title: Primary care characteristics and their association with health screening in a low-socioeconomic status public rental-flat population in Singapore- a mixed methods study.
abstract: BACKGROUND
  In Singapore, subsidized primary care is provided by centralized polyclinics; since 2000, policies have allowed lower-income Singaporeans to utilize subsidies at private general-practitioner (GP) clinics. We sought to determine whether proximity to primary care, subsidised primary care, or having regular primary care associated with health screening participation in a low socioeconomic-status public rental-flat community in Singapore.
  
  
  METHODS
  From 2009-2014, residents in five public rental-flat enclaves (N = 936) and neighboring owner-occupied precincts (N = 1060) were assessed for participation in cardiovascular and cancer screening. We then evaluated whether proximity to primary care, subsidised primary care, or having regular primary care associated with improved adherence to health screening. We also investigated attitudes to health screening using qualitative methodology.
  
  
  RESULTS
  In the rental flat population, for cardiovascular screening, regular primary care was independently associated with regular diabetes screening (adjusted odds ratio, aOR = 1.59, CI = 1.12-2.26, p = 0.009) and hyperlipidemia screening (aOR = 1.82, CI = 1.10-3.04, p = 0.023). In the owner-occupied flats, regular primary care was independently associated with regular hypertension screening (aOR = 9.34 (1.82-47.85, p = 0.007), while subsidized primary care was associated with regular diabetes screening (aOR = 2.94, CI = 1.04-8.31, p = 0.042). For cancer screening, in the rental flat population, proximity to primary care was associated with less participation in regular colorectal cancer screening (aOR = 0.42, CI = 0.17-0.99, p = 0.049) and breast cancer screening (aOR = 0.29, CI = 0.10-0.84, p = 0.023). In the owner-occupied flat population, for gynecological cancer screening, usage of subsidized primary care and proximity to primary care was associated with higher rates of breast cancer and cervical cancer screening; however, being on regular primary care followup was associated with lower rates of mammography (aOR = 0.10, CI = 0.01-0.75, p = 0.025). On qualitative analysis, patients were discouraged from screening by distrust in the doctor-patient relationship; for cancer screening in particular, patients were discouraged by potential embarrassment.
  
  
  CONCLUSIONS
  Regular primary care was independently associated with regular participation in cardiovascular screening in both low-SES and higher-SES communities. However, for cancer screening, in the low-SES community, proximity to primary care was associated with less participation in regular screening, while in the higher-SES community, regular primary care was associated with lower screening participation; possibly due to embarrassment regarding screening modalities.
authors: Singhealth Internal Medicine, Singapore General Hospital, Singapore, Singapore. weeliangen@gmail.com.
authors: Liang En
authors: LE
authors: Wee
authors: Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore. wenqi94@yahoo.com.
authors: Wen Qi
authors: WQ
authors: Cher
authors: Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore. davidsin.ye@gmail.com.
authors: David
authors: D
authors: Sin
authors: Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore. lizongchen27@hotmail.com.
authors: Zong Chen
authors: ZC
authors: Li
authors: Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, #10-03-G, Tahir Foundation Building, Block MD1, 12 Science Drive 2, Singapore, Singapore. Gerald_Koh@nuhs.edu.sg.
authors: Gerald Choon-Huat
authors: GC
authors: Koh
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000175:diagnosis; D002318:Cardiovascular Diseases / Q000175:diagnosis*; D015179:Colorectal Neoplasms / Q000175:diagnosis; D003920:Diabetes Mellitus / Q000175:diagnosis*; D055088:Early Detection of Cancer / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006798:Housing; D006801:Humans; D006973:Hypertension / Q000175:diagnosis; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis*; D016017:Odds Ratio; D011203:Poverty / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011638:Public Housing; D012846:Singapore; D012923:Social Class; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis