What this is
- This research explores public perspectives on lifespan, , and () in Singapore.
- Through discussions with 36 participants, the study refines the Healthy Longevity (HELO) framework.
- It identifies key themes related to health definitions, motivations for health behaviors, and awareness of .
Essence
- Participants in Singapore generally understand lifespan and , emphasizing quality of life and autonomy. They express enthusiasm for but raise concerns about lifestyle changes and loss of control.
Key takeaways
- Participants defined health as the ability to function and maintain autonomy, highlighting its comprehensive nature. They sought a balance between longevity and quality of life.
- Community resources and government initiatives were recognized as valuable for promoting health, yet Singapore's competitive culture was seen as a barrier to healthy behaviors.
- While participants were open to , concerns about autonomy and potential lifestyle changes were prevalent. Their preferences indicate a need for personalized approaches in .
Caveats
- Participant recruitment may have introduced selection bias, as those interested in health likely volunteered. This could skew the representation of the general population.
- The study's design did not include follow-ups, limiting the ability to refine findings or explore participant views over time.
Definitions
- Healthspan: The number of years lived in good health, emphasizing quality of life and well-being.
- Healthy Longevity Medicine (HLM): An approach aimed at extending healthspan alongside lifespan by targeting aging processes.
Simplified
Introduction
The gap between lifespan (the number of years lived) and healthspan (the number of years lived in good health) stands at approximately 9 years globally [1]. This disparity is associated with a higher burden of noncommunicable diseases and total morbidity [2], representing a global health challenge and urging the need for strategies to enhance healthspan. While medical advances have increased the lifespan beyond 80 years in many developed nations, the onset of morbidity has not been substantially delayed [3]. This has prompted an integrated longevity medicine approach that treats ageing as both modifiable and preventative, with the goal of extending healthspan alongside lifespan [4, 5]. Healthy Longevity Medicine (HLM) seeks to address this gap and optimise health and healthspan by targeting the ageing processes across the lifespan [6, 7]. Implemented globally in private and public clinics, HLM could offer personalised primary prevention against chronic conditions, emerging as a prominent public health strategy [8]. Despite its implications, the public's response to these practices remains unclear. Survey data reported diverse preferences regarding lifespan and health compromises [9, 10], as well as socio-demographic and ethical concerns surrounding healthy longevity [11], emphasising the complexity of perceptions around health and healthspan.
To promote healthy living and effectively implement HLM practices in accordance with the population's needs, understanding public opinions is pivotal. A conceptual framework has been developed to examine the determinants of public views towards healthy longevity [12]. The Healthy Longevity (HELO) framework examines three main determinants of public views: knowledge (the public's understanding of lifespan, healthspan, HLM, and biological age), awareness (public perceptions regarding the field of HLM), and motivational factors for pursuing healthy longevity (personality, current behaviours, personal values and beliefs, and health-related perceptions). This framework is meant to serve as a foundation for the creation of population surveys and, subsequently, tailored interventions or policy changes promoting healthy longevity.
The framework has been developed based on the scientific literature published on topics related to HLM and needs to be contrasted with the actual views of members of the public for its validation. This study is designed to explore and refine the HELO framework through a qualitative approach understanding public views towards healthy longevity. The aim of the study was to refine and nuance our understanding of: (a) the Singaporean population's understanding of lifespan and healthspan, (b) the factors underlying their motivations for engaging in specific behaviours relating to health, and (c) its awareness of HLM, illustrated through the concept of a HLM clinic.
Methods
This qualitative descriptive study employing a focus group design was approved by the Institutional Review Board at the National University of Singapore (NUS-IRB-2022-877). Written informed consent was obtained from all participants prior to participation.
Participants
Participants were adults aged 21 years or older living in Singapore. Recruitment posters were displayed at bus stops, community centres, and volunteer groups on social media. Maximum variation sampling was used to ensure the sample's diversity regarding age (21–39 years, 40–59 years, 60+ years), sex (male vs. female), and Singapore's four main ethnic categories (Chinese, Malay, Indian, and other). This required the use of additional targeted searches and snowball sampling to find participants with rarer profiles. After thematic saturation was reached (see under Data Analysis), data collection continued to ensure that all the above demographic characteristics were duly represented in the sample.
Procedure
Focus group and individual discussions were conducted between May and September 2023. Participants completed a short demographic questionnaire containing questions on their smoking, drinking, and exercise behaviours. Group discussions included two to seven participants and made up most of the data collection sessions. Individual discussions were arranged for participants with logistical issues, such as time or location conflicts. Group and individual discussions lasted about 1 h. All sessions were organised, moderated, and co-moderated by trained staff. The topic guide (see online suppl. material; for all online suppl. material, see https://doi.org/10.1159/000548994↗) explored public views towards health and followed the core domains outlined by the HELO framework [12]. The explored domains included health-related knowledge, personal values and beliefs, facilitators and barriers to current behaviours, as well as awareness of HLM and HLM clinics. Participants received a SGD 30 voucher for their participation.
Data Analysis
All focus groups were audio-recorded and transcribed using the open-source software Whisper [13], followed by manual proofreading by the research team. Analysis was based on the approach described by Braun and Clarke [14, 15] and used a combination of inductive and deductive thematic analysis [16] to organise the codes within the HELO framework [12]. Four researchers (B.W., E.S., A.S., Z.M.L.) independently reviewed and coded the transcripts for initial codes to identify potential themes. Recurring topics were grouped under common codes until overarching patterns emerged. Researchers held multiple meetings to discuss and consolidate themes and generate new codes for further coding until data saturation was reached (i.e., no additional themes were identified). Data were analysed in Microsoft Excel (version 1808).
Results
A total of 36 individuals residing in Singapore participated in the study, with 32 interviewed through nine group discussions and the remaining four through individual discussions. Participants were aged 49.4 years (SD = 15.9) on average, 19 among them were male, 15 were Chinese, and 13 were employed full-time. More than half of the participants were married (n = 22), had university-level education (n = 22), exercised 150 min per week (n = 27), and drank alcohol rarely (n = 20). Two participants reported smoking. Table 1 summarises participants' demographic characteristics.
Themes were organised from general to specific, beginning with broad themes such as definitions of lifespan and healthspan, as well as personal values and beliefs. Transitions were made to more specific themes, such as resources in Singapore and participants' lifestyle choices. Awareness and views on HLM clinics were presented last as this was the most specific topic explored in the study.
| Characteristics | n |
|---|---|
| Gender, female | 17 |
| Mean age, years (SD) | 49.4 (15.9) |
| Ethnicity | |
| Chinese | 15 |
| Indian | 9 |
| Malay | 5 |
| Other | 7 |
| Highest educational qualification | |
| Secondary or below | 8 |
| Post-secondary, diploma, and professional qualifications | 6 |
| University | 22 |
| Employment | |
| Employed full-time | 13 |
| Employed part-time | 3 |
| Freelance | 7 |
| Retired | 8 |
| Unemployed | 5 |
| Marital status | |
| Single | 11 |
| Married/in a long-term relationship | 22 |
| Divorced/separated | 0 |
| Widowed | 3 |
| Smoking, yes | 2 |
| Frequency of alcohol consumption | |
| Never/rarely | 20 |
| Once a week | 14 |
| Several times a week | 2 |
| Exercised ≥150 min/week | 27 |
Knowledge of Lifespan and Healthspan
Understanding of Lifespan
Participants provided varied conceptualisations of lifespan, reflecting both quantitative and qualitative aspects of the terms. Those who perceived it more quantitatively described it as the number of years lived regardless of health status:
Other participants integrated qualitative aspects, such as the experience of happiness and well-being, into their definition of lifespan, essentially defining lifespan as healthspan:
Understanding of Healthspan
Participants generally associated healthspan with the number of years spent in good health. Participants acknowledged that achieving perfect health throughout life is unattainable, recognising common minor ailments as part of human life:
Healthspan was associated with quality of life, and participants also emphasised its subjective nature as health can vary over time and between individuals:
For some, healthspan encompassed a sense of stability, autonomy, and the ability to maintain control over one's life without needing assistance from others:
The concept of healthspan was new to some participants, who expressed that they had not heard of it before. Their interpretations were guided by the context of the discussion:
Factors Underlying Motivations towards Healthy Longevity
Personal Values and Beliefs regarding Health and Sickness
Health was primarily conceptualised as the ability to function and maintain a sense of normality. Participants emphasised autonomy and the capacity to care for oneself without reliance on others as a core component of health:
Other participants defined health as the absence of pain, sickness, and restrictions, drawing from personal experiences of injury and recovery:
A more holistic perspective was provided by participants who associated health with happiness and fulfilment, reflecting a definition of well-being beyond physical health, which also encompassed mental and social health:
Personal Values and Beliefs regarding Desired vs. Expected Lifespan
When prompted about their desired lifespan, participants provided a wide range of preferences, citing ages from 60 to 170 years. Some participants provided benchmarks instead of a specified age, such as living up to the national average, living "as long as possible," or living long enough to see their grandchildren. Participants emphasised that their desired lifespan was contingent on several factors, such as maintaining cognitive function, avoiding being housebound, and not becoming a burden to others. The importance of quality of life was a recurrent theme:
When prompted about their expected lifespan, participants provided a range of ages 65–135 years, attributing their expectations to personal factors such as sedentary lifestyles or family health history. Some participants expressed the belief that life expectancy can be unpredictable despite one's efforts to maintain a healthy lifestyle:
Perception of Health-Related Resources and Barriers in Singapore
In their everyday life, participants were aware of resources in Singapore to help them maintain a healthy lifestyle. At a national level, participants were broadly aware of government health campaigns and digital platforms, such as Healthier SG [17], Active SG [18], HealthHub [19], and Healthy 365 [20], which were commonly utilised by older participants:
At the community level, neighbourhood infrastructures and local organisations were viewed as promoting social, physical, and mental health. Organised activities, such as brisk walking, helped foster a sense of belonging and social interaction:
A younger participant noted that these communal spaces enabled her older neighbours to engage in social and physical activities, enhancing community bonds:
Barriers to utilising these resources included external factors such as weather conditions, as well as restrictions and regulations for using facilities. While many participants acknowledged the government's efforts in providing resources for healthier living, they also highlighted the need for resources that address the competitive nature of Singapore's work culture. Participants expressed a desire for more accessible financial and logistical support, including health check-ups, family bonding events, and meaningful engagement activities for older adults. Concerns about the affordability of healthcare and its impact on peace of mind were mentioned:
Facilitators of Healthy Behaviours
Participants described engaging in diverse health behaviours, including physical exercise (e.g., running, swimming), mental health practices (e.g., mindfulness, gratitude exercise), self-care (e.g., connecting with friends, spending time in nature), and healthy eating. Key facilitators of these behaviours emerged, with common internal facilitators being effective time management and incorporating health activities into daily routine highlighted. External facilitators, such as participation in government-promoted health initiatives, were identified. Participants recognised the importance of community programmes in promoting health behaviours, such as healthier eating habits:
Barriers to Healthy Behaviours
Participants nonetheless identified multiple barriers to adopting health behaviours, including lack of time and fatigue. One participant felt that the increasing demands of a professional career, over-emphasis on structured achievements, and the stress imposed by Singapore's competitive work culture kept individuals from actively engaging with Singapore resources that maintain healthy behaviours:
Affordability and accessibility of unhealthy food, limited motivation or enjoyment to exercise, age-related health limitations, and the impact of family responsibilities were also highlighted. One participant described how balancing family duties and personal health goals can be challenging:
Awareness of HLM
First Impressions of a HLM Clinic
Participants reported unfamiliarity with the concept of a HLM clinic. Participants associated the clinic's goals with broader health initiatives they had encountered previously. After providing a brief description of a HLM clinic, those who responded positively to the idea of the clinic highlighted several perceived benefits, including receiving personalised health feedback, having a structured plan for maintaining long-term well-being, and gaining a deeper understanding of their current health status. Participants also recognised the potential role of the clinic in addressing the healthspan-lifespan gap, seeing it as a proactive measure for managing chronic diseases and promoting a healthier population. One participant emphasised the importance of early intervention:
Some participants expressed ambivalence or concerns about the clinic, raising issues such as potential information overload, uncertainty about which health advice to follow, intervention costs, and the novelty of the intervention plans. Participants feared the possibility of receiving unexpected health diagnoses and the impact of lifestyle changes. This uncertainty was captured in the following comment:
Expected Interventions at a HLM Clinic
Participants showed varying levels of understanding regarding potential interventions and assessments aimed at promoting health. Participants named specific assessments they anticipated would be part of the clinic's services, such as bone density scans, genetic testing, and personalised advice on diet and exercise. Others explicitly stated that they did not wish pharmaceutical interventions to be the primary focus of the clinic. Participants expected a more general check-up or expressed uncertainty about what to expect at the clinic:
Willingness to Visit a HLM Clinic
Participants were open to the idea of visiting the clinic, citing reasons such as the opportunity for personalised feedback on health, planning for the future, and general curiosity about the clinic. Participants emphasised the importance of minimising logistical barriers, such as long queues and inconvenient clinic locations. Affordability also emerged as a significant factor, with participants advocating for subsidies or government support to ensure accessibility. One participant remarked on the need for public sector involvement:
Participants who expressed reluctance to visit cited concerns about feeling controlled, preferring to let nature take its course, or feeling confident in their ability to manage their own health without external intervention. One participant expressed this sentiment:
Discussion
Middle-aged individuals residing in Singapore demonstrated a strong understanding of lifespan and were mostly familiar with the concept of healthspan. They defined health comprehensively, emphasising autonomy and control over their behaviour. In terms of factors underlying their motivations for engaging in health behaviours, participants recognised the value of community resources and government-led health initiatives, acknowledging the potential to improve not only physical health but also social and mental health. Participants identified Singapore's achievement-oriented culture as a barrier and noted a lack of time to adequately care for their health. Although participants were not aware of HLM, they expressed enthusiasm about its potential to extend healthspan. Concerns about the need for lifestyle changes and the possibility of losing control over their way of life were recurrent when considering visits to a HLM clinic. These findings highlight the importance of individual values and priorities in shaping motivations towards healthy longevity.
Participants had an overall strong knowledge of the lifespan and were also familiar with or could interpret the meaning of healthspan. Participants tended to incorporate their own values into their definitions of lifespan and healthspan, which sometimes also encompassed quality of life. This echoes a holistic understanding of health as physical, mental, and social health, which was repeatedly brought up during discussions. Members of the public in Singapore adopting such a biopsychosocial perspective could have several explanations. First, mental health awareness is increasing in the world, with mental health and well-being gaining more visibility in the mass media and on social media [21]. Second, Asian cultures have an inherently more holistic approach to health than Western medicine [22]. Finally, whereas somatic medicine is well subsidised in Singapore, mental healthcare remains less accessible, making it a potentially stronger health-related concern [23].
In contrast to a broad understanding of health, there were also participants whose definition of health focused on a specific aspect, such as retaining one's level of functioning. Some participants' perspectives on ageing reflected a similar mindset: not necessarily wishing for a long life, but on maintaining the values and activities most important to them, such as spending quality time with their grandchildren or contributing to society. Drawing from Self-Determination Theory, these perspectives could be interpreted as autonomous motivations, which are intrinsic to individuals or result from well-integrated external sources (e.g., social norms a person has internalised in their own system of values) [24]. Extending this emphasis on autonomy in one's health trajectory, health locus of control offers a complementary perspective. Health locus of control refers to the belief that health outcomes are determined either by one's own actions (internal) or by external forces such as chance, fate, or the influence of others (external) [25, 26]. This concept could help explain the findings in the study further, as participants perceived their health outcomes as largely determined by their own actions rather than external factors. Together, these perspectives highlight the role of personal responsibility, life choices, and engagement with available resources in shaping motivations towards healthy longevity.
Participants also expressed enthusiasm for external sources of motivation, such as national healthcare apps, community activities, and government-led programmes. Instead of experiencing them as sources of controlled motivation, i.e., motivations solely driven by external rules and rewards not aligned with one's individual values [24], participants appeared to view these infrastructures as genuinely valuable resources providing opportunities to reinforce social cohesion and connectedness. This aligns with other Singaporean studies finding that Singaporeans trust their government with respect to health advice [27] and tend to align their perspectives on health with government-led information campaigns [28]. Such receptivity may be explained by Singapore's collectivist cultural orientation and high level of trust in public service institutions, surpassing other Confucian Asian countries such as China, Japan, Hong Kong, Taiwan, or Vietnam [29]), independently of the ethnic background of Singaporeans [30]. Higher levels of collectivism and trust are associated with a higher likelihood of individuals compliance with health interventions perceived as beneficial to the community and aligning with social norms [31]. This aspect of the local culture can be leveraged for the promotion of HLM. Yet, this finding also highlights that public trust in the government may vary considerably between countries and needs to be evaluated in each nation when investigating views towards HLM or the impact of any HLM-related policy.
These observations can be situated within the broader empirical literature linking culture with health behaviours. Emerging evidence from Asian and cross-national studies, notably in the context of COVID-19, underscores how cultural orientations and trust jointly shape responses to government-led health initiatives. For instance, research across eight Asian countries found that social norms explained more variance in vaccination intentions in "tighter" cultures such as Indonesia, Vietnam, and Singapore, where there is a lower tolerance of social norm deviance than in "looser" cultures [32]. Comparative work in Mainland China and Taiwan showed collectivist interpretations of the pandemic – which reflected beliefs that the pandemic is a national issue as opposed to a personal issue – positively predicted acceptance of stringent preventive measures. In addition, trust in government was a strong positive predictor of acceptance [33]. Complementing these findings, a study of 46 countries found that uncertainty avoidance, individualism, and long-term orientation shaped public support for vaccination and quarantine mandates, of which the latter two moderated how fairness beliefs translate into policy support [34]. Taken together, these studies show that public reception of preventive health interventions reflects a variety of cultural orientations, including those that often characterise the Singapore public.
However, participants also highlighted the downsides of Singapore's achievement-focused culture, which they found incompatible with a satisfactory work-life balance or with sufficient time to lead a healthy lifestyle. Consistently, both perceived time pressure and objectively long working hours have been identified as barriers to health behaviours in prior studies [35, 36]. These factors should be considered and addressed by treatment plans provided in the context of HLM.
Finally, while Singaporeans acknowledged the appeal of HLM, their primary concerns about treatment in such a clinic included the fear of losing control over their health or of having to change their lifestyle too much to comply with the clinic's recommendations. Similarly, a sense of control and accomplishment were found important enablers for long-term adherence to health behaviour interventions in chronically ill patients [37]. This supports the need for HLM to generate autonomous motivations by aligning health behaviours with each individual's preferences and values as much as possible. Affordability and institutional support are also key considerations as Singapore's healthcare system combines personal responsibility with government-led subsidies and financing schemes to ensure access to care [38].
Strengths of the present study include its focus on investigating a yet scarcely explored public health question, namely, public views towards HLM, as well as its diverse, multi-ethnic sample, encompassing adults of all ages, and from diverse backgrounds. Singapore provides a unique location to conduct such as study as it mixes Asian and Western cultural influences, while also having high levels of variability in terms of culture, living habits, and activities [39]. The sample was intentionally heterogeneous to capture Singapore's diverse demographics, while remaining homogeneous in terms of national identity. Future research could explore perspectives in specific demographic subgroups to inform more tailored health strategies.
Regarding this study's limitations, participant recruitment may have been subject to selection bias, as likely only individuals interested in health, healthy longevity, or HLM volunteered to participate. For instance, this may explain the low proportion of smokers in the sample. Furthermore, participants who had time to spare for the discussion may have had more free time or an overall more comfortable quality of life than many others in Singapore. Finally, the study's design did not include any follow-ups with participants, making it impossible for the study team to refine some of the findings by revisiting them with the same participants.
The present work augments existing efforts to understand public views on healthy longevity, such as the HELO framework. Most elements mentioned by participants mapped well on the framework's initial structure and included constructs. Certain elements included in the framework, such as ageism, were not explored by participants. The present study highlighted a strong focus on mental and social aspects of health in the Singaporean population, which was not explicitly reflected in the HELO framework. These aspects will need to be investigated quantitatively, ensuring the inclusion of related questions in the HELO population survey. It also found the need to retain autonomy, remain self-reliant, and in control of one's health and life choices to be important factors for Singaporeans when considering any future plans or behavioural changes. These values may be particularly important to address during HLM interventions or when promoting HLM clinics.
Statement of Ethics
This study was reviewed and approved by the Institutional Review Board at the National University of Singapore, Approval No. NUS-IRB-2022-877). Written informed consent was obtained from all participants prior to participation.
Conflict of Interest Statement
Andrea B. Maier was a member of the journal's Editorial Board at the time of submission. The other authors declare that they have no competing interests.
Funding Sources
A startup grant from the National University of Singapore (Grant No. A-0009805-00-00) supported this research.
Author Contributions
B.W., A.S., E.S., E.J.H., P.A.O., L.I., S.R., and A.B.M. contributed to the study conceptualisation and methodology. Investigation and project administration were led by B.W. and supported by E.S. Formal analysis was led by B.W. and A.S. and supported by E.S. and Z.M.L. The first draft of the manuscript was written by B.W. and supported by A.S. This project was supervised by A.B.M. All authors commented on previous versions of the manuscript and read and approved the final manuscript.