Study design

This study took a qualitative approach to gain in-depth insights into young adult workers’ perceptions and experiences of health promotion efforts. Qualitative data collection can be flexibly used to provide detailed, in-depth descriptive data that can help identify new aspects and patterns of social interactions in their context, such as environmental and social structures and nuances in everyday life which quantitative data does not capture [30, 31]. While in general, young adults may encompass teenagers to the mid-30s, ‘young adults’ in this study refers to those in their early 20s to mid-30s. The research was part of a year-long focussed ethnographic study [32] exploring interactions between everyday lives of Singaporean young adults, and their food and health practices and implications for health-promoting practices. Other papers have been published from the same data set [28, 33].

Participants engaged in in-depth, semi-structured interviews, provided socio-demographic information, and answered standardised questionnaires on their time use and physical activities. The lead author conducted participant observation and wrote fieldnotes of public dining occasions which were used to inform her understanding of the information gained during interviews (see details below).

Recruitment

A sample of 15 men and 18 women between 23 to 36 years old took part in the study. All participants were Singaporean citizens or permanent residents who had lived in Singapore and worked full-time or at least 38 hours per week at the same job for at least one year. Participants were recruited between June to October 2016 through two approaches: specifically, via purposive sampling and snowball sampling. Purposive sampling is a strategy use to deliberately seek out and recruit participants of appropriate age with lived experience to provide insight into the studied phenomena [34]. JL contacted research participants in previous studies conducted by the National University of Singapore (NUS) who had consented to be contacted for further research, and friendship networks, to recruit participants who fulfilled the criteria described above at arms-length. After initial contact, potential participants were e-mailed study materials [28]. Prior to participating in the interview, all participants were fully informed regarding the study and their right to refuse to answer any questions and withdraw at any time. Written informed consent was obtained from all participants. There was no prior relationship with the study participants. The first cohort of participants were asked to suggest other potential participants, who were then contacted to recruit in a “snowball” approach [30]. Of the 33 participants, 17 were recruited through the NUS cohort and 16 through JL’s contacts’ acquaintances.

Data collection

The lead author, a female postgraduate student, trained in qualitative methodologies, with Asian heritage and of similar age to participants, collected all data for this study. She had previously lived in Singapore and had developed interest in Singaporean culture. Based on work by Eckermann [35], Hubert [31, 36], Mack [30], Bisogni [37–39], Blake [40], and Jastran [41], a semi-structured interview guide was developed and deployed flexibly to gain insight into participants’ understandings and beliefs related to perceptions of health; self-rated health; self-reported height and weight; food and dietary practices; perceptions of the foodscape; work and work culture, inclusive of working hours; time usage; physical activity; and broader socio-cultural influences such as family, friends, social media elements and government initiatives. Interviews were conducted in English along with a short quantitative questionnaire to capture demographic information; a global physical activity questionnaire; and a three-day time-use diary to record time spent on daily activities like cooking, cleaning and working. Participant observation occurred throughout a year of fieldwork focusing on food-related spaces such as hawker centres (a Singaporean-style food court).

Face-to-face interviews of approximately one hour were conducted at public locations and audio recorded. Field notes were taken after each interview. Interviews were conducted until data saturation occurred when no additional novel data were found [42]. The concept and practice of data saturation were discussed among all authors. None of the recruited participants dropped out of the study.

Data analysis

Interviews were transcribed and the lead author read and reread the transcripts for familiarisation. To minimise the burden on participants member-checking was not used. Transcripts were analysed using Atlas.ti 8 Windows to facilitate the coding process. An inductive and deductive thematic analysis was used [43]. An inductive approach identifies relevant and informative text segment from transcripts which are then coded which may identify new information of the studied phenomena. A deductive approach attaches codes to text that reflect existing literature on the subject matter and is in line with a focussed ethnographic approach [43]. A tentative coding book was developed with initial codes identified from existing literature and novel codes identified from the transcripts. The codebook was then updated and amended several times as more transcripts were coded and new codes were identified [44]. All authors discussed key themes and concepts forming the coding framework. The codes were grouped into higher level categories to identify themes and reviewed further [43]. Quantitative data from questionnaires were analysed using Microsoft Excel to summarise descriptive demographic, work, and physical activity information. Metabolic equivalents (METs) were calculated following the GPAQ analysis guide [45]. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist was followed for this study [46] (S2 Table).

Ethical approval

Ethical approval was attained from the Australian National University Human Research Ethics Committee (Protocol: 2015/813) and the National University of Singapore Institutional Review Board (B-16-076). To protect their anonymity and maintain confidentiality, pseudonyms were assigned or provided by participants. Upon completing research activities, participants were offered a SGD20 supermarket voucher to thank them for their time.

Subjective and self-rated health

Health-related behaviour change is usually driven by a perceived need to initiate new healthy habits or quit existing unhealthy ones. The health belief model suggests that triggers resulting in the awareness of susceptibility or severity of a condition can lead to behavioural changes [49, 50]. Consequently, to consider young people’s acceptance and adoption of health promotion campaigns it is helpful to understand their perceptions of their health. When participants were asked to rate their health out of the following: poor, fair, good, very good, and excellent, nine (27.27%) participants rated their health as poor or fair; most, 16 (48.48%), rated their health as good; and eight (24.24%) participants rated their health as very good or excellent. Two men, but no women, rated their health as excellent.

Considerations that formed the basis of how participants rated their health, revolved around their weight, existing health conditions, and the amount of activities perceived as health-promoting. For instance, Laila (female, 23, nanny, living with partner and housemate, never married) rated herself as having poor health due to a lack of time from work and studies to monitor her weight which had increased. Even participants who rated their health as fair generally thought their health could be better if they actively incorporated one or more health promoting activities such as exercising more and eating healthy foods. For instance, Xin Yi (female, 29, editorial staff, living with parents, never married) thought she should eat more fruits and vegetables. Men who rated their health highly usually mentioned a combination of exercise frequency, healthy eating, and a lack of existing medical conditions. Meanwhile, overweight participants acknowledged that they should be aware of their health habits.

Generally, participants’ BMIs did not align with their self-rated health. A typical example was when a male participant considered himself to have good health although his BMI indicated that he is overweight. He attributed this to muscle mass. Meanwhile, some women rated their health as good or very good despite being classified as underweight. Many women described better health in the context of lower weight and a few women countered weight gain by limiting their food intake, including having only two meals a day. Participants who had a family member with health conditions were somewhat more health conscious and proactive. Older participants were more concerned about their health. Some participants reported phases of eating healthy and exercising due to embodied feelings or their appearance. All participants, regardless of their self-rated health, felt they could improve or incorporate more health-promoting habits to be healthier.

Engagement with health campaigns

Government-sponsored health campaigns (S1 Table) contributed somewhat to participants’ ideas of health and health promoting practices. Participants frequently named the Healthier Choice Symbol and the ‘Ask for’ programme when asked about their experience with health campaigns. The ‘Ask for’ Programme encourages consumers to ask for more vegetables and less oil, salt, sugar and syrups when eating outside of the home (Health Promotion Board 2017). Participants commonly repeated government-endorsed health information during interviews. However, participants said these had a limited impact on them. For example, most were aware of the Healthier Choice Symbol, but it did not strongly influence what food products they purchased. Laila exemplified a commonly held view (female, 23, nanny, living with partner and housemate, never married) saying, “it’s there, but it’s useless, you know? It’s like “yeah yeah I know”, you know you can ask anyone… but they will never do it”. Alex (male, 28, internal auditing, living with parents, never married) explained it this way “I’m aware of [healthier] choice symbols…it doesn’t affect how I decide… I just eat what I want to, so I just don’t really look up for Healthier Choice Symbols”.

Other participants perceived their diets to be healthy enough particularly when incorporating vegetables into food habits. Hence, Healthier Choice Symbols and related healthy diet campaigns made little difference to them because they felt confident in their knowledge about healthy food.

…my diet is actually is pretty, pretty much healthy because I don’t take a lot of oily stuff? Or those with a lot of fats… I just don’t like it… and I’m more of the soupy kind of person so I don’t really take a lot of fried food, barbecue food… So I can quite safely say that I can ignore all these Healthier Choice [Symbols]? Cause anyways, I take a lot of grains… and I’m confident to say I eat a lot of fruits… . –Andrea, female, 24, human resources, living with parents and sibling, never married

The purchase of healthier items for cooking and consumption at home was irrelevant to the substantial proportion of participants who lived in the family home and were not involved with purchasing groceries and food preparation. Conversely, participants with children who cooked at home were more likely to choose healthier items such as cooking oils displaying the Healthier Choice Symbol.

Workplace-based health promotion is a key element in the government’s strategy. The government provided grants for health promotion activities conducted by businesses [18]. Larger and wealthier private and public sector workplaces offered a variety of health promotion activities such as annual health checks and organized activities including optional workshops, seminars, and exercise classes while some participants worked in multinational companies that provided comprehensive workplace health promotion as part of the work package.

One of the well-received health-promoting activities in larger private and public sector workplaces was the annual health check-up which usually included measurements of BMI, waist circumference, blood pressure, fasting venous blood glucose and lipid profile. Additional check-up items were sometimes provided by companies or self-paid by participants or their private health insurance. If participants worked in medium enterprises, they self-paid for health checks, which was a major disincentive. Self-employed participants and participants who worked in small companies did not recall any health-related initiatives in their workplaces.

People generally found the annual health checks helpful. For example, Dhruv (male, 29, public service, living with flatmates, never married), changed his diet when a complimentary annual workplace health check showed he had elevated cholesterol levels. For Uzma, she transitioned to a healthier lifestyle after seeing her weight increase and her doctor’s comments.

[I] was close to [60 kgs], so that was like a wakeup call, so that’s when I decided to exercise… [and] I think it was cholesterol, was on borderline high, and the doctor mentioned that I need to change my diet, yeah so that was also when I decided to, need to change… I was like most young adults when they first start out in their twenties, they think like " my twenties can last another 10 years"- Uzma, female, 34, property executive, living with a parent, never married, also has family health conditions that contributed to being health-conscious

Uptake of workplace annual health checks was dependent on whether participants were allocated time during working hours (as opposed to needing to take personal leave) and the proximity of the healthcare service. Depending on how comprehensive the health checks were, some could take up to half a day. Some participants chose to forgo health checks because they were fearful about what might be found or were disinterested. In addition to health checks, some workplaces offered health-related talks and workshops, but attendance was based on participants’ time and interest.

These talks could impact health-promoting activities amongst participants. For example, one woman recounted how a hands-on workshop on healthy cooking and reading nutrition labels at the supermarket helped her make healthier choices for herself and her whole family. After the workshop, she switched to lower saturated cooking oils for home cooking and purchased healthier items, aided by the Healthier Choice Symbol health campaign.

Often, workplaces provided fruit baskets. However, this did not seem to increase participants’ consumption of fruits as many did not like the offered fruit or could not be bothered to eat it. Regarding physical activity, some participants mentioned corporate sports days or organised group exercise events. Group activities tended to focus building and maintaining social bonds in the workplace. Again, participation was dependent on existing bonds within the workplace. Lim (male, 33, human resources and statistics analyst, living with a parent, married) recalls successfully encouraging a group of co-workers to go on weekly runs with him which stopped when he was relocated. Meanwhile, participants tend to avoid group activities attended or organised by bosses as they did not want more opportunities to talk about work or did not enjoy their bosses’ company. At Andrea’s workplace, the bosses led by example in taking a compulsory stretch or walk break at a designated time every day for about five or ten minutes.

Because it wasn’t top-down initially, it was by my team… but no one seemed to do that because they can … so now the boss says “[designated time] o’clock”, everyone is like “ok [designated time] o’clock”. So, our bosses walk and talk, they walk the talk.–Andrea, female, 24, human resources executive, living with parents and sibling, never married

Most participants had some awareness of the physical activity related health promotion campaigns, although they too had little long-term influence. For instance, Kenneth (male, 27, banking, living with a grandparent, parents, sibling, and helper, never married) remarked that there has been an increase in marathons organised by the government and commercial entities, while Rashid (male, 26, accountant, living with parents, never married) recalled seeing shopping mall workouts, however, they rarely engaged with these events. The ActiveSG promotion (S1 Table) received similar reactions. For instance, Nadia (female, 23, pharmacy technician, living with parents, never married) and her colleagues exercised at the facilities offered by ActiveSG after work, but stopped after a few months with Nadia remarking “So all our energy has been drained [at work], we just want to go home and rest”. Other participants found the location of ActiveSG facilities inconvenient. Some participants and their families and colleagues engaged with the National Steps Challenge of their own volition or were encouraged by their workplaces, although how long they engaged with the challenge depended on whether they lost the steps tracker and their level of interest.

Group physical events after work or on the weekends were less popular due to workers’ social and family commitments. Participants who were married, especially those with children, rarely took part in after-work activities due to household tasks and childcare. Some employees had access to a gym at work, which may even be within a five-minute walk. While some participants utilised the gym during lunchtime, most did not as they may prefer socializing with co-workers over lunch, felt it was inconvenient to shower and change during the workday or felt lunchtimes were limited in duration to accommodate exercise.

Complexities in adhering to healthy eating messages

Few unusually health-conscious participants met the daily dietary requirements. Other participants consistently expressed they were aware of messages about healthy eating but generally did not follow them. Instead, many followed the examples set by family and friends, social media, and the internet. They generally consumed at least some fruits or tried to consume less seasoning, salt, and oil. Their reasons for not complying with health messages ranged from lack of self-control, disinterest, dislike of “healthy” foods and lack of time. They found it easier to meet their daily requirements of vegetables than fruits or to reduce their intake of unhealthy food.

What could I realistically do… I think if I can’t supplement myself with very healthy and good food then, what I can do is cut down on unhealthy food. I think that kind of balances it off right? Like instead of always snacking on chips and all like that, I could eat something else better, I guess?- Adeline, female, 28, account management, married but living at home with parents

Many participants often ate meals at home with their family, so had little control over food purchasing and preparation which was usually done by parents or grandparents. Although home-cooking is generally considered healthier than commercially prepared food [51], some participants blamed home-cooked meals for their weight. The reasons ranged from household preferences for heavily seasoned foods and eating more than needed because the food was tasty and cultural practices where family members show care through providing food.

There’s a lot of vegetables in Malay cuisine but it’s always cooked in chili or curry, it’s never like cooked by itself. Or otherwise it’s like deep fried, like… not even in batter but it can just be fried…but the thing is that if [mum]’s the one cooking, she usually doesn’t listen, she’s just like "but you know, your dad likes it" so … "Don’t complain, you’re not the one cooking"–Sana, female, 23, financial public relations, living with parents and siblings, never married

Conversely, when participants took an active role in meal preparation, they were more likely to increase their fruit and vegetable intake.

I make sure that every day, we eat fruits, and also the vegetables, if I don’t get it during lunch, I will, I make sure that I get it, a big serving, during dinner. Because we cook ourselves, so we can cook whatever we like. –Hui Ting, female, 36, chemist, living with spouse and three children under five, married

It was common for participants to eat at least one daily meal outside the home, where they have minimal control over food portion sizes. Despite government health campaigns to improve the healthfulness of food in hawker centres, participants frequently ate meals with little or no vegetables. At hawker centres that participants frequented, meal expenditures were usually below SGD5, which they considered affordable, however, extra serves of vegetables increased the cost of food and depended on whether the patronised food stall served vegetables.

Hawker stalls tend to sell a small menu of rapidly produced, inexpensive food. Participants expressed reluctance to ask for meals with extra vegetables or less oil and seasoning to avoid disrupting the hawkers’ food preparation and serving practices, especially during rush hours.

Compared to hawker centres, food outlets that served healthier foods tend to be considered beyond the daily budget for meals. Uzma recalled her experience regarding the cost of healthy food options where minimally processed foods are available:

When you go outside to buy, they have those special shops that sell all healthy food. Yea but when I look at the price, it’s actually very expensive, like one plate or one box of what they call clean lean meat or whatever, it can cost like SGD19 –Uzma, female, 34, property executive, living with a parent, never married

Cultural meanings attached to the meaning of healthy foods sometimes evoked thoughts of ‘sick people food’, meaning it was expected to be a tasteless, restricted diet or as one person said: “Healthier food always tastes like crap.”. These perceptions applied to the healthier options recommended by Health Promotion Board campaigns.

Ok there are hawker stores that have these stickers on their glass boards. Ask for more vegetables, ask for less sugar, less cholesterol… Why would I want to? … If I ask for less sugar, less salt, my food will taste not so good? If I ask for more vegetable, I will be charged for it.- Lim, male, 33, human resources and statistics analyst, living with a parent, married

Difficulties in adopting physical activity guidelines

Overall, participants had minimal engagement with health promotion campaigns promoting physical activity. Despite government efforts to provide well-paved streets and sheltered walkways, Singapore’s hot, humid climate deterred participants from outdoor activities, especially when in work clothes. People were concerned about their appearance at work where tidiness is valued. Despite government efforts to encourage cycling by promoting bicycle lanes and facilitate cycling to work by adding showers in workplaces, only a few participants cycled during their leisure time and to travel to locations near their homes.

Many participants had adequate incidental activity, although most spent long periods of time being inactive. During the weekdays, they spent most of their time either sitting at a desk at work (daily average 8.7–9.0 hours), mostly sitting or standing during commutes (1.9–2.4 hours), or relaxing alone during leisure time such as looking at online content (0.9–1.1 hours) [28]. Work-related fatigue and exhaustion led participants to unwind and de-stress by socialising with family and friends, often over meals, or going on the internet. Participants with young children had less time for physical activity. However, a few participants exercised to gain and maintain a certain level of fitness or to reduce stress. They ran, exercised at home, or joined private gyms and classes. Some made use of workplace exercise events and facilities and public facilities to engage in physical activity with their friends. Some men proactively took part in physical activity, particularly in the preceding months, to pass their annual post-conscription fitness tests.

Limitations

The findings of this study do not reflect the conditions of all working young adults in Singapore or in non-metropolitan areas. Due to small sample sizes, qualitative research results cannot be generalised to broader populations. Instead, this study provides an understanding of why people of this age, working in these conditions, struggle to embed and maintain health promoting practices in their daily lives. These findings may well be relevant to other similar populations. Our participants were primarily white-collar workers and there were fewer participants who were obese than in the general population [1]. This could be due to self-selection bias as the study may have appealed more to young adults who are health-conscious. Nevertheless, the study recruited participants from a breadth of jobs, industries and workplaces to provide insights into a range of workers’ experiences of workplace health promotion. Future research could further investigate social and cultural influences impacting on population nutrition and physical activity over the life course.

Overall, this study provides insight into, and complements existing literature on, young adults’ engagement with public and workplace health promotion efforts and their perceptions of health in an urban Asian context.