Navigating health challenges: Singapore’s National University Health System’s approach to child and family well-being

Dear Editor,

Singapore’s progressive commitment to addressing child and family well-being is anchored in its forward-thinking public health agenda. Recognising that long-term population health outcomes are shaped by early-life interventions, Singapore has directed increasing attention towards addressing complex health challenges that emerge during childhood and across the family unit. These challenges are compounded by factors such as rapid urbanisation and rising cost of living, technological shifts and societal transitions that have exacerbated sedentary behaviours. With decreasing total fertility and birth rates, it is of utmost importance to realise each child’s maximum potential as early as possible, beginning from preconception.

In response to these multifaceted challenges, Singapore’s Ministry of Health developed the Child and Maternal Health and Well-being Strategy and Action Plan (2021), which takes a holistic, life-course approach that highlights the importance of early intervention, preventive care and inter-sectoral collaboration as cornerstones of improving health outcomes for families and children from preconception to adolescence.¹ It is critical to enhance the health, safety and development of children and families through integrated, community-based programmes that prioritise early detection, prevention and sustained health interventions across the lifespan.

Key health challenges

Childhood obesity. There is a worrying increase in the proportion of overweight students aged 6–18 years. In 2021, 16% of school-going youths were classified as overweight (body mass index-for-age ≥90th percentile), a rise from 13% in 2017. A significant spike occurred between 2020 and 2021, likely due to the COVID-19 pandemic, which severely limited opportunities for physical activities in schools.²

This situation mirrors a global trend of rising childhood obesity. This poses significant risks to long-term health, with conditions like type 2 diabetes, cardiovascular diseases and metabolic syndrome that may manifest in adulthood. Therefore, addressing childhood obesity in Singapore requires comprehensive community-based strategies that prioritise physical activity, promote healthy eating, and reduce sedentary behaviours from a young age.³

Screen time. Excessive screen time has been linked to a variety of negative outcomes, including poor sleep quality, obesity, and developmental delays in learning and behaviour.^4,7 Studies conducted in Singapore have revealed concerning trends regarding children’s screen time. With the increasing availability of digital devices, children at a mean age of 13.8 months are engaging in passive screen time daily.^6,7 Screen time tends to increase as children grow older, contributing to sedentary behaviours that undermine their physical and cognitive development. Research has shown that children with developmental disorders spend more time on screens compared to their peers, which further exacerbates their challenges.⁸

Global studies, such as one by Madigan et al., found that higher screen time at 24 and 36 months is associated with poorer developmental screening test performance at 36 and 60 months.⁹ These findings highlight the importance of reducing screen time and promoting healthier activities, such as interactive play, outdoor activities and face-to-face interactions.

Reducing screen time among young children requires a multi-pronged approach. This includes educating parents about the risks of excessive screen time, providing alternative engagement strategies for children, and working with schools and community organisations to offer more screen-free activities. In a world where digital devices are becoming increasingly integrated into daily life, regulating screen use is crucial for safeguarding the cognitive and social development of children.

Maternal mental health. While Singapore has made significant strides in reducing maternal and infant mortality, new challenges have emerged concerning maternal mental health. Factors that affect maternal mental health include maternal sleep and breastfeeding.⁴ Approximately 1 in 10 women experience depression before, during, or after pregnancy. This figure is consistent with global data, highlighting the pervasiveness of perinatal mental health disorders. However, these mental health challenges extend beyond depression, encompassing anxiety, stress, and the psychological impact of maternal obesity, all of which can increase the risk of complications during pregnancy and adverse developmental outcomes for offspring.⁵

Singapore has launched several maternal mental health programmes, but there remains a need to scale up support, particularly for mothers in vulnerable or lower-income groups. The stigma associated with seeking help for mental health issues still presents a barrier to care. Addressing maternal mental health issues also involves creating supportive environments for mothers. This includes promoting mental wellness through education, offering peer support groups and ensuring that healthcare professionals are trained to recognise and manage early signs of maternal distress. These efforts can lead to better outcomes for both mothers and their children.

Approach to key health challenges

It is essential to understand the existing processes of community-based programmes, and map them out using a life course framework. As there are multiple existing programme drivers that are targeting different key health challenges, it is important to consolidate, coordinate and support these programmes in order to align programme goals with the overall preventive health strategy for family and child and reduce duplication of efforts. A workforce needs assessment was carried out to understand the strengths of programmes and barriers in their implementation by the National University Health System (NUHS), which forms the Western cluster of healthcare institutions in Singapore (Table 1). This then formed the basis for a theory of change and logic model for health systems transformation at NUHS.

Table 1. Theory of change based on workforce needs assessment at the National University Health System in Singapore.

Challenges in implementation and future directions

Implementation is challenging with issues ranging from cross-sector collaboration to resource allocation, and tackling cultural and social barriers. Singapore is transforming through the HealthierSG movement, which shifts healthcare delivery from a hospital-centric model to a community-focused approach, emphasising value-based care and addressing broader health determinants. This national trend towards holistic healthcare reform shows the importance of addressing fragmentation and promoting alignment within the healthcare system.¹⁰

Future plans involve improving healthcare access through digital health integration, life course approach, telemedicine, data analytics, cross-sector collaborations and developing programmes for at-risk youths, focusing on precision public health. These approaches, while tailored to the Singapore context, may offer valuable insights for addressing similar public health challenges in other regions.

REFERENCES

1. Ministry of Health, Singapore. Task Force Report. Child and Maternal Health & Well-Being Strategy And Action Plan. 14 June 2024. https://www.moh.gov.sg/others/resources-and-statistics/reports-camh-taskforce-report-2024. Accessed 5 December 2024.
2. Ministry of Health, Singapore. Annual prevalence of Obesity for Children aged below 18 over Past Five Years, their profile and Assessed Effectiveness of Preventive Measures. 14 February 2022. https://www.moh.gov.sg/newsroom/annual-prevalence-of-obesity-for-children-aged-below-18-over-past-five-years-their-profile-and-assessed-effectiveness-of-preventive-measures. Accessed 5 December 2024.
3. Loo BKG, Sirisena D, Müller-Riemenschneider F, et al. Consensus statement on Singapore integrated 24-hour activity guide for early childhood. Ann Acad Med Singap 2023;52:310-20.
4. Chen H, Chua TE, Lee TMY, et al. Consensus statement on Singapore perinatal mental health guidelines on depression and anxiety. Ann Acad Med Singap 2023;52:467-75.
5. Banozic A, Cai S, Chong SC, et al. Maternal mental health and well-being during pregnancy linked to brain development and function in children. Evidence Insight, EI001. Singapore: Centre for Holistic Initiatives for Learning and Development; 2021.
6. Mhd Zain NA, Mohd Poot EF, Che Daud AZ, et al. Correlation between screen time age exposure and screen time duration with developmental skills among children aged 6-36 months: A cross-sectional study. JUMMEC 2023;26:79-85.
7. Kiing JSH, Kang YQ, Mulay KV, et al. Screen time and social-emotional skills in preschoolers with developmental, behavioural or emotional issues in Singapore. Ann Acad Med Singap 2024;53:410-9.
8. Ministry of Health, Singapore. MOH COS 2021 Factsheet: Striving for Better Health for All. https://www.moh.gov.sg/docs/librariesprovider5/cos-2021/cos2021-media-factsheet—striving-for-better-health-for-all.pdf. Accessed 31 July 2024.
9. Madigan S, Browne D, Racine N, et al. Association Between Screen Time and Children’s Performance on a Developmental Screening Test. JAMA Pediatr 2019;173:244-50.
10. Ow Yong LM, Yi H, Low LL, et al. A Policy Ethnography Study of a Singapore Regional Health System on its governance adaptations and associated challenges as a project organisation to implement Healthier Singapore. Public Health in Pract (Oxf) 2023;6:100429.