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As COVID-19 will remain a significant threat for at least another year, and even continue to affect us globally for decades, a people-centred approach is the way forward. A people-centred approach starts with a grass-roots level understanding of the problems faced by the people – Pic by Shehan Gunasekara 
After 21 months into the pandemic, the general public of Sri Lanka has widely received the scientific message of COVID-19 response. Though there are residual challenges like risk communication of the vaccines to the youth, most Sri Lankans are now aware about the correct use of face masks, hand hygiene, social distancing and the importance of vaccination and public health safety measures (PHSM). According to a population survey done by a team of health professionals in 2020, 88.3% of Sri Lankans had a good knowledge about PHSM (1). 

However, the challenge of motivating the public to follow health guidelines remains a concern. There were many instances of the public not abiding by the quarantine curfew as expected, despite the high case fatality rates. Religious and political events were organised with large congregations, violating health guidelines. People resort to various irrational and harmful home remedies based on misinformation on social media (2). State authorities and media often use an accusatory and punitive tone when attributing violations of PHSM to low health literacy and intelligence levels. However, from a public health point of view, we cannot find solutions to the current crisis through blame or generalised rationalisations.

At the initial stages of the pandemic, we saw a majority of the people eagerly following public health safety measures; 99.5% of Sri Lankans confirmed that they followed health guidelines during the first wave (1). However, during the multiples waves of infection that followed, people have gradually strayed from public health guidance. Public health experts have emphasised that a sustained voluntary commitment by the people to be an integral part of an effective public health response (3), (4). Thus, this article proposes a context specific public empowerment approach to the pandemic response in Sri Lanka.
 Why do we need public empowerment?
To have the public abide by public health guidance the public needs to be empowered and treated as a key part of the public health response. Concerns raised by the public related to COVID-19 needs to be heard, acknowledged, and addressed (3), (5). Empowerment enables the public to take control over their health in this pandemic. Empowering the public also means considering the day to day challenges the public faces such as traveling by the bus, taking meals at the workplace or visiting clinics in the state sector. Therefore, we need to learn from concepts such health promotion by the Ottawa Charter which advises to empower communities where they live, love, work and play – such as home, school, workplace or any other relevant setting (6).

Examples of such approaches already exist in other countries during the pandemic.

Behavioural insight surveys in many regional countries like Indonesia, Malaysia, Myanmar, and Pakistan helped us understand the knowledge, attitudes, and risk perception about COVID-19 among those communities (7). These findings were useful in adjusting the community engagement methods of both governmental and non-governmental stakeholders involved in COVID-19 response of those countries. Though similar surveys were done in Sri Lanka following the first wave (1), there was no continuous monitoring and evaluation of the behavioural elements of the response. The findings from other behavioural insight surveys were applied for policy decisions like reopening schools in Romania and in risk communication to high-risk groups in Ukraine (5), which helped shape the public health response to suit people’s needs. Teachers were a part of the decision-making process in reopening pre-schools in Norway (5). Novel job retention schemes were introduced by many countries like Thailand, Malaysia, and Vietnam, to acknowledge the difficulties of vulnerable groups like the informal sector (8). 

Asking people to follow a guideline without eliminating the socioeconomic and cultural barriers often leads to failure. Creating a supportive environment and strengthening community action are thus identified as two key strategies that can help in achieving health promotion (6). Developing novel, evidence-based solutions may be the cornerstone of an efficient public health response. But, these examples show us that facilitating existing solutions through health promotion and empowerment, is equally important if we are to guarantee their continuity. 

In current clinical practice, we have shifted from a ‘disease-centred’ approach to a ‘patient-centred’ one, where the clinician prioritises the needs and values of the patient to ensure the quality of care and compliance. This is an evidence-based practice that has led to remarkable benefits in many areas of health. (9) If we apply the same conceptual approach to the public health response, what we need to build is a ‘people-centred’ approach, based on autonomy, holism, and empowerment, the same core elements of a patient-centred care, where the ‘needs and beliefs of the people’ will be prioritised over other aspects. A people-centred approach focuses on helping people to overcome the multiple economic, social, cultural and political barriers of the pandemic as part of the response.

Socio-economic and cultural barriers affecting pandemic response in Sri Lanka
Economic barriers
First considering the economic barriers, over 500000 people are estimated to have fallen below the $ 3.2 poverty line due to the pandemic, as poverty rates in Sri Lanka have increased from 9.2% in 2019 to 11.7%  in 2020 (10). Loss of earning and unemployment due to COVID-19 have been the main drivers of poverty, both of which were experienced more by the informal, lower-income workers based on their job insecurity and the digital divide. 65% of the jobs lost due to COVID-19 were in the private sector (10). Sectors affected the most included tourism and entertainment industry. Inability to afford commodities of social distancing, like a private vehicle or the necessary technology for online communication, were other economic determinants that created an unsupportive environment to respond to COVID-19. Nearly 40% of students in Mulatiyana educational zone in Matara lacked access to devices for online learning (11).

In a survey done among Sri Lankan farmers in the first quarter of 2021, it was noted that nearly half of the households suffered from food insecurity. 30% of them had to sell their assets like livestock to meet with the economic shock of the pandemic (12). We cannot implement health guidelines on the presumption that health is the only priority of the people. If basic essentials like food and security are threatened, then following health guidelines becomes a secondary concern. Studies based on the ‘Health Beliefs Model’ have shown that perceived barriers to a behavioural change are the most powerful single predictors of preventive health behaviour (13). Research studies suggest that this was the case in Sri Lanka, where such perceived barriers had a negative effect on the cues to adopt safety behaviours to COVID-19 by people (14).
Social barriers
Social barriers caused by the disruption of the social structure impede the public health response. Isolation faced by the elderly in their dependent state, the familial responsibilities of the working youth and the recreational needs of the adolescents, all these social determinants lead to departures from the safety behaviours. Also, policymakers need to understand that traditional and religious celebrations can hold value over health for many Sri Lankans, even during a pandemic (15). Additionally, cultural practices that respect the religious traditions especially during times of crisis is important to the physical and mental health of the people. Therefore, lack of sensitivity to burial rights may lead to poor practices, like the public hiding illness from the authorities or covering up deaths due to COVID. These practices born out of fear can result in increased disease spread.
Psychological barriers
With regard to the psychological barriers, research literature in many countries has shown the immense psychological impact, caused by the pandemic and by quarantine lockdowns, with results of depression, anxiety, frustration, social withdrawal, and other psychological distresses across all ages (16). Recent research among the general public and vulnerable groups like front line workers and pregnant mothers in Sri Lanka has shown high rates of fear, anxiety and depression, indicating our population is not immune to these mental barriers (17), (18), (19). Health anxiety related to the fear of infection and death has led to maladaptive safety responses like reluctance to admit patients to hospitals, compulsive behaviours of sterilisation and stigma towards infected patients.
Pandemic fatigue
‘Pandemic Fatigue’ as defined by the WHO is the gradual demotivation in protective measures over continuous exposure to the pandemic due to loss of risk perception, complacency, and urge for freedom (16). It is undoubtedly one of the biggest challenges to the compliance of PHSM. So, at this stage of the pandemic, we have to realise that addressing psychological barriers such as pandemic fatigue is as essential as developing new guidelines and treatments for COVID-19. 
Cultural barriers
Cultural barriers also require closer attention. People have often struggled to identify the intangible origins of infectious diseases or mental illnesses, especially when the enemy is invisible. In such instances, due to the complexity of the science or due to the unknown details of the disease people rely on their base cultural beliefs as a coping mechanism. 

This phenomenon, coupled with the human behaviour of preferring instant and definite cures over prevention, has paved the way for ‘magic potions’ like ‘Dhammika Paniya’, and pseudo-sciences of throwing pots into rivers, or home made remedies that can be harmful.
How can we improve the pandemic response?
As COVID-19 will remain a significant threat for at least another year, and even continue to affect us globally for decades, a people-centred approach is the way forward. A people-centred approach starts with a grass-roots level understanding of the problems faced by the people. The research community should be encouraged and funded to study barriers of adherence to public health guidance that prevent people from following PHSM. This research knowledge then needs to be translated into new policy decisions. 

Public health professionals proposed a ‘whole-of-society’ and ‘whole-of-government’ approach early in the pandemic (3). This means providing pragmatic solutions to the problems outlined above at every level: village, town and regional, through the involvement of the civil society, business and local organisations and religious leaders in addition to the responsible governmental bodies. Decentralisation of these aid programmes is vital for their feasibility. Contributions of other Sri Lankans and the diaspora, who have lined up to support people in need, should be used and use of those resources should be conducted in a transparent manner. Providing financial and other support to lower-income families, incentives to the farmers and informal sector and safe transportation and work environments for front-line workers are essential steps for continuity of PHSM, which require more centralised action.

Mental health professionals, including the National Directorate of Mental Health, have made a significant contribution to safeguard mental health during the pandemic. (20) Their efforts need more support and need to be prioritised to minimise damage caused by stress that arises from socio-economic conditions worsened by the pandemic and due to the constant fear for one’s health. 

Mental health programmes need to be tailored for high-risk groups of psycho-social distress, such as children and the elderly, while making at least basic inquiries into the health of other family members. These gestures can go a long way in building much-needed trust and understanding between people and the health system, in addition to being integral components of a people-centred care.

Existing gaps in knowledge have to be identified through research, and reliable contact points have to be established. ‘Doc Call 247’ telephone service, ‘1904’ short message service and ‘Self Shield’, ‘CoviTriageSL’ self-diagnosis applications recently introduced to assist people under home care or get diagnosed of COVID-19, are the best examples of a people-centred care in action. (21), (22), (23), (24) Similar verified portals, with interdisciplinary teams that can provide scientific advice in social media, will be a useful initiative to overcome the existing Infodemic. We need to strengthen these efforts.

News on mainstream media and public health messaging overall need to be balanced to give due vigilance to PHSM, without instilling a constant fear of infection and death in the minds of the people. Mental health professionals can be consulted to formulate such socially sensitive policies that can provide necessary guidance and advocacy to mass media, who often thrive in sensationalism. The current trend of finger-pointing and the blame game of media hardly encourages a genuine behavioural change. Role models from different social backgrounds, relating to their own experiences on the value of following health guidelines, may create better communication across respective social groups. This is a proven method of observational learning that can improve self-efficacy of people in following safety behaviours (25).

To address the proportion of Sri Lankans who value traditional approaches over scientific methods, state Ayurvedic practitioners can be included in the public health response as agents to encourage evidence-based practices. Their advice on following PHSM while maintaining state-approved Ayurvedic treatments may appeal better to such audiences. Such involvement can also avoid unproven home remedies and exploitation of people by fraudulent parties with promises of cures.

During the phased removal of the restrictions following the lockdown, education should be made a top priority. Students have nearly lost two years of their experience in the psycho-social environment of the classroom, which need to be compensated strategically without putting an undue burden to already stressed minds. When designing solutions students, teachers, parents, and other relevant stakeholders need to be made part of the process to understand challenges faced by all parties. We also need to prioritise the reopening of low-risk outdoor environments, like parks, playgrounds, jogging tracks, open religious sites and outdoor restaurants, where people can enjoy or relax with minimal risks. This is important in reducing anxiety and rebuilding the confidence and connections among people, which lie at the core of a people-centred approach. 

Given the recent stage of the pandemic, with widespread transmission and saturation of the health system, a quarantine lockdown was the necessary strategy. But in facing future waves of the virus, we may need to reconsider such enforced lockdowns. This argument is not made in the mere sense of a health vs. economy ultimatum but based on the myriad psycho-social repercussions described above that affect the resilience of the public health response. 

There is currently a global discussion on shifting towards voluntary lockdowns by people, based on an ‘information effect’, as opposed to lockdowns by the government, based on an ‘intervention effect’. This was noted in Japan, where a three-quarter of its citizens in Tokyo made their decisions to stay at home based on information and not due to state intervention (26). Though Sri Lanka has a long way to go in achieving that level of empowerment, the voluntary lockdown of many towns in the country by local trade organisations, which preceded the quarantine lockdown, is evidence that such a feat is not entirely impossible in Sri Lanka (27).

The ideas above are starting points but crucial if we are to form a user-oriented, empathetic, culturally sensitive, approach that has the pulse of the people at its centre. A people-centred approach is the most practical long-term strategy in defeating this pandemic and will strengthen our preparedness for future outbreaks. 
(Inosha Alwis is a physician and a lecturer at Department of Community Medicine, Faculty of Medicine, University of Peradeniya He is interested in public health, mental health and behavioural sciences.)

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16. Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al. Psychosocial impact of COVID-19. Diabetes Metab Syndr Clin Res Rev [Internet]. 2020;14(5):779–88. Available from: https://www.sciencedirect.com/science/article/pii/S1871402120301545

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19. Patabendige M, Gamage MM, Weerasinghe M, Jayawardane A. Psychological impact of the COVID-19 pandemic among pregnant women in Sri Lanka. Int J Gynaecol Obstet Off organ Int Fed Gynaecol Obstet. 2020 Oct;151(1):150–3. 

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21. ‘DOC CALL 247’ – The Island [Internet]. [cited 2021 Sep 24]. Available from: https://island.lk/doc-call-247/

22. SMS based system introduced to direct COVID cases for treatment & manage Home Quarantine [Internet]. [cited 2021 Sep 24]. Available from: https://www.newsfirst.lk/2021/08/19/sms-based-system-introduced-to-direct-covid-cases-for-treatment-manage-home-quarantine/

23. COVID Shield app introduced to Sri Lanka to fight against COVID-19 pandemic – The Island [Internet]. [cited 2021 Sep 24]. Available from: https://island.lk/covid-shield-app-introduced-to-sri-lanka-to-fight-against-covid-19-pandemic/

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25. White P, Donaldson A, Finch CF. But can someone like me do it? The importance of appropriate role modelling for safety behaviours in sports injury prevention. Br J Sports Med [Internet]. 2016 May 1;50(10):569 LP – 570. Available from: http://bjsm.bmj.com/content/50/10/569.abstract

26. Watanabe T, Yabu T. Japan’s voluntary lockdown. PLoS One [Internet]. 2021 Jun 10;16(6):e0252468–e0252468. Available from: https://pubmed.ncbi.nlm.nih.gov/34111163

27. More businesses go into “voluntary lockdowns” across Sri Lanka [Internet]. [cited 2021 Sep 28.Available from: https://www.newsfirst.lk/2021/08/19/more-businesses-go-into-voluntary-lockdowns-across-sri-lanka/

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