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Table 3 Core indicators of population segmentation – themes and illustrative quotes

From: Identifying optimal indicators and purposes of population segmentation through engagement of key stakeholders: a qualitative study

DomainThemeQuotations
MicroMesoMacro
Demographic characteristics- Linkage between older age and poorer health outcomesWe will focus mainly on the elderly because I think we all know that Singapore is an ageing or rather fast moving to the ageing population. So, we thought that we need to address this from the ground level, from the community.”
#1 Social Service Provider
Ageing-related issues are pretty big right? And [with] ageing population, people [are] living longer, and if we look at [it] broader beyond health, how do you keep them engaged? How do you keep them active? What is successful ageing to them?
#19 Researcher
You know, because of the ageing population, the elderly would be a segment of the population that we would want to work on. Which area of the elderly, we will need to work on it a bit more? Because elderly [the progress] is a continual right?”
#16 Government Official
- Health disparity across ethnic groupsActually anybody 40 and above, who can come to the clinic, can be served.”
#1 Social Service Provider
We choose fifty-five [years old] because it includes sixty-five so it’s a more sensitive measure as opposed to sixty-five where you might exclude some individuals that also need our help.”
#3 Researcher
We also do observe particular races like [the] Malays as their health outcomes in term of life expectancy are actually much lower compared to other races.”
#20 Government Official
- Association between low education and increased risk of poor health outcomesI think [in] the next 10 years, you’ll probably see more people with more years of education, right? The older people will be so called more educated. It might be easier to for them to be able to access and understand [healthcare] information.”
#2 Social Service Provider
I would say maybe education level, you know? [It] will also protect against certain healthcare.
#17 Healthcare Professional
We’ll have other social factors that affect the population health, for example, housing, education level and literacy.”
#4 Government Official
Economic characteristics- Level of income affects health outcomesBasically, poverty yeah, no money means not being able to access erm opportunities, or not being able to participate, you know? You can’t go out, you can’t take the transport to go anywhere, you are kind of stuck there.”
#12 Researcher
The preliminary findings [are] that actually you know patients that are from a lower SES [socioeconomic status] group will tend to have more challenges than the rich or rather they are a bit limited to accessing to services. And that has got to do with a lot of social [factors] that are [present] in their home, that is sort of inhibiting them from access to healthcare.”
#11 Healthcare Professional
The lower SES associated with a particular group of race [is] basically putting them to poorer health outcomes.”
#20 Government Official
- Public rental housing and its association with mortalitySo, for example, whether [the] patients [are] subsidised, non-subsidised, and sometimes even the residential address could help us to understand the patient’s financial status. If the patient was to come from, for example, [a] one room rental property, then that patient [is] more likely to be disadvantaged and have more erm social economic issues that will affect their health outcomes.”
#9 Healthcare Professional
Our outreach is actually based on three main factors that we always look at. One of the most important factor is HFS [Home Financial Status].”
#10 Researcher
We do observe that for err those people who are staying in lower SES conditions, they actually have poorer health outcomes.”
#20 Government Official
Behavioural characteristics- Health-seeking behaviours as a key determinant of health outcomesOf course, it goes back to the patient’s behaviour and personality. For example, like the ‘meals on wheels’. Some patients need meals on wheels, [then] I link you up and you accept it, so there’s no problem. But some will say, ‘Oh I have to pay, you know it’s too expensive, I don’t want it. Oh, I don’t like the food you send to me. I’m going down to buy from the hawker centre.’ You know hawker food is rich in sodium and fats right? Then they’ll have more complications and get readmitted.”
#9 Healthcare Professional
They have some health seeking behaviour that influences the health outcome. So this will affect them as to whether they will seek healthcare early or late.”
#6 Healthcare Professional
I think different people behave differently. Some people get a deep cut and they think it’s nothing whereas some people might kick up a fuss when they have a small cut. So, it is our personal responses.”
#25 Government Official
Disease state- Health as a holistic conceptWe also look at the bio[logical issues]. We look at how the medical condition impacts the patient. Like a dialysis patient. The bio[logical issue] is the dialysis, right? So medically, this person needs to go for dialysis. What is this impact of dialysis on the patient? The impact could be it affects their family relationship you know? Because the burden of care is so great, the spouse may decide that you are so burdensome. Every other day I have to bring you to dialysis centre. So, the impact of this dialysis is that the relationship within the family suffers.”
#15 Healthcare Professional
Segmenting the population into different categories, from the prefrail, frail, to the complex [chronic] care and also the end of life.”
#6 Healthcare Professional
People will need help for mental health issues and this is a broad range of issues right? Also, the younger folks that struggle with say depression, schizophrenia, psychosis and all that, so there’s a mental health need group which cuts across all age groups.”
#13 Government Official
- Tailored healthcare interventions according to disease severityCurrently, we’re using the MOH [Ministry of Health] tiering, which is Tier 1, Tier 2 and Tier 3. So, Tier 1 are those with stable chronic disease. Then Tier 2 is for those with chronic disease and some geriatric syndrome, some complex nursing and physical needs, functional needs. Tier 3 patients are more complex, and more geriatric syndrome.”
#9 Healthcare Professional
Say, for example, illness, right? For example, dementia [patients], they will maybe be of a different group requiring different kind of help.”
#10 Researcher
So segment can be in health state like what the British Columbia [did] where they have health state: there’s the well, patients who are stable, with chronic diseases, those who are frail, pre-frail or the end of life.”
#16 Government Official
Functional status- Frailty as a risk factor for poor health outcome“[To] prevent the frailty period so that they become strong and can actually age well in the community [for] as long as possible.” #5 Social Service ProviderThe polyclinic [government primary care clinic] also controlled the frails, the elderly who have a lot of problems.”
#19 Researcher
We look at the problem of declining function in the elderly, for example, the increasing rate of frailty, the poor control of diseases which lead to more and more complications, the lack of social support leading to readmission.”
#24 Government Official
- Functional status affects quality of lifeWell something simple like coping. Can they leave the house? Or can they not leave the house? Because obviously if they cannot leave the house, then that is the sign that something is not quite right.”
#9 Healthcare Professional
We measure the functional status as well. Function is not just [patient] mobility alone, it can be their ability to function at home, for example, eating, dressing, if they cannot function, it [will] affect their quality of life.”
#6 Healthcare Professional
I think typically we look at their functional ability. So, seniors who need help with ADL [activities of daily living] issues, we help them with grants and subsidy application.”
#13 Government Official
Organisation of care- Multidisciplinary collaboration improves care coordinationSay, for example, if it is an orthopaedic case, then the medical social workers looking after, supporting the orthopaedic team with the knowledge and skills will come in to support them.”
#14 Healthcare Professional
Let’s say this patient is seeing a lot of different doctors in a lot of different hospitals, so [the] care is a bit fragmented. Usually what would be helpful for these patients is if they have like a regular primary doctor who can liaise with all these different health care professionals, it will help to reduce confusion.”
#3 Researcher
We’ll be looking at care coordination. So [by] looking at how well is the care being coordinated, [we can see] how well the patients are being supported, be it socially or medically outside of the hospital after their discharge.”
#13 Government Official
Psychosocial factors- Social support promotes general wellbeingWell I think one of the marker is their care. Are they well looked after? If a person is not well looked after, then we would dive in. We will probably dive in to their social and economic issues rather than looking at their medical conditions solely.”
#8 Healthcare Professional
It could be [the] grandma doesn’t want to take [the] medicine, because no one [is] supporting grandma. Those problems are the ones that our traditional healthcare is not able to solve. So, we are going to have a lot of healthcare issues that we stare at and it’s a problem that we can’t solve if we just look at it from the healthcare perspective.”
#19 Researcher
Poor control of diseases can lead to more and more complications. The lack of social support is one of the key factors leading to readmission.”
#24 Government Official
Service needs of patients- Identifying patient needs improves delivery of careI would say we go mainly through the needs. Like, for example, the end of life care, what are the needs out there for the end of life care?
#15 Healthcare Professional
By trying to identify patient based on needs is a better reflection of the kind of work we do and recognizing the resources we put into.”
#21 Healthcare Professional
To see what kind of services are required for different segments of the population, so segmentation is one way of developing a framework to more coherently decide and identify what are the gaps in terms of care for a particular patient or population segment.”
#16 Government Official