Problems and Purpose

Singaporeans are living longer but spending more years in ill health. According to the Global Burden of Disease Study 2017 findings, in Singapore, life expectancy at birth has risen to 84.8 years in 2017 as compared to 76.1 years in 1990. However, people in Singapore are spending 10.6 years in ill health (measured in years lived with disability, or YLDs) in 2017, which is about 1.5 years longer in 1990. In 2017, NCDs including diabetes were the largest contributors for overall disease burden in Singapore. Diabetes and its complications account for 7% of our total disease burden. ^[1]

Singapore has one of the highest rates of diabetes prevalence worldwide. One in three Singaporeans is at risk of developing diabetes in their lifetime. In 2016, the number of Singapore residents living with diabetes is projected to increase to close to one million by 2050 if nothing is done. ^[2] One in three individuals with diabetes does not know they have the condition. Among those diagnosed with diabetes, one in three has poor control of their condition which increases the risk for serious

In a 2010 report by the National Registry of Disease Office, diabetes (type 1 and type 2 combined) accounted for 10.4% of the total disease and injury burden in Singapore, affecting 1 in 9 Singapore residents between age 18 to 69. In 1998, this figure was 1 in 11. This increase has occurred across all ages, genders, and ethnic groups, and is expected to rise further due to our ageing population, and to more people getting screened. Type 2 diabetes, which accounts for nearly 90% of diabetes cases in Singapore, is a metabolic disorder characterized by resistance to insulin that results in chronically high blood sugar in the body. Left untreated, the condition can result in severe complications, including heart disease, stroke, blindness, kidney failure, and poor blood flow to limbs that can lead to sores, infections, and amputations. Today, diabetes in Singapore is higher than the world average. They also have one of the highest diabetic amputation rates, with an average of 4 lower extremity amputations daily.

The jury members were tasked to come up with ideas on preventing and managing diabetes in Singapore.

Background History and Context

The Ministry of Health (MOH), in collaboration with the Institute of Policy Studies (IPS), embarked on the Citizens’ Jury (CJ) for the War on Diabetes to mobilise citizens to raise awareness about diabetes and generate community-based recommendations on how to better prevent and manage diabetes as a nation. Such deliberative engagement models are premised on the belief that citizens can contribute meaningfully to the co-creation and co-delivery of approaches on issues of significance to them and the community.

The Citizens' Jury is the first health-related public engagement initiative that is done in this manner in Singapore, said MOH, which also worked with public and private healthcare providers, such as polyclinics and specialist clinics, to recruit people for the jury.

It is modelled after similar initiatives in countries such as New Zealand and Australia, where citizens come together to deliberate and propose recommendations for the government to study and, if feasible, implement them.

Organizing, Supporting, and Funding Entities

This initiative was funded by the Singapore Ministry of Health (MOH) in collaboration with the Institute of Policy Studies (IPS)

Participant Recruitment and Selection

The recruitment of participants for the community involvement project took place over six weeks from October 6th to November 15th, 2017. The goal of the project was to create community-based solutions for addressing diabetes, and so the defined community for the project included Singaporeans and Permanent Residents who were directly or indirectly affected by diabetes. This included diabetic patients, their caregivers, and healthcare providers who work with diabetic patients, as well as people in the secondary circle of influence of diabetic patients, such as family members and friends. Additionally, a small group of people who had no personal experience with diabetes was included in the study to ensure that the project was representative of the national problem of diabetes. Recruitment and screening for participants was conducted through a variety of platforms in order to reduce bias towards people who were not digitally connected.

1 The Ministry of Health (MOH) and the Institute of Policy Studies (IPS) announced an open call for applications through their Facebook pages on October 6, 2017. Those interested in participating were required to complete a screener questionnaire, which could be done either online or by phone with IPS

2. The Institute of Policy Studies (IPS) included the call for application in its October 2017 newsletter, which was sent to subscribers.

3. To recruit diabetic patients, the Ministry of Health (MOH) utilized their network of healthcare providers. The contact information of interested patients and healthcare professionals was then forwarded to the Institute of Policy Studies (IPS) for participant screening.

4. In addition to completing the screener questionnaire online or by phone with the Institute of Policy Studies (IPS), interested parties could also access the questionnaire through the Ministry of Health (MOH) microsite.

5. To ensure diverse representation of various groups in the Singapore public, the Ministry of Health (MOH) and the Institute of Policy Studies (IPS) worked together to develop a sampling frame for participant recruitment and screening. The aim of this effort was to ensure that the selected participants reflected a wide range of backgrounds and characteristics.^[1]

Methods and Tools Used

War on Diabetes Citizen's Jury was the first ever citizens jury in Singapore. It was modelled after similar initiatives in countries such as New Zealand and Australia. Through an Independent process, the Institute of Policy Studies carefully recruited the participants. The participants that made up the Jury are 34% of persons living with diabetes, 17% were healthcare professionals (endocrinologist, podiatrist, nurse, physiotherapist, among others), and the remaining were caregivers and persons without any experience with diabetes. ^[4] These was done in order to have a Citizen’s Jury that fulfils the five key principles of Deliberation.

What Went On: Process, Interaction, and Participation

War on Diabetes Citizen’s jury ran from 25 November, 2017 (Day one) to 13 January, 2018 Day four). The jury had four sessions on Saturdays which lasted for seven weeks.^[1]

The first step in the recruitment process was to announce the Citizen’s Jury and invite applications. Subsequently, IPS assessed the applicants for their suitability based on four criteria- (i) Participants' experience and involvement with diabetes was a factor considered during the recruitment process.

(ii) their interest in the topic of War on Diabetes,

(iii) their attitudes towards engaging in group discussions with other people, and

(iv) their ability to commit to all four sessions

To achieve the aforementioned, applicants were required to complete a questionnaire that was developed by MOH and IPS. The questions collected information on the following:

a. Demographics;

b. History with diabetes, e.g., whether they have pre-diabetes or diabetes, a family history of diabetes, and the healthcare provider they go to for treatment;

c. Experience with diabetes, e.g., as a caregiver, friend of diabetic patient, or had no experience with diabetes;

d. Interest in the topic of diabetes, e.g., their opinion pertaining to the causes, challenges and efforts in fighting diabetes;

e. Personality, e.g., their attitudes towards engaging in group discussions; and

f. Ability to attend all four sessions.

The questionnaire was administered online via the Ministry of Health microsite and over the telephone. Phone interviews were conducted with individuals who did not have access to the website and/or preferred to answer the questions with an interviewer. IPS conducted the screening over a period of six weeks, and followed up with applicants who answered the online questionnaire but did not complete it.

76 participants who were recruited for the Citizens’ Jury.

Citizen’s Jury Participants’ Journey

Session 1 (25 November 2017)

(i) Living Room Chat- Participants provided personal experiences with diabetes.

(ii) Jurors discussed: Challenges Singaporeans face in living free from and living well with diabetes. What a future where diabetes is well-managed could look like?

(ii) Jurors formed groups by the end of the day based on preliminary suggestions for diabetes prevention and management.

Session 2 (2 December 2017)

(i) Groups presented their understanding of a diabetes-related problem and offered their preliminary solution(s)

(ii) Resource panellists provided groups with insights on current efforts and future initiatives.

(iii) Problem statements were finalized for further ideation on solutions.

(iv) (Post-session) Groups studied the issues rigorously and prepared evidence-based proposals.

Session 3 (6 January 2018)

(i) Groups pitched their problem statements and proposed solutions backed with evidence

(ii) Groups received feedback and critique from healthcare experts and fellow jurors, then further refined their ideas

(iii) Final pitches were made and voting was done for ideas that should be presented to MOH.

Session 4 (13 January 2018)

The Citizens’ Jury concluded on 13 January 2018 when the 76 participants submitted their recommendations to Senior Minister of State for Health, Dr Amy Khor. SMS Khor commended the Jury’s commitment and enthusiasm to work with the Ministry of Health to co-deliver solutions to fight the War on Diabetes, and that she was encouraged that Singaporeans were ready to step up, take ownership and co-create solutions with the Government to make a difference for our community. ^[3]

The Citizen’s Jury on War on Diabetes fulfilled the five key principles of Deliberation. The principles are briefly explained below:

Inclusivity and diversity

They received a total of 114 applications for the Citizen’s Jury. From this group, they selected 77 participants, 29 based on the quota set for each category of participants. They ensured there was as much diversity as possible in terms of demographics. The main objective was to assemble a Citizen’s Jury that was as inclusive as possible, by giving people from different walks of life and who had different types of lived realities relating to diabetes a chance to be part of the process. This was an essential first step in eliciting as wide a range of views and perspectives as possible.

Fairness and equality

They observed improvement in terms of some participants putting in more effort to listen to one another and “disagreeing in a more agreeable manner” after Day One. For instance, during “The Pitch” on Day Three (where each group had to present their proposal to the Citizen’s Jury for voting), participants generally posed questions in a relatively polite and respectful manner at the end of each presentation, even when they were critiquing and challenging some of the recommendations.

Knowledge gain

The post-Citizen’s Jury survey showed that 84 per cent of participants felt that they learned more about diabetes management and prevention after participating in the Citizen’s Jury. We emphasise that knowledge gain should not be seen just as an outcome of the Citizen’s Jury process, but also as an essential process enabler that contributes to the development of ideas that are substantive (substantiated by evidence), novel and applicable. In addition to the participants learning more about the topic and overcoming their blind spots through discussions within group and with other groups, several features of the War on Diabetes Citizen’s Jury played a critical role in ensuring that participants had a minimum level of subject competency, irrespective of their socioeconomic and professional background.

Efficacy

The survey showed that the participants’ internal efficacy increased after the Citizen’s Jury — about 82 per cent of participants agreed that the Citizen’s Jury experience strengthened their confidence in the value of their contributions as an active citizen. Participants’ external efficacy also increased with close to 88 per cent of them saying that they would favourably consider participating in future citizen engagement opportunities. A large majority of the participants — 90 per cent of them — wanted to be more actively involved in diabetes prevention and management initiatives after attending the Citizen’s Jury.

Applicability

The survey showed that 97 per cent of the participants felt that the Citizen’s Jury’s recommendations were worthy of government support while close to 92 per cent of them felt that the recommendations would be supported by Singaporeans.

Influence, Outcomes, and Effects

According to The Straits Times newspaper, on the 13 Jan, 2018, the 28 recommendations of the citizen’s Jury were presented to Senior Minister of State for Health Dr. Amy Khor other senior civil servants. The minister assured them that within three months, her ministry will respond to the citizen’s jury “unedited and unchanged” recommendations. In fact, some recommendations were accepted on the same day (Jan 13).

At the Citizen’s Jury appreciation event which took place on the 14 April 2018, Ministry of Health announced that it would support 14 of the 28 recommendations and explore another 13. ^[1] Some Mainstream media outlets such as channels NewsAsia FB, Berita Harian FB highlighted the government’s support for the “Drink Water Campaign” and its plans to install more water coolers in public areas.

According to the Ministry of Health Citizen’s Jury report, the following 14 recommendations received support from the Ministry of Health:

1. Public outreach programmes targeted at residents of HDB heartlands.

2.  Inclusion of the at-risk solitary, elderly and illiterate groups through face-to-face interaction.

3. Diabetes awareness campaign and curriculum for children.

4. A platform/repository to consolidate diabetes related material.

5. Raise awareness of this consolidated platform.

6. Re-examine the “Healthy Meals in Schools” Programme and encourage wider adoption Support

7. Popularise “My Healthy Plate” guidelines.

8. Celebrity/mascot endorsements for healthier foods.

9. Citizen-led “Drink Water” Campaign.

10. Healthy food preparation and cooking competitions.

11. Expand, popularise and collaborate with existing organisations that offer cooking courses Support

12. Communication-focused Diabetic Care Clinic that may adopt motivational interviewing as an approach to influence positive behaviour.

13.  Expand the role of Singapore Association for Counselling (SAC) to include clinical communication and chronic disease counselling.

14.Raise the Medisave – claimable amount for CDMP to $750.

The Ministry decided to further explore the following recommendations:

1. Introduction of the “Go Green Guide”

2. Central repository for registered interventions

3. A “Healthy Hawker” competition

4. Limit on fast food and snacks advertisements

5. Restrictions on the use of garnish in food advertisements.

6. Limit promotion on or shelf placement of nutritionally poor foods.

7. Use emotionally targeted counter advertising to improve behaviours.

8. Health points/travel rebates as incentives to encourage physical activity.

9.  A rewards/incentives scheme to encourage better disease management among people living with diabetes.

10.  Expansion of the responsibilities of the Association of Diabetes Educators Singapore (ADES).

11. Increase peer support by expanding the number of peer groups.

12. More effective peer matching through a central health platform.

13. Adoption of a Patient-Outcomes funding model.

“Rating hawker centres” was the only recommendation that could not get the support of the ministry at the moment. ^[4]

Reflecting on the Citizen’s jury on War on Diabetes in Singapore, according to a report published on the 19 October 2018 by Carol Soon and Valerie Yeo from the Institute of Policy Studies, 84% of participants stated they had learnt more about diabetes treatment and prevention as a result of taking part in the Citizen's Jury. The poll revealed that after participating in the Citizen's Jury, participants felt more effective on the inside; over 82% of respondents said that the experience had boosted their confidence in the worth of their contributions as engaged citizens. Nearly 88 percent of participants said they would favourably consider taking part in future opportunities for citizen involvement, which boosted their external efficacy. 90% of the attendees expressed a desire to participate more actively in diabetes prevention and management programs after the four sessions. The study also revealed that nearly 92% of respondents believed that Singaporeans would support the Citizen's Jury's recommendations, while 97% of participants believed that the suggestions were worthy of government support.^[1]

Analysis and Lessons Learned

In the report submitted by the jurors, they stated that the report was only an effort to create a comprehensive knowledge and strategy for the “War on Diabetes”. “The research on this topic - the causes, effects, and methods of prevention and treatment - is by no means complete. As our knowledge deepens and evolves, some recommendations in this report will require modifications, while others might even be discredited”. ^[5]

This implies that to determine which strategies are most likely to be successful, stakeholders or policy makers in Singapore should be prepared to engage in constant trial and error, data collecting and monitoring, and course correction. In addition, the juror stated that “interventions will need to be appraised and monitored for their reach, sustainability, and cost”. [5]

The jurors suggested further researches on these three major areas:

a) Personas & “User Profiles” of the Singaporean population

With respect to managing and preventing diabetes. Following the individual classification of these personas, we could undertake in-person interviews, name and pinpoint significant insights, challenges, and barriers, and get a better knowledge of how to effectively target this audience.

b) Apply More Strategies in Choice Architecture

When a juror was called to narrate his most recent experience on positive behavioural change, the juror said, “I have taken the same 3-in-1 coffee for years, then just last month, the store changed it to a reduced sugar version. The higher sugar one I used to buy is no longer available. I was forced to switch to this new version, but now I’m used to it.” This is an example of how choice architecture can drive us to make positive changes.

c) Research How Newer Diets Specifically Affect Singaporean Diabetics.

There are a wide variety of diets, including Mediterranean, DASH, Ketogenic, Vegan, Vegetarian, Low-Fat, and Low-Carb. As new findings show that the impact of the diet is greatly dependent on our genetics and epigenetics (i.e., different individuals have different optimal diets) 64, we need a deeper understanding of what might be optimal for Singaporeans, taking into account our multi-ethnic background.^[5]

In the Jurors final remarks, they said “we hope that our efforts bring Singapore one step closer to ensuring that effective diabetes prevention and treatment strategies are within the reach of every Singaporean because as jurors we had a glimpse of what is possible when all stakeholders work together toward a healthier Singapore”. ^[5]

In conclusion, for some of the recommendations made by the jurors to stand the test of time, a collective intelligence and effort of members of the society, patients, healthcare providers, healthcare administrators, medical equipment suppliers, employers, school administrators, educators, the health promotion and fitness industry, insurers, food manufacturers, food retailers, restaurant operators, the media, and the government is highly required. This effort might not yield the desired result at the short run, but it is going to be of immense benefit at the long run to the citizens of Singapore.

See Also

Citizen's Jury

References

[1] Soon, C., & Yeo, V. (n.d.). Reflections on the Citizens’ Jury for the War on Diabetes.

[2] The burden of disease in Singapore, 1990-2017: An overview of the global burden of disease study 2017 results. (2019).

[3] https://www.moh.gov.sg/wodcj

[4] https://drive.google.com/file/d/18U_-2jSUE-4jtN2jIa523gZ2xCPQpoWL/view

[5] https://drive.google.com/file/d/1faKeYxDemNew0VBGky9HLJHDGXTeN2zT/view

External Links

Notes