a systematic review of health status, health seeking behaviour … · 2018-04-02 · review open...

Chan et al. International Journal for Equity in Health (2018) 17:39 https://doi.org/10.1186/s12939-018-0751-y

REVIEW Open Access

A systematic review of health status, healthseeking behaviour and healthcareutilisation of low socioeconomic statuspopulations in urban Singapore
Catherine Qiu Hua Chan1,2*, Kheng Hock Lee1,2,3 and Lian Leng Low1,2,3*
Abstract

Introduction: It is well-established that low socioeconomic status (SES) influences one’s health status, morbidityand mortality. Housing type has been used as an indicator of SES and social determinant of health in some studies.In Singapore, home ownership is among the highest in the world. Citizens who have no other housing options areoffered heavily subsidised rental housings. Residents staying in such rental housings are characterised by lowsocioeconomic status. Our aim is to review studies on the association between staying in public rental housing inSingapore and health status.

Methods: A PubMed and Scopus search was conducted in January 2017 to identify suitable articles published from1 January 2000 to 31 January 2017. Only studies that were done on Singapore public rental housing communitieswere included for review. A total of 14 articles including 4 prospective studies, 8 cross-sectional studies and 2retrospective cohort studies were obtained for the review. Topics addressed by these studies included: (1) Healthstatus; (2) Health seeking behaviour; (3) Healthcare utilisation.

Results: Staying in public rental housing was found to be associated with poorer health status and outcomes. Theyhad lower participation in health screening, preferred alternative medicine practitioners to western-trained doctorsfor primary care, and had increased hospital utilisation. Several studies performed qualitative interviews to explorethe causes of disparity and concern about cost was one of the common cited reason.

Conclusion: Staying in public rental housing appears to be a risk marker of poorer health and this may haveimportant public health implications. Understanding the causes of disparity will require more qualitative studieswhich in turn will guide interventions and the evaluation of their effectiveness in improving health outcome of thissub-population of patients.

Keywords: Public rental housing, Low socioeconomic, Health status, Singapore

BackgroundSingapore is an urbanised Asian society with high cost ofliving. In a world-wide survey on the cost of living,Singapore emerged as the most expensive city to live in[1]. The affordability of housing is a major area of con-cern. In a survey of voters, cost of living and affordability

* Correspondence: [email protected];[email protected] of Family Medicine & Continuing Care, Singapore GeneralHospital, Singapore, SingaporeFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This articInternational License (http://creativecommonsreproduction in any medium, provided you gthe Creative Commons license, and indicate if(http://creativecommons.org/publicdomain/ze

of housing was among the top 3 issues that people worryabout most. Income disparity in the country is high with aGINI Co-efficient of 0.458 in 2016 [2]. Even then, this wasthe lowest level in a decade after concerted governmentefforts to reverse a widening trend. At the same time,Singapore’s population is ageing rapidly, and 1 in 5 per-sons will be over 65 years old by the year 2030 [3].Increased healthcare spending is anticipated and Singa-pore’s healthcare costs is expected to rise nearly tenfoldover the next 15 years. With high levels of income dispar-ity, increasing healthcare cost and a decreasing old-age

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Chan et al. International Journal for Equity in Health (2018) 17:39 of 21

support ratio, elderly persons with poor social support areat the highest risk of having poor health outcomes. Theseat-risk seniors are most likely to reside in public rentalhousing which are heavily subsidised by the Singaporegovernment.It is well-established that low socioeconomic status

(SES) influences one’s health, rate of morbidity and mor-tality [4–6]. SES influence health via the interaction be-tween the individual’s socioeconomic characteristics aswell as their area’s socioeconomic conditions [7, 8].Educational level, income status, employment status,

financial assistance requirement are examples ofindividual-level measures of SES. Unfortunately, such in-formation are not routinely collected during healthcareencounters. Hence, using such measures to identify atrisk population may not be practical. On the other hand,housing information such as residency in public rentalhousings are readily available and has been used asan area-level measure of SES. This information iscollected in almost all healthcare encounters and theunique postal codes correspond to individual housesand apartment blocks.Housing has been known to be an important social

determinant of health [9, 10]. In Singapore, housing isnot geographically segregated according to SES, insteadthere is a mixture of public rental housing together withowner-occupied public housing within each residentialprecinct. The home ownership rate of resident house-holds in Singapore is among the highest in the world at90.9% [11]. Households that cannot afford to purchasetheir own homes and have no other housing options areoffered heavily subsidized rental housings under thePublic Rental Scheme [12]. Such rental housings formclusters within residential precincts and studying resi-dents in these micro-communities may provide usefulinsights on the impact of low socioeconomic status onhealth, within a relatively affluent society.Using residency in public rental housing as a marker

of low SES, our aim is to review studies on the associ-ation between staying in public rental housing inSingapore (as a low SES community) and health (healthstatus, health seeking behaviour and healthcareutilisation).

MethodsSearch strategyA PubMed and Scopus search was carried out in January2017 to identify potentially relevant articles publishedfrom 1 January 2000 to 31 January 2017. The followingsearch strategy was applied: “Socioeconomic” (MeSHterm) AND “Housing” (MeSH term) AND “Singapore”(MeSH term) AND (“Health status” OR “Health-seekingbehaviour” OR “Healthcare utilisation”). Hand search ofbibliographic references of the shortlisted articles was

also conducted. The search strategy was summarised inthe following flow chart (Fig. 1).

Inclusion and exclusion criteriaTwo authors (C.Q.H Chan and L.L Low) independentlyreviewed the articles for inclusion and exclusion. We in-cluded only reviews, qualitative and experimental quasi-experimental research articles that studied Singaporepublic rental housing communities, were in English andinvestigated residents above 21 years of age. Articleswere included if they contained information on health(health status, health-seeking behaviour, healthcare util-isation and perceptions of health / health services)related to residents staying in public rental housing inSingapore. We excluded editorial, perspective, commen-tary and expert opinion articles and also those that donot study health, or public rental housing residents spe-cifically or are not done in Singapore.

Quality assessmentThe Newcastle-Ottawa Scale (NOS) was used to assessthe quality of the articles. Out of 9 stars, 0–4 star(s)was/were considered low quality; 5–6 stars were consid-ered for fair quality; 7–9 stars were considered goodquality.

ResultsAs shown in Figs. 1, 26 and 24 potentially relevant arti-cles were retrieved through the PubMed and Scopussearches respectively. The abstracts of these articles wereevaluated for relevance to the aims of this review. Arti-cles that were not related to health, or not done specific-ally on public rental housing or not based in Singaporewere excluded. Another 2 articles were identified fromhand search of bibliographic references of the shortlistedarticles. A total of 14 articles which includes 4 prospect-ive studies [13–16], 8 cross-sectional studies [17–24]and 2 retrospective cohort studies [25, 26] were obtainedfor the review. Among these studies, 4 of the articlesincluded qualitative interviews [14, 20, 23, 24]. Effect ofa community interventional program on outcomes wasalso studied in 4 of the articles [13, 15, 16, 22]. Most ofthe prospective studies were done with the comparison ofoutcomes between the rental housing and owner-occupied housing community. Tables 1 and 2 summarisedthe description and results of the 14 articles reviewed.Socio-demographic characteristics of the population

were collected in all the articles. There was a larger pro-portion of elderly living in the rental housing. More thanhalf of them were single and not married. There was analmost equal distribution of both genders. Most of themhad no formal education or only primary school educa-tion [17]. Singapore is a multi-ethnic urbanised Asiansociety, there is an ethnic integration policy in place to

Fig. 1 Flowchart on selection of articles


maintain a good ethnic mix in our public housing estate(Housing Development board, HDB), thereby helping topromote racial integration and harmony. However, therewas a slightly higher percentage of non-Chinese stayingin the rental housing as compared to owner-occupiedhousings [17–19]. Rental housing are heavily subsidisedhousing for those who have low or no household incomeand have no assets. They were mainly elderly,unemployed and on financial aid for healthcare or dailyliving.Among the 14 articles, seven of them mainly covered

the outcome related to one’s health status, five articleson their health seeking behaviour and the last two wereon the healthcare utilization.

Health statusHealth status was being studied in many aspects in thesearticles, ranging from different diseases namely head andneck carcinoma, hypertension, depression, cognitiveimpairment and chronic pain. Different outcomes ofhealth status were examined as well like mortality,prevalence of disease and various association factorswith some of these being compared between the rentalhousing and owner-occupied housing community.There was only one study done to find out if a

patient’s housing type influenced mortality [26]. In those

with head and neck squamous cell carcinoma, it wasfound that those staying in a smaller size, rental housingcommunity (11% of the total patients analysed) hadpoorer survival [median, 28 months, CI 21–48 months]compared to those staying in larger housing sizes [me-dian 42 months, CI 24–65 months] despite no apparentdelays in presentation.We found the prevalence of depression [17] and cogni-

tive impairment [18] to be higher in the rental housingcommunity as compared to the owner-occupied housingcommunity (depression 26.2 vs 14.8% and cognitive im-pairment 26.2 vs 16.1%). Whereas, the prevalence ofhypertension [14] and chronic pain [19] was similarbetween rental housing community and owner-occupiedhousing community (hypertension 63.5 vs 65.0% andchronic pain 13.4 vs 13.0%). The prevalence of hyperten-sion and chronic pain in the studies were actually higherthan the national estimates. Hypertension prevalencerate was 64.2 while estimate from National Health Sur-vey 2010 was 23.5%. Chronic pain prevalence rate was13.4%, as compared to local population-wide estimatesof 8.7%.More than half of the diagnosed hypertension cases

were untreated (53.5%) and uncontrolled (54.2%) despiteon treatment. A 6-month community-based interventionimproved hypertension management but not significantly

Table

1Descriptio

nandtheresults

ofarticlesreview

ed

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Health

status

Won

gTH

(2017)

[26]

Retrospe

ctivecoho

rtFrom

1992

to2014

Survivalof

patientswith

head

andne

cksquamou

scellcarcinom

a(HNSC

C).

Patientswith

HNSC

Cin

NationalC

ancer

Cen

terdatabase.M

ortalityinform

ation

matched

from

Sing

aporeDeath

Registry.

Non

-residen

tswereexclud

edfro

manalysis.

Samplesize

686patientswereanalysed

,84(11%

)of

them

wererentalho

usingreside

nts.

Prim

aryou

tcom

e•All-causemortality:

Patientslivingin

postalcode

swith

aroom

inde

x<3.0*

hadtheworstsurvival[m

edian,

28mon

ths,CI21–48

mon

ths]comparedto

thosestayingin

larger

housingsizes(highe

rroom

inde

x)andow

neroccupied

.Second

aryou

tcom

eDisease

stageat

presen

tatio

n:Patientslivingin

alower

room

inde

xpo

stal

code

wereno

tmorelikelyto

presen

twith

advanced

disease.

*majority

ofreside

ntslived

inrental

housings

with

amon

thlyho

useh

oldincome

<S$1500

Patientswith

HNSC

Clivingin

smaller,

high

er-sub

sidy

housings

have

poorer

sur-

vivald

espite

noapparent

delays

inpresen

tatio

n.

Poor

Wee

LE(2013)

[13]

Prospe

ctive,

Interven

tional

From

2009

to2011

Hypertensionmanagem

ent

andlifestylechange

sfollowingscreen

ingfor

hype

rten

sion

.

Reside

nts>40

y/o.

twopu

blicrentalho

usingprecincts.

Site

A(W

estern

Sing

apore)

andSite

B(Eastern

Sing

apore).

Interven

tion:

6-mon

thcommun

ity-based

interven

tion

comprisingaccess-enh

ancedscreen

ing

compo

nent

andfollow-up(outreach)

compo

nent.

Samplesize

577reside

nts

Participationrate

83.2%

(577/693)

Follow

uprate

(follow

upfor1year)

80.9%

(467/557)

Prevalen

cerate

Baseline:60.4%

(282/467)

Know

nhype

rten

sion

n=179,New

lydiagno

sedn=103

Prim

aryou

tcom

eUntreated

andun

controlledhype

rten

sion

•Baseline:

Know

nhype

rten

sion

andno

ttreatedn=48

Untreated

hype

rten

sion

53.5%

(151/282)

Know

nhype

rten

sion

andtreatedn=131

Uncon

trolledhype

rten

sion

despite

treated

54.2%

(71/131)

•Po

stinterven

tion:

Untreated

hype

rten

sion

48.3%

(73/151)

Startedtreatm

entn=78

Uncon

trolledhype

rten

sion

47.0%

(70/149)

Second

aryou

tcom

eBP

screen

ing

•Baseline:

Nohype

rten

sion

n=185

Did

notscreen

52.4%

(97/185)

•Po

stinterven

tion

Anaccess-enh

ancedinterven

tionhadsome

successin

improvinghype

rten

sion

man-

agem

ent;ho

wever,itwas

less

successful

inim

provingcardiovascular

riskmanagem

ent,

amon

gstne

wlydiagno

sedhype

rten

sivesin

therentalho

usingcommun

ity.

–


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Did

notscreen

31.9%

(57/185)

Reason

forno

tgo

ingforscreen

ingand

startin

gtreatm

ent.

Cost(fo

rtestandfurthe

rtreatm

ent)and

mispe

rcep

tions

werecommon

barriers.

Wee

LE(2012)

[14]

Prospe

ctiveand

Qualitative

From

Jan2009

toJune

2010

Individu

alandne

ighb

our-

hood

socialfactorsof

hype

r-tensionmanagem

ent.

Reside

nts≥40

y/o.

6blocks

ofasociallyintegrated

housing

precinct.

3blocks

publicrentalflatsvs

3blocks

ofow

ner-occupied

publicho

usingflats.(3

vs3)

Locatedin

Taman

Jurong

(Western

Sing

apore).

Samplesize

710reside

nts

Participationrate

78.9%

(710/900)

Rental:90.0%

(359/400)V

SOwne

d:70.2%

(351/500)

Prevalen

cerate

64.2(456/710)

Rental:63.5%

(228/359)V

SOwne

d:65.0%

(228/351)

Follow

uprate:N

APrim

aryou

tcom

e•Awaren

ess

Rental:61.8%

(141/228)V

SOwne

d:83.3%

(190/228)

•Ontreatm

ent

Rental:69.5%

(98/141)

VSOwne

d:85.3%

(162/190)

•BP

unde

rcontrol

Rental:43.9%

(43/98)V

SOwne

d:66%

(107/

162)

Second

aryou

tcom

eInde

pend

entfactorsassociated

with

hype

rten

sion

awaren

ess,treatm

entand

controlinrentalho

using(lower

SES)

commun

ity.

•Awaren

esshigh

eram

ong:

Diabe

tics(adj

OR6.51,C

I2.59–16.37,p<

0.001)

Dyslipidem

ics(adj

OR6.74,C

I2.74–16.59,

p<0.001)

≥60

years(adj

OR3.08,C

I1.61–5.91,p

<0.001)

Regu

laraccess

toado

ctor

(adj

OR5.63,C

I1.43–22.14,p

<0.013).

•Treatm

entmorelikelyam

ong:

≥60

years(adj

OR2.33,C

I1.08–5.01,p

=0.031)

Treatm

entless

likelyam

ong:

Needfinancialaid(adj

OR0.39,C

I0.18–0.83,

p=0.016).

•Con

trolledBP

less

likelyam

ong:

Hypertensionmanagem

ent(awaren

ess,

treatm

entandcontrol)in

thoseof

rental

housingcommun

ity(lower

SES)

ispo

orer

than

inthoseof

owne

roccupied

housing

commun

ity(highe

rSES).

Inrentalho

usingcommun

ity,awaren

ess

was

high

eram

ongthosewith

diabetes,

dyslipidaemia,tho

se≥60

yearsandthose

with

regu

laraccess

todo

ctors.

Treatm

entwas

morelikelyam

ongthose

≥60

years,bu

tless

likelyam

ongthose

need

ingfinancialaid.

Con

trol

was

less

likely

intheem

ployed

.

–


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Employed

(adj

OR0.13,C

I0.04–0.41,p

<0.001).

Qualitativeinterview:

Reason

sforno

tgo

ingon

hype

rten

sive

treatm

entor

participatingin

regu

lar

hype

rten

sion

screen

ing/mon

itorin

gwere

explored

.In

therentalho

usingcommun

ity:

Unkno

wnhype

rten

siveswho

didno

tgo

for

regu

larBP

screen

ingin

thepast1year

(n=

141),the

topthreereason

s:Toobu

syto

go/notim

e.Testingtooexpe

nsive.

Costof

furthe

rtreatm

ent,ifpo

sitive,too

expe

nsive.

Know

nhype

rten

siveswho

wereno

tmon

itorin

gtheirBP

regu

larly

(n=64),the

topthreereason

sweresimilar:

Toobu

syto

go/notim

e.Mon

itorin

gtooexpe

nsive.

Costof

furthe

rtreatm

ent,ifpo

sitive,too

expe

nsive.

Reason

sforno

ttaking

BPmed

ications

≥90%

ofthetim

eam

ongknow

nhype

rten

sives(n

=43):

30.2%

(13/43)d

idno

tthinkthat

the

med

icinewou

ldbe

nefit

them

.25.6%

(22/43)h

adprob

lemswith

thecostof

chronicmed

ication.

11.6%

(5/43)

preferredto

take

non-Western

med

ication.

Financialb

arriersne

edto

beaddressedfor

therentalho

usingcommun

ity.

Wee

LE(2014)

[17]

Cross-sectio

nal

From

Janto

Feb

2012.

Individu

alandarea-level

socio-econ

omicstatus

and

theirassociationwith

depression

.(GDS-15

≥5)

Reside

nts≥60

y/o.

2integrated

publicho

usingprecinct.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(7vs

2)

Samplesize

559reside

nts

Participationrate

61.5%

(559/909)

Site

A:61.3%

(236/385)V

SSite

B:61.6%

(323/524)

Rental:63.7%

(398/625)V

SOwne

d:56.7%,

(161/284)(p

=0.0473)

Prevalen

cerate

22.9%

(128/559)

Rental:26.2%

(104/397)V

SOwne

d:14.8%

(24/164)

Follow

uprate:N

APrim

aryou

tcom

ePrevalen

cerate

asabove.

Residing

inrentalho

usingwas

inde

pend

ently

associated

with

depression

aftercontrolling

forindividu

alSES.

Poor


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Second

aryou

tcom

eLiving

inarentalho

using(lower

SES)

commun

itywas

inde

pend

ently

associated

with

depression

(adj

OR1.68,C

I1.02–2.84,

p=0.049]

Not

beingmarried(adj

OR2.27,C

I1.35–

3.70),falls

(adj

OR2.72,C

I1.59–4.67)and

poorer

socialne

twork(adj

OR3.70,C

I1.96–

7.14)wereassociated

with

depression

.Other

inde

pend

entfactorsassociated

with

depression

inrentalho

usingcommun

ity:

Falls

(adj

OR2.72,C

I1.59–4.67,p

<0.001)

Visualim

pairm

ent(adj

OR2.37,C

I1.28–4.39.

p=0.006)

Wee

LE(2012)

[18]

Cross-sectio

nal

From

Janto

Feb

2012.

Individu

alandarea

Level

socio-econ

omicstatus

and

Itsassociationwith

cogn

i-tivefunctio

nandcogn

itive

impairm

ent.

(MMSE

<24)

Reside

nts≥60

y/o.

2integrated

publicho

usingprecinct.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(7vs

2)

Samplesize

558reside

nts

Participationrate

61.4%

(558/909)

Site

A:61.0%

(235/385)V

SSite

B:61.6%

(323/524)

Rental:63.7%

(397/625)V

SOwne

d:56.7%,

(161/284)(p

=0.0473)

Prevalen

cerate

23.3%

(130/558)

Rental26.2%

(104/397)VS

Owne

d16.1%

(26/261)

New

lydiagno

sedin

rentalho

using:

96.2%

(100/104)

Follow

uprate:N

APrim

aryou

tcom

ePrevalen

cerate

asabove.

Second

aryou

tcom

eLiving

inarentalho

usingcommun

itywas

inde

pend

ently

associated

with

cogn

itive

impairm

ent(adj

OR5.13,C

I1.98–13.34,p=

0.001).

Living

inrentalho

usingisinde

pend

ently

associated

with

cogn

itive

impairm

ent.

Manyof

them

with

cogn

itive

impairm

ent

wereun

diagno

sedprior.

Poor

Wee

LE(2016)

[19]

Cross-sectio

nal

From

2009

to2014

In2012,a

separate

stud

yin

Site

Aand

Site

Bfocusedon

thoseaged

≥60

years

oldwas

cond

ucted.

Chron

icpain

inalow

socio-

econ

omicstatus

popu

latio

n.Reside

nts40–59y/o.

5integrated

publicho

usingprecincts.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(4vs

5)Site

C(Eastern

Sing

apore)

(3vs

5)Site

D(Eastern

Sing

apore)

(2vs

1)

Samplesize

40–59y/o.2037

reside

nts

≥60

y/o.559reside

nts

Participationrate

40–59y/o.Rental:72.0%

(936/1300)

VSOwne

d:61.2%

(1101/1800)

≥60

y/o.Rental:63.7%

(397/625)V

SOwne

d:56.7%

(162/284)

Prevalen

cerate

Therewas

nodifferencein

pain

prevalen

cebe

tweentherentalho

usingcommun

ityandow

ner-occupied

commun

ity.

Inrentalho

usingcommun

ity,chron

icpain

associated

with

unem

ploymen

tand

functio

nallim

itatio

n.

Poor


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Site

E(Cen

tralSing

apore)

(2vs

1)40–59y/o.Rental:14.2%

(133/936)VS

Owne

d:14.4%

(158/1101)

≥60

y/o.Rental:13.4%

(53/397)

VSOwne

d:13.0%

(21/162)

Follow

uprate:N

APrim

aryou

tcom

ePrevalen

cerate

asabove.

Second

aryou

tcom

eIn

therentalho

usingcommun

ity,

unem

ploymen

twas

associated

with

chronic

pain

(adj

OR1.92,95%

,CI1.05–2.78,p

=0.030)

Amon

gtheelde

rly,d

epen

dencyin

instrumen

talactivities

ofdaily

living(iA

DLs)

was

associated

with

chronicpain

(adj

OR

2.38,C

I1.11–5.00,p

=0.025),aswellas

femalege

nder,b

eing

sing

le,and

having

high

ered

ucation(allp>0.05).

Wee

LE(2017)

[20]

Cross-sectio

nal

andQualitative

From

2009

to2014

Health

screen

ing

participationandits

associationwith

chronic

pain.

Reside

nts40–59y/o.

5integrated

publicho

usingprecincts.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(4vs

5)Site

C(Eastern

Sing

apore)

(3vs

5)Site

D(Eastern

Sing

apore)

(2vs

1)Site

E(Cen

tralSing

apore)

(2vs

1)

Samplesize

40–59y/o.2037

reside

nts

Participationrate

40–59y/o.Rental:72.0%

(936/1300)

VSOwne

d:61.2%

(1101/1800)

Prevalen

cerate

40–59y/o.Rental:14.2%

(133/936)VS

Owne

d:14.4%

(158/1101)

Follow

uprate:N

APrim

aryou

tcom

eIn

therental-hou

sing

commun

ity,chron

icpain

was

associated

with

high

erparticipa-

tionin

screen

ingfor:

Diabe

tes(adj

OR2.11,CI1.36–3.27,p

<0.001)

Dyslipidem

ia(adj

OR2.06,C

I1.25–3.39,p

=0.005)

Colorectalcancer(adj

OR2.28,CI1.18–4.40,

p=0.014)

Cervicalcancer(adj

OR2.65,CI1.34–5.23,

p=0.005)

Breastcancer

(adj

OR3.52,CI1.94–6.41,p

<0.001)

Thisassociationwas

notpresen

tin

the

owne

r-occupied

commun

ity.

Second

aryou

tcom

e:NA

Chron

icpain

was

associated

with

high

ercardiovascular

andcancer

screen

ing

participationin

therentalho

using

commun

ity.

Poor


Tothoselivingin

rentalho

using,

disease

onlyoccurswhe

nsymptom

smanifest,such

aschronicpain.The

reisapo

ssibility

that


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Gen

eralattitud

estowards

screen

ingtests;

andho

wtheirpain

might

affect

their

attitud

esto

screen

ingparticipation.

Threemainthem

esem

erge

dfro

mthe

analysisof

thelinkbe

tweenchronicpain

andscreen

ingparticipation:

Pain

asan

associationof

“major

illne

ss”.

Screen

ingas

asearch

foransw

ersto

pain.

Labe

lling

pain

asan

endin

itself.

chronicpain

may

presen

tas

the“hidde

nagen

da”.

Health

seekingbe

haviou

r

Wee

LE(2012)

[15]

Prospe

ctive,

Interven

tional

From

Jan2009

toMay

2011

Screen

ingforcardio-

vascular

diseaseriskfactors

atbaselineandpo

st-

interven

tion.

2integrated

publicho

usingprecinct.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(7vs

2)Interven

tion:

6-mon

thcommun

ity-based

interven

tion


ancedscreen

ing

compo

nent


compo

nent.

Samplesize

1081

reside

nts

Participationrate

78.2%

(1081/1383)

Site

A:83.4%

(832/998)V

SSite

B:64.6%

(249/385).

Prevalen

cerate:N

AFollow

uprate:N

APrim

aryou

tcom

eBaselinescreen

ingparticipationfor:

Hypertension.Rental41.7%

(150/360)V

SOwne

d54.1%

(139/257)

Diabe

tes.Rental38.8%

(177/456)VS

Owne

d59.6%

(254/426)

Dyslipidaemia.Ren

tal30.8%

(128/416)VS

Owne

d50.2%

(165/329)

Postinterven

tion:


(357/360)V

SOwne

d96.9%

(249/257)

Diabe

tes.Rental45.2%

(206/456)VS

Owne

d67.6%

(288/426)

Dyslipidaemia.Ren

tal37.0%

(154/416)VS

Owne

d58.4%

(192/329)

Second

aryou

tcom

eLiving

inarentalho

usingcommun

ity(adj

RR0.61,C

I0.37–0.99,p

=0.048)

andhaving

hype

rten

sion

(adj

RR0.45,C

I0.18–0.98,p

=0.049)

was

associated

with

lower

participationin

screen

ingfordiabetes

and

dyslipidaemiarespectively.

Employmen

t(adj

RR1.57,C

I1.03–2.60,p

=0.040)

andChine

seethn

icity

(adj

RR1.84,C

I1.00–3.43,p=0.050)

was

associated

with

high

erparticipationin

screen

ingfor

diabetes

anddyslipidaemiarespectively.

Thoselivingin

rentalho

usings

hadlower

participationin

screen

ing

before

interven

tion,whe

ncompared

againstthoselivingin

owne

r-occupied

housings.

Postinterven

tion,participationratesforall

threescreen

ingmod

alities

rose

sign

ificantly

bysimilarprop

ortio

nsin

both

rentaland

owne

r-occupied

commun

ity(allp<0.001).

–

Wee

LE(2012)

[16]

2integrated

publicho

usingprecinct.

Samplesize

–


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Prospe

ctive,

Interven

tional

From

Jan2009

toMay

2011

Socio-econ

omicfactors

affectingcolorectal,b

reast

andcervicalcancer

screen

ingat

baselineand

post-in

terven

tion.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(7vs

2)Interven

tion:

6-mon

thcommun

ity-based

interven

tion


ancedscreen

ing

compo

nent


compo

nent.

1081

reside

nts

Participationrate

78.2%

(1081/1383)

Site

A:83.4%

(832/998)V

SSite

B:64.6%

(249/385).

Prevalen

cerate:N

AFollow

uprate:N

APrim

aryou

tcom

eBaselinescreen


Colorectalcancer.Rental7.7%

(33/427)

VSOwne

d16.6%

(66/397)

Cervicalcancer.Rental20.4%

(44/216)

VSOwne

d41.9%

(93/222)

Breastcancer.Ren

tal14.3%

(46/321)

VSOwne

d15.9%

(48/302)

Postinterven

tion:


(81/427)

VSOwne

d28.2%

(112/397)

Cervicalcancer.Rental25.4%

(55/216)

VSOwne

d47.3%

(105/222)

Breastcancer.Ren

tal17.4%

(56/321)

VSOwne

d16.9%

(51/302)

Second

aryou

tcom

eFactorsassociated

with

cancer

screen

ingin

rentalho

usingcommun

ity:

Males

(adj

OR2.11,C

I1.01–4.42)andthose

overweigh

t(adj

OR2.76,C

I1.32–5.75)was

associated

with

high

erparticipationin

colorectalcancer

screen

ing.

Theem

ployed

(adj

OR1.56,C

I1.03–2.35)

andthoseof

high

ered

ucationalstatus(adj

OR1.96,C

I1.27–3.02)was

associated

with

high

erparticipationin

breastcancer

screen

ing.

Costwas

amajor

factor

inthelow-SES

com-

mun

ity,especially

forpapsm

ears/m

ammo-

gram

s.Mispe

rcep

tions

andlack

oftim

e/aw

aren

esswerealso

impo

rtant.

Thoselivingin

rentalho

usings

hadlower

participationin

colorectalandcervical

cancer

screen

ingbe

fore

interven

tion,whe

ncomparedagainstthoselivingin

owne

r-occupied

housings.

Postinterven

tion,participationratesrose

formostscreen

ingmod

alities

inbo

thcommun

ities

(allp≤0.001),excep

tfor

breastcancer

intheow

ner-occupied

commun

ity.

(p=0.250).

NgCW

(2012)

[21]

Cross-sectio

nal

From

Junto

Oct

2009

Characteristic

associated

with

non-willingn

essto

par-

ticipatein

health

prom

otion

prog

rammes

Reside

nts≥18

y/o.

4blocks

of1to

2room

sho

usingestate.

Locatedin

ToaPayoh.

Samplesize

974reside

nts

Participationrate

79.9%

(778/974)

Prevalen

cerate:N

AFollow

uprate:N

APrim

aryou

tcom

e36.1%

(281/778)o

freside

ntswerewillingto

participatein

atleaston

ehe

alth

prom

otion

Reside

ntslivingin

1to

2room

housing

hadlow

rate

ofparticipationin

health

prom

otionprog

ramme.

Older

reside

ntsandthosewho

dono

texercise

hadlower

rate

ofparticipationas

well.

Poor


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

prog

ramme(health

screen

ing,

talkor

worksho

p).

Older

reside

ntsaged

45–64years(OR0.52,

CI0.35–0.76,p

=0.001)

andmorethan

65years(OR0.44,C

I0.29–0.66,p

<0.001)

wereless

likelyto

participatethan

their

youn

gercoun

terparts(18–44

years).M

alays

(OR1.84,C

I1.27–2.68,p

=0.001)

weremore

likelythan

Chine

seto

participate,and

reside

ntswho

dono

texercise

(OR0.57,C

I0.42–0.78,p<0.001)

wereless

likelyto

participatethan

reside

ntswho

exercise

(regu

larly/occasionally).

Second

aryou

tcom

eReason

sforno

n-willingn

essto

participatewere‘not

inter-

ested’

and‘notim

e’.

Wee

LE(2011)

[22]

Cross-sectio

nal,

Interven

tional

From

Jan2009

toMay

2010

Theeffect

ofne

ighb

our-

hood

socio-econ

omicstatus

andacommun

ity-based

prog

ram

onmulti-disease

health

screen

ing.

Reside

nts≥40

y/o.

6blocks


housing

precinct.

(3vs

3)Locatedin

Taman

Jurong

(Western

Sing

apore).

Interven

tion:

6-mon

thcommun

ity-based

interven

tion


ancedscreen

ing

compo

nent


compo

nent.

Samplesize

707reside

nts

Participationrate

78.6%

(707/900)

Rental:89.0%

(356/400)V

SOwne

d:70.2%

(351/500)

Prevalen

cerate:N

AFollow

uprate:N

APrim

aryou

tcom

eBaselinescreen



(77/215)

VSOwne

d52.2%

(84/161)

Diabe

tes.Rental35.0%

(98/280)

VSOwne

d66.0%

(190/288)

Dyslipidaemia.Ren

tal26.2%

(70/267)

VSOwne

d53.1%

(119/224)


(15/251)

VSOwne

d17.0%

(49/288)

Postinterven

tion:


(212/215)V

SOwne

d100.0%

(161/161)

Diabe

tes.Rental40.0%

(112/280)VS

Owne

d66.7%

(192/288)

Dyslipidaemia.Ren

tal30.3%

(81/267)

VSOwne

d54.0%

(121/224)


(41/251)

VSOwne

d18.7%

(54/288)

Second

aryou

tcom

eLiving

inabe

tter-offne

ighb

ourhoo

dwas

in-

depe

nden

tlyassociated

with

diabetes

melli-

tus(66%

vs.35%

,adj

OR2.12,p

<0.01),

Uptakeof

allscreening

mod

alities

sign

ificantlyincreasedin

therentalho

using

commun

itypo

st-in

terven

tion(allp<0.05).

Poor


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

hype

rlipide

mia(53%

vs.26%

,adj

OR4.34,

p<0.01)andcolorectalcancer

screen

ing

(17%

vs.6%,adj

OR15.43,p<0.01),as

were

individu

alsocioe

cono

micfactorssuch

asem

ploymen

t,ne

edforfinancialaidand

househ

oldincome.

Costwas

citedmorecommon

lyas

abarrier

tohe

alth

screen

ingin

therentalho

using

commun

ity.

Reason

sforno

tparticipatingin

screen

ingin

both

commun

ity,and

foramajority

ofmod

alities:

Mispe

rcep

tions

Lack

oftim

e

Wee

LE(2016)

[23]

Cross-sectio

nal

andQualitative

From

2009

to2014

Prim

arycare

characteristic

andtheirassociationwith

health

screen

ing.

Reside

nts40–59y/o.

5integrated

publicho

usingprecincts.

Site

A(W

estern

Sing

apore)

(3vs

3)Site

B(Eastern

Sing

apore)

(4vs

5)Site

C(Eastern

Sing

apore)

(3vs

5)Site

D(Eastern

Sing

apore)

(2vs

1)Site

E(Cen

tralSing

apore)

(2vs

1)

Samplesize

1996

reside

nts

Participationrate

64.4%

(1996/3100)

Rental:72.0%

(936/1300)

VSOwne

d:58.9%

(1060/1800)

Prevalen

cerate:N

AFollow

uprate:N

APrim

aryou

tcom

eRental:

Regu

larprim

arycare

was

inde

pend

ently

associated

with

regu

lar:

Diabe

tesscreen

ing(adj

OR1.59,C

I1.12–

2.26,p

=0.009).

Hyperlipidem

iascreen

ing(adj

OR1.82,C

I1.10–3.04,p=0.023).

Proxim

ityto

prim

arycare

was

associated

with

less

participationin

regu

lar:

Colorectalcancerscreen

ing(adj

OR0.42,C

I0.17–0.99,p=0.049)

Breastcancer

screen

ing(adj

OR=0.29,C

I0.10–0.84,p=0.023).

Usage

ofsubsidized

prim

arycare

was

only

associated

with

increased

participationin

regu

lar:

Breastcancer

screen

ing(adj

OR2.33,C

I1.23–4.41,p=0.009).

Owne

d:Regu

larprim

arycare

was

inde

pend

ently

associated

with

regu

lar:

Hypertensionscreen

ing(adj

OR9.34

CI1.82–

47.85,p=0.007)

Regu

larprim

arycare

was

inde

pend

ently

associated

with

regu

larparticipationin

cardiovascular

screen

ingin

both

rental

housingandow

neroccupied

commun

ities.

How

ever,for

cancer

screen

ing,

intherental

housingcommun

ity,p

roximity

toprim

ary

care

was

associated

with

less

participation

inregu

larscreen

ing,

whilein

theow

ner

occupied

housingcommun

ity,reg

ular

prim

arycare

was

associated

with

lower

screen

ingparticipation;po

ssiblydu

eto

embarrassm

entregardingscreen

ing

mod

alities.

Poor


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Usage

ofsubsidized

prim

arycare

was

associated

with

regu

lar:

Diabe

tesscreen

ing(adj

OR2.94,C

I1.04–

8.31,p

=0.042).

Proxim

ityto

prim

arycare

was

associated

with

high

erparticipationin

regu

lar:

Colorectalcancerscreen

ing(adj

OR1.48,C

I1.01–2.21,p=0.049).

Usage

ofsubsidized

prim

arycare

was

associated

with

high

erparticipationin

regu

lar:

Cervicalcancerscreen

ing(adj

OR7.93.C

I1.03–62.51,p

=0.047)

Breastcancer

screen

ing(adj

OR6.02,C

I1.69–21.28),p=0.006)

Proxim

ityto

prim

arycare

was

associated

with

high

erparticipationin

regu

lar:

Cervicalcancerscreen

ing(adj

OR3.22,C

I1.72–5.84,p<0.001)

Breastcancer

screen

ing(adj

OR2.22,C

I1.08–4.54),p

=0.032)

Regu

larprim

arycare

follow

upwas

associated

with

less

participationin

regu

lar:

Breastcancer

screen

ing(adj

OR0.10,C

I0.01–0.75,p=0.025).

Second

aryou

tcom

e:NA


Toelicitpe

rcep

tions

abou

tcardiovascular

diseaseandcancer

screen

ing.

Major

them

esandsubthe

mes:

•Prim

arycare

characteristics(Barriers)

Lack

oftrustin

healthcare

system

/health

care

profession

als

Health

care

profession

aldo

esno

toften

discussscreen

ing–no

time

Embarrassm

entabou

tscreen

ingmod

ality

Characteristicsof

clinic(m

anpo

wer,location,

hoursop

en)

•Kn

owledg

e(Barriers)

Not

awareof

screen

ing

None

edscreen

ingas

healthy/not

atrisk

Not

awareof

whe

reto

goforscreen

ing

Screen

ingmay

notbe

accurate/alternative

screen

ingmetho

dsarebe

tter

Lasttestno

rmal,sono

need

togo

again

Con

fusion

that

mam

mog

ram

causes

cancer

•Priorities(Barriers)

Patientswerediscou

rage

dfro

mscreen

ing

bydistrustin

thedo

ctor-patient

relatio

n-ship;for

cancer

screen

ingin

particular,p

a-tientswerediscou

rage

dby

potential

embarrassm

ent.


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Notim

eto

go,too

busy

Can

spen

dmon

eyon

othe

rthings

•Attitu

des(Barriers)

Fatalism

Fear

ofdiagno

sisand/or

treatm

ent

Toooldto

goforscreen

ing

Tradition

almed

icineisbe

tter

Disease

notim

portant

Health

care

utilisatio

n

Wee

LE(2014)

[24]

Cross-sectio

nal

andQualitative

From

Jan2009

toMay

2010

Cho

iceof

prim

aryhe

alth

care

source.

Reside

nts≥40

y/o.

6blocks


housingprecinct.

(3vs

3)

Samplesize

710

Participationrate

88.6%

(710/800)

Rental:89.8%

(359/400)V

SOwne

d:87.8%

(351/400)

Prevalen

cerate:N

AFollow

uprate:N

APrim

aryou

tcom

ePreferredsource

ofmed

icaltreatm

entand

advice

Rental:

Relyon

ownknow

ledg

e.52.6%

(189/359)

Alternativemed

icinepractitione

rs.29.5%

(106/359)

Family/friend

s.6.7%

(24/359)

Western-trained

doctors.11.1%

(40/359)

Owne

d:Relyon

ownknow

ledg

e.54.1%

(190/351)

Alternativemed

icinepractitione

rs.2.0%

(7/

351)

Family/friend

s.14.0%

(49/351)

Western-trained

doctors.29.9%

(105/351)

Second

aryou

tcom

eReside

ntsstayingin

rentalho

using

(com

paredwith

thosestayingin

owne

r-occupied

housing)

wereless

likely:

toseek

advice

from

Western-trained

doctors

(adj

OR0.36,C

I0.21–0.61,p

<0.001)

toseek

advice

from

family

mem

bers

(adj

OR0.36,C

I0.19–0.69,p

<0.002)

They

weremorelikely:

toturn

toalternativemed

icinepractitione

rs(adj

OR14.29,CI4.55–50.00,p<0.001)

Inrentalho

usingcommun

ity:

Western-trained

physicians

areno

tthefirst

choice

ofseekingprim

arycare

intherental

housingcommun

ity.

Poor


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Unm

arriedweremorelikelyto

consult

alternativemed

icinepractitione

rs(adj

OR

3.13,C

I1.41–6.67,p

=0.005)

Minority

ethn

icity

weremorelikelyto

consultfamily

mem

bers

(adj

OR3.23,C

I1.23–8.33,p

=0.016)

Highe

rho

useh

oldincome(≥$500/m

onth)

wereless

likelyto

seek

consultfro

manyone

,relyinginsteadon

theirow

nknow

ledg

e(85.2%

,161/359)

With

dyslipidem

iawereless

likelyto

consult

alternative

med

icinepractitione

rs(adj

OR0.34,C

I0.14–0.83,p

=0.017).

Qualitativeinterviews:

Toelicitpe

rspe

ctives

onbarriers/enablers

that

lower

incomepatientsface

inseeing

aWestern-trained

physicianforprim

arycare.

Patient

andprovider

commen

tsfellinto

the

followingconten

tareas:Prim

arycare

characteristics-trust,distance,w

aitin

gtim

e.Kn

owledg

e-he

althy,no

teffective,minor

ailm

ent.

Costs-fo

rtreatm

ent,subsidies.

Priorities-bu

syAttitu

des-fear

ofdiagno

sisandtreatm

ent

Inform

ationsources-Med

ia(TV,ne

wspaper)

Self-reliancewas

perceivedas

acceptablefor

‘small’illne

sses

butno

tfor‘big’ones.

Com

mun

alspiritwas

citedas

areason

for

consultin

gfamily/friend

s.Socialdistance

from

prim

arycare

practitione

rswas

high

lighted

asareason

for

notconsultin

gWestern-trained

doctors.

Know

ledg

e,prim

arycare

characteristicsand

costswereiden

tifiedas

Potentialb

arriers/enablers.

Low

LL(2016)

[25]

Retrospe

ctivecoho

rtFrom

Jan2014

toDec

2014

Hou

sing

asasocial

determ

inantof

health

and

itsassociationwith

readmission

riskand

increasedutilisatio

nof

hospitalservices.

Patientswho

have

atleaston

eclinical

encoun

ter(adm

ission

orED

visit)to

Sing

aporeGen

eralHospital(SG

H)in

2014.

Patients,who

died

in2014,are

non-

reside

nts,who

reside

din

areaswhe

reSG

Hisno

ttheprim

aryho

spitalo

rpa-

tientsdischarged

tolong

-term

reside

n-tialcarefacilitieswereexclud

ed.

Samplesize

Atotalo

f14,457

patientswereanalyzed

and

2163

patients(15.0%

)wererentalho

using

reside

nts.

Prim

aryou

tcom

eReadmission

with

in15

days

associated

with

reside

ncein

publicrentalho

using:

OR1.19,C

I1.02–1.39,p

=0.029

Readmission

with

in30

days:

OR1.27,C

I1.12–1.43,p

<0.001

Freq

uent

hospitaladm

ission

s:OR1.27,C

I1.14–1.43,p

<0.001

Patientsstayingin

rentalho

usings

have

a19

and27%

high

erod

dsof

being

readmitted

with

in15

and30

days,

respectively.

Patientsstayingin

rentalho

usings

have

a27

and40%

high

erriskof

beingafre

quen

tho

spitaladm

itter

andfre

quen

tED

attend

ee,respe

ctively.

Fair


Table

1Descriptio

nandtheresults

ofarticlesreview

ed(Con

tinued)

Stud

y(Yearof

publication),

Stud

ytype

,Duration

ofstud

y

Research

questio

nDem

ograph

ics/

Interven

tiondo

neResults

Con

clusion

Levelo

feviden

ce(based

onNOS)

Freq

uent

EDattend

ances:

OR1.40,C

I1.21–1.61,p

<0.001,

Stayingin

publicrentalho

usingshow

eda

8%lower

riskpe

ron

eSO

Cvisit,bu

tthe

resultwas

statisticallyno

n-sign

ificant,0.92

(0.83–1.02),p=0.112

Second

aryou

tcom

e:NA


Table 2 List of variables for data extraction of included studies

Health status

1 Mortality

2 Diseases prevalence rate

Diseases incidence rate

3 Diseases management• Being treated, on treatment• Well controlled

Health seeking behaviour

4 Participation in Health screening• Chronic disease: Hypertension, Hyperlipidaemia, Diabetes• Cancer screening: Breast cancer, Cervical cancer, Colorectal cancer

5 Participation in Health promotion programme

Healthcare utilisation

6 Utilisation of primary and community care• Primary care services• Home care services e.g. home nursing, home medical services

7 Utilisation of hospital careHospital admission• Emergency department attendances• Hospital clinics

Including but not limited to


for the screening of hypertension and additional cardio-vascular risk screening. In addition to having higher num-bers of untreated and uncontrolled hypertension, rentalhousing residents had poorer awareness of their disease.From the qualitative interviews, the reasons for poorhypertension management were mainly being busy andlack of time for care. Another common cited reason wascost of screening and treatment.It was also found that medical comorbidities such as

falls [adjusted (adj) OR 2.72, CI 1.59–4.67, p < 0.001] andvisual impairment (adj OR 2.37, CI 1.28–4.39, p = 0.006)were independently associated with depression. Beingmarried (adj OR 0.44, CI 0.27–0.74, p = 0.002) and havinglarger social networks (adj OR 0.27, CI 0.14–0.51, p < 0.001) were protective factors against depression.Staying in a rental housing was found to be independ-

ently associated with cognitive impairment (adj OR 5.13,CI 1.98–13.34, p = 0.001) and many (96.2%) had cogni-tive impairment that was newly diagnosed only after thescreening done during the study.There was an association between chronic pain with

unemployment (adj OR 1.92, CI 1.05–2.78, p = 0.030)and being less independent in instrumental activities ofdaily living (adj OR 0.42, CI 0.20–0.90, p = 0.025). In an-other study on chronic pain [20], it was found that thosewith chronic pain had higher participation in screeningfor diabetes (adj OR 2.11, CI 1.36–3.27, p < 0.001), dysli-pidaemia (adj OR 2.06, CI 1.25–3.39, P = 0.005), colorec-tal cancer (adj OR 2.28, CI 1.18–4.40, p = 0.014),cervical cancer (adj OR 2.65, CI 1.34–5.23, p = 0.005)and breast cancer (adj OR 3.52, CI 1.94–6.41, p < 0.001).

And this was not seen in the owner-occupied housingcommunity. There was a qualitative interview in thisstudy that explored the general attitudes towards screen-ing tests and how their pain might affect their attitudesto screening participation. Three main themes emergedfrom the analysis of the link between chronic pain andscreening participation was: pain was identified as anassociation of “major illness”, screening was as a searchfor answers to pain and labelling pain as an end in itself.

Health seeking behaviourMany people may fail to go for health screening andmay ignore minor symptoms resulting in delayed treat-ment. Participation in a health screening is reflection ofa person’s health seeking behaviour. Four studiesconcentrated mainly on cardiovascular risk factor andcancer screening, including 1 that explored if primarycare characteristic had any association with healthscreening in the rental housing community. The 5thstudy evaluated willingness for health promotionprogramme participation.For these studies [15, 16, 22], there was a comparison

of the screening participation rate between the rentalhousing and owner-occupied housing community. Atthe same time, intervention which included a screeningand follow-up component was done and the change inhealth screening uptake rate was monitored. For cardio-vascular risk factors screening, those staying in rentalhousing had much lower participation rate [Hyperten-sion, 41.7% (rental) vs 54.1% (owned), Diabetes 38.8 vs59.6%, Dyslipidaemia, 30.8 vs 50.2%]. Cancer screeningparticipation rate was also lower in the rental housingcommunity (colorectal cancer 7.7 vs 16.6%, cervical can-cer 20.4 vs 41.9%) except for breast cancer screeningwith not much difference (14.3 vs 15.9%) between thetwo communities.Participation rates had increased for most of the

screening modalities after intervention, however it wasnoted that breast cancer screening participation rate rosethe least even in the owner-occupied housing commu-nity. More commonly cited barrier to health screeningwas concern about cost in the rental housing community[15, 16].Other reasons for not participating in screening were

lack of time, misperceptions about screening (for example,they may feel that they were healthy or not at risk, henceit was not necessary) and lack of interest [21].In the study that explored on the primary care charac-

teristic association with health screening [23], seeing aregular primary care doctor was independently associ-ated with regular diabetes and hyperlipidaemia screen-ing. There was less participation in regular colorectalcancer screening and breast cancer screening with prox-imity to primary care. Lastly, with subsidised primary


care, there was associated increased for participation inregular breast cancer screening.Qualitative interview section elicited perceptions from

the residents of rental housing about cardiovascular riskfactors and cancer screening. The major themes werebarriers related to the primary care characteristics, theresidents’ knowledge, priorities and attitudes. For pri-mary care characteristics, lack of trust in the healthcaresystem or healthcare professionals; lack of time fromhealthcare professionals to discuss about screening andthe embarrassment associated with screening modalitylike PAP smear for cervical cancer. Characteristics ofclinic such as manpower, location and opening hourswere cited as barriers in seeking for health screening. Asto the barriers in knowledge, it was found that manywere not aware of health screening; felt that there wasno need for screening as they were healthy and thereforenot at risk and lack of awareness of where to go forscreening. Some felt that screening may not be accurateand alternative screening methods were better; their pre-vious test was normal with no need to repeat screeningand there was misperception that mammogram causedcancer. Lack of time and cost were re-iterated as barriersto health screening, while fatalism attitudes and old agewere likewise raised. Some had the fear of diagnosisand/or treatment with others who believed that trad-itional medicine was better.

Healthcare utilisationSES and perception may influence the way patientsutilised health care services. The last two studies focusedon the choice of primary health care source [24] in therental housing community and their utilisation ofhospital services [25] respectively.Rental housing residents relied on their own know-

ledge (52.6%) before seeking medical treatment andadvice. More preferred alternative medicine practitioners(29.5%) to western-trained doctors in the primary care(11.1%). There was about 6.7% of them relied on theirfamily/friends. On the other hand, seeking help fromalternative medicine practitioners was the least preferredsource in the owner-occupied housing community. Itwas also noted that among rental housing community,those who consult alternative medicine practitionerswere more likely not married and those of minority eth-nicity were more likely to consult their family members.Qualitative interviews were carried out to elicit the

perspectives on barriers/enablers that they faced in see-ing western-trained doctors in primary care. The viewswere from both the patients and providers with theircomments as per following content areas: primary carecharacteristics like waiting time, knowledge in terms ofperception as minor ailment, costs of treatment, prior-ities, attitudes like fear of diagnosis and lastly depending

on their information sources. ‘Small’ illnesses were per-ceived as acceptable as part of self-reliance but not for‘big’ illnesses. Having the communal spirit was the rea-son for consulting family/friends. An interesting factabout having social distance from primary care doctorswas highlighted as a reason for not consulting western-trained doctors.Staying in public rental housing was an independent

risk factor for readmission, frequent hospital admissionsand ED attendances in Singapore [25]. The consistenttrend of the outcomes showed that there was a strong,consistent link between staying in public rental housingwith an increased in hospital utilisation.

DiscussionWhile there has been numerous studies evaluating theassociation between staying in public rental housing andhealth, this is the first review to summarise these rela-tionships with health (health status, health seeking be-haviour and healthcare utilisation).Singapore is a small, multi-ethnic Asian country

undergoing rapid urbanisation. Urban planning inSingapore takes into consideration the need to preventdevelopment of disadvantaged neighbourhoods [27]. TheUrban Redevelopment Authority of the country is wellknown for its meticulous planning with regards to popu-lation distribution and the allocation of public amenities.This includes ensuring that all residents have ready ac-cess to healthcare facilities. Notwithstanding that, in thisreview, it was found that residents of public rental hous-ings have poorer health status and outcome. These resi-dents had lower participation in health screening,preferred alternative medicine practitioners to western-trained doctors in primary care. Lastly, hospital utilisa-tion was increased among them. Traditionally, studieshad found that different individual markers of SES suchas employment status, educational level and housingtype are associated with poorer health [28, 29]. Com-pared to markers such as employment status and educa-tional level, housing type is part of the patient’s addressand is easily retrievable from the electronic health rec-ord. In Singapore, residents in the same apartment blockshare the same postal code. In the on-going effort to im-prove health and living conditions of the economicallydisadvantaged, policy makers can use this as a proxymarker of SES [30, 31] to identify high-risk populationsand direct intervention programs to where it is mostneeded.This findings in this review provides good insights into

possible reasons for poorer health of residents of publicrental housings in Singapore. We had developed a mech-anism map to explained the association between livingin public rental housing with poorer health (Fig. 2).Firstly, perceptions and health literacy have a major

Fig. 2 Mechanism map of the association between living in public rental housing with poorer health


impact on health. The elderly staying in the rental hous-ing tend not to be highly educated [18] and had poorhealth literacy. For example, many had low awarenessand misperceptions about cognitive impairment or de-mentia, accepting it as part of normal ageing. Studiesthat intervened to increase participation rate in healthscreening were unsuccessful despite making it free ofcharge and providing it at the residents’ doorstep at atime of their choice. A possible reason may be that suchelderly persons are averse to discovering additionalhealth problems when they are already having difficultiescoping with existing problems of living. A differentapproach such as reassuring the participants of the avail-ability of additional support for them when health issuesare discovered may prove to be more effective.Secondly, the juxtaposition of low SES apartment

blocks within communities of higher SES may increaseperception of inequality, a lack of social support and so-cial distance. Local social inequality [7] may have nega-tive impact on the health status of residents of publicrental housings. Wide disparities in income may resultin diminished trust in the community that could lead tosocial withdrawal. Such social isolation may have nega-tive effects on health especially on cognition and depres-sion. The sense of community would be low when onestay in a high-rise apartment where communal inter-action are limited to immediate neighbours due to theshortage of community space. This is exacerbated inelderly staying in rental housing, who had smaller socialnetwork and are mostly living alone. One study foundthat elderly persons with a weak social network are morelikely to suffer from pain and the progression of chronicpain [32]. For cancer patients and those with disabilities,access to amenities in the community and to publictransport is critical especially when they have to com-mute regularly for visits or treatment at healthcare facil-ities. Consideration to these areas should be given when

developing policies or services for patients of low SES.Effort must be made to create opportunities for socialinteraction between residents in high rise apartmentblocks. Another example of social distance hinderinghealth status was the lack of trust between the doctorand the patient when the latter felt that doctors are notin touch with the reality of staying in the public rentalhousing. This could be improved but it requires invest-ment in building a good doctor-patient relationship andensuring continuity of care [33].Thirdly, the anxiety over the affordability of medical

care among residents of public rental housings determany of them from seeking medical help especially inthe screening of chronic disease. In Singapore, one ofthe recent new interventions to improve access tohealthcare for such patients was the Community HealthAssist Scheme (CHAS). It provides additional subsidy toSingaporeans with lower household income for primarycare. Recipients of this assistance scheme can seek treat-ment from private General Practitioners (GP) who areoften located within communities where such rentalhousings are found. At the time of writing there wereabout 1650 GPs in private practice who have signed upfor the CHAS since its inception in 2012. About 1.3 mil-lion Singaporeans are eligible for this scheme [34]. Moreof such targeted subsidy schemes may give elderlypersons with low SES the confidence to take up healthscreening programs and adhere to the managementplans of their chronic diseases.

LimitationEleven out of the 14 studies used for the review weredone by the same author throughout several years at amaximum of five integrated public housing precinctsthat may not be nationally representative of public rentalhousing communities. Therefore, the results may not be


fully generalisable to all the rental housing populationSingapore.However, rental housing applicants are randomly allo-

cated to available housings within the different geo-graphical zones. Therefore, the demographics should besimilar across the different rental housing communitiesin Singapore.For the study on hospital services utilisation [25],

readmissions to other health systems was not accountedfor. In order to reduce bias, patients who stay in geo-graphical locations served by other health systems werenot included in the study.Overall, the 14 appraised articles were mainly of cross-

sectional and retrospective cohort study designs withpoor quality of evidence. For the interventional studies,the follow-up period was relatively short over a year.Lost to follow-up may have led to selection bias. Thosewho were more likely to continue participation in thestudy may have better diseases management.In the cross-sectional studies, there would be response

bias; those who declined to participate may reject to par-ticipate due to presence of condition such as depression.Therefore, it is possible that the prevalence of depressionin the study may be underestimated. Moreover, causalitycannot be inferred. Future studies may validate self-reported chronic diseases with hospital and clinicrecords to determine the true prevalence of chronic dis-eases and psychological conditions.

Direction of future researchStudies can be conducted in a randomly selected,nationally representative sample of public rental housingresidents in Singapore to provide generalisable data.Targeted interventional research studies directed at

the rental housing community may be carried out to ad-dress the health inequalities. More qualitative studiescan be done to interview the residents staying in rentalhousing to further explore on their health seeking be-haviour and health literacy. Such findings can be used toinform and guide the interventional studies as they maybe more unknown entities with regards to the gaps ofcurrent services provided to the community.

ConclusionOur review provides an important summary of theevidence on the association of public rental housing withpoor health status, lower participation in health screen-ing and higher hospital utilisation but under-utilisationin primary care. These findings have important publichealth implications for health and housing policy plan-ners in Singapore. Future studies should be conductedin a nationally representative public rental housingcohort and should include qualitative studies to obtain adeeper understanding of the social circumstances, health

seeking behaviour and their impact on health in thesecommunities.

AcknowledgementsNot applicable

FundingThis is an investigator-initiated study and no grant funding was obtained.

Availability of data and materialsNot applicable

Authors’ contributionsConceived and designed the study: CC, LLL, LKH. Performed the study: CC,LLL. Analyzed the data: CC, LLL. Interpreted the results: CC, LLL. Wrote thepaper: CC, LLL, LKH. Principal Investigator of this study and supervised thisstudy: CC. Revised the paper critically and give final approval for publication:All authors read and approved the final manuscript.

Ethics approval and consent to participateNot applicable

Consent for publicationNot applicable

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Department of Family Medicine & Continuing Care, Singapore GeneralHospital, Singapore, Singapore. 2Family Medicine, Duke-NUS Medical School,Singapore, Singapore. 3Family Medicine Academic Clinical Program,SingHealth Duke-NUS, Singapore, Singapore.

Received: 11 September 2017 Accepted: 20 March 2018

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