Raymond Boon Tar Lim

The Pittsburgh Sleep Quality Index in a multi-ethnic Asian population contains a three-factor structure

PurposeThe Pittsburgh Sleep Quality Index (PSQI) is a widely used measure for assessing sleep impairment. Although it was developed as a unidimensional instrument, there is much debate that it contains multidimensional latent constructs. We examined the dimensionality of the underlying factor structure of PSQI in Singapore, a rapidly industrialising Asian country with multi-ethnicities representing the Chinese, Malays and Indians.MethodsThe PSQI was administered through an interviewer-based questionnaire in two separate population-based cross-sectional surveys. An explanatory factor analysis (EFA) was first used to explore the underlying construct of the PSQI in both studies. Then, a confirmatory factor analysis (CFA) was conducted to evaluate an optimal factor model by comparing against other possible models identified in EFA.ResultsThere are three correlated yet distinguishable factors that account for an individual’s sleep experience from the same best-fit model obtained in both studies: perceived sleep quality, daily disturbances and sleep efficiency. Our three-factor structure of PSQI is superior to the originally intended unidimensional model. Our model also shows the best-fit indices when compared to the previously reported single-factor, two-factor and three-factor (by Cole et al.) models in a multi-ethnic Asian population.ConclusionThere is strong evidence that the PSQI contains a three-factor rather than a unidimensional structure in a multi-ethnic Asian population. Scoring the PSQI along their multidimensional perspectives may provide a more accurate understanding of the relationship between sleep impairment and health conditions rather than using a single global score.

Gender and ethnic differences in incidence and survival of lymphoid neoplasm subtypes in an Asian population: Secular trends of a population-based cancer registry from 1998 to 2012

Descriptive epidemiology on incidence and survival by lymphoid neoplasm (LN) subtypes using the 2008 World Health Organisation (WHO) classification remained limited in Asia. The aim of this study was to evaluate whether gender and ethnic differences in incidence and survival of LN subtypes existed using the Singapore Cancer Registry (SCR) from 1998 to 2012. We derived age standardised incidence rates (ASIRs) by the direct standardisation method and 5‐year relative survival (RSR) by the Ederer II method and period approach. Five‐year observed survival (OS) was obtained for each ethnicity. Malays had the highest ASIR of total LNs among the three ethnicities for each time period. The largest increase in 5‐year RSR subtypes was follicular lymphoma from 43.8% in 1998–2002 to 82.3% in 2008–2012; followed by chronic lymphocytic leukaemia (CLL)/small lymphocytic lymphoma (SLL) from 48.1% in 1998–2002 to 77.9% in 2008–2012. Although males had higher incidence than females in each time period, females had greater 5‐year RSR for follicular lymphoma (89.8% in 2008–2012 for females vs. 76.6% in 2008–2012 for males) and CLL/SLL (78.7% in 2008–2012 for females vs. 76.7% in 2008–2012 for males). All three ethnicities experienced an overall increase in 5‐year OS for mature B‐cell lymphoma, with Indians experiencing the greatest increase (37.1% in 1998–2002 to 61.1% in 2008–2012), followed by Malays (30.8% in 1998–2002 to 48.7% in 2008–2012) and then Chinese (36.4% in 1998–2002 to 51.3% in 2008–2012). Our study demonstrated that improved mature B‐cell lymphoma survival was not only observed in the West, but also in Singapore.

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.

Evaluation of Equations for Predicting 24-Hour Urinary Sodium Excretion from Casual Urine Samples in Asian Adults

BACKGROUND The collection of 24-h urine samples for the estimation of sodium intake is burdensome, and the utility of spot urine samples in Southeast Asian populations is unclear. OBJECTIVE We aimed to assess the validity of prediction equations with the use of spot urine concentrations. METHODS A sample of 144 Singapore residents of Chinese, Malay, and Indian ethnicity aged 18-79 y were recruited from the Singapore Health 2 Study conducted in 2014. Participants collected urine for 24 h in multiple small bottles on a single day. To determine the optimal collection time for a spot urine sample, a 1-mL sample was taken from a random bottle collected in the morning, afternoon, and evening. Published equations and a newly derived equation were used to predict 24-h sodium excretion from spot urine samples. RESULTS The mean ± SD concentration of sodium from the 24-h urine sample was 125 ± 53.4 mmol/d, which is equivalent to 7.2 ± 3.1 g salt. Bland-Altman plots showed good agreement at the group level between estimated and actual 24-h sodium excretion, with biases for the morning period of -3.5 mmol (95% CI: -14.8, 7.8 mmol; new equation) and 1.46 mmol (95% CI: -10.0, 13.0 mmol; Intersalt equation). A larger bias of 25.7 mmol (95% CI: 12.2, 39.3 mmol) was observed for the Tanaka equation in the morning period. The prediction accuracy did not differ significantly for spot urine samples collected at different times of the day or at a random time of day (P = 0.11-0.76). CONCLUSION This study suggests that the application of both our own newly derived equation and the Intersalt equation to spot urine concentrations may be useful in predicting group means for 24-h sodium excretion in urban Asian populations.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Prevention Interventions Targeting Female Entertainment Workers: A Systematic Review and Meta-analysis

Abstract Female entertainment workers (FEWs) working in karaoke lounges, bars, pubs, nightclubs, discotheques, dance halls, massage parlours, restaurants (as hostesses or singers) and beer gardens are at high risk for human immunodeficiency virus (HIV)/sexually transmitted infection (STI). The aim of the systematic review and meta-analysis is to evaluate the efficacy of HIV/STI intervention programmes targeting FEWs. Among the 14 included studies, majority were in Asia and targeted native FEWs. Most studies were quasi-experimental and the overall quality was relatively low. While most studies employed only behavioural strategies, structural interventions were the least common. In studies with structural interventions, there was a preference for behavioural and biomedical-based outcome measurements rather than structural-related indicators. FEWs in the intervention group were significantly more likely to report condom use with paying (odds ratio OR 1.7; 95% CI 1.0–2.9, p 0.04), but not with regular (OR 1.0; 95% CI 0.8–1.3, p 0.84) partner than the control/comparison group post-intervention.

Determinants of Chlamydia, Gonorrhea, and Coinfection in Heterosexual Adolescents Attending the National Public Sexually Transmitted Infection Clinic in Singapore.

Background Amidst recent trends in rising rates of chlamydia and gonorrhea among Singaporean adolescents, there are limited data on risk factors associated with these infections that may inform prevention strategies in this population. Methods A cross-sectional study of chlamydia and gonorrhea positivity was conducted among 1458 sexually active heterosexual adolescents between 14 and 19 years old attending the national public sexually transmitted infection clinic from 2006 to 2013. The association with demographic and behavioral characteristics was assessed by crude prevalence ratio, and negative binomial regression modeling was used to obtain adjusted prevalence ratios (aPRs). Results Chlamydia positivity was found in 23.6% of males and 36.6% of females, gonorrhea positivity in 33.1% of males and 15.9% of adolescent girl, and coinfection positivity in 10.2% of males and 10.1% of females. In multivariable analysis, chlamydia was positively associated with being Malay (aPR, 1.6; 95% confidence interval [CI], 1.1–2.1) and inconsistent condom use for vaginal sex (aPR, 6.5; 95% CI = 2.4–17.4) in males and with being Malay (aPR, 1.9; 95% CI = 1.5–2.4), inconsistent condom use for vaginal sex (aPR, 2.0; 95% CI = 1.1–3.9), and number of lifetime partners in females (aPR, 1.1; 95% CI = 1.0–1.1). Gonorrhea was positively associated with being Malay (aPR, 3.2; 95% CI = 2.4–4.4), inconsistent condom use for vaginal sex (aPR, 5.4; 95% CI = 2.1–14.4), and number of lifetime partners (aPR, 1.1; 95% CI = 1.0–1.1) in males and with being Malay (aPR, 3.7; 95% CI = 2.4–5.7) in females. Malays had a higher proportion of sexual risk behaviors compared with the non-Malays. Conclusions Ethnicity and high-risk sexual behaviors are important determinants of chlamydia, gonorrhea, and coinfection for adolescents attending this clinic. Targeted interventions are needed to lower the prevalence of high-risk sexual behaviors for the Malay adolescents in this clinic.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Trial on Condom Use Among Heterosexual Men Patronizing Entertainment Establishments Who Engaged in Casual or Paid Sex in Singapore

Background We assessed the efficacy of a multi-component sexual health promotion program on condom use and human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing among heterosexual men (HSM) patronizing entertainment establishments who engaged in casual or paid sex in Singapore. Methods This was a quasi-experimental trial with a comparison group using cross-sectional surveys at baseline and 6 months postintervention. A locality patronized by local HSM was assigned the intervention, a comparable and distant area served as the comparison site. Using time location sampling, cross-sectional samples of these men were assessed on sexual behaviors using an anonymous questionnaire at baseline (n = 604) and 6 months postintervention (n = 360) in both groups. The coprimary outcomes were condom use at last vaginal and oral sex with casual partner respectively. Mixed effects Poisson regression model accounting for clustering by establishment was used to compute the adjusted prevalence ratio (aPR) of the outcomes postintervention. Results At postintervention, the intervention group was more likely than the comparison group to report condom use at last vaginal (aPR, 1.41; 95% confidence interval [CI], 1.05–1.89) and oral (aPR, 1.70; 95% CI. 1.11–2.61) sex, respectively, with casual partner. Similar findings were found for consistent condom use in the last 6 months for vaginal (aPR, 1.67; 95% CI, 1.13–2.48) and oral (aPR, 1.97; 95% CI, 1.16–3.32) sex, respectively, with casual partner. The HIV/STI testing was not significantly higher in the intervention than the comparison group (aPR, 1.43; 95% CI, 0.98–2.09). Conclusions This trial was effective in promoting condom use with casual partners but not HIV/STI testing among HSM in Singapore.

Are University Students in Singapore Meeting the International and National Recommended Daily Servings of Fruits and Vegetables

Data are lacking on fruit and vegetable (FV) consumption among young adults in the Asia-Pacific region. The aim of this study is to assess the prevalence of students who met the international and national recommendation of daily consumption of 5 and 4 FV servings, respectively, in a university in Singapore and the factors associated with meeting the national recommendation. A cross-sectional survey using proportional stratified random sampling was conducted on 884 undergraduates in 2013. The prevalence of meeting the international and national recommendation was 13.6% and 27.1%, respectively. The significant factors of meeting national recommendation were those from higher socioeconomic status, those making conscious effort to eat food high in fiber, those not skipping breakfast, those having a lower frequency of deep fried food consumption and those with higher meal frequency. Behavioral and structural interventions to educate, motivate and nudge university students to promote FV consumption are required in Singapore.

How healthy is the Singaporean worker? Results from the Singapore national health survey 2010.

Objective: To compare the prevalence of common medical conditions (including mental health and self-rated health) and lifestyle risk factors for disease of the Singapore workforce with the nonworking population, and evaluate the association of these factors with occupation class. Methods: Data were obtained from a population-representative cross-sectional survey in 2010. Adjusted prevalence ratios (PRs) were obtained by modified Breslow-Cox proportional hazards regression model. Results: Within the workforce, after adjustment for age, sex, and ethnicity, daily smoking (PR = 1.87; 95% confidence interval [CI], 1.40 to 2.51; P < 0.001), no regular exercise (PR = 1.13; 95% CI, 1.07 to 1.20; P < 0.001), and poor self-rated health (PR = 1.46, 95% CI, 1.22 to 1.76; P < 0.001) were more prevalent in the lower-skilled occupation classes. Conclusions: Lower-skilled occupation classes in Singapore are associated with lifestyle risk factors, and tailored workplace health promotion programs addressing their specific health needs are needed.

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.