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  1. Mahadeva S, Wee HL, Goh KL, Thumboo J
    PMID: 19463190 DOI: 10.1186/1477-7525-7-45
    BACKGROUND:
    Treatment objectives for dyspepsia include improvements in both symptoms and health-related quality of life (HRQoL). There is a lack of disease-specific instruments measuring HRQoL in South East Asian dyspeptics.

    OBJECTIVES:
    To validate English and locally translated version of the Short-Form Nepean Dyspepsia Index (SF-NDI) in Malaysian patients who consult for dyspepsia.

    METHODS:
    The English version of the SF-NDI was culturally adapted locally and a Malay translation was developed using standard procedures. English and Malay versions of the SF-NDI were assessed against the SF-36 and the Leeds Dyspepsia Questionnaire (LDQ), examining internal consistency, test-retest reliability and construct validity.

    RESULTS:
    Pilot testing of the translated Malay and original English versions of the SF-NDI in twenty subjects did not identify any cross-cultural adaptation problems. 143 patients (86 English-speaking and 57 Malay speaking) with dyspepsia were interviewed and the overall response rate was 100% with nil missing data. The median total SF-NDI score for both languages were 72.5 and 60.0 respectively. Test-retest reliability was good with intraclass correlation coefficients of 0.90 (English) and 0.83 (Malay), while internal consistency of SF-NDI subscales revealed alpha values ranging from 0.83 - 0.88 (English) and 0.83 - 0.90 (Malay). In both languages, SF-NDI sub-scales and total score demonstrated lower values in patients with more severe symptoms and in patients with functional vs organic dyspepsia (known groups validity), although these were less marked in the Malay language version. There was moderate to good correlation (r = 0.3 - 0.6) between all SF-NDI sub-scales and various domains of the SF-36 (convergent validity).

    CONCLUSION:
    This study demonstrates that both English and Malay versions of the SF-NDI are reliable and probably valid instruments for measuring HRQoL in Malaysian patients with dyspepsia.
  2. Mahadeva S, Wee HL, Goh KL, Thumboo J
    BMC Gastroenterol, 2009;9:20.
    PMID: 19284606 DOI: 10.1186/1471-230X-9-20
    There is little information of the validity of generic instruments in measuring health-related quality of life (HRQOL) in patients with dyspepsia. We aimed to assess the reliability and validity of the EQ-5D, a brief and simple instrument, in measuring HRQOL in adult patients with dyspepsia.
  3. Wee HL, Cheung YB, Li SC, Fong KY, Thumboo J
    PMID: 15644146
    Diabetes mellitus (DM) is an important public health concern, the impact of which is increased by the high prevalence of co-existing chronic medical conditions among subjects with DM. The aims of this study were therefore to (1) evaluate the impact of DM and co-existing chronic medical conditions on health-related quality of life (HRQoL) (which could be additive, synergistic or subtractive); (2) to determine the extent to which the SF-6D (a single-index preference measure) captures the multidimensional information provided by the SF-36 (a profile measure).
  4. Chua B, Ma V, Asjes C, Lim A, Mohseni M, Wee HL
    PMID: 33926019 DOI: 10.3390/ijerph18094586
    In Southeast Asia, cervical cancer is the second most common cancer in women. Low coverage for cervical cancer screening (CCS) becomes a roadblock to disease detection and treatment. Existing reviews on CCS have limited insights into the barriers and facilitators for SEA. Hence, this study aims to identify key barriers and facilitators among women living in SEA. A systematic literature review was conducted on Pubmed, Embase, PsycINFO, CINAHL, and SCOPUS. Primary qualitative and quantitative studies published in English that reported barriers and facilitators to CCS were included. The Mix Methods Appraisal Tool was used for the quality assessment of the included studies. Among the 93 included studies, pap smears (73.1%) were the most common screening modality. A majority of the studies were from Malaysia (35.5%). No studies were from Timor-Leste and the Philippines. The most common barriers were embarrassment (number of articles, n = 33), time constraints (n = 27), and poor knowledge of screening (n = 27). The most common facilitators were related to age (n = 21), receiving advice from healthcare workers (n = 17), and education status (n = 11). Findings from this review may inform health policy makers in developing effective cervical cancer screening programs in SEA countries.
  5. Cheung YB, Yeo KK, Chong KJ, Khoo EYH, Wee HL
    Health Qual Life Outcomes, 2019 Apr 17;17(1):67.
    PMID: 30995918 DOI: 10.1186/s12955-019-1130-0
    BACKGROUND: The WHOQOL-BREF is a widely used questionnaire for measuring quality of life. It is important to establish the measurement equivalence of various language versions of WHOQOL-BREF so that scores from different language versions may be pooled together. The primary aim of this article was to evaluate the measurement equivalence of the English, Chinese and Malay versions of the WHOQOL-BREF.

    METHODS: We analysed data from the previously published, cross-sectional, WONDERS study and used linear regression models to adjust for potential confounding variables. Based on equivalence clinical trial methods, measurement equivalence was assessed by comparing 90% confidence interval (CI) of differences in scores across language versions with a predefined equivalence margin of 0.3 SD. Equivalence was achieved if the 90% CI fell within 0.3 SD. Data from 1203 participants, aged above 21 years, were analysed.

    RESULTS: Participants who completed the different language versions of WHOQOL-BREF expectedly differed in age, ethnicity, highest education level, marital status, smoking status and Body Mass Index (BMI). The English and Malay language versions were definitely equivalent for all domains. The English and Chinese language versions were definitely equivalent for physical and environmental domains but inconclusive for psychological and social domains. Likewise, for Chinese and Malay versions.

    CONCLUSION: The English, Chinese and Malay language versions of the WHOQOL-BREF questionnaire may be considered equivalent, with evidence being more robust for some domains than the others. Given the large number of people who speak/ read Chinese and Malay, this study has widespread relevance.

  6. Wee HL, Li SC, Cheung YB, Fong KY, Thumboo J
    J Diabetes Complications, 2006;20(3):170-8.
    PMID: 16632237 DOI: 10.1016/j.jdiacomp.2005.06.010
    OBJECTIVES: The aims of this study were to evaluate the influence of ethnicity on health-related quality of life (HRQoL) in diabetic participants using both profile [the Short-Form 36 (SF-36)] and single-index (the SF-6D) instruments and to evaluate the usefulness of the SF-6D as a summary measure for the SF-36.
    RESEARCH DESIGN AND METHODS: Using data from a cross-sectional, population-based survey of Chinese, Malay, and Indians in Singapore, we analyzed the influence of ethnicity and other variables on each SF-36 scale and SF-6D scores using linear regression models to adjust for the influence of known determinants of HRQoL.
    RESULTS: Data from 309 diabetic respondents were analyzed. Compared with other ethnicities, Indians were most likely to report impaired HRQoL. The unadjusted influence of ethnicity on HRQoL exceeded the minimum clinically important difference (MCID) for all SF-36 scales (MCID: 5 points) and the SF-6D (MCID: 0.033 points). After adjusting for gender, age, and education, the influence of Chinese ethnicity exceeded the MCID for all SF-36 scales, except vitality (VT) and mental health (MH), as well as for the SF-6D. The influence of Malay ethnicity exceeded the MCID only for the SF-36 MH scale and the SF-6D. The influence of ethnicity on HRQoL persisted after adjusting further for other determinants of HRQoL. The SF-6D reflected the ethnic trends for some but not all SF-36 scales.
    CONCLUSIONS: After adjusting for demographic, socioeconomic, and other factors known to influence HRQoL, ethnicity remained an important factor influencing HRQoL in this population-based multiethnic sample of diabetic Asians. Further studies to identify modifiable factors explaining the ethnic disparities in HRQoL among diabetic participants are needed. The SF-6D may be a useful summary measure for the SF-36.
  7. Leow MK, Griva K, Choo R, Wee HL, Thumboo J, Tai ES, et al.
    PLoS One, 2013;8(6):e67138.
    PMID: 23826215 DOI: 10.1371/journal.pone.0067138
    BACKGROUND: HRQoL is an important outcome to guide and promote healthcare. Clinical and socioeconomic factors may influence HRQoL according to ethnicity.

    METHODOLOGY: A multiethnic cross-sectional national cohort (N = 7198) of the Singapore general population consisting of Chinese (N = 4873), Malay (N = 1167) and Indian (N = 1158) adults were evaluated using measures of HRQoL (SF-36 version 2), family functioning, health behaviours and clinical/laboratory assessments. Multiple regression analyses were performed to identify determinants of physical and mental HRQoL in the overall population and their potential differential effects by ethnicity. No a priori hypotheses were formulated so all interaction effects were explored.

    PRINCIPAL FINDINGS: HRQoL levels differed between ethnic groups. Chinese respondents had higher physical HRQoL (PCS) than Indian and Malay participants (p<0.001) whereas mental HRQoL (MCS) was higher in Malay relative to Chinese participants (p<0.001). Regressions models explained 17.1% and 14.6% of variance in PCS and MCS respectively with comorbid burden, income and employment being associated with lower HRQoL. Age and family were associated only with MCS. The effects of gender, stroke and musculoskeletal conditions on PCS varied by ethnicity, suggesting non-uniform patterns of association for Chinese, Malay and Indian individuals.

    CONCLUSIONS: Differences in HRQoL levels and determinants of HRQoL among ethnic groups underscore the need to better or differentially target population segments to promote well-being. More work is needed to explore HRQoL and wellness in relation to ethnicity.

  8. Wee HL, Li SC, Xie F, Zhang XH, Luo N, Feeny D, et al.
    Value Health, 2008 Mar;11 Suppl 1:S3-10.
    PMID: 18387064 DOI: 10.1111/j.1524-4733.2008.00361.x
    OBJECTIVES: To assess the validity, feasibility and acceptability of standard gamble (SG) and time trade-off (TTO) assessments in a multiethnic Asian population.
    METHODS: Through in-depth interviews performed among Chinese, Malay, and Indian Singaporeans (education >or= 6 years), we assessed validity of SG/TTO methods for eliciting health preferences by hypothesizing that 1) SG/TTO scores for three hypothetical health states (HS) would exhibit ranked order (decreasing scores with worse HS); and 2) more subjects would rate the most severe HS as worse than dead. Subjects also evaluated feasibility and acceptability of SG/TTO using a 10-point visual analog scale (VAS) and open-ended questions. Ratings were compared using Kruskal-Wallis, Wilcoxon signed-rank tests or tests of proportions.
    RESULTS: VALIDITY: In 62 subjects (90% response rate), as hypothesized, SG and TTO scores exhibited ranked order with increasing HS severity (SG: 0.85, 0.08, -19.00; TTO: 0.85, 0.00, -0.18). More subjects rated the most severe HS as worse than dead (SG: 8%, 39%, 59%; TTO: 8%, 45% and 62%).
    FEASIBILITY: Subjects felt SG and TTO were easy to understand (median VAS scores: 8.0 vs. 8.0, P = 0.87) and to complete (8.0 vs. 8.0, P = 0.84). Acceptability: SG and TTO were well accepted, with TTO less so than SG (median [interquartile range] offensiveness: 2.0 [0, 4.0] vs. 2.0 [0, 3.0], P = 0.045). Overall, subjects did not have a clear preference for SG/TTO (50% vs. 45%, P = 0.70).
    CONCLUSIONS: This study suggests the validity, feasibility and acceptability of SG and TTO for population-based HS valuation studies in a multiethnic Asian population.
  9. Wee HL, Loke WC, Li SC, Fong KY, Cheung YB, Machin D, et al.
    Ann Acad Med Singap, 2007 Jun;36(6):403-8.
    PMID: 17597964
    INTRODUCTION: The aims of this study were to cross-culturally adapt and evaluate the validity of the Singaporean Malay and Tamil versions of the EQ-5D.

    MATERIALS AND METHODS: The EQ- 5D was cross-culturally adapted and translated using an iterative process following standard guidelines. Consenting adult Malay- and Tamil-speaking subjects at a primary care facility in Singapore were interviewed using a questionnaire (including the EQ-5D, a single item assessing global health, the SF-8 and sociodemographic questions) in their respective language versions. Known-groups and convergent construct validity of the EQ-5D was investigated by testing 30 a priori hypotheses per language at attribute and overall levels.

    RESULTS: Complete data were obtained for 94 Malay and 78 Indian patients (median age, 54 years and 51 years, respectively). At the attribute level, all 16 hypotheses were fulfilled with several reaching statistical significance (Malay: 4; Tamil: 5). At the overall level, 42 of 44 hypotheses related to the EQ-5D/ EQ-VAS were fulfilled (Malay: 22; Tamil: 20), with 21 reaching statistical significance (Malay: 9; Tamil: 12).

    CONCLUSION: In this study among primary care patients, the Singapore Malay and Tamil EQ-5D demonstrated satisfactory known-groups and convergent validity.

  10. Vaingankar JA, Subramaniam M, Tan LWL, Abdin E, Lim WY, Wee HL, et al.
    BMC Med Res Methodol, 2018 03 15;18(1):29.
    PMID: 29544448 DOI: 10.1186/s12874-018-0487-9
    BACKGROUND: Measures of mental well-being and positive mental health (PMH) have been largely developed and used in Western populations, however, data on representative Asian communities are lacking. Using data from a population sample, this study sought to establish psychometric properties and norms of the PMH Instrument (PMH-I), a measure of positive mental health developed in Singapore.

    METHODS: We conducted a nationally representative survey among 1925 adults aged 18-79 years of Chinese, Malay, Indian or other ethnicity. Participants reported socio-demographic characteristics and completed the PMH-I along with measures of health-related quality of life (HRQoL) and psychological distress. Construct validity of the PMH-I was assessed using confirmatory factor analysis and concurrent validity was tested through correlation with other psychological measures. Normative PMH values and differences in population subgroups were estimated.

    RESULTS: The six-factor-higher-order structure of the PMH-I comprising six subscales of general coping, emotional support, spirituality, interpersonal skills, personal growth and autonomy and global affect was confirmed. Concurrent validity was shown through significant positive correlation of the total PMH score and its subscales with HRQoL and an inverse correlation with psychological distress. Weighted age, gender and ethnicity-specific norms were derived for the Singapore population. Total PMH was significantly higher in participants aged over 40 years as compared with 18-29 year olds and in non-Chinese ethnic groups as compared with Chinese. These differences were observed for all PMH-I subscales, with the exception of emotional support and interpersonal skills score differences by age. In contrast, gender, marital status, and education level were significantly associated with some of the subscales, but not with total PMH.

    CONCLUSIONS: These results support the psychometric properties of the PMH-I in a multi-ethnic Asian population sample. The generalizable population-based norms support the application of the PMH-I for measuring mental health and assessing its determinants within the Singapore general population.

  11. Soon SS, Chia WK, Chan ML, Ho GF, Jian X, Deng YH, et al.
    PLoS One, 2014;9(9):e107866.
    PMID: 25250815 DOI: 10.1371/journal.pone.0107866
    Recent observational studies showed that post-operative aspirin use reduces cancer relapse and death in the earliest stages of colorectal cancer. We sought to evaluate the cost-effectiveness of aspirin as an adjuvant therapy in Stage I and II colorectal cancer patients aged 65 years and older.
  12. Soon SS, Lim HY, Lopes G, Ahn J, Hu M, Ibrahim HM, et al.
    Asian Pac J Cancer Prev, 2013;14(4):2159-65.
    PMID: 23725106
    Cancer registries help to establish and maintain cancer incidence reporting systems, serve as a resource for investigation of cancer and its causes, and provide information for planning and evaluation of preventive and control programs. However, their wider role in directly enhancing oncology drug access has not been fully explored. We examined the value of cancer registries in oncology drug access in the Asia-Pacific region on three levels: (1) specific registry variable types; (2) macroscopic strategies on the national level; and (3) a regional cancer registry network. Using literature search and proceedings from an expert forum, this paper covers recent cancer registry developments in eight economies in the Asia-Pacific region - Australia, China, Hong Kong, Malaysia, Singapore, South Korea, Taiwan, and Thailand - and the ways they can contribute to oncology drug access. Specific registry variables relating to demographics, tumor characteristics, initial treatment plans, prognostic markers, risk factors, and mortality help to anticipate drug needs, identify high-priority research area and design access programs. On a national level, linking registry data with clinical, drug safety, financial, or drug utilization databases allows analyses of associations between utilization and outcomes. Concurrent efforts should also be channeled into developing and implementing data integrity and stewardship policies, and providing clear avenues to make data available. Less mature registry systems can employ modeling techniques and ad-hoc surveys while increasing coverage. Beyond local settings, a cancer registry network for the Asia-Pacific region would offer cross-learning and research opportunities that can exert leverage through the experiences and capabilities of a highly diverse region.
  13. Wee HL, Cheung YB, Loke WC, Tan CB, Chow MH, Li SC, et al.
    Value Health, 2008 Mar;11 Suppl 1:S105-14.
    PMID: 18387053 DOI: 10.1111/j.1524-4733.2008.00374.x
    To evaluate the association between body mass index (BMI) and health-related quality of life (HRQoL) in a multiethnic Asian population in Singapore, and to explore if the World Health Organization (WHO) recommendation of alternative BMI cutoffs for Asians could be further strengthened by evidence of higher risk of impaired HRQoL using these criteria.
  14. Shafiq M, Fong AYY, Tai ES, Nang EEK, Wee HL, Adam J, et al.
    Int J Epidemiol, 2018 10 01;47(5):1399-1400g.
    PMID: 30165399 DOI: 10.1093/ije/dyy168
  15. Wee HL, Canfell K, Chiu HM, Choi KS, Cox B, Bhoo-Pathy N, et al.
    BMC Health Serv Res, 2024 Jan 18;24(1):102.
    PMID: 38238704 DOI: 10.1186/s12913-023-10327-8
    BACKGROUND: The burden of cancer can be altered by screening. The field of cancer screening is constantly evolving; from the initiation of program for new cancer types as well as exploring innovative screening strategies (e.g. new screening tests). The aim of this study was to perform a landscape analysis of existing cancer screening programs in South-East Asia and the Western Pacific.

    METHODS: We conducted an overview of cancer screening in the region with the goal of summarizing current designs of cancer screening programs. First, a selective narrative literature review was used as an exploration to identify countries with organized screening programs. Second, representatives of each country with an organized program were approached and asked to provide relevant information on the organizations of their national or regional cancer screening program.

    RESULTS: There was wide variation in the screening strategies offered in the considered region with only eight programs identified as having an organized design. The majority of these programs did not meet all the essential criteria for being organized screening. The greatest variation was observed in the starting and stopping ages.

    CONCLUSIONS: Essential criteria of organized screening are missed. Improving organization is crucial to ensure that the beneficial effects of screening are achieved in the long-term. It is strongly recommended to consider a regional cancer screening network.

  16. Lou J, Kc S, Toh KY, Dabak S, Adler A, Ahn J, et al.
    Int J Technol Assess Health Care, 2020 Oct;36(5):474-480.
    PMID: 32928330 DOI: 10.1017/S0266462320000628
    There is growing interest globally in using real-world data (RWD) and real-world evidence (RWE) for health technology assessment (HTA). Optimal collection, analysis, and use of RWD/RWE to inform HTA requires a conceptual framework to standardize processes and ensure consistency. However, such framework is currently lacking in Asia, a region that is likely to benefit from RWD/RWE for at least two reasons. First, there is often limited Asian representation in clinical trials unless specifically conducted in Asian populations, and RWD may help to fill the evidence gap. Second, in a few Asian health systems, reimbursement decisions are not made at market entry; thus, allowing RWD/RWE to be collected to give more certainty about the effectiveness of technologies in the local setting and inform their appropriate use. Furthermore, an alignment of RWD/RWE policies across Asia would equip decision makers with context-relevant evidence, and improve timely patient access to new technologies. Using data collected from eleven health systems in Asia, this paper provides a review of the current landscape of RWD/RWE in Asia to inform HTA and explores a way forward to align policies within the region. This paper concludes with a proposal to establish an international collaboration among academics and HTA agencies in the region: the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) working group, which seeks to develop a non-binding guidance document on the use of RWD/RWE to inform HTA for decision making in Asia.
  17. Kc S, Lin LW, Bayani DBS, Zemlyanska Y, Adler A, Ahn J, et al.
    PMID: 37579427 DOI: 10.34172/ijhpm.2023.6858
    BACKGROUND: Globally, there is increasing interest in the use of real-world data (RWD) and real-world evidence (RWE) to inform health technology assessment (HTA) and reimbursement decision-making. Using current practices and case studies shared by eleven health systems in Asia, a non-binding guidance that seeks to align practices for generating and using RWD/RWE for decision-making in Asia was developed by the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) Working Group, addressing a current gap and needs among HTA users and generators.

    METHODS: The guidance document was developed over two face-to-face workshops, in addition to an online survey, a face-to-face interview and pragmatic search of literature. The specific focus was on what, where and how to collect RWD/ RWE.

    RESULTS: All 11 REALISE member jurisdictions participated in the online survey and the first in-person workshop, 10 participated in the second in-person workshop, and 8 participated in the in-depth face-to-face interviews. The guidance document was iteratively reviewed by all working group members and the International Advisory Panel. There was substantial variation in: (a) sources and types of RWD being used in HTA, and (b) the relative importance and prioritization of RWE being used for policy-making. A list of national-level databases and other sources of RWD available in each country was compiled. A list of useful guidance on data collection, quality assurance and study design were also compiled.

    CONCLUSION: The REALISE guidance document serves to align the collection of better quality RWD and generation of reliable RWE to ultimately inform HTA in Asia.

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