Changing New Normal Lifestyle in COVID-19 Pandemic: Sabah, Malaysia

Introduction

The COVID-19 pandemic threatens the world in the beginning of the 2020 [1,2]. The second wave of the Covid-19 infection in Malaysia during the 2^nd week of March which was due to a mass religious gathering involving over 10,000 people from South East Asian countries in a confined area where a lot of close contacts took place, was the turning point for Malaysia when positive cases rocketed as a consequence of sporadic cases of transmission within local community all over Malaysia [3-5]. The need from that time was to break the chain of the virus and to further contain the spread of the virus especially among the vulnerable groups like the elderly people, individuals who have underlying chronic diseases, and also children population. On 10^th April 2020, a further extension of the Movement Control Order (MCO) in the country was announced at that time. There were reminders from Ministry of Health endlessly to adapt to the new norms in the long run, for at least the coming 2 years in order to prevent the formation of new clusters.

Methods

Preventive measures for developing health promotion intervention activities using PABCAR Health Promotion model [6] was applied in preventing spread of Covid-19 infection at State level.

P-Problem identification

The second wave of the Covid-19 infection in Malaysia during the 2^nd week of March which was due to a mass religious gathering involving over 10,000 people from South East Asian countries in a confined area where a lot of close contacts took place, was the turning point for Malaysia when positive cases rocketed as a consequence of sporadic cases of transmission within local community all over Malaysia [3-5]. The need from that time was to break the chain of the virus and to further contain the spread of the virus especially among the vulnerable groups like the elderly people, individuals who have underlying chronic diseases, mental illness or disabilities, pregnant ladies and also children population. Besides that, lacking in hygiene practices as well as awareness were noted as major issues of the rapid spread of Covid-19 diseases all over the world, more so in developing countries when people tend to take things for granted and disregard the importance of basic proper hygiene practices.

A-Amenability to change

i) Education and behavioural

a. Social distancing: Due to the uprising trend of the positive cases as well as morbidity and mortality among the vulnerable groups, the government had no choice but to announce the implementation of Movement Control Order (MCO) beginning from 18^th March 2020 in order to control the spread of the disease. Social Distancing had been the key component in regards to containing the virus [7]. The need of closing the schools, colleges, universities, offices, malls as well as prohibiting any large events or gatherings where people will assemble was the fundamental thing to do [5]. Even with the Conditional MCO (CMCO) nowadays, community are constantly advised to maintain a safe distance of at least 1 metre apart at all times.

b. Avoid gatherings: Besides that, gatherings or big events are still strictly prohibited at the moment. Hence, events like meetings, conferences and trainings are mostly resorted to online basis to avoid any unnecessary close contact. Even though the government allow hosting up to 20 guests during the recent Hari Raya celebration and some hosts even took the extra mile of checking the temperature and sanitizing their guests before allowing them in, the Ministry of Health strongly advised to avoid such gathering especially if the house is considered a confined space [8]. This is to reduce the risk of having a guest who may have contracted the virus yet was asymptomatic until later stages which will then lead to a domino effect or a new cluster where all the other guest including the host would then have to go through examination and have to be quarantined for their own safety as well.

c. Life style changes: Furthermore, wearing face masks is now part of the new norm as this step will help to prevent the spread of the virus [9], more so especially if the individuals who were present with symptoms yet delayed their check-ups. Individuals are also reminded to sanitise regularly as well as constant hand washing while practising good personal hygiene especially when we faced the risk of contracting the virus through any sort of surfaces may it be door handles, escalators handrails, elevator buttons, staircase railings or even the products we are buying. Some individuals had even taken the extra step of wearing gloves while purchasing their items [5]. Community are also reminded to clean and disinfect frequently touched objects and surfaces including our mobile gadgets as well as laptops and computers. Most shops and malls had made it compulsory for temperature monitoring, wearing of face mask and sanitizing your hands before allowed entry into the respective premises. Besides that, community are also advice to practise appropriate cough etiquettes by coughing or sneezing in a bent elbow, not into their hands as well as closing their mouth and nose with tissues if available [10]. The common social practice of shaking hands and hugging are no longer advisable as part of the steps to break the spread of the virus.

ii) Regulatory and policy

a. Travel restrictions: Since the implementation of MCO and now CMCO, a few regulations and policy were implemented in order to prevent the spread of the virus which include travel restrictions internationally and for domestics [7,11,12]. Even though traveling is now allowed interstate for work and family reasons, community are still compulsory to follow the stringent rules implemented which include to have their self-assessment check-up and application to the police department for interstate travel with supporting documents. Some states like Sabah had also made it compulsory for travellers coming in to Sabah to undergo Covid-19 swab test at least 3 days prior to arrival [13,14]. Those with negative results would not need to be quarantined but those who did not have the swab test done, would warrant the 14 days' quarantine either in quarantine centre or home-quarantine if applicable. This is to prevent any new clusters from travellers coming in especially those who are from 'hotspot' high risk areas. During the initial phases of MCO as well as the Hari Raya celebration, a lot of roadblocks were set up and summons were issued to stubborn citizens who disobey the ban of interstate travelling without valid reasons.

b. Avoid gatherings: Furthermore, the authorities are going around to ensure the community is obeying the "no gathering rules. Nevertheless, quite a large number of people were summoned as well for breaking the rules of 20 people per house or had small gatherings or weddings despite knowing they were not allowed to do so. Every person who attended at a certain function and disobeying the rules will be fined RM1000 per person without any compromise [15].

c. Organizational-standard operating procedures for shops/premises/workplace: Owners of shops, premises and workplaces are to follow the standard operating procedure set by the government before re-operating their business or work [16]. This would also mean that, changes need to be done in offices or workplace settings with temperature monitoring, safe social distancing, wearing of face mask and regular sanitization as well. Employers are also compulsory to further strengthen the awareness program in their organizational settings regularly. Workers who presented with symptoms are to be brought immediately to clinics or hospitals for early assessment and treatment.

Shops and premises which are continuing their businesses also need to abide to the rules and regulations set by the government which include only allowing certain numbers of people in the shops or premises at any one time while eateries are also requested to make adjustment in placing the tables and chairs in their premises and limiting the amount of people per table [17]. Temperature measurement, hand sanitizing and taking down basic particulars of patrons/clients (name, phone and time of entry) in all premises before entry are compulsory. This is important and will assist in contact tracing just in case if any new cluster is noted among community present at certain shops or premises. Community are still recommended to avoid going out unnecessarily except to buy their groceries, medical reasons or work commitments and to take away their food [4,18].

d. Environmental: With the new norms being practiced, it is now fairly normal nowadays to see markings on the pavements or areas leading to a shop/premise to remind or act as a guidance for people to practise social distancing. Furthermore, community are now indirectly force to queue up diligently before entering the shop/premise. The way we eat out will also change for fear of contagion or contamination. Community would be more aware of the need to make sure the eateries are clean. We may no longer visit or patronize road stalls without proper sanitation or hygiene practices. Nowadays, most people are also depending on delivery services especially for their meals or even grocery needs. Recreational activities are now allowed, but social distancing as well as avoiding large groups are still mandatory [19].

e. Technological: Since the MCO, many people are working from home. With closure of schools, colleges and universities, e-learning was and will continue to be the main preference in continuing the academic schedules with most classes and discussions done online [20,21]. Seminars, presentations and meetings were also conducted via Webinar sessions. Teleconference and communication via emails was deemed the best communication resorts for business and entrepreneurs worldwide with the travel restrictions. E-commerce plays an important role where community are using cashless payments while purchasing and online transactions are done for bill or loan payments. Telemedicine which involve direct individual consultation with doctors and delivery of medication to chronic patients were also started in health clinics and hospitals to reduce unnecessary visitations [22].

f. Economic: With the restriction movement, many shops and eateries are opening up to delivery options to provide the necessary needs of the community. Sales of home prepared meals were also on the rise which included delivery services as well. Many workers are needed in the delivery partners with the high demands of delivery services as well as runners who offer services of buying groceries, meals or to deal with bill payments or delivery of documents for businesses and offices [23]. With many people working from home, it also reduces the dependence on assistance from foreign domestic workers.

Are intervention B-benefits greater than C-costs?

i) Social impact

Many working parents were glad to be able to work from home, as it means they would have more quality family time especially being able to see the growing stages of their younger children and doing things at home that they have procrastinated. Quite a number of people have also developed new hobbies at home may it be cooking, baking, gardening, sewing and painting. Nevertheless, parents who were both healthcare workers were in distraught with the immediate closure of nurseries and faced difficulties finding nannies during last minute arrangements. Parents who were front liners also made the decision to stay apart from their families especially their children and elderly parents fearing about unintentionally bringing back the contagion to their vulnerable family members.

Other than that, despite a rapid decrease of national crime rate by around 70%, many individuals were also arrested for flouting the MCO [24]. People find it so difficult to be tied down in the house with so much of restrictions. Children and adolescents were caught playing outside the house, adults were roaming around until late at night, some still organize mini gatherings despite so many warnings and the list goes on. As the MCO extended, people were getting more anxious, restless, frustrated, depress as well as angry and fearful with the uncertainties especially those who lost their jobs or students who were trapped in the universities [25]. Students who managed to go back to their hometowns especially those in remote areas were also having difficulties with e-learning and limited communication with other course mates which further lead them to social isolation [26].

Besides that, while some families were happy to have quality family times, at the same time, it was unfortunate that domestic violence cases were on the rise as well in other families with victims needing to spend more time with the perpetrators (usually immediate family members) at a confined environment [27]. Hence, MOH, together with Social Welfare Department as well as other NGOs, students' affair councils, counsellors and related stakeholders took the initiative to step up in Mental Health and Psychosocial Support Network (MHPSS) [28,29], opening up hotlines to provide counselling or therapy and also to 'rescue' affected individual especially victims of abused before things worsen for them.

ii) Ethics

It is undeniable that conditions such as the Covid-19 pandemic will create significant strains between public health interests and individual interests especially when restrictions of rights and freedom were at stake. Therefore, when designing policies and interventions that are meant for the benefit of public health interests, it is of importance to keep in mind the necessity for approaches and measures that minimise harm to individual interests, predominantly the vulnerable populations [30]. Even though the restrictions and limitations of movements or freedom for individuals are methodically obligatory to contain the spread of the virus, actions must be put into place to ensure community are treated with dignity and that susceptible populations including the elderly, the poor, the disabled, the homeless, students and migrant workers, do not have to withstand an unequal burden of the risk.

It was indeed commendable that the Ministry of Health practiced equity by fairly giving everyone the same medical assessment and clinical treatment regardless of nationality, migrants or the illegals despite the limited clinical resources. It was also very important to maintain the confidentiality of patients being treated by not disclosing their personal information to avoid stigmatization or unwanted threats by the society as every individual is to be treated with dignity and respect in times of need.

iii) Economic cost

With the compulsory closure of all business except the ones that deal with daily essentials during the early stages of MCO, most if not all businesses especially tourism related suffered great financial loss [31]. With the extension of MCO and closure of premises, businesses still have to bear the accountability of paying salaries to the workers and covered operating expenses. With the strenuous cash flow, businesses were forced to reduce the employee's salaries or even to operate with reduced workers. Many people lost their jobs and financial support, hence making life even more difficult especially those who were dependent on daily wages to feed their family. Various banks had since stepped in by offering financial assistance including loan deferments, credit facilities, rebates and one-off case assistance, which definitely helped to ease the financial burden of the citizens during this challenging time [32]. Knowing the financial constraints of the citizens, on 27^th March 2020, the government also launched the RM250 billion Prihatin Economic Stimulus Package to assist every level of the community including additional RM10 billion for Small and Medium Enterprises (SMEs) which were critically affected and on the verge of collapsing [33].

Nevertheless, with the conditional MCO and resuming of most businesses since early May 2020, it is hope that the economy will improve slowly as people adapt to the new lifestyle changes. Tourism industry has since opened in Sabah with strict regulations to be followed by the respective operators.

iv) Efficacy

Covid-19 pandemic has certainly shaken the world including Malaysia in many aspects and we are all fighting a 'war' that is yet to be won with so many reservations. Nevertheless, with the implementation of MCO, followed by conditional MCO and stringent new norms, we could all see the effectiveness and efficacy of the measures with the decreasing trend of local transmission cases over the past 3 months from triple digit new positive cases per day to two digits of lately with lesser reported cases of mortality due to Covid-19. It is also impressive to see how the community is empowering the community though simple yet meaningful informative videos and supportive messages daily.

A-Acceptance of the intervention

The Diffusion of Innovation Theory [33] explains the ways in which new health promoting ideas or innovations are adopted by communities and emphasizes on five main factors that determine the success and speed of innovation diffusion which included: i) The characteristics of the potential adopters; ii) The rate of adoption; iii) The nature of the social system; iv) The characteristics of the innovation; and v) The characteristics of change agents.

In health promotion, two important considerations that need to be taken seriously are to maximise diffusion rates and to utilise appropriate strategies to engage and sustain different groups at different times. The characteristics of innovations that have been constantly associated with successful adoption include:

• Compatibility with prevailing socio-economic and cultural values of the adopter.

• Clarity of the relative advantage of the innovation compared with current practices, including the perceived cost-effectiveness, as well as usefulness, convenience and prestige.

• The simplicity and flexibility of the innovation; for example, those that require simple actions and are easily adaptable to different circumstances.

• The reversibility and perceived risk of adoption, if perceived as high risk and requiring irreversible change they are likely to be less easily adopted.

• Observability of the results of adopting an innovation on others.

This theory certainly applies to the situation that we were facing in the initial stages when we were indirectly 'force' to adapt to the restrictions and limitations. Initially, many people were still ignorant of the severity and vulnerability of the contagious virus with many still took the opportunity to travel despite the uprising cases in the country as well as all over the world. Things were still going on as normal even when positive cases were reported in Malaysia. It was when we were hit by the second wave that saw the positive sporadic cases rising at a tremendous rate all over Malaysia that led to MCO being implemented in mid-March, people were more willing to adopt and adapt to the lifestyle changes with most fearing the possibility of contracting the virus unexpectedly. In fact, the lifestyle changes were not difficult to follow. Staying at home, practice personal hygiene and cough etiquettes as well as social distancing were the main changes that need to be done. Even then, there were still groups which were against the MCO, mainly those who were badly affected economically with closure of most of the business which led them to financial constraints.

Besides that, the success of any measure or intervention will depend on all stakeholders acting together with a sense of shared responsibility to coordinate responses and also dependant on a significant professional worker or community member who acts as 'Agent of Change' to facilitate or support the adoption of changes with good risk communication skills. A very good example of risk communication practised by the Malaysian Government during this Covid-19 Pandemic which is still ongoing is the daily press statement given by the Director General of Health (DG) from the Ministry of Health (MOH) who has been updating the Covid-19 situation in Malaysia since day one of the outbreak. Director General of Health conveys and updates the daily situation of COVID-19 based on the facts and figures compiled by the team in MOH whom he acknowledged before he gives his speech daily. The professional handling, clear and transparency in information sharing in a timely manner as well as appropriately and patiently addressing all the questions, concerns and doubts by the media team or public, has directly or indirectly help to calm and gave a sense of reassurance to the community. This could be seen by the strong cooperation and commitment by most of the citizens to adhere to Movement Restriction Order (MCO) later on as they understood the importance and rationale in breaking the chain, flattening the curve and to prevent any new waves of COVID-19.

Actions R-recommended

With the decreasing trend of positive new cases transmitted locally and community are more aware in taking precautionary measures as well as adapting to the new lifestyle changes, hence the government is slowing uplifting restrictions in phases to allow the community to resume to their daily lifestyles and to boost the economy. Nevertheless, everyone, may it be individuals, families, office workers, workers in food and beverages services, business entrepreneurs or even factory workers, the need to avoid the 3Cs (Crowded Places; Confined Space; and Close Conversation) and practice the 3Ws (Washing their hands with water and soap or sanitizer; Wearing face mask especially in public places or when they encounter people who are having fever and flu; and Warning or cautions by the MOH like avoiding handshakes, practice cough and sneezing etiquette, disinfection activities, staying at home as much as possible and seeking immediate treatment if sick) are obligatory as the new norms Figure 1 [34-36].

Conclusion

While we are still coping and adapting with the challenges of this pandemic, it would also be good for us to take this opportunity to support ourselves for these potential changes in our lives, once these trying times are over. The struggle and 'suffering' of this pandemic is real, as it affects every level of the society. Nevertheless, all of us should continue to keep a positive mind set, persevere, be resilient and continue to practise new normal lifestyle and support one another as one day, this struggle will pass, slowly but eventually.

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