Persuasion is better than punishment when it comes to Covid-19 prevention

Individuals tend to make their own assessment of risk, which made not correspond to the actual risk, and act accordingly. — ART CHEN/The Star

The Covid-19 pandemic is not going away soon; it will be around for months, if not years.

While knowledge about SARS-CoV-2, the virus that causes Covid-19, has increased markedly since the beginning of the year, there is still much that is unknown.

There is no cure for Covid-19.

About 80% of the infected have mild or no symptoms (i.e. asymptomatic).

The remainder have moderate to severe symptoms with some of the latter needing intensive care, and even dying from the disease.

Currently, there is no vaccine against the virus.

Numerous candidate vaccines are at various phases of clinical trials.

When a safe and effective vaccine will be available to the Malaysian population, particularly those at risk, is anybody’s guess.

The current methods of containing the spread of Covid-19 are non-pharmaceutical interventions (NPI) i.e. physical distancing, handwashing and the wearing of face masks.

The effectiveness of NPIs requires uptake by the whole population.

This requires changes in the attitudes and behaviours of the general public.

The Health Ministry has been constantly reminding the public to incorporate into their daily life behaviours that avoid the 3Cs, i.e. crowded places, confined spaces and close conversations; and to practise the 3Ws, i.e. wash hands frequently, wear face masks, and warn yourself and others to comply with its advisories.

The government has made orders under the Prevention and Control of Infectious Diseases Act, and issued standard operating procedures (SOPs) for individuals, institutions, businesses and various organisations.

Yet there are daily reports of non-compliance, despite heavy fines for many, and even jail for some.

Promoting change

An example of confusing messaging: While there is a sign reminding passengers to keep their distance on the seat outside one of the departure gates at KLIA, there are none on the seats inside the gate itself. — Dr MILTON LUMAn example of confusing messaging: While there is a sign reminding passengers to keep their distance on the seat outside one of the departure gates at KLIA, there are none on the seats inside the gate itself. — Dr MILTON LUMThe provision of the facts about Covid-19 seldom translates into a change in attitudes and behaviours, even if the public understand the risks.

This is as most individuals’ perception of risk is usually qualitative and not quantitative – the latter being the way information is conveyed by health authorities and professionals.

The former is predominantly psychological, which includes the individual’s own assessment of the potential risk and likelihood of harm to family and close friends.

The willingness or unwillingness to change attitudes and behaviours depends on what our minds tell us to pay attention to, which is also influenced by what people around us tell us.

Changes can be achieved if they are easy to do and to repeat, thereby increasing the likelihood of creating new habits.

The Societal Experts Action Network (SEAN), an activity of the US National Academies of Sciences, Engineering, and Medicine that is sponsored by the US National Science Foundation, addressed this in their report Encouraging adoption of protective behaviours to mitigate the spread of Covid-19.

The report recommended five habit-promoting strategies, i.e:

  • Make the behaviour easy to start and repeat
  • Make the behaviour rewarding to repeat
  • Tie the behaviour to an existing habit
  • Alert people to behaviours that conflict with existing habits and provide alternative behaviours, and
  • Provide specific descriptions of desired behaviours.

The report provided examples of strategies for increasing compliance with health-promoting behaviours, such as:

> Wearing face masks
  • Establish free or low-cost mask distribution sites convenient for populations most in need.
  • Make mask-wearing instantly gratifying, such as by promoting fashionable masks or providing tips for decorating masks to make them fun to wear.
  • Encourage people to keep masks by their front door so that they develop the habit of putting their mask on with their shoes/coat.
  • Use explicit messages, such as “masks required indoors”, instead of “mask required if it is too crowded”, to convey the desired behaviour.
> Physical distancing
  • Proactively provide “space guides”, such as painted circles six to 10 feet (1.83m to 3.05m) apart in parks or on floors, to remind people of physical-distancing guidelines and help them estimate appropriate distance.
  • Use explicit messages, such as “maintain at least six feet (1.83m) of separation from others”, instead of “physically distance”.
  • Encourage safe alternatives to conflicting habits, such as waving, instead of handshaking or hugging.
> Handwashing
  • Instal easily accessible handwashing or sanitising stations in public areas.

The report also discussed 10 strategies for communicating risk, of which an important one is the use of clear, consistent and transparent messaging.

Inconsistent punishments

Two individuals who did not comply with the Health Ministry’s Home Surveillance Order were charged and punished with a fine of RM8,000 and one day jail; and another with a fine of RM12,000 and five months’ jail.

A deputy minister who did not comply with the SOP on physical distancing was charged and fined RM1,000.

A minister who admitted he did not quarantine at home after returning from abroad, was not charged.

The questions raised included whether he and his party were issued Home Surveillance Orders by the Health Ministry, and if not, why not.

It appears that the provisions of an order of the Prevention and Control of Infectious Diseases Act were not applied to him and his party. Why?

These questions have yet to be addressed.

In any public health emergency – which Covid-19 is – punishments should always be a measure of last resort.

However, any legal requirement has to be applied to everyone.

When the law is applied to some and not to others, it leads to public confusion, and worse still, non-compliance.

This would inevitably lead to difficulties in containing the spread of Covid-19.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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