GROUP 2 - PREVALENCE AND FACTORS ASSOCIATED WITH DEPRESSION AMONGST ADOLESCENTS IN
SINGAPORE
Study objectives


Establish the prevalence of depression amongst Singaporean adolescents
factors associated with depression (including socio-demographics, perception of stress, expectations of
academic performance & perceived social support)
Sampling Methodology




Multi-stage sampling
From the schools that agreed to participate, we randomly picked 2 schools above and 2 schools below the
median PSLE aggregate of 240
From the two schools that have an aggregate cut-off more than 240, 1 class from each level (secondary 1-4)
will be selected to give a total of 8 classes
From the two schools that offer Express, Normal (Academic) and Normal (Technical) and have an aggregate
score cut-off not exceeding 240, 1 class from each level (secondary 1-5) will be selected to give a total of 10
classes
Study design






Cross sectional study
Target group: 13-18 year old students from secondary schools
o Exclusion criteria: non-schooling, junior college, polytechnic, non-consenting
Hard copy questionnaire will be administered; no invasive measurements or clinical interviews
self-administered hardcopy survey form which will be completed by the students and collected by the
investigators.
The questionnaire is expected to take between 10-15 minutes to complete, and can be done within the
school premises, at the most convenient time and location chosen at the discretion of the individual schools
Suggest a study design: multi stage sampling. Stage 1 is sampling unit is households, households are
stratified by ethnicity and randomly selected by cluster sampling. In stage 2, households are stratified by age
group of constituent members below 18, stratified random sampling is then used to randomly select
individuals in each age group.
Bias and confounding



Selection bias: only one class from each level is selected, but schools in Singapore segregate class by
academic performance. If the factors associated with depression differs markedly between students of
different academic performance, then the prevalence of depression will be underestimated. Factors such as
academic performance may be poorly represented as students in higher performing classes may see it as
less of a factor associated with depression
Selection bias: Only students still currently studying in school are surveyed. Those who have dropped out of
school may have higher rates of depression. If these students are not surveyed, then the prevalence of
depression in Singapore will be underestimated. There will also be inaccurate representation of the true
factors associated with depression because the youths who are depressed and dropped out and exposed to
the factors will not be captured.
Non-responder bias: Students who do not do the survey, or parents who do not let their children do the
survey may be more likely to be depressed as they may not want to reveal their condition even though the
questionnaire may be anonymous. This will underestimate the prevalence of depression
Oon Ming Liang



Hawthorne effect: on realizing that survey is about depression, students may answer differently and may
give answers that suggest that they might be depressed, even though they might not be
Recall bias: those students who are actually depressed may report higher rates of exposure to correlates
even though this might not be true.
Confounder: age is a possible confounder in the study between the factors associated with depression and
depression. Age is positively associated with depression and age is also positively associated with some of
the factors under study (older student have more national exams, older students may perceive more stress).
Age is not a factor in the causal pathway between the factors a/w depression and depression.
Risks and benefits


Risks
o
o
o
o
o
Recalling distressing events may cause some level of discomfort for the participants.
Invasion of privacy
False identification
a subject responding to a "depression" scale may conclude that he or she is depressed
Stigmatization by both peers and teachers as the questionnaire is done at school, other people can
see
Benefits
o Raise awareness
o Providing brochures on avenues to seek help
o Raise awareness
o Local data on depression amongst adolescents
o Improving existing pastoral care
o Data for the school to explore objectives for pastoral care, factors to target,
o
Research ethics


Autonomy
o A parental consent and student assent form, along with an information sheet will be given to the
students. This will be done about 1 week prior to the actual day of administering the questionnaire.
Ethical issues:
o Autonomy
 Spiteful parent may force a depressed child to do survey in order to wake up his bloody idea,
child has no choice but to comply
o Confidentiality
 Performed in school in full view of classmates, may constitute breech of confidentiality
Applications



Government can target statistically significant factors a/w depression to develop package to combat youth
depression e.g. if academic stress is a significant factor, can design more programs around coping with this
stress rather than other stressors e.g. family problems
Government can target resources to students at highest risk of depression, can use data from this study to
formulate the typical profile of a depressed youth and ask teachers to identify them
Springboard for future research
GROUP 3- SOCIODEMOGRAPHIC, HOME ENVIRONMENTAL FACTORS AND PARENTAL ATTITUDES AS
PREDICTORS OF SCREEN TIME AMONG SINGAPOREAN CHILDREN UNDER 2
Oon Ming Liang
Study objectives



1) To survey the duration of screen time exposure among Singaporean children under the age of two
2) To explore the characteristics of screen time exposure
3) Determine correlates of screen time:
o Sociodemography
o Home Environment
o Parental Attitudes
Study design
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

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

Cross sectional study
Conducted by: Interviewer administered survey
Inclusion criteria: Parents and caregivers of children under age of 2, attending vaccination and
developmental assessment clinics
Exclusion criteria: Non Singaporean citizen and non- permanent resident, nonparental caregivers, vists for
other reasons
Sample size: 800
Location: NHG polyclinics (Yishun & Jurong)
Sampling methodology


Convenience sampling
Suggest a sampling design: multi stage sampling. Stage 1 is sampling unit is households, households are
stratified by ethnicity and randomly selected by cluster sampling. In stage 2, households are stratified by age
group of constituent members, stratified random sampling is then used to randomly select households with
at least one member below 2 years old
Bias and confounding
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


Sampling error: Only take from public polyclinic, never take from private clinics/hospitals. If the
characteristics of children who go to private institutions differ markedly from those who go to public
institutions (e.g. private use less screen exposure), then the survey will overestimate the prevalence of
screen time exposure. Also those who go to private clinics likely to have very different socioeconomic status
and home environments, and may have more positive parental attributes due to better education about
raising children. If this is true, the study will may over/underrepresent the significance of the correlates of
screen time
Interviewer bias: upon knowing that the child has significant amount of screen time, interviewer may probe
for more of the correlates
Recall bias: parents who have children with high screen times may report higher rates of exposure to
correlates even though this might not be true.
Confounder: age is a possible confounder in the study between reduced sleep and screen time. Age may be
associated with reduced sleep as older kids sleep less, and age is also associated with the outcome
(increased screen time) as seen from the survey results. Age is not a step in the causal pathway from
proposed correlates and increased screen time.
Risks and benefits

Benefits
o Establish first ever understanding of paediatric screen time in Singapore
o Complement international studies
o Local screen time guidelines
Oon Ming Liang

o
Risk
o
Opportunistic education after completion of survey
Loss of privacy conducting questionnaire in public area
Research ethics

Autonomy
o

Informed verbal consent, Participant information sheet, Voluntary participation, with the right to
withdraw, Does not directly involve the child
Confidentiality
o
No personal identifiers, No access to medical records/database, Private interview rooms available
Results









46.5% have screen time behavior, 33% have >2h exposure
Television, PPD most commonly used
4/10 fail to supervise screen usage
Screen time usage most common 18-24 months
Lower maternal education, malay/Indian, lower socioeconomic status a/w increased screen time
Parental attitudes (screen time good for kid, confident of restricting use/duration of use) a/w increased
screen time exposure
Parents using screen device as coping tool a/w increased screen time
Screen viewing a/w <13h sleep
Doctors are poor counselors
Applications
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




Government can target statistically significant factors a/w increased screen time to develop package to
combat increased screen time e.g. if lower socioeconomic status is positively a/w increased screen time,
then government can target programs at poorer people rather than other socioeconomic strata
Parental knowledge lacking, pediatric associations can issue guidelines to parents explicitly discouraging
screen time exposure
Formulate resources to target specific parental attitudes, package, specific counseling methods
o Address other means e.g. giving toy, reading book, more interaction as coping tool
o Enforce idea that increased screen time may be a/w undesirable traits e.g. myopia, retarded
language development
Can make specific announcements regarding screen time use instead of using sweeping statements like
"increasing amounts of children using electronic devices"
Pediatric associations can make local recommendations with regards to use of electronic devices for
children under 2 with this information
Springboard for future research
o Private clinics, other polyclinics
o Interventional studies
o Effects on different ages
o Awareness amongst healthcare professionals
GROUP 4 - KNOWLEDGE, ATTITUDES AND PERCEPTIONS OF DEMENTIA AMONGST RESIDENTS IN A HOUSING
ESTATE IN SINGAPORE
Oon Ming Liang
Study objectives





Establish the KAP of the Singapore residents above the age of 21 regarding clinical features, management
and protective factors related to dementia
Evaluation of individual aspects of knowledge and attitudes
Assess effects of respondent characteristics on knowledge and attitudes
Identify potential associations between knowledge and attitude
Identify groups where dementia education would be most effective
Study design

Observational cross-sectional study
Sampling Methodology




Simple random sampling
Target housing estate: the blocks of flats in Ang Mo Kio bounded by Ave 8, Ave 3, Ave 10 and Street 41
Units within the blocks will be chosen randomly, with replacement if necessary (adjacent unit on the Right)
Suggest a sampling design: multi stage sampling. Stage 1 is sampling unit is households, households are
stratified by ethnicity and randomly selected by cluster sampling. In stage 2, households are stratified by age
group of constituent members, stratified random sampling is then used to randomly select individuals from
each age group
Bias and confounding






Selection bias: all taken from AMK, if characteristics of AMK residents differ greatly from other
Singaporeans, then results would not be valid. For example, AMK CC may have held a dementia roadshow
recently, hence the residents may have had a better understanding of dementia compared to other
Singaporeans
Selection bias: Representative member of household will be surveyed, but this may not be ideal as the
person with the best understanding may not be around e.g. at work. Conversely, if it so happens that each
family has one person who understands dementia well, and is consistently chosen to answer the
questionnaire, then the survey will overestimate the prevalence of good understanding of dementia in
Singapore.
o Alternatively, the person who is most courageous/best command of English will be called to answer
but this is biased as that person is likely to have better level of education as well
Interviewer bias: upon knowing that participant has `poor understanding of dementia, interviewer may be
tempted to probe further into the possible barriers even though there may be none
Recall bias: those people who have poor understanding of dementia may recall barriers to justify their
stupidity even though such barriers to effective education may not exist
Non responder bias: people who choose not to participate differ greatly from those who do, for example,
those who do not participate may have little understanding of dementia and may not want to embarrass
themselves with their pathetic knowledge, hence the study in this case would overestimate the prevalence of
good understanding of dementia in Singapore.
Confounder: age is a possible confounder in the study between the proposed barriers and knowledge
regarding dementia. Age may be associated with the correlates that the team proposed e.g. younger
respondents are more well read and know more about dementia, and age is also associated with the
outcome (better knowledge about dementia). Age is not a step in the causal pathway from proposed
correlates and increased screen time.
Risks and benefits
Oon Ming Liang


Risk
o Remote possibility of emotional distress
Benefits
o Participants will gain knowledge pertaining to dementia (information sheet given to all participants)
o Knowledge potentially translated into care for family members with dementia
o Guide public education initiatives
o Guide healthcare initiatives and policies pertaining to dementia
Research ethics


Potential embarrassment if they do not know the answers
Dig up painful memories for those with demented relatives
Results



75% poor overall knowledge, especially for risk factors
o Higher education, family member/contact with dementia a/w better knowledge
Positive attitudes toward screening, favored care siting is at home
Good knowledge about treatability of dementia is associated with positive health seeking behavior
Applications





Government can target statistically significant factors a/w poor understanding of dementia to develop
package to combat poor understanding of demetnia e.g. if lower socioeconomic status is positively a/w
increased poor understanding, then government can target programs at poorer people rather than other
socioeconomic strata
Screening, forcus on care siting at home, increase resources for dementia home care
Formulate resources to target specific attitudes, package, specific counseling methods
Can use the results to provide quality caregiver training and education for caregivers of demented people
Springboard for future research
GROUP 6 - HEALTH-SEEKING BEHAVIOURS AMONG WOMEN AGED 40 AND ABOVE IN SINGAPORE
ATTENDING PRIVATE SECTOR GENERAL PRACTICE CLINICS
Study objectives



Assessing health-seeking behaviours in women eligible for breast cancer screening
o ‘Stages of change’ model
o Consideration of, or actual uptake of mammography
Evaluating effectiveness of specific interventions in promoting uptake of mammography
o Opportunistic health promotion
Ultimately, to further improve the currently low mammography rates
Study design


single-blinded, cluster-randomised trial based in up to 60 private sector general practice clinics with two
arms: 1 intervention arm, and 1 control arm
Female Singaporeans and permanent residents, aged 40-69, who have not undergone regular
mammography
Sampling Methodology
Oon Ming Liang


Convenience sampling
Suggest a sampling design: Recruitment of survey participants for 2 months prior to actual study, make
planned visit/consultation
Bias and confounding



Observer bias: doctor who knows he is in the treatment group may more aggressively push for mammogram
out of line with the recommended counseling script
Observer bias: data interpreters who know that the patient is in the treatment group may wrongly assign the
patient to the "consideration" or "actual uptake of mammography" more frequently than those in the control
group because they are not blinded to the status of the patient (whether in treatment or control group)
Selection bias: only chose patients attending private GP, neglected public patients. If it is indeed true that
the characteristics of private patients differ significantly from that of public patient, results not generalizable
to larger public. For example, if private patient more likely to take up mammogram because of greater
affluence, this may not be true in wider public who may not have the funds to go for mammogram
Risks and benefits


Risks
o
o
o
o
Participants may feel uncomfortable or vulnerable sharing sensitive personal information
Theoretical risk of GPs (in control arm) stopping usual practice of counseling
Risks of subsequent procedures
Related to mammography, e.g. pain/discomfort, radiation exposure, false positive or negative
results
o Related to additional tests and procedures, if necessary e.g. biopsy, surgery
Benefits
o Encourage mammography uptake
o Potentially earlier detection of breast pathology
o Potential reassurance if mammogram is normal
o Control arm may also encourage healthy lifestyle/eating habits
o Future benefits to wider public
o If research data gathered is used by health policy-makers to plan breast cancer screening programs
o Or to plan programs promoting healthy living
o In addition, there will be unmasking of the control arm – participants will subsequently be advised to
go for a mammography if they are not already adherent to the screening guidelines, and given the
relevant information e.g. cost, clinic. Hence participants in the control arm will also be able to receive
the same benefits as those in the intervention arm.
Research ethics

Autonomy
o Objectives of study adequately explained
o Patients not forced to disclose information they are unwilling to share
o May choose to opt out at any point
o Decision to book mammography is entirely their choice
o Doctors to continue with their usual standard of care regardless of assignment to
control/intervention arms
 Doctors in control arm should not alter their usual practice of counseling patients to attend
mammography, where applicable
 Doctors in intervention arm reminded to counsel eligible patients to attend mammography,
but free to exercise judgment in situations where they feel this is inappropriate
Oon Ming Liang


Informed consent
o Patients in control arm initially blinded to the study being geared towards breast cancer in particular
o Temporary “deception” deemed necessary to the study, or would otherwise be a major limitation
o Exposure (e.g. questioning about mammograms with the knowledge it is the study’s focus) may in
itself be a cue to consider mammography
o “Hawthorne effect”
o However, there will be unmasking of patients in control arm eventually, and information on how to
book a mammogram will also be provided
o Hawthorne effect describes a psychological phenomenon where participants in a study alter their
behaviour as a result of their participation, usually with respect to the goals of the study. Hence the
purpose of incomplete disclosure in this study is to prevent inherent bias from knowing that breast
cancer screening is the intervention under consideration for the control group. If one was told at the
start that the aim of our study was to measure the uptake of mammography screening, her
perceptions and behaviour towards mammography screening might have differed. This would have
diluted the accuracy of our study results and conclusions, and may result in a falsely elevated uptake
of mammography in the control group
o That said, there will be unmasking for the control arm of our research participants at the second
follow-up in the post-consultation period, which includes informing those in the control arm that they
should get a mammography if they have not had one, or if they have not been going for their
mammography regularly as per guidelines. Information on where and how to book a mammography
is also provided
Ethical issues
o Autonomy
Applications



If research data gathered is used by health policy-makers to plan breast cancer screening programs or to
plan programs promoting healthy living
If it indeed shows counseling effective compared to video alone, can make recommendations for all GPs to
provide counseling re: mammogram routinely to all women not following the recommended screening
schedule
Springboard for future research
GROUP 7 - KNOWLEDGE & ATTITUDES OF FIRST AID IN HOUGANG
Study objectives




1) Investigate which groups of people in the community have poor knowledge of general and specific first aid
2) Investigate attitudes towards first aid in general and first aid courses
Secondary objectives:
3) Identify barriers to the learning and administering of first aid and suggest specific measures to counter
this
Study design


Cross sectional study
Data will be collected via an interviewer-administered structured questionnaire
Sampling Methodology

Systematic sampling
Oon Ming Liang



zone comprising of 36 blocks (3582 units) within the Hougang housing estate will constitute the sampling
frame
select every odd unit on every floor out of all the blocks within the zone to achieve a sampling interval of 2
Suggest a sampling design: multi stage sampling. Stage 1 is sampling unit is households, households are
stratified by ethnicity and randomly selected by cluster sampling. In stage 2, households are stratified by age
group of constituent members, stratified random sampling is then used to randomly select individuals from
each age group
Bias and confounding






Selection bias: all taken from hougang, if characteristics of hougang residents differ greatly from other
Singaporeans, then results would not be valid. For example, hougang CC may have held a first aid
roadshow recently, hence the residents may have had a better understanding of first aid compared to other
Singaporeans
Selection bias: Representative member of household will be surveyed, but this may not be ideal as the
person with the best understanding may not be around e.g. at work. Conversely, if it so happens that each
family has one person who understands first aid well, and is consistently chosen to answer the
questionnaire, then the survey will overestimate the prevalence of good understanding of dementia in
Singapore.
Interviewer bias: upon knowing that participant has `poor understanding of first aid, interviewer may be
tempted to probe further into the possible barriers even though there may be none
Recall bias: those people who have poor understanding of first aid may recall barriers to justify their stupidity
even though such barriers to effective education may not exist
Non responder bias: people who choose not to participate differ greatly from those who do, for example,
those who do not participate may have little understanding of first aid and may not want to embarrass
themselves with their pathetic knowledge, hence the study in this case would overestimate the prevalence of
good understanding of first aid in Singapore.
Confounder: age is a possible confounder in the study between the proposed barriers and first aid
knowledge. Age may be associated with the correlates that the team proposed e.g. younger parents take
part in more first aid courses, and age is also associated with the outcome (better first aid knowledge). Age
is not a step in the causal pathway from proposed barriers and poorer first aid knowledge .
Risks and benefits


Risks
o Distress over being unable to answer question
o Unhappiness over time spent on survey
Benefits
o Upon realizing their poor knowledge, may want to take up first aid courses
Research ethics


Autonomy
o Interviewees can choose not to participate in the study, no forcing/coercion
Confidentiality
o No personal identifiers, questionnaires to be coded with serial numbers, All questionnaires are
anonymous, Responses entered only by PI and members of research team
Results

Mean score 4.4/9, globally poor performance in identification, management of injuries and knowledge
Oon Ming Liang
o





Lowest score is old, female, poor, low education, unemployed, no previous FA training, negative
attitude to FA
People think first aid important
Younger the age, more willing to attend FA course
Most common obstruction to attending course: lack of time
Ideal responders
o Male, higher education, employed, previous FA training
Poorest responders
o Chinese, lower education, unemployed, previous FA training, poor attitude
Applications





If research data gathered is used by health policy-makers to plan first aid education
o Opportunistic education at Emergency Department for patients about their conditions if they come in
with choking or burns at P3
o . Making course more accessible (at Community Centers and providing variety of schedules
o Raise awareness about first aid via media
o Establish reminder system for refresher courses
Identify areas that Singaporeans most lacking in
Allow relevant organizations e.g. red cross to target or formulate programs targeted at age groups in which
the knowledge is most poor
o Tailor basic first aid courses in multiple languages for elderly
o Training caregivers in first aid course to take care of elderly
Target groups in which first aid most effective
o School children: primary school basic, secondary certification, tertiary refresher
Springboard for future research
GROUP 8 - B FREE
Study objectives



Assess the KAP regarding HBV infection, screening and vaccination
Identify possible barriers to screening and vaccination
Explore the associations between knowledge, attitudes, practices and their impact on health outcomes
Study design

Cross sectional
Sampling Methodology



Simple random sampling
Bedok residents
Suggest a sampling design: multi stage sampling. Stage 1 is sampling unit is households, households are
stratified by ethnicity and randomly selected by cluster sampling. In stage 2, households are stratified by age
group of constituent members, stratified random sampling is then used to randomly select individuals from
each age group
Bias and confounding

Selection bias: all taken from Bedok, if characteristics of Bedok residents differ greatly from other
Singaporeans, then results would not be valid. For example, Bedok CC may have held a hep B roadshow
Oon Ming Liang





recently, hence the residents may have had a better understanding of first aid compared to other
Singaporeans
Selection bias: Representative member of household will be surveyed, but this may not be ideal as the
person with the best understanding may not be around e.g. at work. Conversely, if it so happens that each
family has one person who understands hep B well, and is consistently chosen to answer the questionnaire,
then the survey will overestimate the prevalence of good understanding of hep B in Singapore.
Interviewer bias: upon knowing that participant has poor understanding of hep B, interviewer may be
tempted to probe further into the possible barriers even though there may be none
Recall bias: those people who have poor understanding of hep B may recall barriers to justify their stupidity
even though such barriers to effective education may not exist
Non responder bias: people who choose not to participate differ greatly from those who do, for example,
those who do not participate may have little understanding of hep B and may not want to embarrass
themselves with their pathetic knowledge, hence the study in this case would overestimate the prevalence of
good understanding of hep B in Singapore.
Confounder: age is a possible confounder in the study between the proposed barriers and vaccination. Age
may be associated with the barriers that the team proposed e.g. older people more stubbron, and age is
also inversely related to amount of people vaccinated because previously not in schedule. Age is not a step
in the causal pathway from proposed barriers and lower vaccination pick up rates.
Risks and benefits


Benefits
o Raise awareness about Hep B
o Sharing of experience and knowledge
o Receive information about Hep B after survey
o Brochures from HPB
o Better estimate of the knowledge, attitudes and practices of the population with regards to Hep B
o Hope to help guide HPB public health education programmes surrounding Hep B
o Facilitate the referral of participants to relevant medical attention
Risks
o Outrage sensitivities
o Trigger emotional response in respondents who have relatives/acquaintances with Hep B
Research ethics



Autonomy
o Informed consent given verbally, Allowed to ask questions throughout the survey, Allowed to
withdraw at any time of the survey
Privacy and confidentiality
o No identification
Ethical issues
Applications




research data gathered can be used by health policy-makers to plan hep B education especially in older
generation to encourage vaccination
Identify areas that Singaporeans most lacking in
Findings may be generalizable to at-risk population and allow MOH to formulate strategies to encourage
pickup of vaccine in these populations e.g. sex workers
Allow relevant organizations e.g. MOH to target or formulate programs targeted at age groups in which the
knowledge is most poor
Oon Ming Liang

Springboard for future research e.g. perception of family members with relative with chronic hep B infection
GROUP 5- BARRIERS TO EFFECTIVE ANTICOAGULATION IN AF
Study objectives





To investigate the underlying reasons for non-treatment with anticoagulants among AF patients
To describe the prevalence of anti-coagulation therapy in patients with AF in Singapore.
To offer recommendations to overcome these barriers
To increase the rate of anti-coagulation in patients with atrial fibrillation
To raise awareness of AF and its serious but preventable complications
Study design













Cross sectional
Inclusion Criteria
Patients presenting with previously diagnosed AF
Heart centre (NUH, SGH)
Emergency department (NUH, SGH)
Exclusion Criteria
Non Singaporean or non PR
Newly diagnosed AF
Identify AF patients at all 4 sites
Recruit patients by explaining the rationale of the project – Patients who are agreeable will sign a consent
form
Conduct interviews using questionnaire (whether patients are on anti-coagulants or otherwise)
Search electronic medical records for further information (Eg. Past Medical History)
PRN: Activate phone protocol for patients discharged from ED if there was no opportunity to conduct
interview (Eg. Patient was in P1 area)

Sampling Methodology


Convenience sampling
Suggest method of sampling: Request list of all current AF patients and AOR discharge patients from all
hospitals, OPC, enumerate them perform simple random sampling to select random amount of AF patients
and approach them via telephone call
Bias and confounding


Selection bias: only those in regular attendance at OPC or presenting acutely at ED are interviewed. This
neglects the majority of AF patients who are stable in the community or on f/u at polyclinic with pharmacist
warfarin service and may be noncompliant . If the characteristics of these patients are vastly different from
those presenting to ED and SOC, then the results from this study will not be generalizable to the wider
public. Those who bother to turn up for regular appointments at SOC are likely to be more compliant
anyway, and could be more so as compared to the average AF patient. Conversely, those presently acutely
at the ED may be suffering from complications from AF e.g. embolic stroke, and is likely to be less compliant
as compared to the average AF patient
Main caregiver may not know personal factors relating to patient's beliefs regarding AF, may arbitrarily
choose answers and cause results to be inaccurate.
Oon Ming Liang




Interviewer bias: on realizing patient is nonadherent/not taking anticoagulation, may probe further into the
reasons behind non adherence more than necessary than is stated in protocol, leading to inaccurate results
Recall bias: nonadherent patients may recall exposure to factors that lead to nonadherence even though
they may not be exposed to such factors in an attempt to account for their nonadherence
Non responder bias: people who choose not to participate differ greatly from those who do, for example,
those who do not participate may have little understanding of AF and may not want to embarrass
themselves with their pathetic knowledge, hence the study in this case would overestimate the prevalence of
good understanding of AF in Singapore.
Confounder: age is a possible confounder in the study between the proposed barriers and vaccination. Age
may be associated with the barriers that the team proposed e.g. older people more stubborn, and age may
also be related to some of the factors identified for poor compliance e.g. risk of bleeding. Age is not a step in
the causal pathway from proposed barriers and factors identified for poor compliance.
Risks and benefits
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Benefits
o Participants will be able to learn more regarding their condition, and perhaps seek help if necessary
o Long- term benefits would include the eventual implementation of recommendations that may
improve management and reduce complications of their AF
o Implementation of recommendations may reduce presentation of complications of AF to the hospital
Risks
o Distress
o Unstable patient deteriorate when being interviewed - Conduct interview only after patient has been
adequately stabilized or activate phone protocol if patient is discharged
Research ethics
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Autonomy
o Involve potential vulnerable subjects whereby obtaining informed consent form from the subject is
not possible and informed consent is required from a Legally Acceptable Representative (LAR)
Confidentiality
o Data will be owned and shared across the institutions.
o The study team would store all research data within the institution
o Soft copy data will be stored in password protected PC/laptop belonging to the principal coinvestigators and site PIs
o Hard copy data will be stored in A/Prof Mikael Hartman's SSHSPH office under lock and key
o All patient identifiers are to be kept within the respective institutions
o All soft copies will be eventually deleted except for a compiled copy with each PI (that does not have
patient identifiers)
o Study data may be kept as a database
o No part of the study procedures will be recorded on audiotape, film/video, or other electronic medium
Ethical issues
o Autonomy: consent taken from caregiver if unable to take from patient himself. However, in absence
of any LPA, cannot assume that the caregiver is entitled to make decisions for the patient including
decision to take part in survey or not
o Autonomy: patient is in a disadvantaged solution, may agree to whatever so that he can quickly get
on with treatment (in symptomatic patient)
Applications
Oon Ming Liang
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research data gathered can be used by health policy-makers to plan AF compliance to anticoagulation
education especially in older generation to encourage anticoagulation compliance
Identify areas that Singaporeans most lacking in
Findings may be generalizable to at-risk population and allow MOH to formulate strategies to encourage
pickup of anticoagulation in these populations e.g. old people with poor social support
Allow relevant organizations e.g. MOH to target or formulate programs targeted at age groups in which the
knowledge about AF and its complicationis most poor
Springboard for future research e.g. perception of family members with relative with AF
Oon Ming Liang