key: cord-0776712-fchmjetd authors: Voo, Teck Chuan; Ballantyne, Angela; Jenn, Ng Chirk; Cowling, Benjamin J.; Xiao, Jingyi; Chang, Phang Kean; Kaur, Sharon; Jenarun, Grazele; Kumar, Vishakha; Lim, Jane Mingjie; Tun, Zaw Myo; Wong, Nigel Chong Boon; Tam, Clarence C. title: Public acceptability of COVID-19 control measures in Singapore, Hong Kong, and Malaysia: A cross-sectional survey date: 2022-04-14 journal: Int J Infect Dis DOI: 10.1016/j.ijid.2022.04.021 sha: 6851893badf2d2434cab482553879102c16fe740 doc_id: 776712 cord_uid: fchmjetd Background Several countries have implemented control measures to limit SARS-CoV-2 spread, including digital contact tracing, digital monitoring of quarantined individuals and testing of travelers. These raise ethical issues around privacy, personal freedoms and equity. However, little is known regarding public acceptability of these measures. Methods In December 2020, we conducted a survey among 3635 respondents in Singapore, Hong Kong and Malaysia to understand public perceptions on the acceptability of COVID-19 control measures. Findings Hong Kong respondents were much less supportive of digital contact tracing and monitoring devices than those in Malaysia and Singapore. Around three-quarters of Hong Kong respondents perceived digital contact tracing as an unreasonable restriction of individual freedom; <20% trusted that there were adequate local provisions preventing these data being used for other purposes. This was the opposite in Singapore, where nearly three-quarters of respondents agreed that there were adequate data protection rules locally. In contrast, only a minority of Hong Kong respondents viewed mandatory testing and vaccination for travelers as unreasonable infringements of privacy or freedom. Less than two-thirds of respondents in all territories were willing to be vaccinated against COVID-19, with a quarter of respondents undecided. However, support for differential travel restrictions for vaccinated and unvaccinated individuals was high in all settings. Interpretation Our findings highlight the importance of socio-political context in public perception of public health measures and emphasize the need to continually monitor public attitudes towards such measures to inform implementation and communication strategies. Funding This work was funded by the World Health Organization. Background Several countries have implemented control measures to limit SARS-CoV-2 spread, including digital contact tracing, digital monitoring of quarantined individuals and testing of travelers. These raise ethical issues around privacy, personal freedoms and equity. However, little is known regarding public acceptability of these measures. In December 2020, we conducted a survey among 3635 respondents in Singapore, Hong Kong and Malaysia to understand public perceptions on the acceptability of COVID-19 control measures. Hong Kong respondents were much less supportive of digital contact tracing and monitoring devices than those in Malaysia and Singapore. Around three-quarters of Hong Kong respondents perceived digital contact tracing as an unreasonable restriction of individual freedom; <20% trusted that there were adequate local provisions preventing these data being used for other purposes. This was the opposite in Singapore, where nearly three-quarters of respondents agreed that there were adequate data protection rules locally. In contrast, only a minority of Hong Kong respondents viewed mandatory testing and vaccination for travelers as unreasonable infringements of privacy or freedom. Less than two-thirds of respondents in all territories were willing to be vaccinated against COVID-19, with a quarter of respondents undecided. However, support for differential travel restrictions for vaccinated and unvaccinated individuals was high in all settings. Our findings highlight the importance of socio-political context in public perception of public health measures and emphasize the need to continually monitor public attitudes towards such measures to inform implementation and communication strategies. Ipsos, 2021) . Acceptance is likely to depend on numerous factors, including the epidemic situation, perceived effectiveness, individual burdens, trust in authorities, and mechanisms to ensure data privacy. We conducted surveys in Singapore, Hong Kong and Malaysia to understand public perceptions on the acceptability of digital contact tracing, wearable quarantine monitoring devices, and travel-related COVID-19 testing and vaccination measures due to the paucity of information on public perceptions of their acceptability in these settings. We focused on these measures because they were novel technological responses to the pandemic which raise significant ethical issues and selected these sites because of their common heavy reliance on digital contact tracing and digital monitoring of quarantined individuals to reduce spread. At the time of survey, Singapore and Hong Kong had very low levels of transmission, at around 2 and 12 new COVID-19 cases daily per million population; serological studies indicate that <0.2% of the Singapore population had been infected with SARS-CoV-2 at the time (Clapham et al., 2022) . Malaysia was experiencing an upsurge in transmission, but mortality was very low, with fewer than 5 COVID-19 deaths reported daily (Dong et al., 2020) . there were plans for bilateral arrangements for quarantine-free interstate travel using virological testing (so-called "travel bubbles") between Singapore and Malaysia (Tham, 2020) , and Singapore and Hong Kong (ChannelNewsAsia, 2020), which would likely -and indeed have now extended -to include use of proof of vaccination." COVID-19 vaccination had yet to roll out in any country in December 2020 when we conducted the survey. The surveys were conducted during December 2020 in all three territories. In Singapore and Hong Kong, respondents were recruited from population-representative online panels. In Malaysia, a market surveyor recruited respondents at shopping malls, community town halls and residential halls. Respondents were adults aged 18 years or older in Hong Kong and Malaysia, and 21 years or older in Singapore, corresponding to the minimum age of consent in each setting. Details of sampling and recruitment procedures are given in the Supplementary Information. We developed a series of questions to understand general population sentiment toward policies that had been introduced or were likely to be introduced in the three jurisdictions. Respondents were first asked about their perceptions of digital contact tracing and the use of wearable monitoring devices during quarantine, the broader implications on privacy, as well as their trust in their respective governments and private companies to responsibly manage data collected via digital contact tracing. Subsequent sections included questions that prompted respondents' general attitudes towards vaccines, willingness to get vaccinated, prioritization of vaccines across population segments, as well as COVID-19 testing and vaccine policies relevant to international travel. The same questionnaire was used in all three territories, with modifications made to collect setting-specific sociodemographic information for comparison with census statistics. General vaccine attitudes were measured using the Vaccine Confidence Scale (Larson et al., 2016) , and respondents were also asked whether they would be willing to take a safe and effective COVID-19 vaccine when it became available. To measure public opinion on the use of monitoring devices during quarantine and digital contact tracing, respondents were asked to register their level of agreement with a series of statements using a 5-point scale. These statements pertained to perceived effectiveness and benefits of digital contact tracing, concerns about privacy and personal freedom, and trust in governance of contact tracing data. Additionally, we asked respondents for their opinions on travel-related COVID-19 testing and vaccination policies. To measure public perception of policies related to COVID-19 vaccination for travel, we used two different scenarios: in the first, respondents were asked to imagine that a COVID-19 vaccine had been approved for general use and is widely available, while in the second, respondents were asked to imagine that a COVID-19 vaccine had been approved but was in limited supply. The core questions under each scenario were the same and the two scenarios were administered to randomly selected subsets of survey respondents, to allow for comparison of whether vaccine availability influences people's perception of vaccination policies. For instance, we asked respondents if they thought it would be reasonable to allow travel only for vaccinated individuals or that additional restrictions be placed on unvaccinated travelers. Lastly, to measure vaccination intention, we asked respondents if they would be willing to get a COVID-19 vaccine to travel abroad. The questionnaire was field tested in the respective countries prior to data collection to ensure questions were easily comprehensible within the local context. We assessed representativeness of survey samples by comparing the socio-demographic characteristics of the survey sample from each site with those from their national census in terms of age group, gender, ethnicity, educational level, and socioeconomic status. For each territory, we computed response frequencies and percentages for each survey question. For socio-demographic variables with notable deviations from the census distribution, we assessed the impact on survey responses by using post-stratification weights, to re-weight sample responses in proportion to the census distribution. For each respondent, we calculated scores for vaccine confidence, support for use of monitoring devices during quarantine, and support for digital contact tracing (Supplementary Information Tables S9-S11) We further investigated whether willingness to be vaccinated against COVID-19 was influenced by general confidence in vaccines, and level of support for use of monitoring devices during quarantine and digital contact tracing using Spearman's correlation coefficient. All analyses were performed using R version 4.0.3 (R Core Team, 2020). Ethical approval for this study was obtained from the Ethics Review Committee of the Saw There were 982 eligible respondents in Singapore, 1974 in Malaysia and 679 in Hong Kong. Response rates for the Singapore and Hong Kong panels were 79.0% and 8.9% respectively. A response rate was not available for the Malaysia convenience sample. In Singapore, the survey sample was comparable to the census population in terms of marital status and housing type, but there was an over-representation of females and those with post-secondary and tertiary education, while those of Malay ethnicity and people in the highest income bracket were under-represented. In the Malaysia sample, those aged 30-49 years, females, those of Chinese ethnicity, unmarried individuals and those living in condominiums or single occupancy housing were overrepresented compared to the census population. In Hong Kong, the survey sample comprised proportionately more males, people with tertiary education, people in the highest income bracket and those living in public housing (Supplementary Information Tables S1-S3) . In general, vaccine confidence was higher in Malaysia compared with Singapore and Hong Kong ( Figure 1 ); 68% of respondents agreed that vaccines are safe (compared with 42% in Hong Kong and 56% in Singapore), 60% agreed that vaccines are effective (Hong Kong: 50%, Singapore: 61%), and 71% agreed that vaccines are an important health intervention for children (Hong Kong: 52%, Singapore 67%). In addition, 79% of Malaysian respondents agreed that vaccines are compatible with their religious beliefs (Table S4 ). This figure was higher than in both Singapore and Hong Kong, where less than two-thirds and less than half of respondents respectively felt that vaccines were compatible with their religious beliefs. Across all three settings, two-thirds or fewer respondents said that they would be willing to be vaccinated against COVID-19 when an approved vaccine became available ( Figure 1 and Table S4) . Notably, about a quarter of respondents in all three settings were undecided about vaccination. Willingness to vaccinate was strongly associated with vaccine confidence in all three settings (Supplementary Information Tables S9-S11). Willingness to vaccinate was also higher among those displaying greater support for digital contact tracing, use of monitoring devices during quarantine and travel-related vaccination requirements ( Supplementary Information Figures S1-S3 ). [ Figure 1 here] In general, respondents in Singapore and Malaysia demonstrated greater support for control measures compared with Hong Kong, with higher mean scores for support of digital contact tracing, use of wearable monitoring devices, and travel-related vaccination (Table 1 ). In Singapore, 75% of respondents believed that digital contact tracing was effective at reducing the risk of COVID-19 spread and 65% felt that the benefits of digital contact tracing outweighed the harms. In contrast, only 22% of Hong Kong respondents agreed that the benefits outweighed the risks and 35% believed such technologies to be effective at reducing risk of COVID-19 spread (Table S14) . Differences were also seen between settings in the perceived intrusiveness of different control measures. In Hong Kong, 73% of respondents perceived that digital contact tracing technologies were unreasonable restrictions of individual freedom, compared with with 55% in Malaysia and 17% in Singapore (Figure 2 and Table S5 ). Interestingly, in Hong Kong, mandatory use of testing and vaccination for travelers were viewed far more positively; only 32% and 14% of respondents respectively believed these measures to be unreasonable infringements of privacy or freedom. In Singapore, testing was considered less intrusive but vaccination more intrusive compared with digital contact tracing and use of monitoring devices. In Malaysia, intrusiveness concerns were similar for all measures, with around 50% of respondents stating that these were unreasonable intrusions. [ Figure 2 here] These differing views were also reflected in differences in the level of trust in how digital contact tracing data would be used in different settings. In Hong Kong, 16% of respondents trusted that there were strict rules in place locally to prevent these data from being used for other purposes, while 28% trusted that there were such rules in place in other countries. This was the opposite in Singapore, where 73% of respondents agreed that there were adequate data protection rules in place locally, but 30% felt that this was the case in other countries. In Malaysia, two-thirds of respondents agreed that there were adequate data protection rules in place both locally and in other countries ( Figure 3 and Table S6 ). Similarly, support for mandatory use of digital contact tracing during the pandemic was low in Hong Kong. Only 39% agreed that this technology could help reduce the risk they posed to others if they became infected, while 24% agreed that digital contact tracing was a way for them to contribute to pandemic control efforts. In contrast, more than two-thirds and three-quarters of respondents in Malaysia and Singapore respectively agreed with these statements. [ Figure 3 here] Support for travel-related COVID-19 vaccination was higher in Malaysia than in the other two settings; 69% of respondents in Malaysia agreed that it was reasonable to allow travel only for vaccinated people, that it was reasonable to require all travelers to be vaccinated, and that it was reasonable to allow all travel for vaccinated people, but only essential travel for unvaccinated individuals. These figures were slightly lower in Singapore, while in Hong Kong less than half of respondents agreed with these statements (Figure 4 and Table S7 ). [ Figure 4 here] Perceptions of equity implications of vaccination policies were mixed. Around a half of respondents in all three settings agreed that banning unvaccinated people from traveling internationally would be unfair. The majority of respondents in all three settings also agreed that it was reasonable to place different restrictions on vaccinated and unvaccinated travelers, and around a half agreed that it was reasonable for travelers to pay for vaccination, even if it meant that some groups in the population may not be able to afford to travel ( Figure 5 and Table S8 ). [ Figure 5 here] Views on vaccination requirements for travel were not strongly influenced by whether vaccines were widely available or in limited supply, and applying weights to reflect the census distribution of demographic variables made little difference to the results. Like many countries and territories, Singapore, Malaysia and Hong Kong have adopted Kong expressed concern about domestic measures in place to prevent use of contact tracing data for other purposes. Our study indicates that in Singapore, Hong Kong and Malaysia there is high public acceptance of COVID-19 testing to support safe international travel. Moreover, testing was It should also be noted that public perceptions of control measures are dynamic and can change over time, particularly during an epidemic. In Singapore, our survey was conducted prior to the government's announcement that digital contact tracing data could legally be used for criminal investigations, despite earlier public assurance that data would be used solely for contact tracing (Illmer, 2021) . Subsequent to this announcement, in its efforts to maintain trust, the Singapore government passed a bill to limit criminal investigation uses of the data to specific serious offences, and set stronger penalties for data misuse than what is set out in current public sector data protection laws. In Hong Kong, the government recently announced that residents would be able to choose which vaccine to receive from those available in order to build trust in its vaccination program (Cheung, 2020) . Such policy developments influence the public discourse around public health control measures and likely shape the public's opinion on the use of these measures over time. This emphasizes the need to continually monitor public perception of public health measures both during peacetime and during the course of a public health emergency. This can inform policy by providing an understanding of the limits of public acceptance of control measures in different contexts, identifying areas of concern to be addressed in the design, implementation and communication of control measures, and anticipating changes in public opinion that may affect acceptance or adherence to these measures. For example, a recommended intervention to promote public trust and acceptance of digital surveillance and monitoring is to implement an ethics oversight mechanism (Mello and Wang, 2020; WHO, 2017; Ferretti et al., 2020), but much will likely depend on how impartial, independent and inclusive this mechanism is regarded by the public. Routine community engagement and public deliberation exercises could be useful mechanisms to better understand and respond to specific local concerns, rather than relying on historical research, research findings from other settings, or on abstract normative analysis alone. The authors declare no conflicts of interest. Yes What data in particular will be shared? All of the individual, de-identified participant data collected during the study What other documents will be available? Study questionnaires When will data be available? Beginning 9 months after article publication for an indefinite period With whom? Anyone who wishes to access the data For what types of analyses? Any purpose By what mechanism will the data be made available? The data will be available in our university's data warehouse or other public data repository but without investigator support other than deposited metadata The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Dr. Tam reports grants from Roche, outside the submitted work. COVID-19 Contact-Tracing Technology: Acceptability and Ethical Issues of Use Necessity and least infringement conditions in public health ethics. Med Health Care Philos Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia Hong Kong air travel bubble to start on Nov 22 with 200 travellers each way per day Hong Kong residents should be allowed to choose which Covid-19 vaccine they take, experts say. SCMP Contrasting SARS-CoV-2 epidemics in Singapore: cohort studies in migrant workers and the general population The Singaporean response to the SARS outbreak: knowledge sufficiency versus public trust An interactive web-based dashboard to track COVID-19 in real time Behavioural responses to Covid-19 health certification: a rapid review Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing Attitudes Toward a Potential SARS-CoV-2 Vaccine: A Survey of U.S. Adults Digital tools against COVID-19: taxonomy, ethical challenges, and navigation aid Attitudes and opinions on quarantine and support for a contacttracing application in France during the COVID-19 outbreak Effect of Vaccination on Household Transmission of SARS-CoV-2 in England Policymaking in a low-trust state: legitimacy, state capacity, and responses to COVID-19 in Hong Kong Passport to a Mighty Nation: Exploring Sociocultural Foundation of Chinese Public's Attitude to COVID-19 Vaccine Certificates Singapore reveals Covid privacy data available to police. BBC Global public backs COVID-19 vaccine passports for international travel An ethics framework for public health The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey A global survey of potential acceptance of a COVID-19 vaccine How the Hong Kong government lost the public trust in SARS: Insights for government communication in a health crisis Initial report of decreased SARS-CoV-2 viral load after inoculation with the BNT162b2 vaccine Understanding COVID-19 vaccine demand and hesitancy: A nationwide online survey in China Ethics and governance for digital disease surveillance Ethical guidelines for COVID-19 tracing apps SEROCoV-Pop Study Team. Perceptions of immunity and vaccination certificates among the general population: a nested study within a serosurvey of anti-SARS-CoV-2 antibodies (SEROCoV-POP) A national survey of attitudes to COVID-19 digital contact tracing in the Republic of Ireland R: A language and environment for statistical computing. R Foundation for Statistical Computing Malaysia to launch vaccinated travel lane between Changi Airport and KLIA. ChannelNewsAsia Immunity certification for COVID-19: ethical considerations Fighting COVID-19 in Hong Kong: The effects of community and social mobilization World Health Organization. WHO guidelines on ethical issues in public health surveillance World Health Organization. Ethical considerations to guide the use of digital proximity tracking technologies for COVID-19 contact tracing: interim guidance Public health considerations while resuming international travel Emergency Committee regarding the coronavirus disease (COVID-19) pandemic Emergency Committee regarding the coronavirus disease (COVID-19) pandemic The Perfect Moral Storm: Diverse Ethical Considerations in the COVID-19 Pandemic We thank the Singapore Population Health Studies (SPHS) unit for their assistance in pretesting and data management for the questionnaire fielded to the online panel.