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Many countries remain in the grip of the COVID-19 global pandemic, with a considerable journey still ahead toward normalcy and free mobility. Contact tracing smartphone apps are among a raft of measures introduced to reduce spread of the virus, but their uptake depends on public choice.
The objective of this study was to ascertain the views of citizens in Wales on their intended use of a COVID-19 contact tracing smartphone app, including self-proposed reasons for or against use and what could lead to a change of decision.
We distributed an anonymous survey among 4000 HealthWise Wales participants in May 2020. We adopted a mixed methods approach: responses to closed questions were analyzed using descriptive and inferential statistics; open question responses were analyzed and grouped into categories.
A total of 976 (24.4%) people completed the survey. Smartphone usage was 91.5% overall, but this varied among age groups. In total, 97.1% were aware of contact tracing apps, but only 67.2% felt sufficiently informed. Furthermore, 55.7% intended to use an app, 23.3% refused, and 21.0% were unsure. The top reasons for app use were as follows: controlling the spread of the virus, mitigating risks for others and for oneself, and increasing freedoms. The top reasons against app use were as follows: mistrusting the government, concerns about data security and privacy, and doubts about efficacy. The top response for changing one’s mind about app use from being willing to being unwilling was that nothing would; that is, they felt that nothing would cause them to become unwilling to use a contact tracing app. This was also the top response for changing one’s mind from being unwilling to being willing to use contact tracing apps. Among those who were unsure of using contact tracing apps, the top response was the need for more information.
Respondents demonstrated a keenness to help themselves, others, society, and the government to avoid contracting the virus and to control its spread. However, digital inclusion varied among age groups, precluding participation for some people. Nonetheless, unwillingness was significant, and considering the nature of the concerns raised and the perceived lack of information, policy and decision-makers need to do more to act openly, increase communication, and demonstrate trustworthiness if members of the public are to be confident in using an app.
In common with many countries worldwide, Wales remains in the grip of the COVID-19 global pandemic, with a considerable journey still ahead toward normalcy and free mobility. With a population of 3.1 million individuals, Wales accounts a relatively small fraction of the 66.8 million individuals in the United Kingdom [
There has been considerable debate in the media about the use of contact tracing smartphone apps during the pandemic. Some concerns that have been raised are the perceived risk to individual privacy, data security, and the ethics of automated data collection with a person’s own private device [
The published literature shows that there have been large-scale quantitative studies with the public and small-scale qualitative studies to gain insight into citizens’ perceptions about the use of an app in various countries. These have included a variety of study designs: surveys providing a menu of options for respondents to indicate their reasons for or against the use of an app [
The objective of this study was to ascertain the views of citizens in Wales on their intended use of a COVID‑19 contact tracing smartphone app, including self-proposed reasons for or against it, and what could lead to a change of decision.
We designed and distributed an anonymous survey among 4000 HealthWise Wales (HWW) participants. HWW is a cohort of approximately 40,000 people who have signed up to help shape the health and well-being of future generations in Wales. Compared with the wider population, there was a higher percentage of HWW participants older than 45 years. The percentage of women was higher than that in the general population (72% vs 51%). The percentage of participants in ethnic groups other than White ethnicity (2%) matched that in the Welsh population. Around half of participants are in higher managerial or professional occupations, which is significantly greater than the general population; however, each quintile of the Welsh Index of Multiple Deprivation was represented [
The survey was released from May 22 to 28, 2020, and was closed when the response rate had tailed off. At this time, the United Kingdom was testing the NHSX app which was intended to operate on a centralized data collection model. This model was abandoned shortly after the survey was conducted, and the National Health Service (NHS) COVID-19 contact tracing app (operating on a decentralized model) was rolled out in England and Wales on September 24, 2020. Both models collect data via Bluetooth technology, but in a decentralized model, data processing is performed on the smartphone rather than being transferred to and stored in a central database.
All the survey questions were in a closed or structured format apart from those about reasons for being willing or unwilling to use a contact tracing app, and reasons for a change of mind regarding app use. Participants were invited to provide up to 3 reasons for or against app use and were not asked to rank them. They were asked for one reason for why they might change their mind. These responses were open in the free-text format and were analyzed and grouped manually by a consensus with 2 researchers. The quantitative data were analyzed using SPSS (version 26), using descriptive (n [%]) and inferential (chi-square) statistics. A list of survey questions is provided in
A total of 976 (24.4%) full survey responses were received from across all main postcode areas of Wales (Cardiff, Llandrindod, Wrexham, Newport, Swansea, and Shrewsbury). Only the first part of the postcode was requested to preserve anonymity. Among 968 respondents, 504 (52.1%) responded as being male, 461 (47.6%) as being female, and 3 (0.3%) as being nonbinary. In terms of ethnicity (N=965), 923 (95.5%) identified as White, 7 (0.7%) as being Asian or Asian British, 4 (0.4%) as being Black, African, Black British, or Caribbean, 26 (2.7%) as being mixed or of multiple ethnic groups, and 5 (0.5%) as being of other ethnicities. The age distribution of respondents (N=974) is shown in
Age distribution among the survey respondents. In total, 974 people (of 976 in total) provided their ages in 10-year bands.
Smartphone usage was reported as 91.5% overall, but this varied by age groups (
Of 971 respondents, 291 (29.8%) considered themselves at high risk of infection and 680 (69.7%) did not believe that they were at high risk. There was no significant difference in the responses among all ethnic groups. Minority ethnicities were considered a single group in this instance as the numbers among each group were small. The distribution of these responses showing differences in the perception of personal risk among these age bands, with older people being at higher risk (
Respondents’ perceptions of being high risk of COVID-19 infection. In total, 971 respondents (of 976 in total) provided their perception of their personal risk of COVID-19.
Participants were asked about their knowledge and use of symptom tracking apps before proceeding to focus on contact tracing apps. A common symptom tracking app used in the United Kingdom is operated by the COVID Symptom Study, commonly referred to as “the Zoe app” [
There were no significant differences in the willingness to use a contact tracing app based on ethnicity or main postcode area. However, intentions varied by sex and by age. Females were more likely to be willing to use a contact tracing app than males (
Respondents’ intentions on the use of a COVID-19 contact tracing app (N=970). This table shows the numbers and percentages of people intending to use, not intending to use, and unsure about using a COVID-19 contact tracing app.
Response type | Responses, n (%) | |
|
||
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Yes | 482 (73.9) |
|
No | 83 (12.7) |
|
Unsure | 87 (13.3) |
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||
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Yes | 58 (18.2) |
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No | 143 (45.0) |
|
Unsure | 117 (36.8) |
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Yes | 540 (55.7) |
|
No | 226 (23.3) |
|
Unsure | 204 (21.0) |
The top 10 reasons among people willing to use a contact tracing app are shown in
Respondents’ reasons for their willingness to use a COVID-19 contact tracing app. Participants provided their own, open responses on their reasons for being willing to use a contact tracing app. The top 10 reasons are shown here as percentages of those willing (N=540).
Some quoted responses from willing participants are given here as illustrations of their viewpoints.
I feel it will be an essential part of combating the spread of the virus, and gives me an element of control and decision making.
We need to emulate those countries that have managed to control their pandemic by use of this type of technology.
To help stop the spread of COVID-19 and to help inform decision to ease lockdowns.
I wish to be able to move safely in my residential area; wish to know if I have been in contact with anyone diagnosed with the virus; wish to keep up to date with latest developments.
For my own peace of mind.
For my own safety and that of others & so that scientists have good data.
I would use one as I am keen to get the country going again.
Want lockdown to end, want pubs back open.
To help to overcome Covid, get back to work and enable a more normal life.
We collectively owe it to our country to participate in track and trace to improve our chances of getting on top of Covid19.
Effective contact tracing, alongside widespread virus testing, is the best answer we have to managing the ongoing Covid 19 pandemic.
The sooner everyone takes responsibility for learning as much as possible about COVID 19 the sooner we’ll control it.
The top 10 reasons among those unwilling to use a contact tracing app are shown in
Respondents’ reasons for their unwillingness to use a COVID-19 contact tracing app. Participants provided their own, open responses on their reasons for being unwilling to use a contact tracing app. The top 10 reasons are shown here as percentages of those unwilling (N=226). TTT: test, track, and trace.
Some quotations from unwilling participants are given here as illustrations of their viewpoints.
I do not like the idea of the Government storing my data on a centralised system.
Creepy, 1984 stuff. Given how incompetent and chaotic Westminster's response to the virus has been so far, I wouldn't bet on information remaining confidential.
I have zero faith that the Westminster administration would not use the data for purposes other than tracing the virus.
An app forcibly enabling Bluetooth which is inherently insecure is not something I will let happen on my phone.
Not confident my information won't be hacked or misused.
Insufficient evidence of preservation of privacy and lack of adverse effects on device performance / battery life / security.
I worry about personal privacy.
I am concerned that I may get into a cycle of being informed to self isolate multiple times because I might have been near somebody who may have the virus as I'm shopping for my wife and several neighbours once a week at a supermarket.
Info is confusing. Not willing to self isolate until person I've been in close contact with has confirmed COVID-19.
I am not paying for a smartphone because of the stupid [expletive] in government won’t make an app that can be used on all mobile phones.
Concerns about data held centrally.
Mobile coverage in my area is patchy, this could be detrimental to the effectiveness of the app if you can't get a signal.
Risk of false warnings by malicious persons.
When asked what would change their mind from being willing to being unwilling to use a contact tracing app, participants gave a range of reasons, with the top 10 reasons shown in
When asked what would change their mind from being unwilling to being willing to use a contact tracing app, there were a variety of reasons, with the top 10 reasons shown in
Participants’ responses to what would change their mind on app use from willing to unwilling. Participants who expressed willingness to use an app (N=540) provided their own, open responses on what would make them change to being unwilling to use a contact tracing app. The top 10 reasons are shown here. TTT: test, track, and trace.
Participants’ responses to what would change their mind on app use from being unwilling to being willing. Participants who expressed unwillingness to use an app (N=226) provided their own open responses on what would make them change their mind to being willing to use a contact tracing app. The top 10 reasons are shown here.
As would be expected, respondents who were unsure (n=204) about using an app gave mixed reasons for and against app use. In response to the question of what would lead to a change of mind (or for them, decision-making), the most frequent response by far was the need for more information (27.5%). This was followed by a preference for a decentralized app (6.4%), being unsure what could change their mind (5.9%) and proof that the app is functional (5.4%). Some quotes from unsure participants are given here as illustrations of their viewpoints. As shown, respondents needed further information in a variety of areas including how the app would function, the data to be collected and its use, the risks to privacy, data security, and the impact on the phone battery, location tracking, and data usage.
Much more detailed understanding about how it works, and credibility of the organisation launching/running the app.
Info about how it works and why it matters.
More information on impact upon phone battery life and privacy (location tracking).
Very detailed, clear, public explanation of the App's findings.
More knowledge and a better understanding of the way it works.
Full disclosure about what is and isn't tracked and stored, and confidence in the people evaluating this and reporting it.
Complete honesty as to what happens to all the personal data collected.
I would happily use it if I understood more about what the potential risk to my personal information is and how that is mitigated.
Decentralised data handling and storage.
Legally binding commitments on how data will be used and how long it will be stored. Fully anonymised decentralised system.
I'll use one once the tech has had a chance to bed in. I'd much prefer to use one which is coordinated with those in use in other countries so as to facilitate travel.
Not sure but if there was some way to ensure the data would be safe (don’t trust gov to do as they say necessarily).
Not sure cos all authorities lie.
I'm not sure, a lot of reassurance that it's secure.
Good evidence that it works and is safe.
Independent confirmation of adequate security and usefulness of the app.
If it was widely used and therefore accurate.
A guarantee that the information would not be used for anything else and it was secured.
Assurance in law that my data would be solely used for contact tracing and that no private companies would have the right to hold or use my data.
Some very clear advice on how to install, use, etc. Support with what kind of phone is needed.
The price of a smart phone. It might be just easier for me to wear a mask and maintain physical distancing.
To our knowledge, this is the only study on the use of a COVID-19 contact tracing app to use a mixed methods approach and combine qualitative and quantitative data collection and analysis at this scale. This is also the only known study focusing on Welsh citizens, thus adding Wales to the countries studied. In particular, allowing participants to provide open responses on their reasoning, and what would cause them to change their mind, demonstrated the value of asking more than closed questions and provided rich information at scale to augment the simple categorical answers. This information is important if policy and other decision-makers are to address and respond to concerns and to support use of a contact tracing app.
Our mixed methods survey among citizens of Wales found that over half (55.7%) of the respondents explicitly stated they planned to use a contact tracing app; a further 21% were unsure and just less than a quarter (23.3%) stated that they were unwilling. These values are based on actual responses plus inferred choices for those participants who did not answer the question. In contrast with the other closed questions in our survey, which were completed by over 95% of people, the response rate for this question was only 66%. This is interesting as it suggests some reluctance to respond to this question; nonetheless, almost all nonresponders gave reasons for being for, against, or unsure of using a contact tracing app in the free-text responses. The reasons for this are unknown, but it might indicate forms of response bias, such as acquiescence or social desirability, since after inferring from reasons, the proportions shifted toward unwillingness and unsureness. By comparison, almost three-fourth (74.8%) of participants in a multi-country survey using Likert scales stated they would probably or definitely download a contact tracing app [
In February 2021, the NHS Test and Trace program released the first detailed data about app use since it was rolled out in England and Wales in September 2020, and it reported that 21.7 million people had downloaded the app [
In our survey, the top reasons in favor of app use were controlling spread of the virus, mitigating risks for others and for oneself, and increasing freedoms to enable society to open up. By comparison, the top reasons among some other surveys, which were based on predefined choices were as follows. In the US survey [
We included a question in our survey on what could lead people to change their mind on app use as we expected it to yield interesting results, given that this was a first-of-its-kind app and global context. As observed, 24% of people who downloaded the NHS app in England and Wales are not using it, which indicated a change of mind from being willing to being unwilling [
Since contact tracing apps require the use of a smartphone and a suitable network connection, digital inclusion and exclusion and underlying links with socioeconomic status, are important factors. In our survey, although 91.5% of overall respondents reported being smartphone users, this was only 78% among individuals aged 76-85 years and only 40% among those aged over 85 years. Not having, not wanting to, or being unable to buy, a smartphone, difficulties in using their smartphone, lack of knowledge on how to download and use an app, and lack of a reliable network connection were among the free-text reasons given for not using the app. At least one of these reasons was given by almost 10% (n=93) of our respondents. In April 2020, the Ada Lovelace Institute [
As is common in one-time surveys, our work was based on a defined period and, as such, presents a snapshot of citizen views at that time. Further, the timing of the survey may have had an impact as it was early in the “first wave” of the pandemic and at a time when the NHSX model was the only model being tested at scale in the United Kingdom. As the data were collected anonymously, we cannot repeat the survey with the same respondents to compare their intentions with their actual decisions on the use of a contact tracing app. We acknowledge that our respondents are not fully representative of the people of Wales in terms of age profile, digital literacy, and ethnic heterogeneity. Other survey models were piloted with the aim of hearing from underrepresented groups, with some success, but the results are not reported here owing to adaptations in method reducing the viability of comparison with the HWW cohort.
The following are some recommendations arising from our survey to inform decisions on enhancing the use of a contact tracing app to promote its effectiveness and build public trust. Although these arose from a survey with people in Wales, they are more widely applicable as in accordance with survey findings from other countries.
Concurrent with the transparency in a democratic society, there should be more engagement with the public to gain viewpoints, listen to concerns, and provide more information. This would also benefit decision-makers in developing transparent policy plans with social license.
There is an issue with digital inclusion among some groups, such as older people, being less likely to use a smartphone. In some cases, it is the lack of a smartphone or stable network connection, but for others it is a lack of knowledge on app use. For the latter, this could be at least partly addressed by an education program with straightforward information and a step-by-step guide to download and use the app.
The reasons people gave for being willing to use a contact tracing app demonstrate a keenness to help themselves, others, society, and the government to avoid the virus and control its spread. However, the reasons they might change their mind, notably, the need to safeguard against security breaches and data misuse, and to be able to demonstrate app effectiveness are critical to trust and success. Regularly updated reliable information is crucial to this.
The reasons people gave for their unwillingness to use an app were topped by mistrust in the government, followed by concerns about data security and privacy and the efficacy of the app. Policy and decision makers must address these issues and demonstrate trustworthiness if members of the public are to be confident their data are safe and that using an app is worthwhile.
In summary, we recommend greater public involvement in the development and implementation of policy and technologies from the outset and on an ongoing basis.
As a separate question alongside the survey, we asked respondents to indicate which topics interested them for an in-depth discussion and to email us outside the survey if they would like to take part. These topics were as follows: (1) what counts as acceptable use of digital technologies including apps, (2) the development and implementation of Wales-specific policy responses to COVID-19, (3) the potential benefits and challenges of using personal data gathered in the COVID-19 response for research purposes beyond the pandemic, (4) public engagement with proposed government strategies prior to implementation (and ongoing), (5) the impact of digital technologies introduced in response to the COVID-19 crisis on disadvantaged groups, and (6) the ethical challenges of designing, developing, and implementing technologies that support the exit strategy. The most frequently chosen was topic 3. Accordingly, we have embarked on deliberative public involvement [
This is the only known citizen survey on the use of contact tracing apps to use a mixed methods approach, combining qualitative and quantitative data collection and allowing respondents to suggest their own reasons for and against app use, plus what would cause them to change their decision. Our findings show that citizens are intent on helping themselves, others, society, and government to avoid the virus and control its spread. The fact that contact tracing apps are necessarily smartphone-based raises issues of digital inclusion, such that participation is precluded for individuals who do not have a smartphone, have difficulty using one, or lack a stable network connection. However, the most prominent concerns raised about app use, namely, mistrusting the government, concerns about data security and privacy, and doubts about efficacy, could be addressed by greater efforts by policy and decision-makers to act openly, provide clearer information, and demonstrate trustworthiness. These actions are essential if the potential of contact tracing apps in contributing to controlling the pandemic are to be realized and may be useful in the ethical development and roll out of other health apps.
Survey questions.
HealthWise Wales
National Health Service
We would like to express our grateful thanks to the citizens of Wales who took part in the survey. We gratefully acknowledge the assistance of HealthWise Wales in administering the survey and disseminating findings. The work conducted in this study was supported by Administrative Data Research (Wales) funded by the Economic and Social Research Council (ref: ES/S007393/1), and the SAIL Databank funded by Health & Care Research Wales (this funder does not use reference numbers).
None declared.