Empathy is a key attribute of healthcare professionals. While it can be nurtured, predispositions toward empathy predict success in healthcare training and practice. We examined empathy and empathic care intentions among newly enrolled healthcare students from Dentistry, Medicine, Nursing, and Pharmacy in Singapore to inform admissions and curriculum planning. Newly enrolled students from the four disciplines at the National University of Singapore were invited to participate. Empathy was measured using the Jefferson Scale of Empathy-Health Professions Student version (JSE-HPS), while empathic care intentions were assessed with a custom-designed seven-item instrument. Parametric or non-parametric statistical tests were used to compare scores between disciplines and across demographic categories. A p-value of < 0.05 was considered statistically significant. A total of 646 students participated, with a 37

Background and objectives Multiple lifestyle and health factors could contribute to cognitive health, while not many studies examined the factors in a combined way, especially in Asian population. This study aims to examine the association of Life’s Simple 7 (LS7) with cognitive function and its change in a multi-ethnic Asian population. Methods Longitudinal data were drawn from the Singapore Multi-Ethnic Cohort, involving 2601 participants (45–86 years). LS7 at baseline was calculated by summing seven metrics, and a higher LS7 (range: 0–7) score indicates a healthier lifestyle. Cognitive function was measured at two revisits with Mini-Mental State Examination (MMSE). Association of baseline LS7 with MMSE percentiles (10th, 30th and 50th) and its change over time were examined using linear quantile mixed model. Interactions between LS7 and age group, sex, ethnicity, education level and marital status were also explored. Results Higher LS7 was significantly associated with higher MMSE scores at 10th (β = 0.11, 95% CI 0.01, 0.20), 30th (β = 0.12, 95% CI 0.05, 0.19), and 50th (β = 0.07, 95% CI 0.03, 0.11) percentiles. These associations were particularly pronounced among currently unmarried individuals, participants aged 60 and above, those with education above primary school and Chinese ethnicity. No significant association was found between LS7 and MMSE change over time. Discussion Higher LS7 was significantly associated with better cognition particularly among older, unmarried individuals and participants with higher education or of Chinese ethnicity. These findings highlight the value of composite lifestyle scores for cognitive impairment risk modification in Asian populations.

Background There are increasing numbers of cancer survivors who have finished their primary treatment, but whose quality of life remains consistently poor over years. There is limited evidence for pragmatic, brief interventions to support cancer survivors in primary care, where most patients are managed. Objective To develop, trial and assess the effectiveness and cost-effectiveness of a digital intervention to support cancer survivors (named ‘Renewed’) designed to require minimal health service resources. Design Qualitative development of the intervention, then open randomised controlled trial, with a process analysis and health economic analysis. Setting United Kingdom primary care Interventions: Development of the intervention We systematically reviewed the relevant qualitative and quantitative literature to inform initial intervention planning, intervention content and design features of a digital intervention. This was followed by iterative development and optimisation of intervention content and the human support component – in qualitative studies of the views of cancer survivor, and of National Health Service, volunteer and charity workers. Main trial: Participants People who had finished primary treatment for colorectal, breast or prostate cancer with lower quality of life (European Organization for Research and Treatment of Cancer QLQ-C30 score < 85) within the last 10 years. Participants were randomised to one of three groups: (1) ‘generic’ advice: detailed digital National Health Service support for healthier living (‘Living Well’), (2) a bespoke digital intervention (‘Renewed’) addressing symptom management, physical activity, diet, weight, distress and/or fear of recurrence, or (3) ‘Renewed’ plus support (additional brief support by e-mail, telephone, or face to face) Main outcome measures Primary outcome: European Organization for Research and Treatment of Cancer QLQ-C30 (overall score). Secondary outcomes: subscales of European Organization for Research and Treatment of Cancer QLQ-C30 (global self-rated health; functional subscales; symptom subscales), EuroQol-5 Dimensions, five-level version, psychological measures and costs. Results At the primary time point of 6 months, there were clinically important improvements in European Organization for Research and Treatment of Cancer QLQ-C30 score contrary to the expected trajectory of quality of life in this population, but with no evidence of differences between groups. By 12 months, the Renewed plus support group had continued to improve and was better than generic advice (1.42, 95% confidence intervals 0.33 to 2.51), with the largest differences in the prostate cancer subgroup. 13 of the 14 subscales also improved compared to generic advice, statistically significant for self-rated global health (Renewed: 3.06, 1.39 to 4.74; Renewed plus support: 2.78, 1.08 to 4.48), dyspnoea, constipation and enablement. For Renewed plus support, there were also statistically significant differences for physical, cognitive and emotional functioning and fatigue. Renewed and Renewed plus support were dominant given improved effectiveness combined with and lower mean primary care National Health Service costs per patient (respectively −£141, −153 to −128; −£77, −90 to −65). Limitations Of those sent invitation letters, 14% (7883/59,295) were assessed for eligibility and 35% (2732/7883) of those assessed were eligible and agreed to participate – which is normal with the ‘cold calling’ method of invitation. The digital intervention would not suit people who find technology or the internet difficult to access, but only 25% (2649/10,697) of those who gave reasons for declining did so due to lack of internet access. The extensive generic advice available to participants in the National Health Service limited the ability to assess the specific benefits of Renewed in the short term, but nevertheless longer-term benefit and lower National Health Service costs are likely to be achieved with the bespoke intervention. Conclusions Cancer survivors with lower quality of life given detailed generic online support improve significantly. Providing robustly developed, low-cost, bespoke digital support can provide further modest long-term improvements in enablement, symptom management and self-rated global health, with substantially lower National Health Service costs. Future work The cost-effectiveness and benefits for symptom management on self-rated health suggest a more widespread implementation study should be undertaken. Trial registration This trial is registered as Current Controlled Trials ISRCTN 96374224. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-0514-20001) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 4. See the NIHR Funding and Awards website for further award information. Plain language summary We aimed to make and assess a website for use in general practices to support people who have poor quality of life after their initial cancer treatment. We made our website, called ‘Renewed’, based on the few studies about websites or apps. We tested ‘Renewed’ with people who had finished their initial treatment, National Health Service staff and others, and used their feedback to improve it. Then we asked others to join a study to see how well ‘Renewed’ works. Each person invited to join the study had finished initial treatment for bowel, breast or prostate cancer but had poor quality of life. We placed them at random (by chance) into one of three groups: given general advice from the NHS website for more healthy living (‘Living Well’) given ‘Renewed’, with help designed for cancer survivors in managing symptoms, exercise, diet, weight, distress, and fear of cancer coming back given ‘Renewed’, plus brief support by e-mail, telephone or face to face. After 6 months, all groups reported better quality of life. After 12 months, the Renewed plus support group carried on improving and was a little better than general advice for quality of life. At this time both the Renewed groups had improved in their rating of their health, shortness of breath, constipation and feeling more able to manage their problems. People in the Renewed plus support group also had improved physical and emotional functioning and less fatigue. Both Renewed and Renewed plus support not only had improved outcomes but also lower costs for the NHS. This study suggests that the online support provided by the Renewed website can help improve the quality of life of people who have finished initial cancer treatment, with both better outcomes and lower costs for the National Health Service. Scientific summary Background There are increasing numbers of cancer survivors who have finished their primary treatment, but quality of life remains consistently poor over years for many patients. There is limited evidence for pragmatic, brief interventions to support cancer survivors in primary care, where most patients are managed. Objective To develop, trial and assess the effectiveness and cost-effectiveness of a digital intervention to support cancer survivors (‘Renewed’) designed to require minimal health service resources. Methods Intervention development Collating the evidence Rapid review of web-based interventions designed to improve quality of life in adults who have completed primary treatment for breast, prostate and colorectal cancer. A range of study designs were included, and information about intervention characteristics, experiences and outcomes was extracted. The data were analysed using thematic analysis. Rapid scoping review of barriers and facilitators. A search identified studies during the past 20 years and further studies were identified by experts in the team and examination of reference lists. Development of Guiding Principles The rapid scoping review was used to identify key context-specific behavioural issues, and key intervention features were developed to meet each design objective. These Guiding Principles were improved in consultation with the development team and an expert stakeholder panel. Behavioural analysis A behavioural analysis table documented likely barriers for target behaviours, and for each barrier, interventions were described and coded according to three theoretical frameworks [Behaviour Change Techniques Taxonomy (BCTv1); Behaviour Change Wheel (BCW); Normalisation Process Theory (NPT)]. Logic model Using Medical Research Council guidance, the behavioural analysis was used to develop the logic model – describing the problem, intervention targets/ingredients to resolve the problem, mechanisms of action, and outcomes. Qualitative research: think-aloud interviews with cancer survivors Think-aloud interviews were conducted with 32 cancer survivors. Positive and negative comments were then collated, modifications made, and further rounds of interviews conducted with the modified versions of the prototype until no important further changes were required. Qualitative research: focus groups with National Health Service and cancer charity staff and volunteers Seven focus groups were carried out with staff from five general practitioner practices, staff and volunteers from two cancer charities, addressing support and training materials, and the integration of the intervention in everyday practice. Modifications were made and further rounds of focus groups were organised until no further improvements were identified. Main trial Participants For the main trial, people who had finished primary treatment for colorectal, breast or prostate cancer up to 10 years previously, reporting suboptimal quality of life [European Organization for Research and Treatment of Cancer QLQ-C30 (EORTCQLQ-C30) score < 85]. Interventions Participants were randomised to one of three groups: (1) ‘Generic’ advice: detailed digital NHS support for healthier living (‘Living Well’), (2) a bespoke digital intervention (‘Renewed’) addressing symptom management, physical activity, diet, weight loss, distress management and/or fear of recurrence, or (3) ‘Renewed’ with additional brief support by e-mail, telephone, and face to face. Automated randomisation with stratification was implemented using LifeGuide software (www.lifeguideonline.org) with a 1 : 1 allocation ratio stratified by: cancer type: breast/prostate/colorectal and EORTCQLQ-C30 score (64 or less/65 or more). Main outcome measures Primary outcome: EORTCQLQ-C30 (overall score). Secondary outcomes: subscales of EORTCQLQ-C30 (global self-rated health; functional subscales; symptom subscales), psychological measures, quality of life measured by EuroQol-5 Dimensions, five-level version (EQ-5D-5L) and costs. Main statistical analysis All participant data were analysed on an intention-to-treat basis, that is, as randomised. The primary analysis used imputed data, employing a chained equation multiple imputation model for missing data. A complete-case analysis was a sensitivity analysis. Generalised linear mixed regression models were used for continuous variables, controlling for baseline and stratification variables, including a random effect for practice. Pre-planned subgroup analyses were set out in the statistical analysis plan for age, gender and comorbidities. We also performed post hoc within-group analyses documenting the changes from baseline. Health economic analysis Cost per quality-adjusted life-year (QALY) was estimated. The base case took an NHS perspective using primary care consultation and medication costs, but with sensitivity analyses including secondary care costs. Resource use data were collected by a medical record review in primary care. Unit costs of primary care consultation, community services, outpatient visits and accident and emergency attendances were costed based on the Personal Social Services Research Unit. National reference costs were used to cost hospital stay based on corresponding diagnostic categories. Medications were priced based on the British National Formulary. All costs were based on 2019 prices. QALYs were estimated using the EQ-5D-5L and were based on the recommended national tariff. Process analyses Qualitative analysis Forty-two patients were interviewed to explore their experiences of using the Renewed intervention and to understand the potential barriers and facilitators to using Renewed. Quantitative analysis Patients were included if they completed the 12-month follow-up measures and were classified according to how much of the intervention was accessed, and this was then related to the impact on outcomes. Results Intervention development Rapid review The database search identified 6327 papers, and 16 relevant papers relating to 9 interventions fulfilled eligibility criteria. Identified themes addressed aspects of intervention design (participant factors, characteristics of the online intervention, techniques used to change behaviour and preferred features of web-based interventions), including issues of uptake, adherence and attrition, engagement, feasibility, efficacy, positive behaviour change and acceptability of the interventions. Scoping review Facilitators and barriers were grouped according to key characteristics, including factors influencing participation; information included in the intervention; motivation/self-esteem/self-efficacy; self management/monitoring; emotions/mood; social support; intervention design/content; technical aspects and various practical issues. Guiding principles Target users did not see themselves as having health needs, so the content promoted well-being, rather than illness management. Cancer survivors felt that their usual behaviour in part caused their cancer, so suggestions for behavioural change did not stigmatise users’ current behaviour. Target users form a heterogeneous group; hence the intervention provided tailored information to each user, based on answers to baseline questions. Participants wanted brief accessible information; hence short sessions on specific topics were provided and the intervention targeted behaviours which had the potential to improve multiple symptoms. Behavioural analysis Three target behaviours were identified (physical activity, diet and intervention engagement) and specific intervention components included to minimise barriers to each, mapped to elements of the BCTv1, BCW and NPT theoretical frameworks. Qualitative research: think-aloud interview with cancer survivors Participants found the intervention to be generally easy to navigate and the content being relevant and useful. Negative comments described barriers to engagement which resulted in modifications to the prototype; for example some were worried about overdoing physical activity, so changes emphasised that increasing physical activity should be done gradually. Qualitative research: focus groups with National Health Service and cancer charity staff and volunteers Several concerns were raised which led to further modifications; for example some questioned the use of the Congratulate, Ask, Reassure, Encourage approach, so additional information about how to provide support with patients who had not achieved their goals was added. Main trial At the primary time point of 6 months, there were clinically important improvements in EORTCQLQ-C30 score contrary to the expected trajectory of quality of life in this population, but with no evidence of differences between groups. By 12 months, the Renewed plus support group continued to improve and was better than generic advice (1.42, 95% confidence intervals 0.33 to 2.51), with the largest differences in the prostate cancer subgroup. Thirteen of the 14 functional and symptom subscales also improved compared to generic advice, statistically significant for self-rated global health (Renewed: 3.06, 1.39 to 4.74; Renewed plus support: 2.78, 1.08 to 4.48), dyspnoea, constipation and enablement. For Renewed plus support, there were also significant differences for physical, cognitive and emotional functioning and fatigue. Renewed and Renewed plus support demonstrated little or no change in QALY estimates using the EQ-5D-5L, but were dominant – with both a range of better health outcomes while incurring lower mean NHS primary care costs per patient (respectively −£141, −153 to −128; −£77, −90 to −65). Process analyses Qualitative process study The results showed that even limited usage of Renewed Online may provide enough information to motivate behaviour change in those with less need for more tailored support. Novel information may need to be presented earlier in the intervention to motivate further engagement with Renewed in those who need more detailed and tailored information to make behaviour changes. Quantitative process analysis The majority of patients accessed the Core content of Renewed and completed the Core content. Approximately half of participants continued to use Renewed past the Homepage to access the Optional content. Those who used Optional content had higher quality of life (QoL) scores compared to those who only accessed the Core content. Conclusions Cancer survivors with lower quality of life given detailed generic online support improve significantly. Providing robustly developed, low cost, bespoke digital support can provide further modest long-term improvements in enablement, symptom management, and self-rated global health, with substantially lower primary care NHS costs. Implications for health care The current study provides reasonable evidence that a novel bespoke intervention to support cancer survivors could be integrated into current practice since there are both some longer-term benefits combined with lower costs to the NHS. However, all trial participants by definition had to engage with the trial and trial procedures, and so may not represent the wider patient population, and all were followed up with questionnaires and with phone calls where questionnaires were not returned. This could be mimicked in routine practice by brief follow-up contacts, which could be assessed in a larger implementation study. Recommendations for research The cost-effectiveness and benefits for symptom management self-rated health for both Renewed interventions suggest that an implementation study is the next step, including further assessment of the impact in different socio-economic groups and cancer types. To consider using and/or developing more sensitive primary outcome measures among cancer survivors, particularly for briefer, low resource interventions – since the overall EORTCQLQ-C30 summary score is not sensitive to change, in contrast to both symptom subscales and self-rating of health. To develop QALY measures that capture the benefit to QoL for low intensity, low resource interventions among cancer survivors given that neither the EQ-5D-5L or the EORTC-8d reflected important changes in patients’ self-rating of health. Further work is indicated to explore why people with some cancers may not be as willing to use the intervention as others and exploration of the key barriers for those from ethnic minority backgrounds to take part. Trial registration This trial is registered as Current Controlled Trials ISRCTN 96374224. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-0514-20001) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 4. See the NIHR Funding and Awards website for further award information.

IntroductionLow quality of life is common in cancer survivors. Increasing physical activity, improving diet, supporting psychological well-being and weight loss can improve quality of life in several cancers and may limit relapse. The aim of the randomised controlled trial outlined in this protocol is to examine whether a digital intervention (Renewed), with or without human support, can improve quality of life in cancer survivors. Renewed provides support for increasing physical activity, managing difficult emotions, eating a healthier diet and weight management.Methods and analysisA randomised controlled trial is being conducted comparing usual care, access to Renewed or access to Renewed with brief human support. Cancer survivors who have had colorectal, breast or prostate cancer will be identified and invited through general practice searches and mail-outs. Participants are asked to complete baseline measures immediately after screening and will then be randomised to a study group; this is all completed on the Renewed website. The primary outcome is quality of life measured by the European Organization for Research and Treatment of Cancer QLQ-c30. Secondary outcomes include anxiety and depression, fear of cancer recurrence, general well-being, enablement and items relating to costs for a health economics analysis. Process measures include perceptions of human support, intervention usage and satisfaction, and adherence to behavioural changes. Qualitative process evaluations will be conducted with patients and healthcare staff providing support.Ethics and disseminationThe trial has been approved by the NHS Research Ethics Committee (Reference 18/NW/0013). The results of this trial will be published in peer-reviewed journals and through conference presentations.Trial registration numberISRCTN96374224; Pre-results.

Workplaces are potentially effective settings for promoting mental health. Changes to working styles from the pandemic offer opportunities for organizations to rethink traditional approaches to improve mental health in the workplaces. This includes digital health platforms with the capability to deliver information, resources and interventions at scale across the mental health continuum. This study explored the desired features of a workplace mental health app and potential drivers or barriers to adoption. Twenty-three participants aged 21–63 years working in Singapore were recruited for semi-structured interviews. A reflexive thematic analysis was used to extract constructs and themes from the data. Participants felt mental health apps increased accessibility to mental health services and reduced stigma towards help-seeking. Participants desired self-help features like educational content, reminders, social features like gamified challenges and online communities. Potential drivers of app adoption include incentives, timely and relevant campaigns, good user experience and the ability to integrate with existing platforms that users were familiar with. Potential barriers included data privacy and cost. Some participants preferred alternative coping strategies like social media over using mental health apps. Mental health apps could play a role in workplace mental health promotion. Self-help and social features are key elements desired by participants. Organizations could provide incentives and a good user experience for employees to promote app adoption while communicating transparency on data privacy policies.

Physical inactivity among university students is a prevalent global health concern with long-term implications. Emerging technologies, such as wearable devices and AI-driven chatbots, offer promising avenues to promote physical activity (PA). However, empirical studies assessing the engagement, usability, and efficacy of next-generation large language model-based AI chatbots remain limited. This study aimed to evaluate the engagement, usability, and efficacy of an AI Coach intervention, based on the Doubao large language model, in enhancing PA levels among university students in China. A parallel-group quasi-randomized controlled trial was conducted over 8 weeks with 60 eligible university student participants (intervention group, n=30; control group, n=30). The intervention group used both their wearable devices and the AI Coach delivered via WeChat, while the control group used wearable devices only. Outcome measures included system-recorded interaction metrics to assess engagement, the System Usability Scale (SUS) and user experience questionnaires for usability, and changes in average daily step counts and weekly moderate-to-vigorous physical activity (MVPA) duration for efficacy. Data were analyzed using mixed-design ANOVA and appropriate non-parametric tests. Participants engaged actively with the AI Coach, exchanging an average of 17.20 conversation rounds (SD = 8.72), with 60.27% of conversations initiated by participants. The average conversation duration was approximately 3 minutes. The mean SUS score was 85.75 (SD = 3.99), indicating excellent usability. Compared to the control group, the intervention group showed significant increases in average daily steps (mean increase 557 steps; p < 0.001) and weekly MVPA duration (mean increase 8.73 minutes; p < 0.001). No adverse events were reported. The Doubao-based AI Coach is a safe, practical, and efficacious tool to enhance PA among university students. Its high engagement and usability suggest potential for scalable digital health interventions. This study highlights the value of combining AI chatbots with wearable devices to deliver personalized, real-time coaching. Future research should focus on automating data collection, expanding to diverse populations, and exploring user experiences to improve the intervention’s effectiveness and broader public health impact. Ethical approval was obtained from the Research Ethics Committee of Jiangxi University of Technology (JXUT.TNC2/JXUTREC2409).

BACKGROUND:Physical inactivity is rising globally, exacerbating the burden of preventable deaths and diseases. Despite extensive research on promoting physical activity in the workplace, synthesising the existing literature is challenging due to the wide variety of interventions and outcomes. This study aims to provide a comprehensive synthesis of intervention effects to inform health promotion initiatives and guide future research efforts. METHODS:In this umbrella review, we conducted systematic searches of six databases (Cochrane, MEDLINE, Embase, CINAHL, Scopus, and Web of Science) for systematic reviews and meta-analyses published between Jan 1, 2000, and May 31, 2024, evaluating workplace interventions targeting sedentary behaviour or physical activity in working adults aged 18 years and older without specific health conditions or mobility impairments. Outcomes encompassed any behavioural changes related to sedentary behaviour or physical activity. Evidence for each relevant combination of intervention and outcome categories was summarised using either meta-analysis or narrative synthesis, with primary study data extracted as needed. This study is registered with PROSPERO, CRD42020171774. FINDINGS:We included 36 systematic reviews and meta-analyses covering 214 unique primary studies. Despite considerable heterogeneity in the evidence, several effect trends emerged with moderate-to-high confidence. First, sit-to-stand workstations produced the largest reductions in sedentary time, decreasing it by up to 75 min per day (95% CI -109 to -41) when used alone, with reductions increasing by up to 33% when paired with psychosocial strategies. However, these interventions did not significantly increase physical activity at any intensity. Second, self-monitoring combined with psychosocial strategies yielded the largest increases in step count, with average gains of 1056 steps per day (371 to 1740). Third, no specific strategy consistently increased moderate-to-vigorous physical activity, although the available evidence remains sparse. Additional trends were observed but with lower confidence levels. Analysis of publication bias suggested an inflated effect of environmental-level interventions on occupational sedentary time. Adjusting for this bias using the trim-and-fill method only slightly reduced the effect size, but this result should be interpreted with caution due to high heterogeneity (I2=84·80%). INTERPRETATION:Current evidence highlights the modest effect of existing workplace interventions on physical activity. Some strategies, such as sit-to-stand workstations and gamified interventions, effectively reduce sedentary behaviour and encourage lighter forms of physical activity, but none consistently improves moderate-to-vigorous physical activity, which provides the greatest health benefits. With many countries falling short of the WHO target to reduce physical inactivity prevalence by 15% from 2010 levels by 2030, intensified efforts are needed to address this gap, meet global goals, and alleviate the health burden of physical inactivity. FUNDING:None.

Despite the necessary focus on clinical skills and knowledge during the tertiary education of healthcare professionals, the literature highlights the importance of developing psycho-social competencies. Empathy, a cognitive-behavioral attribute linked to various benefits for patients and healthcare professionals, is one such competency. Pedagogical approaches to successfully develop empathy in tertiary healthcare students are available. However, these approaches are often integrated piecemeal throughout the tertiary education journey. Research on a more empathy-focused curriculum is scarce. This manuscript describes the design of a study that aims to examine the effects of a more empathy-focused curriculum on empathy in tertiary healthcare profession students in Singapore. Freshmen dentistry, medicine, nursing, and pharmacy students enrolled in a novel curriculum with a strong empathy focus will be recruited for the study and followed for the program’s extent. Mixed-methods data collection at various time points will be conducted. Quantitative data will be collected on cognitive-behavioral empathy, intentions to provide empathic care, and engagement in courses of the curriculum. Qualitative data on perceptions of patient care and empathy in relation to relevant courses of the curriculum will be collected to provide context for quantitative findings. Ethics approval was granted by the Departmental Ethics Review Committee of the Saw Swee Hock School of Public Health, National University of Singapore (Ethics ID: SSHSPH-214).

Background:Integration of mobile health data collection methods into cohort studies enables the collection of intensive longitudinal information, which gives deeper insights into individuals' health and lifestyle behavioral patterns over time, as compared to traditional cohort methods with less frequent data collection. These findings can then fill the gaps that remain in understanding how various lifestyle behaviors interact as students graduate from university and seek employment (student-to-work life transition), where the inability to adapt quickly to a changing environment greatly affects the mental well-being of young adults. Objective:This paper aims to provide an overview of the study methodology and baseline characteristics of participants in Health@NUS, a longitudinal study leveraging mobile health to examine the trajectories of health behaviors, physical health, and well-being, and their diverse determinants, for young adults during the student-to-work life transition. Methods:University students were recruited between August 2020 and June 2022 in Singapore. Participants would complete biometric assessments and questionnaires at 3 time points (baseline, 12-, and 24-month follow-up visits) and use a Fitbit smartwatch and smartphone app to continuously collect physical activity, sedentary behavior, sleep, and dietary data over the 2 years. Additionally, up to 12 two-week-long bursts of app-based ecological momentary surveys capturing lifestyle behaviors and well-being would be sent out among the 3 time points. Results:Interested participants (n=1556) were screened for eligibility, and 776 participants were enrolled in the study between August 2020 and June 2022. Participants were mostly female (441/776, 56.8%), of Chinese ethnicity (741/776, 92%), undergraduate students (759/776, 97.8%), and had a mean BMI of 21.9 (SD 3.3) kg/m(2), and a mean age of 22.7 (SD 1.7) years. A substantial proportion were overweight (202/776, 26.1%) or obese (42/776, 5.4%), had indicated poor mental well-being (World Health Organization-5 Well-Being Index <= 50; 291/776, 37.7%), or were at higher risk for psychological distress (Kessler Psychological Distress Scale >= 13; 109/776, 14.1%). Conclusions:The findings from this study will provide detailed insights into the determinants and trajectories of health behaviors, health, and well-being during the student-to-work life transition experienced by young adults. Trial Registration:ClinicalTrials.gov NCT05154227; https://clinicaltrials.gov/study/NCT05154227 International Registered Report Identifier (IRRID):DERR1-10.2196/56749

Unhealthy food marketing is contributing to the obesity epidemic, but real-time insights into the mechanisms of this relationship are under -studied. Digital marketing is growing and following food and beverage (F &B) brands on social media is common, but measurement of exposure and impact of such marketing presents novel challenges. Thus, this study aimed to evaluate the feasibility of collecting data on exposure and impact of digital F &B marketing (DFM) using a smartphone-based ecological momentary assessment (EMA) methodology. We hypothesized that DFM-induced food cravings would vary based on whether (or not) participants engaged with F &B brands online. Participants were Singapore residents (n = 95, 21 -40 years), recruited via telephone from an existing cohort. Participants were asked to upload screenshots of all sightings of online F &B marketing messages for seven days, and answer in -app contextual questions about sightings including whether any cravings were induced. Participants provided a total of 1310 uploads (median 9 per participant, Q1 -Q3: 4 -21) of F &B marketing messages, 27% of which were provided on Day 1, significantly more than on other days (P < 0.001). Followers of food/beverage brands on social media encountered 25.6 percentage points (95% CI 11.4, 39.7) more marketing messages that induced cravings than participants who were not followers. University education was also associated with more (18.1 percentage points; 95% CI 3.1, 33.1) encounters with marketing messages that induced cravings. It was practical and acceptable to participants to gather insights into digital F &B marketing exposure and impact using EMA in young adults, although a shorter study period is recommended in future studies. Followers of food and beverage brands on social media appear to be more prone to experience cravings after exposure to digital F &B marketing.

Background Integration of mobile health data collection methods into cohort studies enables the collection of intensive longitudinal information, which gives deeper insights into individuals’ health and lifestyle behavioral patterns over time, as compared to traditional cohort methods with less frequent data collection. These findings can then fill the gaps that remain in understanding how various lifestyle behaviors interact as students graduate from university and seek employment (student-to-work life transition), where the inability to adapt quickly to a changing environment greatly affects the mental well-being of young adults. Objective This paper aims to provide an overview of the study methodology and baseline characteristics of participants in Health@NUS, a longitudinal study leveraging mobile health to examine the trajectories of health behaviors, physical health, and well-being, and their diverse determinants, for young adults during the student-to-work life transition. Methods University students were recruited between August 2020 and June 2022 in Singapore. Participants would complete biometric assessments and questionnaires at 3 time points (baseline, 12-, and 24-month follow-up visits) and use a Fitbit smartwatch and smartphone app to continuously collect physical activity, sedentary behavior, sleep, and dietary data over the 2 years. Additionally, up to 12 two-week-long bursts of app-based ecological momentary surveys capturing lifestyle behaviors and well-being would be sent out among the 3 time points. Results Interested participants (n=1556) were screened for eligibility, and 776 participants were enrolled in the study between August 2020 and June 2022. Participants were mostly female (441/776, 56.8%), of Chinese ethnicity (741/776, 92%), undergraduate students (759/776, 97.8%), and had a mean BMI of 21.9 (SD 3.3) kg/m2, and a mean age of 22.7 (SD 1.7) years. A substantial proportion were overweight (202/776, 26.1%) or obese (42/776, 5.4%), had indicated poor mental well-being (World Health Organization-5 Well-Being Index ≤50; 291/776, 37.7%), or were at higher risk for psychological distress (Kessler Psychological Distress Scale ≥13; 109/776, 14.1%). Conclusions The findings from this study will provide detailed insights into the determinants and trajectories of health behaviors, health, and well-being during the student-to-work life transition experienced by young adults. Trial Registration ClinicalTrials.gov NCT05154227; https://clinicaltrials.gov/study/NCT05154227 International Registered Report Identifier (IRRID) DERR1-10.2196/56749

Singapore, located strategically at the meeting point of the Malacca Strait and the South China Sea, has established itself as a global financial and economic hub. Despite its small geographical size, Singapore is home to over 5 million people from diverse cultural backgrounds. The city-state's medical education landscape has evolved significantly over the past century. Originally, Singapore had only one undergraduate medical school, the NUS Yong Loo Lin School of Medicine, established in 1905. Over time, this institution has grown into Singapore's largest and oldest medical school. NUS Medicine's vision centres on developing highly competent, values-driven, and inspired healthcare professionals to transform the practice of medicine and improve health worldwide. A curriculum overhaul in 2020 introduced new educational components to prepare future healthcare professionals for the challenges of Singapore's resilient healthcare system. This includes proficiency in integrated care, collaboration across disciplines, and leveraging AI and data science in clinical decision-making. The introduction of a common curriculum in August 2023 for Medicine, Nursing, Dentistry, and Pharmacy undergraduates further aligns with Singapore's 'Healthier SG' vision, ensuring that graduates are well-equipped to meet the evolving needs of the healthcare landscape. The common curriculum aims to address professional hierarchies and foster interprofessional collaboration among students from diverse academic backgrounds. By promoting frequent interaction and a team-oriented mindset, the curriculum seeks to instil a collective approach to healthcare, emphasising the importance of interprofessional practice in achieving the broader goals of healthcare delivery. This paper describes the reforms that took place and how the challenges were mitigated in a research-intensive top-ranked academic medical institution. This strategic alignment of medical education with national healthcare priorities underscores NUS Medicine's commitment to transforming medical practice and improving health outcomes in Singapore and beyond.

Massive Open Online Courses (MOOCs) are a primary mode of scaled-up online learning. They have enjoyed great popularity which grew significantly during the Covid-19 pandemic. Despite the growing demand for MOOCs and the desire of institutions to develop high-quality courses, research indicates that the educational impact of MOOCs is limited. Low instructional design quality has been cited as a culprit for the failure of MOOCs to support learning and skill development, prompting calls for a more thorough design of MOOCs. The aims of our work are to describe the systematic development of guiding principles that informed instructional design decisions for our MOOC on health behaviors, and to showcase how these principles were implemented in practice. Through triangulation of various sources of evidence on anticipated learners and the MOOC learning environment, we identified four key aspects we needed to address with our instructional design to facilitate learning. We formulated guiding principles that both addressed these aspects and served as a reference point during instructional design. Our approach to making instructional design decisions can serve as a practical blueprint for other MOOC developers.

Background: While it has been established that physical activity (PA) is key to promote overall health and well-being, insufficient physical activity among children and adolescents is a global problem, including Singapore. It is important to understand the local PA landscape among children and adolescents to decrease surveillance gaps and identify areas for improvement in promoting PA. The present article provides an overview of the development of the 2022 Active Healthy Kids Singapore Report Card and the results, as well as underscore limitations and gaps in the available evidence related to PA among children and adolescents in Singapore. Methods: Following the Global Matrix 4.0, the available data between July 2010 to July 2020 was synthesized for all 10 indicators by the work group and reviewed by a panel of experts. Data sources included published scientific articles, government and non-government reports, national surveys, and unpublished data from on-going research studies. Where possible, grades were informed by nationally representative surveys or large-scale longitudinal studies. Results: The grades assigned were: Overall Physical Activity (C-), Organized Sport and Physical Activity (B-), Active Play (C-), Active Transportation (C), Sedentary Behaviours (C-), Physical Fitness (Incomplete), Family and Peers (C-), School (Incomplete), Community and Environment (A+), Government (B). Conclusion: This is the first comprehensive evaluation of PA among children and adolescents in Singapore. It provides baseline grades valuable for future comparison. It also illustrates gaps in the existing evidence which can inform future surveillance, facilitate international comparisons and enable global efforts in promoting physical activity. (c) 2022 The Society of Chinese Scholars on Exercise Physiology and Fitness. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Sedentary behaviour and physical inactivity increase the risks of non-communicable diseases. Rapid industrialisation and urbanisation have resulted in more sedentary occupations, increasing the number of those suffering from the diseases. This paper describes the two main phases:1) prototype development and 2) feasibility of the process of complex, i.e., multi-component intervention development for the Physical Activity at Work (PAW) – a cluster-randomised trial with 6-month active multi-component intervention to reduce sedentary behaviour and increase physical activity in Thai office workers. The prototypedevelopment phase aimed to review existing theories and frameworks to synthesise the prototype intervention and conducted semi-structured interviews to understand office workers’ attitudes towards overall and occupational physical activity as well as sedentary behaviour. The feasibility phase aimed to implement a 2-week prototype intervention and conducted semi-structured interviews to investigate the attitude towards the intervention. The multi-component intervention was developed based on the Socio-Ecological Model framework, including 1) individual-level: a wearable activity tracker and lottery-based incentives, 2) societal-level: team movement break and team-based incentives, 3) environmental-level: posters with education on sedentary behaviours and how to perform movement breaks, and 4) organisational-level: leaders’ encouragement messages. Behaviour Change Techniques were used to mediate the effect of each component. Refinements were made throughout the intervention development process, guided by the results from each step. These processes inform other development of similar interventions for a large-scale study aiming at multifaceted behavioural change. Trial registration: The PAW study was registered at the Thai Clinical Trials Registry (Registration number: ID TCTR20200604007) on 02 June 2020 (02/06/2020).

Background : Smartphones and wrist-worn activity trackers are increasingly popular for step counting purposes and physical activity promotion. Although trackers from popular brands have frequently been validated, the accuracy of low-cost devices under free-living conditions has not been adequately determined. Objective : To investigate the criterion validity of smartphones and low-cost wrist-worn activity trackers under free-living conditions. Methods : Participants wore a waist-worn Yamax pedometer and seven different low-cost wrist-worn activity trackers continuously over 3 days, and an activity log was completed at the end of each day. At the end of the study, the number of step counts reflected on the participants’ smartphone for each of the 3 days was also recorded. To establish criterion validity, step counts from smartphones and activity trackers were compared with the pedometers using Pearson’s correlation coefficient, mean absolute percentage error, and intraclass correlation coefficient. Results : Five of the seven activity trackers underestimated step counts and the remaining two and the smartphones overestimated step counts. Criterion validity was consistently higher for the activity trackers ( r = .78–.92; mean absolute percentage error 14.5%–36.1%; intraclass correlation coefficient: .51–.91) than the smartphone ( r = .37; mean absolute percentage error 55.7%; intraclass correlation coefficient: .36). Stratified analysis showed better validity of smartphones among female than for male participants. Phone wearing location also affected accuracy. Conclusions : Low-cost trackers demonstrated high accuracy in recording step counts and can be considered with confidence for research purposes or large-scale health promotion programs. The accuracy of using a smartphone for measuring step counts was substantially lower. Factors such as phone wear location and gender should also be considered when using smartphones to track step counts.

The objective of this study was to assess the perceptions as well as to explore the facilitators and barriers to the regular use of self-reflection as a pedagogical tool by teachers in public health education during COVID-19. We used a mixed methods approach, comprising a cross-sectional survey followed by in-depth interviews. Quantitative findings revealed that there was a significantly greater proportion of regular users of self-reflection who knew how to incorporate self-reflection elements in their teaching than the infrequent users. Qualitative findings revealed that a recurring reason for using self-reflection in teaching was to better understand students, given the online classroom environment during COVID-19. Teachers expressed the need for support to sustain the regular use of reflection in teaching. Facilitating factors could be external or internal to the teacher. For external factors, a recurring subtheme was institutional support, indicating that teachers expected support (or at least no objections) from their organisation. For internal factors, perceived positive impacts on students was identified as a recurring subtheme. Several barriers to the regular use of reflection were described. These included external factors such as the lack of peer sharing, as well as internal factors such as the prioritisation of other contents to teach.