Diabolical dilemmas of COVID-19: An empirical study into Dutch society's trade-offs between health impacts and other effects of the lockdown

Trading-off health safety, civil liberties, and unemployment based on communication strategies: the social dilemma in fighting pandemics

Crisis management often requires decisions that prioritize the collective good over individual interests. Effective crisis communication strategies can influence individuals' behavior towards the collective good, preventing negative societal externalities. However, little is known about how these strategies affect individual acceptance of decisions that involve trade-offs between individual and collective interests. We study individual choice behavior regarding maintaining or lifting government-imposed restrictions on private and public life in a referendum setting in the context of the COVID-19 pandemic. Maintaining or lifting the restrictive measures represents a social dilemma that involves trade-offs between civil liberties, health safety, and economic consequences. In three online experiments, we test the impact of communication strategies that focus on health and/or economic factors, as well as risk attribution (i.e. who is at risk by an increase of infections), on individual acceptance of restrictive measures. Results across all experiments show that the majority favors maintaining the COVID-19 measures, indicating that individuals act ethically by trading off individual harm (i.e., restrictions on private and public life) for the prevention of increased societal harm (i.e., infections, deaths). When communication focuses only on health factors, acceptance levels remain robust, regardless of whether the risk is attributed to others, the individual's group, or the individual. However, when economic factors (i.e., unemployment rates) are included, acceptance of restrictive measures significantly drops. Notably, in an economic-focused communication, attributing risk to the individual's group increases acceptance such that significantly less individuals vote to lift measures when their group is at higher risk. Overall, these results demonstrate the impact of communication strategies on acceptance of crisis management measures: Our findings have implications for policy makers who design communication strategies to enforce restrictive policies in times of crisis.

Are we ready for the next pandemic? Public preferences and trade-offs between vaccine characteristics and societal restrictions across 21 countries

In vaccination decisions, individuals must weigh the benefits against the risks of remaining unvaccinated and potentially facing social restrictions. Previous studies have focused on individual preferences for vaccine characteristics and societal restrictions separately. This study aims to quantify public preferences and the potential trade-offs between vaccine characteristics and societal restrictions, including lockdowns and vaccine mandates, in the context of a future pandemic. We conducted a discrete choice experiment (DCE) involving 47,114 respondents from 21 countries between July 2022 and June 2023 through an online panel. Participants were presented with choices between two hypothetical vaccination programs and an option to opt-out. A latent class logit model was used to estimate trade-offs among attributes. Despite some level of preference heterogeneity across countries and respondents' profiles, we consistently identified three classes of respondents: vaccine refusers, vaccine-hesitant, and pro-vaccine individuals. Vaccine attributes were generally deemed more important than societal restriction attributes. We detected strong preferences for the highest levels of vaccine effectiveness and for domestically produced vaccines across most countries. Being fully vaccinated against COVID-19 was the strongest predictor of pro-vaccine class preferences. Women and younger people were more likely to be vaccine refusers compared to men and older individuals. In some countries, vaccine hesitancy and refusal were linked to lower socioeconomic status, whereas in others, individuals with higher education and higher income were more likely to exhibit hesitancy. Our findings emphasize the need for tailored vaccination programs that consider local contexts and demographics. Building trust in national regulatory authorities and international organizations through targeted communication, along with investing in domestic production facilities, can improve vaccine uptake and enhance public health responses in the future.

Preferences for the Societal Impacts of a Pandemic when it Transitions into an Endemic: A Discrete Choice Experiment

BACKGROUND

The stage of the pandemic significantly affects people's preferences for (the societal impacts of) COVID-19 policies. No discrete choice experiments were conducted when the COVID-19 pandemic was in a transition phase.

OBJECTIVES

This is the first study to empirically investigate how citizens weigh the key societal impacts of pandemic policies when the COVID-19 pandemic transitions into an endemic.

METHODS

We performed two discrete choice experiments among 2181 Dutch adults that included six attributes: COVID-19 deaths, physical health problems, mental health problems, financial problems, surgery delays and the degree to which individual liberties are restricted. We used latent class choice models to identify heterogeneous preferences for the impacts of COVID-19 measures across different groups of respondents.

RESULTS

A large majority of the participants in this study was willing to accept deaths to avoid that citizens experience physical complaints, mental health issues, financial problems and the postponement of surgeries. The willingness to tolerate COVID-19 deaths to avoid these societal impacts differed substantially between participants. When participants were provided with information about the stringency of COVID-19 measures, they assigned relatively less value to preventing the postponement of non-urgent surgeries for 1-3 months across all classes.

CONCLUSIONS

Having gone through a pandemic, most Dutch citizens clearly prefer pandemic policies that consider citizens' financial situations, physical problems, mental health problems and individual liberties, alongside the effects on excess mortality and pressure on healthcare.

Ethical challenges during critical phases of the COVID-19 pandemic: An interpretive synthesis

BACKGROUND

During the most critical phases of COVID-19 pandemic, dramatic situations were experienced in hospitals and care centers that nurses could hardly verbalize. Especially relevant were deep challenges related to terminal illness, situations of extreme sacrifice, as well as reflections on protective measures mixed with beliefs. We intend to analyze which problems had the greatest impact on professionals.

AIM

The aim is to explore the ultimate basis for action when making decisions and the orientation of their behavior in the face of moral conflicts.

METHOD

The methodological strategy is an interpretive synthesis. Narrative review of academic articles that analyzed ethical dilemmas during the pandemic was carried out by searching five databases (Pubmed, Scopus, Psycinfo, CINHAL, and WOS) between January 2020 and December 2022. Finally, 43 articles were selected.

ETHICAL CONSIDERATIONS

Ethical requirements were respected in all study phases.

RESULTS

The reading and review of the 43 articles initiated the first phase of inductive coding which resulted in 14 initial sub-themes. Based on this structure, a second phase of coding was carried out, giving rise to six categories or emerging themes. To facilitate the process of identifying the central category, the authors agreed to carry out a phase of synthesis, grouping the six themes into three meta-themes: the identification and acceptance of human vulnerability; the discovery of positive paradigms in traumatic situations in society; the prevalence of the common good over the particular interest, as the core structure of any society.

CONCLUSION

The study has shown the need to consider healthcare benevolence as a new dimension of health care upon global vulnerability. Responsibility is required to ensure the well-being of a global society, prioritizing the common good over particular interests and building solutions on solid moral structures. A new ethical landscape is essential, starting with a humanistic curricular training of all healthcare professionals.

Navigating Public Policy Responses to a Pandemic: The Balancing Act Between Physical Health, Mental Health, and Household Income

OBJECTIVE

During COVID-19, governments imposed restrictions that reduced pandemic-related health risks but likely increased personal and societal mental health risk, partly through reductions in household income. This study aimed to quantify the public's willingness to accept trade-offs between pandemic health risks, household income reduction, and increased risk of mental illness that may result from future pandemic-related policies.

METHODS

A total of 547 adults from an online panel participated in a discrete choice experiment where they were asked to choose between hypothetical future pandemic scenarios. Each scenario was characterized by personal and societal risks of dying from the pandemic, experiencing long-term complications, developing anxiety/depression, and reductions in household income. A latent class regression was used to estimate trade-offs.

RESULTS

Respondents state a willingness to make trade-offs across these attributes if the benefits are large enough. They are willing to accept 0.8% lower household income (0.7-1.0), 2.7% higher personal risk of anxiety/depression (1.8-3.6), or 3.2% higher societal rate of anxiety/depression (1.7-4.7) in exchange for 300 fewer deaths from the pandemic.

CONCLUSION

Results reveal that individuals are willing to accept lower household income and higher rates of mental illness, both personal and societal, if the physical health benefits are large enough. Respondents placed greater emphasis on maintaining personal, as opposed to societal, mental health risk and were most interested in preventing pandemic-related deaths. Governments should consider less restrictive policies when pandemics have high morbidity but low mortality to avoid the prospect of improving physical health while simultaneously reducing net social welfare.

A Metric of Societal Burden Based on Virus Succession to Determine Economic Losses and Health Benefits of China's Lockdown Policies: Model Development and Validation

BACKGROUND

The COVID-19 pandemic had a profound impact on the global health system and economic structure. Although the implementation of lockdown measures achieved notable success in curbing the spread of the pandemic, it concurrently incurred substantial socioeconomic costs.

OBJECTIVE

The objective of this study was to delineate an equilibrium between the economic losses and health benefits of lockdown measures, with the aim of identifying the optimal boundary conditions for implementing these measures at various pandemic phases.

METHODS

This study used a model to estimate the half-lives of the observed case fatality rates of different strains. It was based on global infection and death data collected by the World Health Organization and strain sequence time series data provided by Nextstrain. The connection between the health benefits and economic losses brought by lockdown measures was established through the calculation of disability-adjusted life years. Taking China's city lockdowns as an example, this study determined the cost-benefit boundary of various lockdown measures during the evolution of COVID-19.

RESULTS

The study reveals a direct proportionality between economic losses due to lockdowns and the observed case fatality rates of virus strains, a relationship that holds true irrespective of population size or per capita economic output. As SARS-CoV-2 strains evolve and population immunity shifts, there has been a notable decrease in the observed case fatality rate over time, exhibiting a half-life of roughly 8 months. This decline in fatality rates may offset the health benefits of maintaining unchanged lockdown measures, given that the resultant economic losses might exceed the health benefits.

CONCLUSIONS

The initial enforcement of lockdown in Wuhan led to significant health benefits. However, with the decline in the observed case fatality rate of the virus strains, the economic losses increasingly outweighed the health benefits. Consequently, it is essential to consistently refine and enhance lockdown strategies in accordance with the evolving fatality and infection rates of different virus strains, thereby optimizing outcomes in anticipation of future pandemics.

From polarity to plurality: Perceptions of COVID-19 and policy measures in England and Scotland

AIM

The aim of this study was to uncover perspectives on the COVID-19 pandemic and the responses implemented by the UK and Scottish Governments to help control the spread of infection. Such understanding could help to inform future responses to pandemics at individual, community and national levels.

METHOD

Q methodology was used to elicit perspectives from people in England and Scotland with different experiences of the pandemic including public health officials, key workers, those on furlough, those who were unvaccinated or vaccinated to different levels, those who were 'shielding' because they were at higher risk and people with different scientific expertise. Participants rank-ordered phrases about different aspects of COVID-19 according to their viewpoint. Factor analysis was then conducted in conjunction with interview material from the same respondents.

RESULTS

A four-factor solution was statistically supported and was interpretable alongside the qualitative accounts of participants loading on these factors. These four perspectives are titled Dangerous and Unaccountable Leadership, Fear and Anger at Policy and Public responses, Governing Through a Crisis and Injustices Exposed.

CONCLUSION

The four perspectives demonstrate plurality and nuance in views on COVID-19 and the associated policies and restrictions, going beyond a binary narrative that has been apparent in popular and social media. The four perspectives include some areas of common ground, as well as disagreement. We argue that understanding the detail of different perspectives might be used to build cohesion around policy initiatives in future.

PATIENT OR PUBLIC CONTRIBUTION

The development of the statement set, which is rank-ordered by participants in a Q study, and factor interpretations were informed by views of the general public. The statement set was initially developed using existing publicly available material based on members of the general public experiencing the pandemic first hand. It was then piloted with members of the public experiencing different challenges as a result of COVID-19 and the subsequent lockdown and updated based on feedback. Finally, interpretations of the identified factors were presented publicly and edited according to their feedback.

Preparing for future pandemics: A multi-national comparison of health and economic trade-offs

Government investment in preparing for pandemics has never been more relevant. The COVID-19 pandemic has stimulated debate regarding the trade-offs societies are prepared to make between health and economic activity. What is not known is: (1) how much the public in different countries are prepared to pay in forgone GDP to avoid mortality from future pandemics; and (2) which health and economic policies the public in different countries want their government to invest in to prepare for and respond to the next pandemic. Using a future-focused, multi-national discrete choice experiment, we quantify these trade-offs and find that the tax-paying public is prepared to pay $3.92 million USD (Canada), $4.39 million USD (UK), $5.57 million USD (US) and $7.19 million USD (Australia) in forgone GDP per death avoided in the next pandemic. We find the health policies that taxpayers want to invest in before the next pandemic and the economic policies they want activated once the next pandemic hits are relatively consistent across the countries, with some exceptions. Such results can inform economic policy responses and government investment in health policies to reduce the adverse impacts of the next pandemic.

Towards machine learning for moral choice analysis in health economics: A literature review and research agenda

BACKGROUND

Discrete choice models (DCMs) for moral choice analysis will likely lead to erroneous model outcomes and misguided policy recommendations, as only some characteristics of moral decision-making are considered. Machine learning (ML) is recently gaining interest in the field of discrete choice modelling. This paper explores the potential of combining DCMs and ML to study moral decision-making more accurately and better inform policy decisions in healthcare.

METHODS

An interdisciplinary literature search across four databases - PubMed, Scopus, Web of Science, and Arxiv - was conducted to gather papers. Based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, studies were screened for eligibility on inclusion criteria and extracted attributes from eligible papers. Of the 6285 articles, we included 277 studies.

RESULTS

DCMs have shortcomings in studying moral decision-making. Whilst the DCMs' mathematical elegance and behavioural appeal hold clear interpretations, the models do not account for the 'moral' cost and benefit in an individual's utility calculation. The literature showed that ML obtains higher predictive power, model flexibility, and ability to handle large and unstructured datasets. Combining the strengths of ML methods with DCMs has the potential for studying moral decision-making.

CONCLUSIONS

By providing a research agenda, this paper highlights that ML has clear potential to i) find and deepen the utility specification of DCMs, and ii) enrich the insights extracted from DCMs by considering the intrapersonal determinants of moral decision-making.

The Causal Role of Lockdowns in COVID-19: Conclusions From Daily Epidemiological, Psychological, and Sociological Data

Much has been written about the COVID-19 pandemic's epidemiological, psychological, and sociological consequences. Yet, the question about the role of the lockdown policy from psychological and sociological points of view has not been sufficiently addressed. Using epidemiological, psychological, and sociological daily data, we examined the causal role of lockdown and variation in morbidity referring to emotional and behavioral aspects. Dynamics of support requests to the Sahar organization concerning loneliness, depression, anxiety, family difficulties, and sexual trauma were investigated alongside processes of emergency and domestic violence reports to the Ministry of Welfare and Social Affairs. By exploring the signals and predictive modeling for a situation with no lockdown implementation, the lockdown was found as a critical factor in distress rising among the general population, which could affect long after the improvement in pandemic case counts. Applications and implications are discussed in the context of decision-making in dealing with crises as well as the need to allocate resources for adaptive coping.

The ethical dilemmas of risky decisions

Even in a pandemic there seem to be inherent conflicts of interest between the individual and societal consequences of remedial actions and strategies. Actions taken in the sole interests of patients, as required by the Hippocratic oath, can have broadly inconvenient economic implications for the State. ("Average" benefits for a population can impose individual inconveniences for the vulnerable.). Understandably these decisions are not normally made explicitly and transparently by governments. This leads to seemingly illogical and inhumane strategies which are not understood and hence mistrusted and often ignored by the public. Vaccination sentiments on social media are often an unwanted symptom of this dilemma. This article outlines and discusses a number of examples of such situations with a focus on ethical aspects. It concludes that each case must be considered individually as to the issues that need to be weighed in these difficult decisions; and that there are no clear and universally acceptable ethical solutions. What can be learned from the COVID-19 crisis is that short term utilitarianism has consequences that in the eyes of the population are unacceptable. This lesson seems equally valid for cost benefit evaluations regarding other risks, such as from hazardous industries, flood defenses, and air transport. Decisionmakers and politicians can learn that persuasion only goes so far. In the end the people appear to prioritize in terms of deontology.

In-store or online grocery shopping before and during the COVID-19 pandemic

This paper presents results of a unique stated choice (SC) experiment to uncover the determinants of grocery shopping channel choice during the first wave of COVID-19 infections, where the most restrictive containment measures were in place. The choice sets were framed under regular and pandemic conditions, allowing for the estimation of pandemic-specific effects for each of the choice attributes. Our results show a significant overall increase of about 13%-points in online grocery shopping under pandemic conditions. Shopping and delivery costs were found to be the major decision drivers in both experimental settings, while the waiting time in front of the grocery store and risk of infection only played an secondary role. The value of delivery time savings (VDTS) decreases from about 10.8 CHF/day in the regular to 7.4 CHF/day in the pandemic case, indicating that respondents show an increased patience when waiting for the delivery of the ordered groceries. However, choice attributes related to the shopping trip, i.e. travel time and cost, do not show any notable effects. The COVID-19 death risk was valued rather low by the respondents and the relatively unrestricted Swiss containment measures are in line with the respondents' average preferences, as shown by a relatively low value of statistical life (VSL) of about 800,000 CHF.

For Me or for My Relatives? Approximating Self-Protection and Local Altruistic Motivations Underlying Preferences for Public Health Policies Using Risk Perception Metrics

OBJECTIVES

Research efforts evaluating the role of altruistic motivations behind health policy support are usually based on direct preference elicitation procedures, which may be biased. We propose an indirect measurement approach to approximate self-protection-related and altruistic motivations underlying preferences for public health policies.

METHODS

Our new approach relies on associations between on the one hand decision makers' perceived health risk for themselves and for close relatives and on the other hand their observed preferences for health policies that reduce such risks. The approach allows to make a rough distinction between health-related self-protection and local altruistic motives behind preferences for health policies. We illustrate our approach using data obtained from a discrete choice experiment in the context of policies to relax coronavirus-related lockdown measures in The Netherlands.

RESULTS

Our results show that the approach is able to uncover that (1) people who think they have a high chance of experiencing health risks from a COVID-19 infection are more willing to accept a societal or personal sacrifice, (2) people with a higher health risk perception for their relatives have a higher willingness to accept sacrifices than people with a higher health risk perception for themselves, and (3) people who perceive that they have a high risk of dying of COVID-19 have a higher willingness to accept sacrifices than those anticipating less severe consequences of COVID-19.

CONCLUSIONS

Our method offers a useful proxy metric to distinguish health-related self-protection and local altruism as drivers of citizens' responses to healthcare policies.

Trade-offs during the COVID-19 pandemic: A discrete choice experiment about policy preferences in Portugal

The need to control the sanitary situation during the COVID-19 pandemic has led governments to implement several restrictions with substantial social and economic impacts. We explored people's trade-offs in terms of their income, life restrictions, education, and poverty in the society, compared to their willingness to avoid deaths. We applied a web-based discrete choice experiment to elicit preferences of the Portuguese citizens for these attributes and computed the marginal rate of substitution in terms of avoided deaths. We recorded 2,191 responses that faced the possibility of having 250 COVID-19 related deaths per day as the worst possible outcome from the choice levels presented. Estimates suggested that individuals would be willing to sacrifice 30% instead of 10% of their income to avoid approximately 47 deaths per day during the first six months of 2021. For the same period, they would also accept 30% of the students' population to become educationally impaired, instead of 10%, to avoid approximately 25 deaths; a strict lockdown, instead of mild life restrictions, to avoid approximately 24 deaths; and 45% of the population to be in risk of poverty, instead of 25%, to avoid approximately 101 deaths. Our paper shows that avoiding deaths was strongly preferred to the remaining societal impacts; and that being a female, as well as working on site, led individuals to be more averse to such health hazards. Furthermore, we show how a DCE can be used to assess the societal support to decision-making during times of crisis.

Population preferences for non-pharmaceutical interventions to control the SARS-CoV-2 pandemic: trade-offs among public health, individual rights, and economics

PROBLEM

Policymakers must decide on interventions to control the pandemic. These decisions are driven by weighing the risks and benefits of various non-pharmaceutical intervention alternatives. Due to the nature of the pandemic, these decisions are not based on sufficient evidence regarding the effects, nor are decision-makers informed about the willingness of populations to accept the economic and health risks associated with different policy options. This empirical study seeks to reduce uncertainty by measuring population preferences for non-pharmaceutical interventions.

METHODS

An online-based discrete choice experiment (DCE) was conducted to elicit population preferences. Respondents were asked to choose between three pandemic scenarios with different interventions and impacts of the Corona pandemic. In addition, Best-worst scaling (BWS) was used to analyze the impact of the duration of individual interventions on people's acceptance. The marginal rate of substitution was applied to estimate willingness-to-accept (WTA) for each intervention and effect by risk of infection.

RESULTS

Data from 3006 respondents were included in the analysis. The DCE showed, economic effect of non-pharmaceutical measures had a large impact on choice decisions for or against specific lockdown scenarios. Individual income decreases had the most impact. Excess mortality and individual risk of infection were also important factors influencing choice decisions. Curfews, contact restrictions, facility closures, personal data transmissions, and mandatory masking in public had a lesser impact. However, significant standard deviations in the random parameter logit model (RPL) indicated heterogeneities in the study population. The BWS results showed that short-term restrictions were more likely to be accepted than long-term restrictions. According to WTA estimates, people would be willing to accept a greater risk of infection to avoid loss of income.

DISCUSSION

The results can be used to determine which consequences of pandemic measures would be more severe for the population. For example, the results show that citizens want to limit the decline in individual income during pandemic measures. Participation in preference studies can also inform citizens about potential tradeoffs that decision-makers face in current and future decisions during a pandemic. Knowledge of the population's preferences will help inform decisions that consider people's perspectives and expectations for the future. Survey results can inform decision-makers about the extent to which the population is willing to accept certain lockdown measures, such as curfews, contact restrictions, lockdowns, or mandatory masks.

Applications of discrete choice experiments in COVID-19 research: Disparity in survey qualities between health and transport fields

Published choice experiments linked to various aspects of the COVID-19 pandemic are analysed in a rapid review. The aim is to (i) document the diversity of topics as well as their temporal and geographical patterns of emergence, (ii) compare various elements of design quality across different sectors of applied economics, and (iii) identify potential signs of convergent validity across findings of comparable experiments. Of the N = 43 published choice experiments during the first two years of the pandemic, the majority identifies with health applications (n = 30), followed by transport-related applications (n = 10). Nearly 100,000 people across the world responded to pandemic-related discrete choice surveys. Within health applications, while the dominant theme, up until June 2020, was lockdown relaxation and tracing measures, the focus shifted abruptly to vaccine preference since then. Geographical origins of the health surveys were not diverse. Nearly 50% of all health surveys were conducted in only three countries, namely US, China and The Netherlands. Health applications exhibited stronger pre-testing and larger sample sizes compared to transport applications. Limited signs of convergent validity were identifiable. Within some applications, issues of temporal instability as well as hypothetical bias attributable to social desirability, protest response or policy consequentiality seemed likely to have affected the findings. Nevertheless, very few of the experiments implemented measures of hypothetical bias mitigation and those were limited to health studies. Our main conclusion is that swift administration of pandemic-related choice experiments has overall resulted in certain degrees of compromise in study quality, but this has been more so the case in relation to transport topics than health topics.

Using Best-Worst Scaling to investigate younger adult Canadians' preferences for COVID-19 vaccination and public health measures: An observational study

Containing the COVID-19 pandemic is dependent on compliance with public health recommendations and mandates which is lower in younger compared to older adults. Furthermore, younger adults have demonstrated lower uptake of COVID-19 vaccines. The aim of this study was to assess preferences for COVID-19 related preventive health measures and vaccination and to explore their association with COVID-19 vaccine acceptability. Canadians aged 18-39 years were invited to participate in a web-based survey in August 2021. We used the Best-Worst-Scaling (BWS) methodology to collect and analyze preference data and multivariable binary logistic regression to estimate associations with vaccine acceptability. Based on 266 complete responses, we found strong preferences for physical distancing and wearing face masks, as compared to general hygiene and respiratory etiquette. High vaccine accessibility independent of the location, receiving successive doses of the same vaccine brand and higher vaccine uptake of people in younger adults' social circle were highly preferred. Higher preferences for mandates requiring proof of vaccination and altruistic motives focused on protecting others by getting vaccinated were associated with vaccine acceptability. As the COVID-19 pandemic waxes and wanes, studies using larger, nationally representative samples are needed to replicate and validate these results to assess preferences for health behaviors corresponding to the latest recommendations. The use of this methodology could provide public health authorities with a unique opportunity to develop targeted, preference-based messaging that aligns with the latest guidelines to effectively encourage compliance and COVID-19 vaccine uptake.

Public acceptability of non-pharmaceutical interventions to control a pandemic in the UK: a discrete choice experiment

OBJECTIVE

To understand how individuals trade off between features of non-pharmaceutical interventions (eg, lockdowns) to control a pandemic across the four nations of the UK.

DESIGN

A survey that included a discrete choice experiment. The survey design was informed using policy documents, social media analysis and input from remote think-aloud interviews with members of the public (n=23).

SETTING

A nationwide survey across the four nations of the UK using an online panel between 29 October and 12 December 2020.

PARTICIPANTS

Individuals who are over 18 years old. A total of 4120 adults completed the survey (1112 in England, 848 in Northern Ireland, 1143 in Scotland and 1098 in Wales).

PRIMARY OUTCOME MEASURE

Adult's preferences for, and trade-offs between, type of lockdown restrictions, length of lockdown, postponement of routine healthcare, excess deaths, impact on the ability to buy things and unemployment.

RESULTS

The majority of adults are willing to accept higher excess deaths if this means lockdowns that are less strict, shorter and do not postpone routine healthcare. On average, respondents in England were willing to accept a higher increase in excess deaths to have less strict lockdown restrictions introduced compared with Scotland, Northern Ireland and Wales, respectively. In all four countries, one out of five respondents were willing to reduce excess deaths at all costs.

CONCLUSIONS

The majority of the UK population is willing to accept the increase in excess deaths associated with introducing less strict lockdown restrictions. The acceptability of different restriction scenarios varies according to the features of the lockdown and across countries. Governments can use information about trade-off preferences to inform the introduction of different lockdown restriction levels and design compensation policies that maximise societal welfare.

Investigating the effectiveness of COVID-19 pandemic countermeasures on the use of public transport: A case study of The Netherlands

During the COVID-19 pandemic, public transport in many cities faces dramatic reduction of passenger demand. Various countermeasures such as social distancing and in-vehicle disinfection have been implemented to reduce the potential risks concerning infection, the effectiveness in promoting the use of public transport however remains unclear. Unlike the usual situation where time and cost are the main factors affecting travel decisions, the uncertainty hiding behind the behavior change of public transport users in a pandemic might be greatly affected by the control measures and the perception of people. This paper therefore aims to examine the effects of COVID-19 related countermeasures implemented in public transport on individuals' travel decisions. We explore the extent to which do policy countermeasures influence different groups of people on the use of public transport. An error component latent class choice model was estimated using the data collected in the Netherlands. Results show that the restrictions policy lifted by the Dutch central government have significant effect on individuals' transportation mode choice decision during the pandemic. The related measures adopted by the public transport sector, by contrast, present different effects on different people. The older and highly educated people are more susceptible to enforcement measures, whereas young and single Dutch citizens are more accessible to non-compulsory measures. Moreover, compared with other private modes, public transport is generally identified as a riskier option, and the average willingness to travel descends. Findings of this study are helpful for the authorities in designing and promoting effective policies in the context of pandemics.

Facing the Pandemic in Italy: Personality Profiles and Their Associations With Adaptive and Maladaptive Outcomes

The negative impact of the COVID-19 pandemic on individuals' psychosocial functioning was widely attested during the last year. However, the extent to which individual differences are associated with adaptive and maladaptive outcomes during quarantine in Italy remains largely unexplored. Using a person-oriented approach, the present study explored the association of personality profiles, based on three broad individual dispositions (i.e., positivity, irritability, and hostile rumination) and two self-efficacy beliefs in the emotional area (i.e., expressing positive emotions and regulating anger emotion), with adaptive and maladaptive outcomes during the first Italian lockdown (March-June 2020). In doing so, we focused also on how different age groups (i.e., young adults and adults) differently faced the pandemic. The study was conducted through an online survey from May to June 2020 and included 1341 participants living in Italy, divided into two groups: 737 young adults aged 18-35 and 604 adults aged 36-60 years old. Latent Profile Analysis identified three personality profiles: resilient, vulnerable, and moderate. A subsequent path analysis model showed that the resilient profile was positively associated with prosocial behavior as an indicator of adaptive outcome, and negatively associated with three maladaptive outcomes: interpersonal aggression, depressive symptoms, and anxiety problems. Contrarily, the vulnerable profile resulted negatively associated with prosocial behavior and positively associated with the three maladaptive outcomes. Finally, regarding age group differences, young adults belonging to the vulnerable profile showed a greater association especially with interpersonal aggression, depression, and anxiety problems, as compared to adults belonging to the same profile. Overall, the results of the present study highlighted the importance to analyze individual functioning during an isolation period by using a person-oriented approach. Findings evidenced the existence of three different profiles (i.e., Resilient, Vulnerable, and Moderate) and subsequent path analysis revealed, especially for the vulnerable profile and young adults, a greater maladaptive consequence of the quarantine. The practical implications will be discussed.

Deciphering the COVID-19 Health Economic Dilemma (HED): A Scoping Review

Lessons learnt from the initial stages of the COVID-19 outbreak indicate the need for a more coordinated economic and public health response. While social distancing has been shown to be effective as a non-pharmaceutical intervention (NPI) measure to mitigate the spread of COVID-19, the economic costs have been substantial. Insights combining epidemiological and economic data provide new theoretical predictions that can be used to better understand the health economy tradeoffs. This literature review aims to elucidate perspectives to assist policy implementation related to the management of the ongoing and impending outbreaks regarding the Health Economic Dilemma (HED). This review unveiled the need for information-based decision-support systems which will combine pandemic spread modelling and control, with economic models. It is expected that the current review will not only support policy makers but will also provide researchers on the development of related decision-support-systems with comprehensive information on the various aspects of the HED.

Public participation in crisis policymaking. How 30,000 Dutch citizens advised their government on relaxing COVID-19 lockdown measures

Following the outbreak of COVID-19, governments took unprecedented measures to curb the spread of the virus. Public participation in decisions regarding (the relaxation of) these measures has been notably absent, despite being recommended in the literature. Here, as one of the exceptions, we report the results of 30,000 citizens advising the government on eight different possibilities for relaxing lockdown measures in the Netherlands. By making use of the novel method Participatory Value Evaluation (PVE), participants were asked to recommend which out of the eight options they prefer to be relaxed. Participants received information regarding the societal impacts of each relaxation option, such as the impact of the option on the healthcare system. The results of the PVE informed policymakers about people's preferences regarding (the impacts of) the relaxation options. For instance, we established that participants assign an equal value to a reduction of 100 deaths among citizens younger than 70 years and a reduction of 168 deaths among citizens older than 70 years. We show how these preferences can be used to rank options in terms of desirability. Citizens advised to relax lockdown measures, but not to the point at which the healthcare system becomes heavily overloaded. We found wide support for prioritising the re-opening of contact professions. Conversely, participants disfavoured options to relax restrictions for specific groups of citizens as they found it important that decisions lead to "unity" and not to "division". 80% of the participants state that PVE is a good method to let citizens participate in government decision-making on relaxing lockdown measures. Participants felt that they could express a nuanced opinion, communicate arguments, and appreciated the opportunity to evaluate relaxation options in comparison to each other while being informed about the consequences of each option. This increased their awareness of the dilemmas the government faces.

United States COVID-19 Vaccination Preferences (CVP): 2020 Hindsight

Background

Shortly after the 2020 US election, initial evidence on first-generation COVID-19 vaccines showed 70–95% efficacy and minimal risks. Yet, many US adults expressed reluctance.

Aims

The aim of this study was to compare persons willing and unwilling to be vaccinated against COVID-19 and to estimate the effects of vaccination attributes on uptake: proof of vaccination, vaccination setting, effectiveness, duration of immunity, and risk of severe side effects.

Method

Between 9 and 11 November 2020, 1153 US adults completed a discrete choice experiment (DCE) on Phase 2 of the CDC Vaccination Program (August 2021). Each of its eight choice tasks had three vaccination alternatives and “no vaccination for 6 months.” An opt-out inflated logit model was estimated to test for respondent differences and attribute effects.

Results

Respondent demographics were unrelated to one’s willingness to be vaccinated (p value 0.533), but those with less education were more likely to be unwilling (p < 0.001). Among those willing, uptake ranged from 61.70 to 97.75%, depending on the vaccination attributes. Effectiveness and safety had the largest effects. Offering proof of vaccination and a choice of setting increased uptake as much as increasing immunity from 3 to 6 months.

Conclusions

To maximize uptake, the CDC Program should standardize proof of vaccination and offer a choice of setting, instead of a one-size-fits-all approach. If the first-generation vaccines are efficacious, widely available, and free, overall predicted uptake is 68.81% by the end of Phase 2 (August 2021), which is well below the 75–90% needed for herd immunity. Further health preference research is necessary to uncover and address unwillingness and reluctance to vaccinate against COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00508-0.

Exploring the Trade-Off Between Economic and Health Outcomes During a Pandemic: A Discrete Choice Experiment of Lockdown Policies in Australia

Background

All countries experienced social and economic disruption and threats to health security from the COVID-19 pandemic in 2020, but the responses in terms of control measures varied considerably. While control measures, such as quarantine, lockdown and social distancing, reduce infections and infection-related deaths, they have severe negative economic and social consequences.

Objectives

The objective of this study was to explore the acceptability of different infectious disease control measures, and examine how respondents trade off between economic and health outcomes.

Methods

A discrete choice experiment was developed, with attributes covering: control restrictions, duration of restrictions, tracking, number of infections and of deaths, unemployment, government expenditure and additional personal tax. A representative sample of Australians (n = 1046) completed the survey, which included eight choice tasks. Data were analysed using mixed logit regression to identify heterogeneity and latent class models to examine heterogeneity.

Results

In general, respondents had strong preferences for policies that avoided high infection-related deaths, although lower unemployment and government expenditure were also considered important. Respondents preferred a shorter duration for restrictions, but their preferences did not vary significantly for the differing levels of control measures. In terms of tracking, respondents preferred mobile phone tracking or bracelets when compared to no tracking. Significant differences in preferences was identified, with two distinct classes: Class 1 (57%) preferred the economy to remain open with some control measures, whereas Class 2 (43%), had stronger preferences for policies that reduced avoidable deaths.

Conclusions

This study found that the Australian population is willing to relinquish some freedom, in the short term, and trade off the negative social and economic impacts of the pandemic, to avoid the negative health consequences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00503-5.

Social Study Resources and Social Wellbeing Before and During the Intelligent COVID-19 Lockdown in The Netherlands

The first intelligent COVID-19 lockdown resulted in radical changes within the tertiary educational system within the Netherlands. These changes posed new challenges for university students and many social welfare agencies have warned that it could have adverse effects on the social wellbeing (SWB) of university students. Students may lack the necessary social study-related resources (peer- and lecturer support) (SSR) necessary to aid them in coping with the new demands that the lockdown may bring. As such, the present study aimed to investigate the trajectory patterns, rate of change and longitudinal associations between SSR and SWB of 175 Dutch students before and during the COVID-19 lockdown. A piecewise latent growth modelling approach was employed to sample students' experiences over three months. Participants to complete a battery of psychometric assessments for five weeks before the COVID-19 lockdown was implemented, followed by two directly after and a month follow-up. The results were paradoxical and contradicting to initial expectations. Where SSR showed a linear rate of decline before- and significant growth trajectory during the lockdown, SWB remained moderate and stable. Further, initial levels and growth trajectories between SSR and SWB were only associated before the lockdown.

Public participation in crisis policymaking. How 30,000 Dutch citizens advised their government on relaxing COVID-19 lockdown measures

Following the outbreak of COVID-19, governments took unprecedented measures to curb the spread of the virus. Public participation in decisions regarding (the relaxation of) these measures has been notably absent, despite being recommended in the literature. Here, as one of the exceptions, we report the results of 30,000 citizens advising the government on eight different possibilities for relaxing lockdown measures in the Netherlands. By making use of the novel method Participatory Value Evaluation (PVE), participants were asked to recommend which out of the eight options they prefer to be relaxed. Participants received information regarding the societal impacts of each relaxation option, such as the impact of the option on the healthcare system. The results of the PVE informed policymakers about people's preferences regarding (the impacts of) the relaxation options. For instance, we established that participants assign an equal value to a reduction of 100 deaths among citizens younger than 70 years and a reduction of 168 deaths among citizens older than 70 years. We show how these preferences can be used to rank options in terms of desirability. Citizens advised to relax lockdown measures, but not to the point at which the healthcare system becomes heavily overloaded. We found wide support for prioritising the re-opening of contact professions. Conversely, participants disfavoured options to relax restrictions for specific groups of citizens as they found it important that decisions lead to "unity" and not to "division". 80% of the participants state that PVE is a good method to let citizens participate in government decision-making on relaxing lockdown measures. Participants felt that they could express a nuanced opinion, communicate arguments, and appreciated the opportunity to evaluate relaxation options in comparison to each other while being informed about the consequences of each option. This increased their awareness of the dilemmas the government faces.

Understanding public preferences and trade-offs for government responses during a pandemic: a protocol for a discrete choice experiment in the UK

INTRODUCTION

Social distancing and lockdown measures are among the main government responses to the COVID-19 pandemic. These measures aim to limit the COVID-19 infection rate and reduce the mortality rate of COVID-19. Given we are likely to see local lockdowns until a treatment or vaccine for COVID-19 is available, and their effectiveness depends on public acceptability, it is important to understand public preference for government responses.

METHODS AND ANALYSIS

Using a discrete choice experiment (DCE), this study will investigate the public's preferences for pandemic responses in the UK. Attributes (and levels) are based on: (1) lockdown measures described in policy documents; (2) literature on preferences for lockdown measures and (3) a social media analysis. Attributes include: lockdown type; lockdown length; postponement of usual non-urgent medical care; number of excess deaths; number of infections; impact on household spending and job losses. We will prepilot the DCE using virtual think aloud interviews with respondents recruited via Facebook. We will collect preference data using an online survey of 4000 individuals from across the four UK countries (1000 per country). We will estimate the relative importance of the attributes, and the trade-offs individuals are willing to make between attributes. We will test if respondents' preferences differ based on moral attitudes (using the Moral Foundation Questionnaire), socioeconomic circumstances (age, education, economic insecurity, health status), country of residence and experience of COVID-19.

ETHICS AND DISSEMINATION

The University of Aberdeen's College Ethics Research Board (CERB) has approved the study (reference: CERB/2020/6/1974). We will seek CERB approval for major changes from the developmental and pilot work. Peer-reviewed papers will be submitted, and results will be presented at public health and health economic conferences nationally and internationally. A lay summary will be published on the Health Economics Research Unit blog.