Health Lives
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Health Lives
Diabetes mellitus is one of the leading causes of mortality across the world. The World Health Organisation (2020) revealed that diabetes was the 9th leading cause of mortality globally, causing about 1.5 million deaths. It affects over 450,000 people worldwide, and this number is expected to rise to 640,000 by 2040 (Yong & Koe, 2021). It also means that the proportion of the global population with diabetes is set to rise from 8.8% to 9.9% between 2017 and 2015, a 48% increase in the number of individuals (Standl et al., 2019). Unfortunately, the prevalence of and mortality caused by diabetes are increasing, alarming the healthcare professionals and policymakers. The same scenario is relocated in Singapore, where the prevalence is as high as 711.8 people diagnosed with diabetes out of every 1,000 Singapore residents aged between 20 and 79 years, as of 2021 (International Diabetes Federation, 2021). This prevalence is projected to increase to 872.3 and 898.9 for every 1000 individuals in 2030 and 2045, respectively. This translates to an increase of diabetic people from 670,000 to 1 million between 2030 and 2050 for those aged below 70 years (Boh, 2017). In the same vein, 358.7 people in every 1,000 were undiagnosed with diabetes, presenting 50.4% of the population of the country between 20 and 79 years (Diabetes Atlas, 2021). In addition, about 430,000 or 14% of the adolescents aged between 18 and 19 years in Singapore are diagnosed with pre-diabetes, and therefore at risk of developing diabetes later in life (Yong & Koe, 2021). The number of young people diagnosed with diabetes is particularly alarming due to the obesity epidemic (Standl et al., 2019). Therefore, what is most worrisome is that although the Singaporean government has invested heavily in healthcare and implemented programs to address the diabetes epidemic in the country, through the ministry of health and its war on diabetes program, prevalence rates keep rising as more people are diagnosed with the chronic disease.
This discussion focuses on health promotion that would help resolve the diabetes epidemic in Singapore and hopefully reverse the high prevalence rates. Singapore is rated as a high-income country, and the high prevalence of diabetes has been associated with the change of their lifestyle since the 1970s when the country embarked on rapid economic development and growth (Lau, 2021). Therefore, the health promotion initiative should target lifestyle changes through the behavioural transformation of Singapore’s residents. The merits and barriers encountered when using posters as the health promotion communication tool is discussed, and necessary interventions to counter the barriers explained.
Diabetes
Diabetes is a chronic disease occurring when the body produces insufficient insulin or cannot utilise it to regulate blood sugar. Consequently, hyperglycaemia results due to elevated sugar levels. Unfortunately, high blood sugar levels have adverse effects on body organs and systems, leading to comorbidities, reduced quality of life, and high mortality rate. The two types of diabetes are type-1, which is hereditary, rare and more common among children, and type-2, which is more prevalent and related to lifestyle practices. The greatest danger with this disease is that it has no cure and therefore has to be managed for the entirely of a patient’s lifespan. In addition, it is associated with other adverse health conditions, like cardiovascular disease, kidney disease, cancer, and liver disease (Lin et al., 2020). In the long term, it presents serious complications such as problems with the nervous system, partial vision and blindness, neuropathy and amputations (Standl et al., 2019). For instance, Ming and Ting (2017) revealed that about 1,200 people underwent amputations due to diabetes every year in Singapore, which averaged about four people every day. Patients of Chinese, Malayan, and Indian descent suffered the most, comprising 53%, 27% and 14% of the amputees, respectively.
Besides, diabetes placed a heavy economic burden on countries, costing Singapore from S$1 billion to S$2.5 billion between 2010 and 2050. Png et al. (2016) estimated that the total cost of managing diabetes for a working patient was $5,646 comprising of 42% and 58% direct and indirect costs. The direct costs are associated with medical care, while the indirect costs are the productivity-related losses of patients that cannot work efficiently or not at all due to diabetes-related complications. Png et al. (2016) projected that the economic cost would increase to $7,791 per worker, 65% of which would be due to indirect costs. Similarly, they argued that the total economic cost of diabetes for the entire diabetic population in Singapore would increase by 2.4 times, from $787 million to $1,867 between 2010 and 2050. Therefore, diabetes was a debilitating health issue that needed to be addressed urgently in Singapore.
Main Issues and Concerns about Diabetes in Singapore
The main issues about diabetes in Singapore include the high prevalence, risk factors, early detection and screening, and prevention.
High Prevalence
Singapore has a high diabetes prevalence rate. In 2015, the country ranked second after the United States in diabetes prevalence rates, meaning that it is an issue of national concern because of its economic toll on individuals and the country’s healthcare system and quality of life reduction among the patients, reducing their productivity and health wellbeing (Lim, 2016). Similarly, Khow et al. (2021) revealed that in 2019, Singapore had a 14.2% diabetes prevalence rate, which was much higher than the global rate of 9.3%. They also noted that by 2050, Singapore’s prevalence rate would reach 15.6% of the population. In the same vein, Ming and Ting (2017) revealed that the prevalence of gestational diabetes mellitus was 17.6% in Singapore compared to 9.2% in the United States, meaning that every 1 in 5 pregnant women in Singapore was diagnosed with gestational diabetes.
Although Singapore has made much progress in modernising its healthcare system and improving access to healthcare, Singaporeans are yet to adopt and embrace health-seeking behaviours. In this regard, they continue engaging in unhealthy lifestyles even when they know that it could be detrimental to their health. In turn, while early detection and screening technologies are present in the country, Singaporeans hardly take advantage of them.
Risk Factors of Diabetes in Singapore
Consequently, Singaporeans consume high-sugar goods, smoke, and lead sedentary lives, which contributes to the high prevalence of type-2 diabetes in the country. Jannasch, Kröger and Schulze (2017) noted that eating red and unprocessed meat, high alcohol intake, and excessive consumption of high-fat dairy products, refined cereals and fried foods increased the risk of diabetes. These feeding habits were common in Singapore, especially in urban settings. In the same vein, Lau et al. (2021) found that 17% of Singapore’s population did not meet the required minimum physical exercises recommended by the Ministry of Health and half of the country’s population led considerably sedentary lives. .
Besides, many of Singapore’s residents are of the Asian origin, and thus are predisposed to develop diabetes than their counterparts from western countries. A study by Narayan et al. (2021) found that south Asians has higher diabetes incidences despite their lower insulin resistance and body mass index (BMI). It has been suggested that the high prevalence of type-2 diabetes among those of Asian descent is due to having more abdominal fat compared to their Caucasian counterparts, despite having a lower BMI and inducing resistance.
In Singapore, the risk factors differ along ethnic lines between the country’s residents of Chinese, Malayan, and Indian origin, who are the three most populous ethnic groups in the country. Chan et al. (2020) disclosed that although the prevalence of diabetes was higher compared to Malayans and Chinese, at 17.2%, 16.6% and 9.7%, respectively, Malayans smoked more frequently, exercised less regularly, and took alcohol less frequently than the Chinese and Indians.
Early Detection and Screening of Diabetes in Singapore
Singapore has improved in early detection and screening of diabetes capabilities through heavy governmental investment in the health sector. Singaporeans can now be screened in healthcare facilities or at home using mobile devices to help them detect diabetes early. Lim et al. (2018) noted that Singapore advised the use of fasting plasma glucose for first screening and the oral glucose tolerance (OGTT) test after that as a second screen for individuals registering fasting plasma glucose of between 6.1 and 6.9 mill moles per liter. However, the ministry of health discourages the use of glycated hemoglobin (HbA1c) for screening and diagnosis of diabetes because of the influence of race and ethnicity on the results (Lim et al., 2018).
Prevention of Diabetes in Singapore
The Ministry of Health has several initiatives for addressing the diabetes epidemic in Singapore. Khow et al. (2021) noted that the Ministry of Health announced the war against diabetes (WoD) campaign to demonstrate its commitment to address the health problem comprehensively. This campaign targeted behavioural change against risk factors like consuming alcohol, smoking tobacco, having an unhealthy diet, not engaging in physical activity, and obesity. The campaign also had a communication campaign dunned “Let’s Beat Diabetes”, which deployed social media and out-of-home channels with messages imploring Singapore’s residents to act as individuals and combat diabetes (Khow et al., 2021). The campaign targeted 18 to 39 year olds thought to be most at risk of developing diabetes mellitus in the future. However, despite these efforts, the new cases of diabetes continue to emerge in the country, raising concerns about the effectiveness of the ministerial intervention strategy.
Media Reports on Diabetes in Singapore
The diabetes situation in Singapore has hit the news headlines severally. For instance, a newspaper article by Lim, J. (2016) revealed that while the number of diabetic adults had increased four-fold in almost four decades, Singapore had the second-highest proportion of people living with diabetes among the developed countries. It also revealed that 12% of Singapore’s residents had pre-diabetes and a third of them would become diabetic in the future (Lim, 2016). Similarly, Han (2020) reported in The Straits Times that the Ministry of Health had disclosed to parliament that 19,000 people in the country were diagnosed with diabetes each year and that this number was expected to rise. This figure accounted for people with type 1 and type 2 diabetes and it was bound to rise because of increased access to screening and awareness of the importance of early detection. The report disclosed that in 2017, 8.6% of Singapore residents had diabetes prompting the Ministry of Health to consult stakeholders and propose measured of curtailing the consumption of sweetened drinks. Consequently, the ministry had arrived at two interventions it planned to implement, ban on advertising of unhealthy drinks and mandatory front-of-pack labeling indicating the nutritional values. Another news report by Boh (2017) in the same newspaper explained why Singaporeans were prone to type 2 diabetes compared to the global population, and especially those from the west. The news item disclosed the findings of a study involving Singaporeans of Asian descent comprising mostly of Chinese Singaporeans, which indicated that they were unable to produce sufficient insulin to regulate their blood sugar levels. However, future studies needed to include Singaporeans of Indian and Malay descent to product conclusive results. Boh (2017) reported that this study had been motivated by the large number of Singaporeans with diabetes, having reached 400,000 thus ranking the country second from the United States. The report indicated that it left unattended, this situation would worsen with figures reaching 670,000 and 1 million in 2030 and 2050, respectively. This study has been lauded for providing insights for addressing the uniquely high and peculiar diabetes incidence in Singapore, which implicates possible ethnic and racial attributes. In the same vein, Kaur (2021) reported that type-2 diabetes was becoming more prevalent in young people due to their sedentary lifestyles, poor diets, and childhood obesity. She noted that this trend has existed in the last 10 years and gave an example of a hospital whose number of paediatric patients diagnosed with diabetes has increased from 15 to 24 patients between 2005 and 2015. Similarly, Kaur (2021) revealed that Singaporeans aged between 18 and 34 were unaware of diabetes and its symptoms.
However, Kurohi (2021) reported that the Singaporean government had finally taken the step of addressing obesity and diabetes by requiring that all beverages contain nutritional labeling and a nutri-grade rating by the end of 2022. The nutri-grade, which ranges from “A” to “D”, assigns an “A” to the beverage with the highest nutrition value and “D” to the one with the lowest among commercial beverages. In addition, the government, through the Ministry of Health banned advertising of beverages rated “D” and insisted that they have this rating displayed conspicuously on their labels. Consequently, non-compliance with this regulation would attract a fine of not more than $1,000 and $2,000 for first and repeated offenders, respectively.
Communication Strategies
Communication strategies are critical for delivering an effective health promotion intervention or initiative. They comprise plans for communicating specific information relating to a particular situation, event or issue targeted to a specific audience that could consist of colleagues at the workplace, stakeholders or the public. Gu and Shah (2019) contended that the communication quality in healthcare settings had a significant effect on patient-clinician relationship, care-team teamwork, patient safety, patient satisfaction, health outcomes, and professional accountability. However, communication quality was challenged by the increased linguistic and cultural diversity due to changing population demographics and the global migration of healthcare professionals (Gu & Shah, 2019). Consequently, Gu and Shah (2019) observed that the communication between the healthcare professionals and their colleagues or patients was challenges by the globalized healthcare labor force and patient population. However, Anderson et al. (2019) contended that patients and their relatives often complained about the poor communication from healthcare professions, particularly about end-of-life issues. Healthcare practitioners found communicating such issues with patients and their relatives challenging and often waited for the clients and their families to initiate the conversations.
Barbosa and Silva (2017) noted that information and communication technologies had pervaded the communication space because of the affordances they provide. However, this trend had complicated communication in healthcare because of the requirement of new skills for communicating in virtual environment. Specifically, digital technologies had compressed space and time by reducing distance and timing of communicating, thus enabling healthcare workers to work in virtual teams and communicate with their patients over vast distances. However, Barbosa and Silva (2017) noted that the downside of technology-assisted communication was the limiting of interpersonal communication by curtailing sensory and nonverbal communication. In turn, such communication was not effective because the message was lost or distorted during transmission and reception. From another perspective, Garfin, Silver and Holman (2020) argued that while media played a significant role in raising awareness about the Covid-19 pandemic, it has instigated excessive health-seeking behavior, which overwhelmed the healthcare system in many countries and produced stress responses from the fear of contracting the virus.
Based on this information, effective communication strategies in healthcare should be culturally-sensitive, culturally-appropriate, present accurate and relevant messages, target specific audiences, and be devoid of alarmist messages. The aim of such strategies is to motivate action or behavior change in people that would improve their health wellbeing in the long-term. In this case, the effective communication strategies used to address the diabetes epidemic in Singapore should be sensitive towards the cultural diversity of the population, informative without being alarmist, utilize multiple channels to target different audiences, and deliver specific and consistent messages to avoid ambiguity. The communication strategies should aim at transforming the behavior and lifestyles of Singapore’s residents to reduce the prevalence of diabetes in the country by encouraging healthy eating and physical activity. Altogether, the communication strategy adopted for this health promotion will utilise a poster for promotional messaging.
Target Population
The communication strategy will target all Singaporeans aged between 18 and 70 years because they are supposedly the most active and productive segment of the population. Singapore with the geographical location of interest and Singaporeans living in urban settings will be targeted by the health promotion communication strategy. Singapore’s residents in urban settings are more likely to engage in unhealthy lifestyles, such as eating poorly, smoking, and being physically inactive.
Health Promotion Messaging Through Posters
Posters are an appropriate and effective avenue of passing health promotion messages among a literate and busy target audience. Posters have the advantage of being place able in locations where people frequent the most without being intrusive. When well designed and placed prominently in strategic locations, posters can attract the attention of the general population and pass the desired information. Urban areas have ample places frequented by huge numbers of people, including highways, hotels and restaurants, pubs, schools and universities, offices, recreation parks, taxis, trains and buses, hospitals and many others. Posters can be stuck in these to maximize the targeted audience exposure.
Barriers to Health Promotion and How a Poster Will Address Them
Health promotion encounters several barriers, including the cultural practices, literacy levels, individual complacency, lifestyle choices, poor selection of communication channel, poor targeting of messages, and many others. Sacca et al. (2022) revealed that the barriers of implementing evidence-based interventions are classified into three categories; intrapersonal, interpersonal and organsational barriers. The intrapersonal or individual berries include attitudes and implementation skills, while interpersonal barriers comprise training skills and the roles of mentors, peers, and family members. Organizational barriers include poor resource management and lack of administrative support (Sacca et al., 2022). In the same vein, Liljas et al. (2017) explained that health promotion among older people was challenged by reduced cognitive capabilities, immobility, cultural incongruence, disinterest, and fatigue.
Posters can address these barriers by firstly, enabling the targeted population to interact with the health information at their convenience and pace. (Bavdekar, Vyas & Anand, 2017) explained that posters provide a snap shot about an issue because of their conciseness, provided valuable information through feedback and promote networking, which can enhance the understating of the material and message contained therein. This would be particularly beneficial to impatient and busy individuals that have limited time or are too frail to visit the health facilities for diabetes-related information. The poster will target an adult audience aged between 18 and 79 years. The younger adults are likely to be busy and therefore, would be inconvenienced by invasive messaging strategies that deliver the health promotion intervention through their mobile devices of through healthcare professionals that want face-to-face interaction. Similarly, the older segment of the audience may be too frail to go to healthcare facilities to seek health-related information about diabetes. They may also not be confortable or skilled sufficiently to use digital technologies to access diabetes-related information. Therefore, posters can reach both segments of the target population because they would at least be literate enough to read and understanding the diabetes-related information therein. Secondly, posters can be placed in locations with a high traffic of the targeted audience. Therefore, the message they contain can reach more people than one-on-one interaction with healthcare professionals. In this regard, although the posters may be costly to mass produce, they can be used to inform the hard-to-reach population segments when they are located in the residential areas of the targeted urban population. This would encourage communities to discuss the message contained in the posters and encourage them to amend their lifestyles while encouraging other members to do so (Bavdekar, Vyas & Anand, 2017). In this aspect, posters can instigate community conversations on diabetes and encourage collective action that would lead to healthy eating and more physical activity to prevent the onset and manage diabetes.
Conclusion
Singapore has a serious problem of diabetes in its population. Its attempts to resolve this escalating problem have borne suboptimal results as the prevalence of diabetes is still rising. The proposed health promotion intervention intends to deploy a poster to communicate to the vulnerable population about the importance of behavioral and lifestyle change. A poster can be placed in multiple locations and be used to target an urban audience. Although the target population cuts across all adult age groups, particularly those between 18 and 70 years, it will target the urban population in Singapore because this is the setting where the risk factors, such as poor diet and sedentary lifestyle, are prevalent.
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