key: cord-0772408-n6cmdkvc authors: Huang, Zhilian; Guo, Huiling; YeeFen Lim, Hannah; Chow, Angela title: Awareness, acceptance, and adoption of the national digital contact tracing tool post COVID-19 lockdown among visitors of a public hospital in Singapore() date: 2021-01-20 journal: Clin Microbiol Infect DOI: 10.1016/j.cmi.2021.01.007 sha: f6da9af4fc4b49f9a375ac6b3a49288bb6b6cfa2 doc_id: 772408 cord_uid: n6cmdkvc nan To the Editor, Coronavirus disease 2019(COVID-19) was first imported into Singapore on 22 nd January 2020 by a tourist from Wuhan, China. Since 4 th February 2020, local clusters of COVID-19 emerged, which rapidly progressed to multiple unlinked clusters over the subsequent months [1] . A partial lockdown, including restrictions on social activities and physically close proximity activities (e.g. employment), was implemented from 7 th April to 1 st June 2020 to curb local transmissions. These restrictions were gradually lifted as cases of Severe Acute Respiratory Syndrome Coronavirus 2(SARS-CoV-2) infections in the general community decreased [2] . A good contact tracing system that enables rapid identification and quarantine of COVID-19 close contacts is crucial for outbreak management in the early phase of an outbreak [3] . However, manual contact tracing is laborious, time-consuming, and non-scalable in a pandemic. Therefore, Singapore developed a national digital contact tracing (DCT) tool-"TraceTogether" (available as a smartphone application(app) and Bluetooth-enabled token)-to augment the nation's manual contact tracing efforts [4] . Since March 2020, the "TraceTogether" app has been upgraded to enhance its performance [5] . DCT tools are effective only if adoption consistently attains a critical mass of >60% of the population during activities involving prolonged close contact [6] . As Singapore gradually eased restrictions, substantial media coverage has informed the public on the importance of "TraceTogether" in complementing Singapore's contact tracing efforts. From 14 th September 2020, the Singapore government began distributing "TraceTogether" tokens to all Singapore residents, in preparation for the further lifting of restrictions (i.e. reopening of bars and nightclubs). On 20 th October, announcement was made on the mandatory use of "TraceTogether" for entry to public venues (i.e. restaurants, workplaces, schools and shopping malls) [7] . Since awareness and acceptance(willingness-to-use) of DCT are prerequisites of adoption (actual use) of DCT technologies, understanding the levels of awareness and acceptance of such tools within communities can guide strategies to increase adoption. We interviewed visitors(patients and caregivers) of two busiest ambulatory clinics at Tan Tock Seng Hospital, a large public hospital in Singapore, to assess their awareness, willingness-touse(acceptance), and actual use(adoption) of "TraceTogether", from 6 th July through 31 st December 2020. Up to 160 Singapore residents were purposively sampled weekly, stratified by gender and age categories, giving a study sample of: 1) 21-50 years (n=818 males; 793 females) and 2) 51-80 years (n=807 males; 822 females). In an interviewer-administered questionnaire, we asked respondents if they were aware of the "TraceTogether" app or token. Depending on whether the respondent owned a smartphone, we assessed their willingness-to-use and their actual use of the app or token. Of 3240 respondents surveyed, 92% were aware of "TraceTogether" and 74% were willing to use the tool, but only 49% adopted the app or token. In July(1 month post-lockdown), the awareness, acceptance, and adoption rates of "TraceTogether" among older adults(aged 51 -80) with smartphones were lower compared with younger adults(aged 21 -50). Among smartphone users, the levels of awareness of "TraceTogether" increased from 88% in July to 100% in December in younger adults and from 80% to 99% in older adults. While acceptance rates increased from 66% to 90% in older adults and 68% to 82% in younger adults, adoption rates only increased moderately to 79% in older adults and 68% in younger adults (Figure) . In contrast, the adoption rates among respondents without a smartphone more than doubled from 17% in July to 47% in December after the mass distribution of tokens (Figure) . Although the awareness of "TraceTogether" was approaching 100%, adoption had prominently lagged behind, suggesting gaps between the user's perception and actual functionality of the DCT tool. The higher acceptance but lower adoption rates of "TraceTogether" among older adults earlier in the study suggests an intergenerational digital divide with the adoption of DCT tools [8] . As the widespread distribution of "TraceTogether" tokens only occurred halfway through the study, older adults without smartphones were unable to adopt "TraceTogether", while those with smartphones may have faced difficulties in downloading and using the app. Although the distribution of tokens may have addressed adoption barriers for older adults, it may not increase adoption in younger adults who preferred the token less and were also less accepting of DCT tools [8] . The mass distribution of tokens was an appropriate move as adoption rates of "TraceTogether" among older adults and respondents without smartphones increased substantially after the distribution was implemented. The tokens also served as an alternative for smartphone users who have concerns on the compatibility and battery consumption of the "TraceTogether" app. We expect the adoption of "TraceTogether" to increase in the coming months with its mandatory use for entry to public venues. Despite this, users' concerns with the use of DCT (including privacy and technical issues) should be continuously addressed to further increase acceptance and voluntary adoption. Further work to assess pertinent factors surrounding user acceptance of DCT tools is critical to increase adoption and sustained use of such tools during the COVID-19 pandemic. One limitation of the study was its focus on visitors to a public hospital, although a good representation of gender and ages were sampled. Nonetheless, the insights from the J o u r n a l P r e -p r o o f study could provide guidance on strategies to enhance contact tracing during the protracted pandemic. Given the multifaceted factors influencing the use of DCT tools, a tailored approach comprising a mix of engagement, education, enforcement, and tool enhancements targeting different segments of the population would be required to increase and sustain the nationwide adoption rate of "TraceTogether" at ≥70% [7] . J o u r n a l P r e -p r o o f Real-time monitoring the transmission potential of COVID-19 in Singapore Singapore's circuit breaker and beyond: Timeline of the COVID-19 reality channelnewsasia.com: Channel News Asia Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures. The Lancet Poster: Why use TraceTogether? Performance of Digital Contact Tracing Tools for COVID-19 Response in Singapore: Cross-Sectional Study Covid-19 contact tracing: a briefing Use of TraceTogether app or token mandatory by end Dec. The Straits Times COVID-19 and the digital divide in the UK. The Lancet Digital Health All authors reviewed and approved the final version of the manuscript prior to submission. All authors declare that they have no competing interests. This project is supported by the NISTH Seed Grant from the NTU Institute of Science and Technology for Humanity, Nanyang Technological University. We would like to acknowledge Evonne Tay, Nur Azzriyani, Jeanette Yeo, Keagan Kee, Leane Leong, Jac Guo, and Vivien Phang for data collection assistance for this study.J o u r n a l P r e -p r o o f Figure: Awareness, acceptance, and adoption of "TraceTogether" among visitors to a public hospital in Singapore Authors' contributions ZH, HG, and AC conceived the manuscript. ZH drafted the manuscript and interpreted the data. HG analyzed the data and provided inputs to the manuscript draft. HYFL and AC provided support for the study and study planning. All authors critically reviewed the manuscript. This study was approved by the National Healthcare Group Domain Specific Review Board in Singapore. NHG DSRB Ref: 2020/00775