to use them as advocates for CRC screening among family and community.

Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore.

BACKGROUND: There is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention. METHODS: In-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation. RESULTS: We estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group. CONCLUSIONS: The qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02780986 . Registered 23 May 2016 (retrospectively registered).

Trends in unprotected intercourse among heterosexual men before and after brothel ban in Siem Reap, Cambodia: a serial cross-sectional study (2003-2012).

BACKGROUND: Following Cambodia's implementation of the 100% condom use program with enforcement of condom use and STI treatment services for sex workers in 2001, sexually transmitted infection and HIV declined markedly. In 2008, Cambodia implemented a law to ban brothel-based sex work. We reported trends in unprotected vaginal intercourse with sex workers among heterosexual men buying sex before (2003-2008) and after (2009-2012) the brothel ban in Cambodia. We also determined the association of brothel ban with these men's reports of unprotected intercourse with sex workers. METHODS: In this serial cross-sectional study, we collected yearly behavioural data on random cross-sectional samples of heterosexual men buying sex who attended the only government health centre in Siem Reap for voluntary confidential counselling and testing (VCCT) between 2003 and 2012. We used multivariable Poisson regression analysis on the 10-year data of 976 men to obtain the adjusted prevalence ratio (aPR) of unprotected intercourse in the last 6 months by brothel closure. RESULTS: Men buying sex from non-brothel-based sex workers increased almost 3-fold from 17% in 2007-2008 before brothel closure to 55% in 2011-2012 after brothel closure (p < 0.001). Unprotected intercourse with sex workers in the last week increased significantly from 37% (2003-2004) before brothel closure to 65% (2011-2012) after brothel closure. This increase corresponded closely with the increase in self-reported unprotected intercourse from 35% to 61% by the sex workers (n = 1805) attending the same clinic for VCCT. Brothel closure was associated with an increased risk (aPR: 1.65; 95% CI: 1.40-1.94) of unprotected intercourse with sex workers. HIV prevalence in the heterosexual men declined significantly from 26% in 2003-2004 to 4.8% in 2007-2008 and 0 case in 2009-2010 before increasing to 5.6% in 2011-2012. CONCLUSION: Our findings suggest that the brothel ban had led to an increase in unprotected intercourse with all sex workers for men buying sex. This effect could be attributed to reduced condom access, a consequence of the lack of feasibility to implement the 100% condom use program following the brothel ban. The ban on brothels in Cambodia should be reviewed.

Factors associated with consistent condom use and STIs among foreign female entertainment workers: results from a cross-sectional survey in Singapore.

OBJECTIVES: We assessed the prevalence of consistent condom use and laboratory-confirmed STIs among foreign female entertainment workers (FEWs) who engaged in paid or casual sex in Singapore and the factors associated with these characteristics. METHODS: A cross-sectional survey, using time-location sampling, was conducted on 220 FEWs (115 Vietnamese and 105 Thai) in 2015. For multivariable analysis, we used a mixed-effects Poisson regression model with backward stepwise approach to account for clustering by venue and to obtain the adjusted prevalence ratios (aPRs) of factors associated with consistent condom use and STI positivity, respectively. RESULTS: Consistent condom use with paid or casual partners in the past month was 39.6% and 36.2% for vaginal and oral sex, respectively. The prevalence of STI (cervical chlamydia, cervical gonorrhoea or pharyngeal gonorrhoea) positivity was 13.6%. In multivariable analysis, consistent condom use for both vaginal and oral sex increased with high self-perceived risk of getting STI/HIV (vaginal: aPR 2.09; 95% CI 1.26 to 3.46; oral: aPR 2.41; 95% CI 1.23 to 4.69) and condom negotiation (vaginal: aPR 3.74; 95% CI 2.07 to 6.75; oral: aPR 2.81; 95% CI 1.51 to 5.26). STI positivity decreased with consistent condom use for vaginal sex (aPR 0.22; 95% CI 0.07 to 0.75) and increased with number of sexual partners (aPR 1.43; 95% CI 1.07 to 1.92). CONCLUSION: In addition to advocating for policy decisions to provide a safer work environment, behavioural interventions on condom negotiation skills and condom use and biomedical interventions on STI/HIV testing and treatment interventions are needed among the FEWs in Singapore. TRIAL REGISTRATION NUMBER: NCT02780986; pre-results.