Early Perceptions of COVID-19 Contact Tracing Apps in German-Speaking Countries: Comparative Mixed Methods Study

Contact tracing strategies for infectious diseases: A systematic literature review

Contact tracing has been a crucial public health strategy for breaking infectious diseases chains of transmission. Although many resources exist for disease outbreak management none address the rationale of contact tracing. This comprehensive review aims to evaluate contact tracing strategies, their effectiveness, and health systems governance across various diseases to inform a disease-agnostic contact tracing guideline. This systematic review was registered with PROSPERO (ID: CRD42023474507) and follows Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Descriptive and interventional studies in the six official United Nations languages were included, excluding modelling studies and animal-to-human transmission. An electronic search was conducted in Embase, Medline, Medline-in-process, and Cochrane libraries from inception to September 2023. The revised Cochrane Risk of Bias Tool and the Risk of Bias in Non-Randomized Studies of Interventions were used for bias assessment. The search yielded 378 studies, primarily from Europe (29.6%) and North America (21.6%) and focusing on diseases such as the coronavirus disease (COVID-19) (47.4%) or tuberculosis (26.7%). 244 (64.5%) studies addressed contact tracing definitions, commonly based on physical proximity, including duration of contact and sexual partnerships (47.6%) and household exposure (27%). Effectiveness was examined in 330 (87.3%) studies, showing variation across diseases and contexts, with only five studies evaluating epidemiological impacts. Socio-cultural aspects were covered in 166 (43.9%) studies, revealing that stigma and public trust may affect the adherence to contact tracing. Health systems governance was discussed in 278 (73.5%) studies, emphasising the need for coordination among international organisations, national governments, and local health authorities, alongside a sustained and adequately supported workforce. This review provides critical insights into optimising contact tracing strategies. Effective contact tracing requires robust health systems governance, adequate resources, and community involvement. Future research should focus on establishing standardised metrics for comparative analysis and investigating the impact of contact tracing on disease incidence and mortality.

Innovative public strategies in response to COVID-19: A review of practices from China

The COVID-19 pandemic presented unparalleled challenges to prompt and adaptive responses from nations worldwide. This review examines China's multifaceted approach to the crisis, focusing on five key areas of response: infrastructure and system design, medical care and treatment, disease prevention and control, economic and social resilience, and China's engagement in global health. This review demonstrates the effectiveness of a top-down command system at the national level, intersectoral coordination, a legal framework, and public social governance. This study also examines medical care and treatment strategies, highlighting the importance of rapid emergency response, evidence-based treatment, and well-planned vaccination rollout. Further discussion on disease prevention and control measures emphasizes the importance of adaptive measures, timely infection control, transmission interruption, population herd immunity, and technology applications. Socioeconomic impact was also assessed, detailing strategies for disease prevention, material supply, livelihood preservation, and social economy revival. Lastly, we examine China's contributions to the global health community, with a focus on knowledge-sharing, information exchange, and multilateral assistance. While it is true that each nation's response must be tailored to its own context, there are universal lessons to be drawn from China's approach. These insights are pivotal for enhancing global health security, especially as the world navigates evolving health crises.

Contextual Acceptance of COVID-19 Mitigation Mobile Apps in the United States: Mixed Methods Survey Study on Postpandemic Data Privacy

BACKGROUND

The COVID-19 pandemic gave rise to countless user-facing mobile apps to help fight the pandemic ("COVID-19 mitigation apps"). These apps have been at the center of data privacy discussions because they collect, use, and even retain sensitive personal data from their users (eg, medical records and location data). The US government ended its COVID-19 emergency declaration in May 2023, marking a unique time to comprehensively investigate how data privacy impacted people's acceptance of various COVID-19 mitigation apps deployed throughout the pandemic.

OBJECTIVE

This research aims to provide insights into health data privacy regarding COVID-19 mitigation apps and policy recommendations for future deployment of public health mobile apps through the lens of data privacy. This research explores people's contextual acceptance of different types of COVID-19 mitigation apps by applying the privacy framework of contextual integrity. Specifically, this research seeks to identify the factors that impact people's acceptance of data sharing and data retention practices in various social contexts.

METHODS

A mixed methods web-based survey study was conducted by recruiting a simple US representative sample (N=674) on Prolific in February 2023. The survey includes a total of 60 vignette scenarios representing realistic social contexts that COVID-19 mitigation apps could be used. Each survey respondent answered questions about their acceptance of 10 randomly selected scenarios. Three contextual integrity parameters (attribute, recipient, and transmission principle) and respondents' basic demographics are controlled as independent variables. Regression analysis was performed to determine the factors impacting people's acceptance of initial data sharing and data retention practices via these apps. Qualitative data from the survey were analyzed to support the statistical results.

RESULTS

Many contextual integrity parameter values, pairwise combinations of contextual integrity parameter values, and some demographic features of respondents have a significant impact on their acceptance of using COVID-19 mitigation apps in various social contexts. Respondents' acceptance of data retention practices diverged from their acceptance of initial data sharing practices in some scenarios.

CONCLUSIONS

This study showed that people's acceptance of using various COVID-19 mitigation apps depends on specific social contexts, including the type of data (attribute), the recipients of the data (recipient), and the purpose of data use (transmission principle). Such acceptance may differ between the initial data sharing and data retention practices, even in the same context. Study findings generated rich implications for future pandemic mitigation apps and the broader public health mobile apps regarding data privacy and deployment considerations.

Investigating Citizens' Acceptance of Contact Tracing Apps: Quantitative Study of the Role of Trust and Privacy

BACKGROUND

The COVID-19 pandemic accelerated the need to understand citizen acceptance of health surveillance technologies such as contact tracing (CT) apps. Indeed, the success of these apps required widespread public acceptance and the alleviation of concerns about privacy, surveillance, and trust.

OBJECTIVE

This study aims to examine the factors that foster a sense of trust and a perception of privacy in CT apps. Our study also investigates how trust and perceived privacy influence citizens' willingness to adopt, disclose personal data, and continue to use these apps.

METHODS

Drawing on privacy calculus and procedural fairness theories, we developed a model of the antecedents and behavioral intentions related to trust and privacy perceptions. We used structural equation modeling to test our hypotheses on a data set collected at 2 time points (before and after the launch of a national CT app). The sample consisted of 405 Irish residents.

RESULTS

Trust in CT apps was positively influenced by propensity to trust technology (β=.074; P=.006), perceived need for surveillance (β=.119; P<.001), and perceptions of government motives (β=.671; P<.001) and negatively influenced by perceived invasion (β=-.224; P<.001). Perceived privacy was positively influenced by trust (β=.466; P<.001) and perceived control (β=.451; P<.001) and negatively influenced by perceived invasion (β=-.165; P<.001). Prelaunch intentions toward adoption were influenced by trust (β=.590; P<.001) and perceived privacy (β=.247; P<.001). Prelaunch intentions to disclose personal data to the app were also influenced by trust (β=.215; P<.001) and perceived privacy (β=.208; P<.001) as well as adoption intentions before the launch (β=.550; P<.001). However, postlaunch intentions to use the app were directly influenced by prelaunch intentions (β=.530; P<.001), but trust and perceived privacy only had an indirect influence. Finally, with regard to intentions to disclose after the launch, use intentions after the launch (β=.665; P<.001) and trust (β=.215; P<.001) had a direct influence, but perceived privacy only had an indirect influence. The proposed model explained 74.4% of variance in trust, 91% of variance in perceived privacy, 66.6% of variance in prelaunch adoption intentions, 45.9% of variance in postlaunch use intentions, and 83.9% and 79.4% of variance in willingness to disclose before the launch and after the launch, respectively.

CONCLUSIONS

Positive perceptions of trust and privacy can be fostered through clear communication regarding the need and motives for CT apps, the level of control citizens maintain, and measures to limit invasive data practice. By engendering these positive beliefs before launch and reinforcing them after launch, citizens may be more likely to accept and use CT apps. These insights are important for the launch of future apps and technologies that require mass acceptance and information disclosure.

Evaluating the Added Value of Digital Contact Tracing Support Tools for Citizens: Framework Development

BACKGROUND

The COVID-19 pandemic revealed that with high infection rates, health services conducting contact tracing (CT) could become overburdened, leading to limited or incomplete CT. Digital CT support (DCTS) tools are designed to mimic traditional CT, by transferring a part of or all the tasks of CT into the hands of citizens. Besides saving time for health services, these tools may help to increase the number of contacts retrieved during the contact identification process, quantity and quality of contact details, and speed of the contact notification process. The added value of DCTS tools for CT is currently unknown.

OBJECTIVE

To help determine whether DCTS tools could improve the effectiveness of CT, this study aims to develop a framework for the comprehensive assessment of these tools.

METHODS

A framework containing evaluation topics, research questions, accompanying study designs, and methods was developed based on consultations with CT experts from municipal public health services and national public health authorities, complemented with scientific literature.

RESULTS

These efforts resulted in a framework aiming to assist with the assessment of the following aspects of CT: speed; comprehensiveness; effectiveness with regard to contact notification; positive case detection; potential workload reduction of public health professionals; demographics related to adoption and reach; and user experiences of public health professionals, index cases, and contacts.

CONCLUSIONS

This framework provides guidance for researchers and policy makers in designing their own evaluation studies, the findings of which can help determine how and the extent to which DCTS tools should be implemented as a CT strategy for future infectious disease outbreaks.

Trust and Health Information Exchanges: Qualitative Analysis of the Intent to Share Personal Health Information

BACKGROUND

Digital health has the potential to improve the quality of care, reduce health care costs, and increase patient satisfaction. Patient acceptance and consent are a prerequisite for effective sharing of personal health information (PHI) through health information exchanges (HIEs). Patients need to form and retain trust in the system(s) they use to leverage the full potential of digital health. Germany is at the forefront of approving digital treatment options with cost coverage through statutory health insurance. However, the German population has a high level of technology skepticism and a low level of trust, providing a good basis to illuminate various facets of eHealth trust formation.

OBJECTIVE

In a German setting, we aimed to answer the question, How does an individual form a behavioral intent to share PHI with an HIE platform? We discussed trust and informed consent through (1) synthesizing the main influence factor models into a complex model of trust in HIE, (2) providing initial validation of influence factors based on a qualitative study with patient interviews, and (3) developing a model of trust formation for digital health apps.

METHODS

We developed a complex model of the formation of trust and the intent to share PHI. We provided initial validation of the influence factors through 20 qualitative, semistructured interviews in the German health care setting and used a deductive coding approach to analyze the data.

RESULTS

We found that German patients show a positive intent to share their PHI with HIEs under certain conditions. These include (perceived) information security and a noncommercial organization as the recipient of the PHI. Technology experience, age, policy and regulation, and a disposition to trust play an important role in an individual's privacy concern, which, combined with social influence, affects trust formation on a cognitive and emotional level. We found a high level of cognitive trust in health care and noncommercial research institutions but distrust in commercial entities. We further found that in-person interactions with physicians increase trust in digital health apps and PHI sharing. Patients' emotional trust depends on disposition and social influences. To form their intent to share, patients undergo a privacy calculus. Hereby, the individual's benefit (eg, convenience), benefits for the individual's own health, and the benefits for public welfare often outweigh the perceived risks of sharing PHI.

CONCLUSIONS

With the higher demand for timely PHI, HIE providers will need to clearly communicate the benefits of their solutions and their information security measures to health care providers (physicians, nursing and administrative staff) and patients and include them as key partners to increase trust. Offering easy access and educational measures as well as the option for specific consent may increase patients' trust and their intention to share PHI.

The French General Population's Perception of New Information and Communication Technologies for Medical Consultations: National Survey

BACKGROUND

The development of telehealth and telemedicine, in the form of increased teleconsultation and medical telemonitoring, accelerated during the COVID-19 health crisis in France to ensure continued access to care for the population. Since these new information and communication technologies (ICTs) are diverse and likely to transform how the health care system is organized, there is a need better to understand public attitudes toward them and their relationship with peoples' current experience of health care.

OBJECTIVE

This study aimed to determine the French general population's perception of the usefulness of video recording/broadcasting (VRB) and mobile Health (mHealth) apps for medical consultations in France during the COVID-19 health crisis and the factors associated with this perception.

METHODS

Data were collected for 2003 people in 2 waves of an online survey alongside the Health Literacy Survey 2019 (1003 in May 2020 and 1000 in January 2021) based on quota sampling. The survey collected sociodemographic characteristics, health literacy levels, trust in political representatives, and perceived health status. The perceived usefulness of VRB in medical consultations was measured by combining 2 responses concerning this technology for consultations. The perceived usefulness of mHealth apps was measured by combining 2 responses concerning their usefulness for booking doctor appointments and for communicating patient-reported outcomes to doctors.

RESULTS

The majority (1239/2003, 62%) of respondents considered the use of mHealth apps useful, while only 27.6% (551/2003) declared VRB useful. The factors associated with the perceived usefulness of both technologies were younger age (≤ 55 years), trust in political representatives (VRB: adjusted odds ratio [aOR] 1.68, 95% CI 1.31-2.17; mHealth apps: aOR 1.88, 95% CI 1.42-2.48), and higher (sufficient and excellent) health literacy. The period of the beginning of the COVID-19 epidemic, living in an urban area, and being limited in daily activities were also associated with perceiving VRB positively. The perceived usefulness of mHealth apps increased with the level of education. It was also higher in people who had 3 or more consultations with a medical specialist.

CONCLUSIONS

There are important differences in attitudes toward new ICTs. Perceived usefulness was lower for VRB than for mHealth apps. Moreover, it decreased after the initial months of the COVID-19 pandemic. There is also the possibility of new inequalities. Hence, despite the potential benefits of VRB and mHealth apps, people with low health literacy considered them to be of little use for their health care, possibly increasing their difficulties in accessing health care in the future. As such, health care providers and policy makers need to consider those perceptions to guarantee that new ICTs are accessible and beneficial to all.

Newspaper coverage on solidarity and personal responsibility in the COVID-19 pandemic: A content analysis from Germany and German-speaking Switzerland

Solidarity and personal responsibility have been repeatedly called upon during the COVID-19 pandemic. This study quantifies and contextualizes the use of these terms in newspaper coverage in Germany and German-speaking Switzerland based on n = 640 articles from six functionally equivalent newspapers. The term solidarity in the context of the COVID-19 pandemic was mentioned in 541/640 articles (84.5%) and was primarily used during phases with high death rates and comparatively stringent policies in place, supporting the idea that solidarity was used to explain restrictive measures to the population and motivate people to comply with these measures. German newspapers published more articles on solidarity than Swiss-German newspapers, consistent with more stringent COVID-19 policies in Germany. Personal responsibility was mentioned in 133/640 articles (20.8%), meaning that the term was less frequently discussed than solidarity. Articles covering personal responsibility included more negative evaluations during phases of high infection rates as compared to phases of low infection rates. Findings indicate that the two terms were, at least to some extent, used in newspaper reporting to contextualize and justify COVID-19 policy during phases of high infection rates. Moreover, the term solidarity was used in a high variety of different contexts and the inherent limits of solidarity were rarely mentioned. Policymakers and journalists need to take this into account for future crises to not jeopardize the positive effects of solidarity.

["Sending a signal of solidarity via bluetooth?"-A medical ethical analysis of the public debate on the Corona-Warn-App]

Definition of the problem

In the public debate in Germany on the Corona-Warn-App, the concept of solidarity is a prominent, but contested normative reference point. Thus, different uses of the concept with heterogeneous assumptions, normative implications and practical consequences stand next to each other and require medical ethical investigation. Against this backdrop, this contribution aims firstly to illustrate the spectrum of understandings of the concept of solidarity in the public debate on the Corona-Warn-App. Secondly, it elaborates the preconditions and normative implications of these uses and evaluates them from an ethical perspective.

Arguments

Starting with an introduction of the Corona-Warn-App and a general definition of the concept of solidarity, I present four examples for different uses of the concept of solidarity from the public discourse on the Corona-Warn-App that vary regarding the underlying identification, the group of solidarity, the solidarity contribution and the normative goal. They highlight the need for further ethical standards in order to assess their legitimacy. Hence, I use four normative criteria of a context-sensitive, morally substantial conception of solidarity (openness, malleable inclusivity, adequacy of the contribution, normative dependence) to ethically evaluate the solidarity recourses presented.

Conclusion

Critical remarks can be formulated for all presented notions of solidarity. On the one hand, the potentials and limitations of solidarity recourses in public debates become apparent. On the other, criteria can be derived for a solidarity-promoting use of the Corona-Warn-App.

Addressing Complexity in the Pandemic Context: How Systems Thinking Can Facilitate Understanding of Design Aspects for Preventive Technologies

The COVID-19 pandemic constitutes a wicked problem that is defined by rapidly evolving and dynamic conditions, where the physical world changes (e.g., pathogens mutate) and, in parallel, our understanding and knowledge rapidly progress. Various preventive measures have been developed or proposed to manage the situation, including digital preventive technologies to support contact tracing or physical distancing. The complexity of the pandemic and the rapidly evolving nature of the situation pose challenges for the design of effective preventive technologies. The aim of this conceptual paper is to apply a systems thinking model, DSRP (distinctions, systems, relations, perspectives) to explain the underlying assumptions, patterns, and connections of the pandemic domain, as well as to identify potential leverage points for design of preventive technologies. Two different design approaches, contact tracing and nudging for distance, are compared, focusing on how their design and preventive logic are related to system complexity. The analysis explains why a contact tracing technology involves more complexity, which can challenge both implementation and user understanding. A system utilizing nudges can operate using a more distinct system boundary, which can benefit understanding and implementation. However, frequent nudges might pose challenges for user experience. This further implies that these technologies have different contextual requirements and are useful at different levels in society. The main contribution of this work is to show how systems thinking can organize our understanding and guide the design of preventive technologies in the context of epidemics and pandemics.

Using a Proximity-Detection Technology to Nudge for Physical Distancing in a Swedish Workplace During the COVID-19 Pandemic: Retrospective Case Study

BACKGROUND

The recent COVID-19 pandemic has contributed to the emergence of several technologies for infectious disease management. Although much focus has been placed on contact-tracing apps, another promising new tactic is proximity tracing, which focuses on health-related behavior and can be used for primary prevention. Underpinned by theories on behavioral design, a proximity-detection system can be devised that provides a user with immediate nudges to maintain physical distance from others. However, the practical feasibility of proximity detection during an infectious disease outbreak has not been sufficiently investigated.

OBJECTIVE

We aimed to evaluate the feasibility of using a wearable device to nudge for distance and to gather important insights about how functionality and interaction are experienced by users. The results of this study can guide future research and design efforts in this emerging technology.

METHODS

In this retrospective case study, a wearable proximity-detection technology was used in a workplace for 6 weeks during the production of a music competition. The purpose of the technology was to nudge users to maintain their physical distance using auditory feedback. We used a mixed methods sequential approach, including interviews (n=8) and a survey (n=30), to compile the experiences of using wearable technology in a real-life setting.

RESULTS

We generated themes from qualitative analysis based on data from interviews and open-text survey responses. The quantitative data were subsequently integrated into these themes: feasibility (implementation and acceptance-establishing a shared problem; distance tags in context-strategy, environment, and activities; understanding and learning; and accomplishing the purpose) and design aspects (a purposefully annoying device; timing, tone, and proximity; and additional functions).

CONCLUSIONS

This empirical study reports on the feasibility of using wearable technology based on proximity detection to nudge individuals to maintain physical distance in the workplace. The technology supports attention to distance, but the usability of this approach is dependent on the context and situation. In certain situations, the audio signal is frustrating, but most users agree that it needs to be annoying to ensure sufficient behavioral adaption. We proposed a dual nudge that involves vibration followed by sound. There are indications that the technology also facilitates learning how to maintain a greater distance from others, and that this behavior can persist beyond the context of technology use. This study demonstrates that the key value of this technology is that it places the user in control and enables immediate action when the distance to others is not maintained. This study provides insights into the emerging field of personal and wearable technologies used for primary prevention during infectious disease outbreaks. Future research is needed to evaluate the preventive effect on transmission and investigate behavioral changes in detail and in relation to different forms of feedback.

Continued Use of Contact-Tracing Apps in the United States and the United Kingdom: Insights From a Comparative Study Through the Lens of the Health Belief Model

BACKGROUND

To contain the spread of SARS-CoV-2, contact-tracing (CT) mobile apps were developed and deployed to identify and notify individuals who have exposure to the virus. However, the effectiveness of these apps depends not only on their adoption by the general population but also on their continued use in the long term. Limited research has investigated the facilitators of and barriers to the continued use of CT apps.

OBJECTIVE

In this study, we aimed to examine factors influencing the continued use intentions of CT apps based on the health belief model. In addition, we investigated the differences between users and nonusers and between the US and UK populations.

METHODS

We administered a survey in the United States and the United Kingdom. Respondents included individuals who had previously used CT technologies and those without experience. We used the structural equation modeling technique to validate the proposed research model and hypotheses.

RESULTS

Analysis of data collected from 362 individuals showed that perceived benefits, self-efficacy, perceived severity, perceived susceptibility, and cues to action positively predicted the continued use intentions of CT apps, while perceived barriers could reduce them. We observed few differences between the US and UK groups; the only exception was the effect of COVID-19 threat susceptibility, which was significant for the UK group but not for the US group. Finally, we found that the only significant difference between users and nonusers was related to perceived barriers, which may not influence nonusers' continued use intentions but significantly reduce experienced users' intentions.

CONCLUSIONS

Our findings have implications for technological design and policy. These insights can potentially help governments, technology companies, and media outlets to create strategies and policies to promote app adoption for new users and sustain continued use for existing users in the long run.

Democratic research: Setting up a research commons for a qualitative, comparative, longitudinal interview study during the COVID-19 pandemic

The sudden and dramatic advent of the COVID-19 pandemic led to urgent demands for timely, relevant, yet rigorous research. This paper discusses the origin, design, and execution of the SolPan research commons, a large-scale, international, comparative, qualitative research project that sought to respond to the need for knowledge among researchers and policymakers in times of crisis. The form of organization as a research commons is characterized by an underlying solidaristic attitude of its members and its intrinsic organizational features in which research data and knowledge in the study is shared and jointly owned. As such, the project is peer-governed, rooted in (idealist) social values of academia, and aims at providing tools and benefits for its members. In this paper, we discuss challenges and solutions for qualitative studies that seek to operate as research commons.

The relationship between trust and attitudes towards the COVID-19 digital contact-tracing app in the UK

During the COVID-19 pandemic, digital contact-tracing has been employed in many countries to monitor and manage the spread of the disease. However, to be effective such a system must be adopted by a substantial proportion of the population; therefore, public trust plays a key role. This paper examines the NHS COVID-19 smartphone app, the digital contact-tracing solution in the UK. A series of interviews were carried out prior to the app's release (n = 12) and a large scale survey examining attitudes towards the app (n = 1,001) was carried out after release. Extending previous work reporting high level attitudes towards the app, this paper shows that prevailing negative attitudes prior to release persisted, and affected the subsequent use of the app. They also show significant relationships between trust, app features, and the wider social and societal context. There is lower trust amongst non-users of the app and trust correlates to many other aspects of the app, a lack of trust could hinder adoption and effectiveness of digital contact-tracing. The design of technology requiring wide uptake, e.g., for public health, should embed considerations of the complexities of trust and the context in which the technology will be used.

Efficacy and pitfalls of digital technologies in healthcare services: A systematic review of two decades

The use of technology in the healthcare sector and its medical practices, from patient record maintenance to diagnostics, has significantly improved the health care emergency management system. At that backdrop, it is crucial to explore the role and challenges of these technologies in the healthcare sector. Therefore, this study provides a systematic review of the literature on technological developments in the healthcare sector and deduces its pros and cons. We curate the published studies from the Web of Science and Scopus databases by using PRISMA 2015 guidelines. After mining the data, we selected only 55 studies for the systematic literature review and bibliometric analysis. The study explores four significant classifications of technological development in healthcare: (a) digital technologies, (b) artificial intelligence, (c) blockchain, and (d) the Internet of Things. The novel contribution of current study indicate that digital technologies have significantly influenced the healthcare services such as the beginning of electronic health record, a new era of digital healthcare, while robotic surgeries and machine learning algorithms may replace practitioners as future technologies. However, a considerable number of studies have criticized these technologies in the health sector based on trust, security, privacy, and accuracy. The study suggests that future studies, on technological development in healthcare services, may take into account these issues for sustainable development of the healthcare sector.

Motivations and Limits for COVID-19 Policy Compliance in Germany and Switzerland

BACKGROUND

In contrast to neighboring countries, German and Swiss authorities refrained from general curfews during the first pandemic wave in spring 2020, calling for solidarity and personal responsibility instead. Using a qualitative methodology, this study aims to explore why people in Germany and Switzerland were motivated to comply with policy measures during the first wave of the coronavirus disease 2019 (COVID-19) pandemic, and what factors hindered or limited their motivation. While quantitative surveys can measure the level of compliance, or broadly ask what motives people had for compliance, we here strive to explain why and how these motives lead to compliance.

METHODS

This publication has been made possible by the joint work of the members of the "Solidarity in times of pandemics" (SolPan) research commons. Seventy-seven semi-structured qualitative interviews were conducted with members of the general public in Germany (n = 46) and the German-speaking part of Switzerland (n = 31) in April 2020. Interviews were transcribed and analyzed following a grounded theory approach.

RESULTS

Three themes were identified that summarize factors contributing to compliant or noncompliant behavior. (1) Social cohesion was, on the one hand, an important motivator for compliance, but at the same time related to conflicting needs, illustrating the limits of compliance. (2) Consequences were considered on both the individual level (eg, consequences of individual infection) and societal level (eg, the societal and economic consequences of restrictions). (3) While for some participants following the rules was perceived as a matter of principle, others stressed the importance of making their own risk assessment, which was often associated with with a need for evidence on the effectiveness and reasons behind measures.

CONCLUSION

A variety of motives contribute to COVID-19 related compliance. Authorities should seek to address these multi-faceted aspects to support motivation for compliance in a large proportion of the population.

Acceptability of the COVID-19 contact-tracing app - Does culture matter?

During the pandemic, several countries deployed contact-tracing apps in order to contain or reduce the community spread of COVID-19. However, the success rate in terms of acceptance and use of these apps was reportedly low. Using information gathered from citizens across four European countries and the United States of America, this study explores the role of national culture in relation to the acceptance of these apps. Using partial least squares structural equation modelling (PLS-SEM), an analysis was undertaken of 3595 records from a cross-country survey dataset that is in the public domain and can be obtained from the Centre for Open Science (Study 1). This analysis was followed by another survey comprising 910 respondents (Study 2). The research model was then validated by using a qualitative approach and undertaking interviews with 51 participants from four countries (Study 3). The results confirmed the moderating role of national culture on the acceptability of the contact-tracing apps in relation to power-distance, masculinity, individualism, long-term orientation and indulgence in the pre-deployment phase (Study 1). There were, however, no significant differences in acceptability of the apps between countries in relation to uncertainty avoidance; and none of the hypotheses in Study 2 was supported. The study concludes that national culture is significant in terms of the acceptance of COVID-19 apps only during the pre-deployment phase; therefore attention is required with pertinence to pre-deployment strategies. Recommendations regarding how governments and public health institutions can increase the acceptability of contact-tracing apps have been highlighted.

Tracing app technology: an ethical review in the COVID-19 era and directions for post-COVID-19

We conducted a systematic literature review on the ethical considerations of the use of contact tracing app technology, which was extensively implemented during the COVID-19 pandemic. The rapid and extensive use of this technology during the COVID-19 pandemic, while benefiting the public well-being by providing information about people's mobility and movements to control the spread of the virus, raised several ethical concerns for the post-COVID-19 era. To investigate these concerns for the post-pandemic situation and provide direction for future events, we analyzed the current ethical frameworks, research, and case studies about the ethical usage of tracing app technology. The results suggest there are seven essential ethical considerations-privacy, security, acceptability, government surveillance, transparency, justice, and voluntariness-in the ethical use of contact tracing technology. In this paper, we explain and discuss these considerations and how they are needed for the ethical usage of this technology. The findings also highlight the importance of developing integrated guidelines and frameworks for implementation of such technology in the post- COVID-19 world.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10676-022-09659-6.

Privacy Risks in Microbiome Research: Public Perspectives before and during a Global Pandemic

We assessed public perspectives of microbiome research privacy risks before and after a nationwide emergency was declared in the United States regarding the Covid-19 pandemic. From January to July of 2020, we conducted an online survey of perceived privacy risks of microbiome research among U.S. adults. Among 3,106 participants (the preemergency group), most expressed that the microbiome posed privacy risks similar to those associated with DNA (60.3%) or medical records (50.6%) and that they would prefer detailed explanations (70.2%) of risk in consent materials. Only 8.9% reported moderate to high familiarity with microbiome privacy risks. In adjusted analyses, individuals who participated in the study after the Covid-19 emergency was declared (the Covid-19 emergency group) were less likely to express that microbiome privacy risks were similar to those of DNA or medical records and more likely to report familiarity with the privacy risks of microbiomes. There was a trend toward increased concern after the Covid-19 emergency was declared (p = 0.053). Overall, the study revealed that many U.S. adults believe that microbiome privacy risks are similar to those associated with DNA or medical records, and they prefer detailed explanations in consent documents. Individuals who participated after the Covid-19 emergency was declared reported greater knowledge of microbiome privacy risks but had more concern.

Comfort with and willingness to participate in COVID-19 contact tracing: The role of risk perceptions, trust, and political ideology

OBJECTIVE

Contact tracing (CT) can limit the spread of infectious diseases, however its effectiveness hinges on public participation. We evaluated perceptions of the financial and health risk posed by COVID-19 and trust in information about COVID-19 provided by the state health department that manages CT as predictors of comfort and willingness to comply with CT. We further examined the moderating effect of political ideology on these relationships.

METHODS

We used structural equation modeling to test hypotheses in data from a cross-sectional survey completed by a representative sample of Michigan residents (N = 805) in 2020.

RESULTS

Perceptions of the risk of COVID-19 to one's health (but not finances) was negatively related to comfort and willingness to participate in CT. Trust in information about COVID-19 and liberalism were positively related to comfort and willingness. There was also a moderating effect of political ideology, such that conservatives were less comfortable and willing at greater perceptions of health risk.

CONCLUSIONS

Conservatives and those who perceive a greater health risk may require targeted messaging and more deliberate engagement strategies to increase CT participation.

Evaluation of the Patient Experience with the Mawid App during the COVID-19 Pandemic in Al Hassa, Saudi Arabia

(1) Introduction: The objective of this study was to evaluate the patient experience with the Mawid application during the COVID-19 pandemic in Al Hassa, Saudi Arabia. (2) Methodology: A quantitative cross-sectional survey was designed to evaluate the patient experience with the Mawid app during the COVID-19 pandemic in Al Hassa, Saudi Arabia. A total of 146 respondents completed the questionnaire. (3) Results: More than half of the participants (65.8%) opined that application was easy to use. Furthermore, 65.1% of the participants considered it to be very easy and easy to search for the required information; and 63.7% of the respondents reflected that it was easy to book an appointment. There was a statistically significant difference between the ease of searching for the required information (p-value = 0.006); the ease of undoing an unwanted move and gender (p-value = 0.049); the ease of searching for the required information and educational level (p-value = 0.048); the ease of booking an appointment and educational level (p = 0.049); and the ease of searching for the required information and the labor sector of the respondents (p value= 0.049) among the genders. No significant differences were identified among the age groups. (4) Conclusions: Overall, most participants suggested that the Mawid app was easy to use and had a potentially useful set of features to help mitigate and manage the COVID-19 pandemic in Al Hassa, Saudi Arabia.

Use and Perception of Digital Health Technologies by Surgical Patients in Germany in the Pre-COVID-19 Era: Survey Study

BACKGROUND

This survey study investigates surgical patients' use and perception of digital health technologies in Germany in the pre-COVID-19 era.

OBJECTIVE

The objective of this study was to relate surgical patients' characteristics to the use and perception of several digital health technologies.

METHODS

In this single-center, cross-sectional survey study in the outpatient department of a university hospital in Germany, 406 patients completed a questionnaire with the following three domains: general information and use of the internet, smartphones, and general digital health aspects. Analyses were stratified by age group and highest education level achieved.

RESULTS

We found significant age-based differences in most of the evaluated aspects. Younger patients were more open to using new technologies in private and medical settings but had more security concerns. Although searching for information on illnesses on the web was common, the overall acceptance of and trust in web-based consultations were rather low, with <50% of patients in each age group reporting acceptance and trust. More people with academic qualifications than without academic qualifications searched for information on the web before visiting physicians (73/121, 60.3% and 100/240, 41.7%, respectively). Patients with academic degrees were also more engaged in health-related information and communication technology use.

CONCLUSIONS

These results support the need for eHealth literacy, health literacy, and available digital devices and internet access to support the active, meaningful use of information and communication technologies in health care. Uncertainties and a lack of knowledge exist, especially regarding telemedicine and the use of medical and health apps. This is especially pronounced among older patients and patients with a low education status.

Physician perceptions of surveillance: Wearables, Apps, and Chatbots for COVID-19

Background and Purpose

To characterize the global physician community's opinions on the use of digital tools for COVID-19 public health surveillance and self-surveillance.

Materials and Methods

Cross-sectional, random, stratified survey done on Sermo, a physician networking platform, between September 9 and 15, 2020. We aimed to sample 1000 physicians divided among the USA, EU, and rest of the world. The survey questioned physicians on the risk-benefit ratio of digital tools, as well as matters of data privacy and trust.

Statistical Analysis Used

Descriptive statistics examined physicians' characteristics and opinions by age group, gender, frontline status, and geographic region. ANOVA, t-test, and Chi-square tests with P < 0.05 were viewed as qualitatively different. As this was an exploratory study, we did not adjust for small cell sizes or multiplicity. We used JMP Pro 15 (SAS), as well as Protobi.

Results

The survey was completed by 1004 physicians with a mean (standard deviation) age of 49.14 (12) years. Enthusiasm was highest for self-monitoring smartwatches (66%) and contact tracing apps (66%) and slightly lower (48-56%) for other tools. Trust was highest for health providers (68%) and lowest for technology companies (30%). Most respondents (69.8%) felt that loosening privacy standards to fight the pandemic would lead to misuse of privacy in the future.

Conclusion

The survey provides foundational insights into how physicians think of surveillance.

Practices and attitudes of Bavarian stakeholders regarding the secondary-use of health data for research purposes during the COVID-19 pandemic: a qualitative interview study (Preprint)

Background

The COVID-19 pandemic is a threat to global health and requires collaborative health research efforts across organizations and countries to address it. Although routinely collected digital health data are a valuable source of information for researchers, benefiting from these data requires accessing and sharing the data. Health care organizations focusing on individual risk minimization threaten to undermine COVID-19 research efforts, and it has been argued that there is an ethical obligation to use the European Union’s General Data Protection Regulation (GDPR) scientific research exemption during the COVID-19 pandemic to support collaborative health research.

Objective

This study aims to explore the practices and attitudes of stakeholders in the German federal state of Bavaria regarding the secondary use of health data for research purposes during the COVID-19 pandemic, with a specific focus on the GDPR scientific research exemption.

Methods

Individual semistructured qualitative interviews were conducted between December 2020 and January 2021 with a purposive sample of 17 stakeholders from 3 different groups in Bavaria: researchers involved in COVID-19 research (n=5, 29%), data protection officers (n=6, 35%), and research ethics committee representatives (n=6, 35%). The transcripts were analyzed using conventional content analysis.

Results

Participants identified systemic challenges in conducting collaborative secondary-use health data research in Bavaria; secondary health data research generally only happens when patient consent has been obtained, or the data have been fully anonymized. The GDPR research exemption has not played a significant role during the pandemic and is currently seldom and restrictively used. Participants identified 3 key groups of barriers that led to difficulties: the wider ecosystem at many Bavarian health care organizations, legal uncertainty that leads to risk-adverse approaches, and ethical positions that patient consent ought to be obtained whenever possible to respect patient autonomy. To improve health data research in Bavaria and across Germany, participants wanted greater legal certainty regarding the use of pseudonymized data for research purposes without the patient’s consent.

Conclusions

The current balance between enabling the positive goals of health data research and avoiding associated data protection risks is heavily skewed toward avoiding risks; so much so that it makes reaching the goals of health data research extremely difficult. This is important, as it is widely recognized that there is an ethical imperative to use health data to improve care. The current approach also creates a problematic conflict with the ambitions of Germany, and the federal state of Bavaria, to be a leader in artificial intelligence. A recent development in the field of German public administration known as norm screening (Normenscreening) could potentially provide a systematic approach to minimize legal barriers. This approach would likely be beneficial to other countries.

Attitudes Toward Mobile Apps for Pandemic Research Among Smartphone Users in Germany: National Survey

BACKGROUND

During the COVID-19 pandemic, but also in the context of previous epidemic diseases, mobile apps for smartphones were developed with different goals and functions, such as digital contact tracing, test management, symptom monitoring, quarantine compliance, and epidemiological and public health research.

OBJECTIVE

The aim of this study was to explore the potential for the acceptance of research-orientated apps (ROAs) in the German population. To this end, we identified distinctive attitudes toward pandemic apps and data sharing for research purposes among smartphone users in general and with a focus on differences in attitudes between app users and nonusers in particular.

METHODS

We conducted a cross-sectional, national, telephone-based survey of 1003 adults in Germany, of which 924 were useable for statistical analysis. The 17-item survey assessed current usage of pandemic apps, motivations for using or not using pandemic apps, trust in app distributors and attitudes toward data handling (data storage and transmission), willingness to share coded data with researchers using a pandemic app, social attitudes toward app use, and demographic and personal characteristics.

RESULTS

A vast majority stated that they used a smartphone (778/924, 84.2%), but less than half of the smartphone users stated that they used a pandemic app (326/778, 41.9%). The study focused on the subsample of smartphone users. Interestingly, when asked about preferred organizations for data storage and app distribution, trust in governmental (federal or state government, regional health office), public-appointed (statutory health insurance), or government-funded organizations (research institutes) was much higher than in private organizations (private research institutions, clinics, health insurances, information technology [IT] companies). Having a university degree significantly (P<.001) increased the likelihood of using a pandemic app, while having a migration background significantly (P<.001) decreased it. The overwhelming majority (653/778, 83.9%) of smartphone users were willing to provide their app data for state-funded research. Regarding attitudes toward app usage, striking differences between users and nonusers were found. Almost all app users (317/327, 96.9%) stated they would be willing to share data, whereas only 74.3% (336/452) of nonusers supported data sharing via an app. Two-thirds (216/326, 66.3%) of app users fully or rather agreed with the statement that using a pandemic app is a social duty, whereas almost the same proportion of nonusers entirely or rather disagreed with that statement (273/451, 60.5%).

CONCLUSIONS

These findings indicate a high potential for the adoption of ROAs among smartphone users in Germany as long as organizational providers engaged in development, operation, and distribution are state-funded or governmental institutions and transparency about data-using research institutions is provided.

Reasons for Nonuse, Discontinuation of Use, and Acceptance of Additional Functionalities of a COVID-19 Contact Tracing App: Cross-sectional Survey Study

BACKGROUND

In several countries, contact tracing apps (CTAs) have been introduced to warn users if they have had high-risk contacts that could expose them to SARS-CoV-2 and could, therefore, develop COVID-19 or further transmit the virus. For CTAs to be effective, a sufficient critical mass of users is needed. Until now, adoption of these apps in several countries has been limited, resulting in questions on which factors prevent app uptake or stimulate discontinuation of app use.

OBJECTIVE

The aim of this study was to investigate individuals' reasons for not using, or stopping use of, a CTA, in particular, the Coronalert app. Users' and nonusers' attitudes toward the app's potential impact was assessed in Belgium. To further stimulate interest and potential use of a CTA, the study also investigated the population's interest in new functionalities.

METHODS

An online survey was administered in Belgium to a sample of 1850 respondents aged 18 to 64 years. Data were collected between October 30 and November 2, 2020. Sociodemographic differences were assessed between users and nonusers. We analyzed both groups' attitudes toward the potential impact of CTAs and their acceptance of new app functionalities.

RESULTS

Our data showed that 64.9% (1201/1850) of our respondents were nonusers of the CTA under study; this included individuals who did not install the app, those who downloaded but did not activate the app, and those who uninstalled the app. While we did not find any sociodemographic differences between users and nonusers, attitudes toward the app and its functionalities seemed to differ. The main reasons for not downloading and using the app were a perceived lack of advantages (308/991, 31.1%), worries about privacy (290/991, 29.3%), and, to a lesser extent, not having a smartphone (183/991, 18.5%). Users of the CTA agreed more with the potential of such apps to mitigate the consequences of the pandemic. Overall, nonusers found the possibility of extending the CTA with future functionalities to be less acceptable than users. However, among users, acceptability also tended to differ. Among users, functionalities relating to access and control, such as digital certificates or "green cards" for events, were less accepted (358/649, 55.2%) than functionalities focusing on informing citizens about the spread of the virus (453/649, 69.8%) or making an appointment to get tested (525/649, 80.9%).

CONCLUSIONS

Our results show that app users were more convinced of the CTA's utility and more inclined to accept new app features than nonusers. Moreover, nonusers had more CTA-related privacy concerns. Therefore, to further stimulate app adoption and use, its potential advantages and privacy-preserving mechanisms need to be stressed. Building further knowledge on the forms of resistance among nonusers is important for responding to these barriers through the app's further development and communication campaigns.

Data privacy during pandemics: a systematic literature review of COVID-19 smartphone applications

BACKGROUND

On January 8, 2020, the Centers for Disease Control and Prevention officially announced a new virus in Wuhan, China. The first novel coronavirus (COVID-19) case was discovered on December 1, 2019, implying that the disease was spreading quietly and quickly in the community before reaching the rest of the world. To deal with the virus' wide spread, countries have deployed contact tracing mobile applications to control viral transmission. Such applications collect users' information and inform them if they were in contact with an individual diagnosed with COVID-19. However, these applications might have affected human rights by breaching users' privacy.

METHODOLOGY

This systematic literature review followed a comprehensive methodology to highlight current research discussing such privacy issues. First, it used a search strategy to obtain 808 relevant papers published in 2020 from well-established digital libraries. Second, inclusion/exclusion criteria and the snowballing technique were applied to produce more comprehensive results. Finally, by the application of a quality assessment procedure, 40 studies were chosen.

RESULTS

This review highlights privacy issues, discusses centralized and decentralized models and the different technologies affecting users' privacy, and identifies solutions to improve data privacy from three perspectives: public, law, and health considerations.

CONCLUSIONS

Governments need to address the privacy issues related to contact tracing apps. This can be done through enforcing special policies to guarantee users privacy. Additionally, it is important to be transparent and let users know what data is being collected and how it is being used.

Does age matter? The influence of age on citizen acceptance of a proximity tracing application in France

Previous literature has suggested that age indirectly influences the intention to adopt an information technology, and notably a m-health application. However, few studies have investigated this link. Voluntarily proximity tracing applications (PTA) are the first mobile applications to be implemented nationwide for population health issues. Our paper investigates the effect of age on the antecedents (perceived ease of use and usefulness, trust, and privacy control) of the intention to adopt a PTA. Our model is tested on a representative sample of 1000 French citizens. All variables were measured using scales drawn from the extant literature and adapted to suit the context. Age was measured as a continuous variable. . We found that age directly influences privacy control, but it has no direct effect on trust nor on the perceived ease of use or the perceived usefulness of a PTA. The results show that age is not a direct determinant of the antecedents of behavioral intention except of privacy control.

Understanding 'passivity' in digital health through imaginaries and experiences of coronavirus disease 2019 contact tracing apps

Growing interest is being directed to the health applications of so-called 'passive data' collected through wearables and sensors without active input by users. High promises are attached to passive data and their potential to unlock new insights into health and illness, but as researchers and commentators have noted, this mode of data gathering also raises fundamental questions regarding the subject's agency, autonomy and privacy. To explore how these tensions are negotiated in practice, we present and discuss findings from an interview study with 30 members of the public in the UK and Italy, which examined their views and experiences of the coronavirus disease 2019 contact tracing apps as a large-scale, high-impact example of digital health technology using passive data. We argue that, contrary to what the phrasing 'passive data' suggests, passivity is not a quality of specific modes of data collection but is contingent on the very practices that the technology is supposed to unobtrusively capture.

Exploring User Acceptance Determinants of COVID-19-Tracing Apps to Manage the Pandemic

Tracing infectious individuals and clusters is a major tactic for mitigating the pandemic. This paper explores the factors impacting the intentions and actual use of COVID-19 contact tracing apps based on a technology acceptance model. A partial least squares structural equation model has been applied to understand determinants for the usage of tracing apps based on a large sample (N = 2,398) from more than 30 countries (mainly from Germany and USA). Further, the paper presents a classification of COVID-19 apps and users. Through that, the study provides insights for technologists and designers of tracing apps as well as policy makers and practitioners to work toward enhancing user acceptance. Moreover, the results are abstracted to general social participation with apps in order to manage future strategies. The theoretical contribution of this work includes the results of our acceptance model and a classification of COVID-19 tracing and tracking apps.

Characteristics and determinants of population acceptance of COVID-19 digital contact tracing: a systematic review

BACKGROUND AND AIM

As recently outlined in the WHO-ECDC Indicator framework (1) to evaluate the public health effectiveness of digital proximity tracing solutions, one of the main barriers to digital contact tracing (DCT) is population acceptance, which, in turns, is influenced by digital literacy, attitudes and practice. DCT came to public prominence during the COVID-19 pandemic but evidence on its population acceptance have not been comprehensively analyzed.  Methods: We carried out a systematic review (PROSPERO: CRD42021253668) following the PRISMA guidelines to collect, systematize and critically appraise the available evidence on population DCT acceptance.  Original studies reporting on different measures of population DCT acceptance were included.

CONCLUSIONS

The systematic review was based on 41 articles meeting our a priori defined inclusion criteria, comprising aa total of 186144 surveyed subjects, 50000 tweets, 5025 Reddit posts and 714 written comments. Data extraction and synthesis required a qualitative outcome grouping, performed ex-post, in 14 different benchmarks components. They constitute a narrative analysis of actionable points for public health policy. Population acceptance is a key component of  DCT effective adoption and infection control during infectious diseases outbreaks. Assessing DCT acceptance's determinants in different settings, populations an cultural contexts it is of fundamental importance to inform the planning, implementation and monitoring of public health interventions. The results of our in-depth qualitative and quantitative analysis  will provide context for prospective improvements and actionable items and should guide future research aimed at exploring how digitalization can serve people-centred care.

How Identification With the Social Environment and With the Government Guide the Use of the Official COVID-19 Contact Tracing App: Three Quantitative Survey Studies

BACKGROUND

Official contact tracing apps have been implemented and recommended for use across nations to track and contain the spread of COVID-19. Such apps can be effective if people are willing to use them. Accordingly, many attempts are being made to motivate citizens to make use of the officially recommended apps.

OBJECTIVE

The aim of this research was to contribute to an understanding of the preconditions under which people are willing to use a COVID-19 contact tracing app (ie, their use intentions and use). To go beyond personal motives in favor of app use, it is important to take people's social relationships into account, under the hypothesis that the more people identify with the beneficiaries of app use (ie, people living close by in their social environment) and with the source recommending the app (ie, members of the government), the more likely they will be to accept the officially recommended contact tracing app.

METHODS

Before, right after, and 5 months after the official contact tracing app was launched in Germany, a total of 1044 people participated in three separate surveys. Structural equation modeling was used to test the hypotheses, examining the same model in all studies at these critical points in time.

RESULTS

Across the three surveys, both identification with the beneficiaries (people living in their social environment) and with the source recommending the app (members of the government) predicted greater intention to use and use (installation) of the official contact tracing app. Trust in the source (members of the government) served as a mediator. Other types of identification (with people in Germany or people around the world) did not explain the observed results. The findings were highly consistent across the three surveys.

CONCLUSIONS

Attempts to motivate people to use new health technology (or potentially new measures more generally) not only for their personal benefit but also for collective benefits should take the social context into account (ie, the social groups people belong to and identify with). The more important the beneficiaries and the sources of such measures are to people's sense of the self, the more willing they will likely be to adhere to and support such measures.

Exploring the drivers and barriers to uptake for digital contact tracing

Digital contact tracing has been deployed as a public health intervention to help suppress the spread of Covid-19 in many jurisdictions. However, most governments have struggled with low uptake and participation rates, limiting the effectiveness of the tool. This paper characterises a number of systems developed around the world, comparing the uptake rates for systems with different technology, data architectures, and mandates. The paper then introduces the MAST framework (motivation, access, skills, and trust), adapted from the digital inclusion literature, to explore the drivers and barriers that influence people's decisions to participate or not in digital contact tracing systems. Finally, the paper discusses some suggestions for policymakers on how to influence those drivers and barriers in order to improve uptake rates. Examples from existing digital contact tracing systems are presented throughout, although more empirical experimentation is required to support more concrete conclusions on effective interventions.

Factors Influencing the Intention of Actors in Hospitals to Use Indoor Positioning Systems: Reasoned Action Approach

BACKGROUND

Indoor positioning systems (IPS) have become increasingly important for several branches of the economy (eg, in shopping malls) but are relatively new to hospitals and underinvestigated in that context. This research analyzes the intention of actors within a hospital to use an IPS to address this gap.

OBJECTIVE

To investigate the intentions of hospital visitors and employees (as the main actors in a hospital) to use an IPS in a hospital.

METHODS

The reasoned action approach was used, according to which the behavior of an individual is caused by behavioral intentions that are affected by (1) a persuasion that represents the individual's attitude toward the behavior, (2) perceived norms that describe the influence of other individuals, and (3) perceived norms that reflect the possibility of the individual influencing the behavior.

RESULTS

The survey responses of 323 hospital visitors and 304 hospital employees were examined separately using SmartPLS 3.3.3. Bootstrapping procedures with 5000 subsamples were used to test the models (one-tailed test with a significance level of .05). The results show that attitude (β=.536; P<.001; f²=.381) and perceived norms (β=.236; P<.001; f²=.087) are predictors of hospital visitors' intention to use an IPS. In addition, attitude (β=.283; P<.001; f²=.114), perceived norms (β=.301; P<.001; f²=.126), and perceived behavioral control (β=.178; P=.005; f²=.062) are predictors of hospital employees' intention to use an IPS.

CONCLUSIONS

This study has two major implications: (1) our extended reasoned action approach model, which takes into account spatial abilities and personal innovativeness, is appropriate for determining hospital visitors' and employees' intention to use an IPS; and (2) hospitals should invest in implementing IPS with a focus on (a) navigational services for hospital visitors and (b) asset tracking for hospital employees.

Impact of COVID-19 on patient health and self-care practices: a mixed-methods survey with German patients

OBJECTIVE

This study aimed to examine German patients': (1) self-estimation of the impact of the pandemic on their health and healthcare; and (2) use of digital self-care practices during the pandemic.

DESIGN

Cross-sectional mixed-methods survey.

SETTING AND PARTICIPANTS

General practice patients from four physicians' offices located in urban and rural areas of Bavaria, Germany, between 21 July 2020 and 17 October 2020. A total of 254 patients participated (55% response rate); 57% (262 of 459) identified as female and participants had an average age of 39.3 years. Patients were eligible to participate if they were 18 years or older and spoke German, and had access to the internet.

RESULTS

(1) Healthcare for patients was affected by the pandemic, and the mental health of a small group of respondents was particularly affected. The risk of depression and anxiety disorder was significantly increased in patients with quarantine experience. (2) Self-care practices have increased; more than one-third (39%) of participants indicated that they started a new or additional self-care practice during the pandemic, and about a quarter (23%) of patients who were not previously engaged in self-care practices started new self-care activities for the first time; however, such practices were not necessarily digital.

CONCLUSIONS

Further investigation is required to understand the relationship between digital self-care and public health events such as the COVID-19 pandemic, and to develop strategies to alleviate the burden of the quarantine experience for patients.

Public perception on the use of digital contact tracing tools post COVID-19 lockdown: Sentiment analysis and opinion mining (Preprint)

Background

Singapore’s national digital contact-tracing (DCT) tool—TraceTogether—attained an above 70% uptake by December 2020 after a slew of measures. Sentiment analysis can help policymakers to assess public sentiments on the implementation of new policy measures in a short time, but there is a paucity of sentiment analysis studies on the usage of DCT tools.

Objective

We sought to understand the public’s knowledge of, concerns with, and sentiments on the use of TraceTogether over time and their preferences for the type of TraceTogether tool.

Methods

We conducted a cross-sectional survey at a large public hospital in Singapore after the COVID-19 lockdown, from July 2020 through February 2021. In total, 4097 respondents aged 21-80 years were sampled proportionately by sex and 4 age groups. The open-ended responses were processed and analyzed using natural language processing tools. We manually corrected the language and logic errors and replaced phrases with words available in the syuzhet sentiment library without altering the original meaning of the phrases. The sentiment scores were computed by summing the scores of all the tokens (phrases split into smaller units) in the phrase. Stopwords (prepositions and connectors) were removed, followed by implementing the bag-of-words model to calculate the bigram and trigram occurrence in the data set. Demographic and time filters were applied to segment the responses.

Results

Respondents’ knowledge of and concerns with TraceTogether changed from a focus on contact tracing and Bluetooth activation in July-August 2020 to QR code scanning and location check-ins in January-February 2021. Younger males had the highest TraceTogether uptake (24/40, 60%), while older females had the lowest uptake (8/34, 24%) in the first half of July 2020. This trend was reversed in mid-October after the announcement on mandatory TraceTogether check-ins at public venues. Although their TraceTogether uptake increased over time, older females continued to have lower sentiment scores. The mean sentiment scores were the lowest in January 2021 when the media reported that data collected by TraceTogether were used for criminal investigations. Smartphone apps were initially preferred over tokens, but the preference for the type of TraceTogether tool equalized over time as tokens became accessible to the whole population. The sentiments on token-related comments became more positive as the preference for tokens increased.

Conclusions

The public’s knowledge of and concerns with the use of a mandatory DCT tool varied with the national regulations and public communications over time with the evolution of the COVID-19 pandemic. Effective communications tailored to subpopulations and greater transparency in data handling will help allay public concerns with data misuse and improve trust in the authorities. Having alternative forms of the DCT tool can increase the uptake of and positive sentiments on DCT.

Self-Focused and Other-Focused Health Concerns as Predictors of the Uptake of Corona Contact Tracing Apps: Empirical Study

BACKGROUND

Corona contact tracing apps are a novel and promising measure to reduce the spread of COVID-19. They can help to balance the need to maintain normal life and economic activities as much as possible while still avoiding exponentially growing case numbers. However, a majority of citizens need to be willing to install such an app for it to be effective. Hence, knowledge about drivers for app uptake is crucial.

OBJECTIVE

This study aimed to add to our understanding of underlying psychological factors motivating app uptake. More specifically, we investigated the role of concern for one's own health and concern to unknowingly infect others.

METHODS

A two-wave survey with 346 German-speaking participants from Switzerland and Germany was conducted. We measured the uptake of two decentralized contact tracing apps officially launched by governments (Corona-Warn-App, Germany; SwissCovid, Switzerland), as well as concerns regarding COVID-19 and control variables.

RESULTS

Controlling for demographic variables and general attitudes toward the government and the pandemic, logistic regression analysis showed a significant effect of self-focused concerns (odds ratio [OR] 1.64, P=.002). Meanwhile, concern of unknowingly infecting others did not contribute significantly to the prediction of app uptake over and above concern for one's own health (OR 1.01, P=.92). Longitudinal analyses replicated this pattern and showed no support for the possibility that app uptake provokes changes in levels of concern. Testing for a curvilinear relationship, there was no evidence that "too much" concern leads to defensive reactions and reduces app uptake.

CONCLUSIONS

As one of the first studies to assess the installation of already launched corona tracing apps, this study extends our knowledge of the motivational landscape of app uptake. Based on this, practical implications for communication strategies and app design are discussed.

Do you have COVID-19? How to increase the use of diagnostic and contact tracing apps

Diagnostic and contact tracing apps are a needed weapon to contain contagion during a pandemic. We study how the content of the messages used to promote the apps influence adoption by running a survey experiment on approximately 23,000 Mexican adults. Respondents were randomly assigned to one of three different prompts, or a control condition, before stating their willingness to adopt a diagnostic app and contact tracing app. The prompt emphasizing government efforts to ensure data privacy, which has been one of the most common strategies, reduced willingness to adopt the apps by about 4 pp and 3 pp, respectively. An effective app promotion policy must understand individuals’ reservations and be wary of unintended reactions to naïve reassurances.

Digital Contact Tracing Applications during COVID-19: A Scoping Review about Public Acceptance

Digital contact tracing applications (CTAs) have been one of the most widely discussed technical methods of controlling the COVID-19 outbreak. The effectiveness of this technology and its ethical justification depend highly on public acceptance and adoption. This study aims to describe the current knowledge about public acceptance of CTAs and identify individual perspectives, which are essential to consider concerning CTA acceptance and adoption. In this scoping review, 25 studies from four continents across the globe are compiled, and critical topics are identified and discussed. The results show that public acceptance varies across national cultures and sociodemographic strata. Lower acceptance among people who are mistrusting, socially disadvantaged, or those with low technical skills suggest a risk that CTAs may amplify existing inequities. Regarding determinants of acceptance, eight themes emerged, covering both attitudes and behavioral perspectives that can influence acceptance, including trust, privacy concerns, social responsibility, perceived health threat, experience of and access to technologies, performance expectancy and perceived benefits, and understanding. Furthermore, widespread misconceptions about the CTA function are a topic in need of immediate attention to ensure the safe use of CTAs. The intention-action gap is another topic in need of more research.

Best Practice Guidance for Digital Contact Tracing Apps: A Cross-disciplinary Review of the Literature

BACKGROUND

Digital contact tracing apps have the potential to augment contact tracing systems and disrupt COVID-19 transmission by rapidly identifying secondary cases prior to the onset of infectiousness and linking them into a system of quarantine, testing, and health care worker case management. The international experience of digital contact tracing apps during the COVID-19 pandemic demonstrates how challenging their design and deployment are.

OBJECTIVE

This study aims to derive and summarize best practice guidance for the design of the ideal digital contact tracing app.

METHODS

A collaborative cross-disciplinary approach was used to derive best practice guidance for designing the ideal digital contact tracing app. A search of the indexed and gray literature was conducted to identify articles describing or evaluating digital contact tracing apps. MEDLINE was searched using a combination of free-text terms and Medical Subject Headings search terms. Gray literature sources searched were the World Health Organization Institutional Repository for Information Sharing, the European Centre for Disease Prevention and Control publications library, and Google, including the websites of many health protection authorities. Articles that were acceptable for inclusion in this evidence synthesis were peer-reviewed publications, cohort studies, randomized trials, modeling studies, technical reports, white papers, and media reports related to digital contact tracing.

RESULTS

Ethical, user experience, privacy and data protection, technical, clinical and societal, and evaluation considerations were identified from the literature. The ideal digital contact tracing app should be voluntary and should be equitably available and accessible. User engagement could be enhanced by small financial incentives, enabling users to tailor aspects of the app to their particular needs and integrating digital contact tracing apps into the wider public health information campaign. Adherence to the principles of good data protection and privacy by design is important to convince target populations to download and use digital contact tracing apps. Bluetooth Low Energy is recommended for a digital contact tracing app's contact event detection, but combining it with ultrasound technology may improve a digital contact tracing app's accuracy. A decentralized privacy-preserving protocol should be followed to enable digital contact tracing app users to exchange and record temporary contact numbers during contact events. The ideal digital contact tracing app should define and risk-stratify contact events according to proximity, duration of contact, and the infectiousness of the case at the time of contact. Evaluating digital contact tracing apps requires data to quantify app downloads, use among COVID-19 cases, successful contact alert generation, contact alert receivers, contact alert receivers that adhere to quarantine and testing recommendations, and the number of contact alert receivers who subsequently are tested positive for COVID-19. The outcomes of digital contact tracing apps' evaluations should be openly reported to allow for the wider public to review the evaluation of the app.

CONCLUSIONS

In conclusion, key considerations and best practice guidance for the design of the ideal digital contact tracing app were derived from the literature.

Normative positions towards COVID-19 contact-tracing apps: findings from a large-scale qualitative study in nine European countries

Mobile applications for digital contact tracing have been developed and introduced around the world in response to the COVID-19 pandemic. Proposed as a tool to support 'traditional' forms of contact-tracing carried out to monitor contagion, these apps have triggered an intense debate with respect to their legal and ethical permissibility, social desirability and general feasibility. Based on a large-scale study including qualitative data from 349 interviews conducted in nine European countries (Austria, Belgium, France, Germany, Ireland, Italy, the Netherlands, German-speaking Switzerland, the United Kingdom), this paper shows that the binary framing often found in surveys and polls, which contrasts privacy concerns with the usefulness of these interventions for public health, does not capture the depth, breadth, and nuances of people's positions towards COVID-19 contact-tracing apps. The paper provides a detailed account of how people arrive at certain normative positions by analysing the argumentative patterns, tropes and (moral) repertoires underpinning people's perspectives on digital contact-tracing. Specifically, we identified a spectrum comprising five normative positions towards the use of COVID-19 contact-tracing apps: opposition, scepticism of feasibility, pondered deliberation, resignation, and support. We describe these stances and analyse the diversity of assumptions and values that underlie the normative orientations of our interviewees. We conclude by arguing that policy attempts to develop and implement these and other digital responses to the pandemic should move beyond the reiteration of binary framings, and instead cater to the variety of values, concerns and expectations that citizens voice in discussions about these types of public health interventions.