The Impact of Sociocultural Influences on the COVID-19 Measures-Reflections From Singapore.

The coronavirus disease 2019 (COVID-19) pandemic presents unique challenges to Asian countries like Singapore with a predominantly Confucian culture. Palliative care providers play an important role in supporting their patients and family members in these difficult times.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in tremendous strain on health care systems globally. The discipline of palliative medicine prides itself on patient autonomy and fulfillment of personal care preferences. We believe that each patient is unique with needs based on personal experiences and cultural, familial, and social influences. These considerations impact how we communicate and treat each patient. Similarly, for policy makers drafting infection control measures in the COVID-19 pandemic, cultural and societal norms warrant special consideration to ensure that measures implemented are acceptable and feasible to the general public.

Singapore is a city-state with a population of about five million in Southeast Asia. Although it was one of the first countries to institute measures to tackle the COVID-19 epidemic, it had at one point of time the highest number of confirmed COVID-19 patients outside of China where the infection was first reported. Since then, it has reported more than 9000 infected patients despite tightening of infection control measures that include the shutting of nonessential businesses and schools.

Confucianism is the prevailing social model in Singapore, where family-centric obligations and practices are important pillars of the Singaporean identity. These include obligations to provide financial and physical support for the elderly and sick, the reciprocal obligations of the elderly to provide care for the young, and the need for a familial consensus in health care decisions. As the COVID-19 pandemic worsens in the country, the impact of these values on the success of national disease containment policies is becoming increasingly apparent.

On the third of April 2020, the prime minister of Singapore announced a series of enhanced measures to control the spread of COVID-19, collectively known as the “circuit breaker.” These include the closing of most businesses except essential services like health care, the shutting of schools, and the restriction of movements and gathering of people. What followed was a noticeably noncompliance of these measures by the elderly, who continued to gather in market places and traveled between households. The prime minister subsequently had to make a special televised appeal to the elderly to adhere to the instituted measures as the elderly are at a higher risk of mortality from COVID-19.

This disregard of the restrictions, like a “noncompliant” patient refusing to take oral morphine for his cancer pain, would have been duly investigated by the palliative care physician looking for concerns of addiction and side effects.

In this case, noncompliance of the measures by the elderly specifically can be explained by the personal and societal expectations of the elderly as the caretaker of the family unit. The duty toward their working children requires the elderly to provide care for their young grandchildren, prepare daily meals, and oversee or perform other household chores. These are so important that they may supersede the importance of personal safety.

With the welfare of the family unit as the focus, the elderly must also avoid being a burden to their children. This includes being physically healthy and having a network of friends to provide them with support in the community. These goals are achieved through activities like morning walks and Taiqi exercises, commonly followed by breakfast at the local eateries. Social distancing means that such activities are no longer possible. This disruption in the daily routine of the elderly erodes the image of the “ideal” independent elderly. Like the terminally ill patient who refuses to move in to stay with his children, the fear of being perceived as even being potentially a burden to the family may overshadow even the most severe financial disincentive for breaking the law.

Conversely, family members of the elderly also flout rules on restrictions on movement. Filial piety, which is defined by the principle of nonabandonment, motivates carers of the frail or sick elderly to continue traveling between households to provide care. Restrictions on traveling are particularly agonizing for families who need to support an elderly patient with cancer, who may wish to achieve a home death with home hospice support. Reciprocally, the elderly sick may also perceive themselves as a threat to the harmony of the family unit by being a source of emotional, financial, and physical burden. This complex web of reciprocal familial obligations and self-sacrifice across both the patient and family members is commonly witnessed in the practice of palliative medicine.

Like the palliative care team that invests effort and time to retrieve important aspects of the patient's cultural and social preferences, measures implemented during the COVID-19 outbreak need to be drafted with awareness about potential pitfalls and the local context. While the intention of instituting tough infection control measures is undisputed just like our intention to minimize symptoms and provide psychoemotional support, the compliance and success of our interventions depend more than the biomedical evidence supporting them. Practicalities “on the ground” based on societal norms need to be considered to allow satisfaction from both the patient and the health care team.

Demonstrating an awareness about the challenges that impact the public and providing solutions can decrease frustrations without compromising the effectiveness of restrictive measures. For example, campaigns to institute greater awareness about personal hygiene run parallel with the tightening of infection control measures. Since 15 April 2020, all individuals who leave their homes must wear a mask in Singapore, allowing alleviation of the risks of disease transmission between persons. Accurate and timely dissemination of information to the vulnerable groups of the population is essential. There are ongoing outreach programs that cater to the elderly about personal hygiene through various media channels conducted in their native dialect languages.

Flexibility is also important. The Singaporean government had implemented a measure that disallowed the sending of children to their grandparents' residences when their parents were at work. Upon realizing the role of the elderly in the care of the young and the high prevalence of such a practice, this rule was waived for parents who could not work from home due to the nature of their employment.

Palliative care providers have a role in supporting national efforts while equipped with the knowledge of the unique challenges our patients and family members face. Individual patient discussions help to address distress from perceived challenges to personhood, whereas family conferences facilitated by the multidisciplinary palliative care team provide a safe platform for patients and family members to communicate with each other. Financial and caregiving limitations can be tackled with relevant assistance schemes by the palliative care social workers according to individual circumstances.

Although there is strong incentive for the implementation of strict measures in the COVID-19 pandemic, awareness and compassion go a long way in ensuring that these measures remain effective and acceptable. There is no better time than now to illustrate the importance of the palliative care approach, where understanding the sociocultural factors relevant to patients and their families is integral to what we do.