Background Information
Globally, the COVID-19 pandemic, which began in January 2020, affected all facets of people’s lives in profound ways. By May 11, 2021, coronavirus had killed at least 3,299,764 and infected at least 158,651,638 people around the world (WHO, 2021). In Qatar, the total number of cases by the same date was 211,732 cases with 516 confirmed deaths (Ministry of Public Health, 2021). One of the most effective responses to the pandemic is mass vaccination (OECD, 2021). The work on the vaccines began as soon as COVID-19 spread. Currently, 94 vaccines are being tested in human clinical trials and 32 have reached the final phases of testing (Zimmer et al., 2021). Although numerous studies have confirmed the efficacy of these vaccines, COVID-19 continues to decimate several nations (Moghadas et al., 2020). For instance, according to Our World in Data (2021), 387 thousand new cases of coronavirus are reported in India every day. Furthermore, there remains the possibility that new pandemics will emerge in the future (RahimiRad et al., 2016). While the exact probability of another 21st century pandemic is difficult to predict, Domínguez-Andrés et al. (2020) state that new pandemics within the next 100 years are highly possible due to globalization and high population density. Therefore, other measures apart from vaccination, such as systematic testing and contract tracing, are required to control epidemics.
Testing and contact tracing work best in tandem, as contact tracing improves the efficiency of testing. The tests for coronavirus are made in three cases: when people voluntarily ask to take the test and pay for it, when a patient has symptoms of the disease, and when a person had close contact with a COVID-19 patient (Callaghan et al., 2020). To help identify those who may have been exposed to COVID-19 due to close contact with a carrier, public health officials use a process called “contact tracing.” If people are informed that they may have had close contact with a COVID-19 carrier, they will be tested for coronavirus, isolated, and treated if necessary. These measures help to break the chains of infection transmission (WHO, 2020).
The potential dangers of COVID-19 spreading asymptomatically and pre symptomatically highlights the need for identifying all possible contacts through a prompt and effective contact tracing (O’Callaghan et al., 2020). WHO (2020) defines contact tracing as “the process of identifying, assessing, and managing people who have been exposed to someone who has been infected with the COVID-19 virus” (para. 1). Contact tracing is crucial for slowing down epidemics, as it helps to reduce transmission rates through timely identification, isolation, and treatment of new cases (WHO, 2020). Before digital technologies became widespread, contact tracing was done with a “pen and paper” approach. People were asked to write down all their contacts during the period of infection so that public health officials could notify them of the possibility of infection. With the advancement of technology, many countries developed cellphone applications to track contacts of COVID-19 patients (O’Callaghan et al., 2020). EHTERAZ is a contact tracing application used in Qatar that had a significant positive impact on the country’s pandemic situation (Varma et al., 2020). This paper assesses the attitudes of the public toward contract tracing using EHTERAZ.
Significance
COVID-19’s ongoing spread makes contact tracing crucial for preventing further outbreaks. Modern contact tracing applications can use the latest technological advances to automatically identify the possibility of contamination with a short time delay (Colizza et al., 2020). Horvath et al. (2020) emphasized that contact tracing applications can moderate the spread of the disease. According to Munzert et al. (2021), governments view contact tracing applications as one of the most promising methods for addressing the COVID-19 pandemic. The applications can help both citizens and authorities in responding quickly to the possibility of contamination to minimize health risks in communities. Such applications, however, can only be effective if they are integrated with local health policy, infectious people are isolated quickly and appropriately, rapid notification is in place, and effectiveness can be transparently assessed (Colizza et al., 2020). Additionally, users’ adherence and integration of the application in all communities is critical for the effectiveness of such applications (Yang et al., 2020). This study aims to provide crucial information about the attitude of the public towards the EHTERAZ contact tracing application, which can help to modify the application to increase its effectiveness now and in future pandemics.
Problem Statement
Over the past year, contact tracing applications have gained increasing importance in mitigating COVID-19 (Munzert et al., 2021). At the same time, the attitude of the public towards such applications varied. Williams et al. (2020) conducted a study of contact tracing apps in the UK, which found significant evidence that misconceptions, privacy concerns, stigma, and uptake issues have negatively affected public’s perception of contact tracing applications. Horvath et al. (2020) conducted a study with a similar focus on public attitudes based on a sample from Dynata, a research firm based in the United States. These studies demonstrated concerns the users of contact tracing had, which provided valuable insights to improve the applications. For instance, Horvath et al. (2020) revealed that people prioritize centralized government contact tracking systems regardless of privacy issues. In summary, research on people’s perception of contact tracing applications became prevalent in 2020.
Research on Qatar’s EHTERAZ application is centered on its adoption, privacy analysis, and usage policies, but little is known about the public’s attitudes toward it. This knowledge is crucial for improving the application and the associated infection control practices. Thus, this paper attempts to close a gap in the literature concerning the attitudes, beliefs, perceptions, and concerns of citizens of Qatar to EHTERAZ.
Purpose, Thesis, and Hypothesis
Purpose statement: The research aims to explore the public’s attitudes toward EHTERAZ, a COVID-19 contact tracing application in Qatar, and assess opportunities to improve EHTERAZ use and effectiveness to mitigate the further spread of COVID-19 and for contract tracing in future pandemics.
Thesis statement: The perception of EHTERAZ is affected by a wide variety of factors.
Hypothesis statement: While Qatar residents EHTERAZ generally view EHTERAZ as a beneficial and trustworthy application, uptake level, quality, privacy concerns, trust in the government, and awareness about the functionality of the application have a significant impact on the attitude toward EHTERAZ.
Research Questions
- RQ1: What are the public’s attitudes toward Qatar’s COVID-19 contact tracing application (EHTERAZ)?
- RQ2: What are the perceived benefits of using EHTERAZ to mitigate the spread of COVID-19?
- RQ3: What are the drivers and barriers of the public in using EHTERAZ?
COVID-19 Pandemic
The COVID-19 pandemic has a significant impact on the global economy and people’s lives. The impact would have been even greater if humanity had not learned from the previous pandemics. Due to the measures taken by governments and international organizations, the COVID-19 pandemic is not yet among the top-five deadliest pandemics in human history. Some of the most famous pandemics include smallpox, Influenza of 1918 (Spanish Flu), Plague of Justinian, AIDS, and Black Plague (West, 2020). Currently, only 2% of the global population has been documented to have coronavirus, while the Influenza of 1918 infected 500 million people or one third of the world population at that time (Taubenberger & Morens, 2006). While some questions concerning the origins, virus-related features, and underlying causes remained unanswered, the knowledge gained from studying Spanish Flu aided in the development of strategies to control the COVID-19 pandemic (Morens et al., 2020). In particular, the studies of Spanish Flu together with other pandemics helped to understand the importance of hygiene and lockdown measures to control the spread of the disease.
While there are certain common features among all the pandemics mentioned above, there are some distinct features of the COVID-19 pandemic. First, all of the recent pandemics, including coronavirus, have emerged in the context of globalization, which distinguishes them from previous epidemics by accelerating disease transmission (West, 2020). Second, the COVID-19 pandemic was addressed using unprecedented measures that were a result of close collaboration of numerous government and international organizations. Humanity acted together to control the pandemic by implementing lockdown measures. Third, modern technology was used to treat and diagnose the disease (Gavi, 2020). Previously, during the Black Plague, Spanish Flu, and Justinian Plague, such measures were not available for a variety of reasons. However, when compared to recent pandemics, such as swine flu and Ebola, the measures used to control the transmission of disease were comparable. Finally, the pandemic was addressed using the experience gained from other epidemics to control the disease (Morens et al., 2020). In particular, it was the first pandemic that used the experience of automated contact tracing to control the outbreak. Having the experience of automated contact tracing was crucial as the global society could quickly develop mobile applications and implement policies to control the transmission of the disease. In summary, there are some unique features of the COVID-19 pandemic, some of which were favorable and unfavorable for controlling it.
Brief History of Contact Tracing
Contact tracing is the process of finding, evaluating, and managing people who have been exposed to an infection (WHO, 2020). It is crucial for timely diagnosis of new cases along with quarantine measures to effectively break the chain of transmission (WHO, 2020). Traditional contact tracing involved asking patients to write down all their contacts during the period of infection so that public health officials could notify them of the possibility of infection (Müller et al., 2000). Today, technology has evolved to the point where contact tracing applications can automatically gather information about people’s possible contacts (O’Callaghan et al., 2020). Contact tracing is effective for controlling infectious diseases when combined with other methods such as vaccination and screening (Müller et al., 2000). Before delving into the attitudes toward contact tracing, it is beneficial to look back at the history of its development.
Contact tracing was first mentioned in the UK in Sanitary Inspector’s Handbook by Taylor (1901). In the late 1800s, the UK established a large administrative body to control the spread of infectious diseases. The standard procedures of the sanitary inspectors during that time included a careful examination of infected people’s homes, the extraction of patients, and the investigation of possible contacts. There was no legal framework requiring patients to reveal all their contacts, and doctors had to rely on persuasion to acquire relevant information (Mooney, 2020). Other nations used similar practices.
In the US, contact tracing was associated primarily with sexually transmitted diseases (STDs or STIs). The practice started in the early 1900s and raised several ethical issues (Bland, 2020). In the 1990s, CDC launched partner counseling and referral services aimed at helping the partners of STD/STI patients acquire healthcare services (Janssen et al., 2001; Bland, 2020). Thus, contact tracing is not a new measure developed specifically for controlling pandemics.
In the 21st century, the need for contact tracing has received increased attention. According to a research concerning various epidemic models, random screening did not have the desired effect on controlling the spread of infectious diseases. Random screening is testing for the virus without following a particular pattern in patient selection. Nevertheless, when combined with individual contact tracing, the effectiveness of screening and vaccination was found to increase significantly (Müller et al., 2000). If a person is found to be contagious, contact tracing can help to find, screen, isolate, and treat people who are at high risk of being contaminated (WHO, 2020). Hyman et al. (2003) claimed that the effectiveness of contact tracing is dependent on the cause of the disease. In the case of HIV, contact tracing was found to be more helpful for identifying super spreaders i.e. individuals who spread infections to a large group of people. On the other hand, random screening was more effective in the epidemics with no superspreaders (Hyman et al., 2003). Thus, both contact tracing and random screenings were found to be effective measures for HIV epidemic mitigation.
The first established idea to use technology for contact tracing emerged in the 2010s. The primary problems with conventional contact tracing by interviewing infected people involve privacy issues (Farrahi et al., 2014). Privacy issues often resulted in insufficient knowledge about the contacts and increased time to receive the required information (Hyman et al., 2003). In order to avoid these problems, Farrahi et al. (2014) proposed the model of contact tracing using communication traces. The researcher assumed that communication by mobile phone is a good proxy for future physical interaction. Empirical evidence also demonstrated that contact tracing via phone traces was an effective tool for controlling the spread of disease at the beginning of an epidemic due to fast-growing costs with an increased number of cases (Farrahi et al., 2014).
The idea of using mobile applications for contact tracing first appeared in the mid-2010s, during the Ebola epidemic in Africa. Sacks et al. (2015) described early testing of mobile applications for contact tracing in Guinea. Even though the results were promising, the data was limited, and future research was required to assess the effectiveness of the new approach. Danquah et al. (2019) conducted an extensive study of the effectiveness of using contact tracing applications in comparison with paper-based contact tracing. The results revealed that mobile application use was associated with increased detection ability and increased detection time. While paper-based contact tracing returned only 39% of contacts, mobile contact tracing found 68% of contacts (Danquah et al., 2019). Thus, it can be concluded that even the earliest versions of mobile contact tracing applications were effective.
Before 2020, the studies of the effectiveness of contact tracing focused primarily on Ebola, tuberculosis, leprosy, and HIV. Saurabh and Prateek (2017) noticed that even though the potential of using contact tracing of any kind for addressing the spread of disease was high, it was limited by the trust of the population in the healthcare system. Smith and Aerts (2014) mentioned that the international medical associations found contact tracing one of the major strategies for diminishing the spread of the disease. Dennis et al. (2018) found that contact tracing with effective analysis techniques can improve the identification of HIV cases. Underwood et al. (2003) found that contact tracing was more effective for controlling tuberculosis than new entrants’ screening strategy. Thus, the history of contract tracing practices before the COVID-19 pandemic is rich in data.
Automated Contact Tracing Applications
Automated contact tracing applications are viewed as one of the most effective methods for reducing the spread of COVID-19 and other highly contagious infections (Kim & Paul, 2020). Since proximity data can be automatically collected by mobile devices, it can be used for identifying possible contacts of an infected person (Braithwaite et al., 2020). In 2020, Google and Apple announced a partnership about creating a Bluetooth-powered contact tracing algorithm to help with the early identification of new COVID-19 cases (Veale, 2020). Both companies made slight changes in their privacy policies to allow healthcare authorities to gather contact data and store it in a decentralized database (Veale, 2020). Thus, global automated contact tracing is an emerging theme in recent research.
There are several issues that limit the effectiveness of automated contact tracing. Kim and Paul (2020) state that there are problems of automated contact tracking associated with determining the significant contact time with infected individuals. Additionally, adequate contact tracing is impossible without engaging a vast majority of the population (Braithwaite et al., 2020). Nevertheless, it should be acknowledged that the effectiveness of contact tracing will remain very limited, which implies that other measures, including systematic screening and vaccination, should be utilized together with automated contact tracing (Kim & Paul, 2020).
People’s Perception of Automated Data Collection
Automated data collection and analysis are currently being used in different spheres in modern society. One of the most excessively studied spheres is personalized marketing, both online and offline. People’s attitude towards personalized ads is affected by different factors. Tessier (2021) argues that the frequency of appearance of personalized advertisements has a high impact on people’s perception of the benefits of such ads. Relatively rare advertisements are generally viewed as beneficial, while frequent personalized ads often cause the feeling of intrusiveness. Thus, people experience privacy concerns when the gathered data is used too often. Additionally, poorly processed data that leads to wrong conclusions cause dissatisfaction among people (Tessier, 2021). O’Callaghan et al. (2020) also supported the notion that privacy worries contact tracing application users. Therefore, privacy concerns and feelings of intrusiveness are among the central problems associated with automated data collection.
Marketing studies demonstrated that many customers were ready to share their private information in some cases. For instance, Kerem and Ulla (2018) conducted a qualitative study, which revealed that people are often ready to share their private information with marketers. Customers are willing to share their private information only if the perceived benefits of such sharing are high (Ziefle et al., 2016). In other words, people are ready to trade-off their privacy for access to items and services in which they have a high degree of interest. Dahl and Fridh (2019) confirm this notion, stating that consumers can often be irritated by personalized ads after the purchase, as the ad is no longer perceived as beneficial. Moreover, personalized advertisements may lead to the feeling that a wrong decision was made, which causes regret (Dahl & Fridh, 2019). Thus, attitudes towards automated data collection are very closely connected to the perceived benefits of information disclosure.
Another factor that affects the attitude towards automated data collection is the transparency of their procedures. In particular, Strycharz (2018) stated that privacy concerns emerge based on the available knowledge. Thus, marketers are encouraged to provide extensive information for the users about the policies and measures implemented to protect and use private information (Strycharz, 2018). Additionally, informing the customers about adhering to the government standards of privacy protection is crucial for improving the attitude towards automated data collection (Hess et al., 2020).
Attitudes Toward COVID-19 Automated Contact Tracing Applications
The literature review revealed several themes associated with attitudes toward contact tracing applications. The common themes included uptake issues, the possibility of stigma, privacy concerns, inadequate knowledge about contact tracing applications, and perceived benefits of contact tracing.
Uptake Issues
The effectiveness of contact tracing applications depends on the level of uptake of the population under analysis. Braithwaite et al. (2020) stated that contact tracing applications could help limit the spread of COVID-19 if at least 56% of the population uses them. This implies that determining the factors that affect the support of contact tracing is crucial for the applications’ success. After conducting extensive survey-based research in France, Guillon and Kergall (2020) revealed three basic factors that affected the level of uptake of the application. These factors included trust in the government, perceived individual health consequences, and time preference. This implies that if governments improve public’s trust and educate the public about the consequences of being infected, then the adoption of contact tracing applications will increase.
Sharma et al. (2021) conducted research to identify sociodemographic factors affecting the adoption of a contact tracing application in India. The results demonstrated that the level of income, number of years of formal education, age, and gender were significant determinants of the willingness to install the application. One of the major problems for adopting the application in India was the lack of cellphones, as the country’s level of poverty is very high (Mehta & Shah, 2003). Thus, the reasons for failure to adopt contact tracing applications in India were different from those in France. Yet another study conducted by Jansen-Kosterink et al. (2020) analyzed a large sample of Dutch citizens and revealed that the central reason for failure to adopt contact tracing applications was privacy concerns—different from both France and India.
The review of the literature concerning the uptake of contact tracing applications demonstrated that factors affecting the matter differed depending on the region. Therefore, the findings of research in other countries can be applied to Qatar with significant limitations. This finding confirms the need for further research concerning the attitudes toward contact tracing application (EHTERAZ) in Qatar.
Privacy Concerns
Privacy concerns are among the central reason for people refusing to use contact tracing applications in various regions. As mentioned in the previous section, a study based on a large sample of Dutch citizens showed that fear of security breaches of centralized databases with personal data was the primary reason for refusing to use contact tracing applications (Jansen-Kosterink et al., 2020). Similarly, a survey of Irish citizens demonstrated that the primary reason for refusing to use contact tracing applications was the fear of technological companies and mistrust in the government (O’Callaghan et al., 2020). In other words, the Irish population feared that their privacy would be breached, and the government would use the data in the future for other purposes. Thus, privacy issues associated with automated contact tracing are named as central reasons for refusing to use contact tracing applications in Europe.
The effect of privacy concerns on the adoption level can be moderated by the privacy policies implemented and communicated by the government. Hassandoust et al. (2021) stated that privacy initiatives implemented by the government had a positive impact on people’s attitudes toward contact tracing applications. Additionally, privacy-controlling technological features, such as anonymity and utilization of less sensitive data were positively perceived by users of contact tracing applications in the United States (Hassandoust et al., 2021; Utz et al., 2021). Bengio et al. (2021) suggest that contact tracing applications should incorporate informed consent, strict oversight, virtual data acquisition based on the principles of anonymity, and informed decision-making. In summary, privacy issues of automated contact tracing applications are a matter of increased concern to the users.
Stigma
Social stigma is another crucial issue associated with the adoption of contact tracing applications. Williams et al. (2020) explain that people may fear learning about being infected, which causes them to become anxious and depressed. Since avoiding is one of the most common coping mechanisms for depression and anxiety, people prefer to abstain from using contact tracing applications, prompt testing, and timely treatment (Peprah & Gyasi, 2020). Apart from creating barriers to adoption levels of contact tracing applications, stigma can also lead to under-reporting of new COVID-19 cases and an increase in the number of fatalities (Kisa & Kisa, 2020). The anxiety and avoidance are associated with the fear of being discriminated against, causing delayed diagnosis, increased transmission, and delayed notification of contacts (Sotgiu & Dobler, 2020). Thus, social stigma is associated with low adoption levels and decreased effectiveness of contact tracking applications.
Inadequate Knowledge
Low adoption levels of contact tracing applications may be associated with inadequate knowledge about such applications and associated misconceptions. Williams et al. (2020) reported that many people from a sample of UK citizens were unaware of the existence of contact tracing applications utilization for fighting COVID-19. Similarly, Hassandoust et al. (2021) claimed that privacy concerns are associated with the lack of knowledge about the privacy measure that was implemented to defend the sensitive information shared through the application. For instance, some people believed that contact tracing applications created some interactive maps visible to everybody, where infected people are shown (Williams et al., 2020). Huang et al. (2021) reported that high awareness about the importance of contact tracing is the key to high adoption levels. Appleby‐Arnold et al. (2019) suggested that using social media to promote the idea that the government uses such applications to share control and inform the public about possible dangers. Thus, a low level of awareness and accurate knowledge about contact tracing is one of the key factors associated with the promotion of contact tracing.
Perceived Benefits
The adoption of contact tracing applications was also dependent on the perceived benefits received from using them. Guillon and Kergall (2020) stated that perceived individual health consequences were one of the dominant factors encouraging the adoption of contact tracing applications in France. In other words, the higher the perceived health benefits, the higher the chance of adopting such applications (Guillon & Kergall, 2020). Williams et al. (2020) indicated that people who use contact tracing are those who believe it serves a greater good. For instance, citizens of the UK who were ready to use the application believed that the benefits of using it exceeded any perceived drawbacks (Williams et al., 2020). Thus, learning about how the public understands the associated benefits is crucial for high uptake of the application.
EHTERAZ
Even though EHTERAZ is a relatively new application for contact tracing, there is a significant body of research assessing its technical characteristics. The assessment of the application differed among the reviewed studies. For instance, Raman et al. (2021) evaluated the application as inadequate, as it was not available in the local language and did not have an adequate tutorial. Additionally, Raman (2021) criticized the application for being very low in transparency rights, ease of accessibility, and security. However, Zhao et al. (2020) reported that the application had very accurate proximity measurements that incorporated Bluetooth technology and GPS. In other words, the application could accurately determine the contacts automatically. According to Varma et al. (2020), the implementation of the contact tracing policies and EHTERAZ as an obligatory measure for addressing the spread of COVID-19 helped to minimize the impact of the pandemic on society and economics.
Knowledge Gap
The literature review demonstrated that contact tracing is a well-established practice. The utilization of modern technology had a mixed impact on contact tracing, as it was associated with significant benefits and challenges. Although research in various countries regarding the citizens’ attitudes toward the COVID-19 applications was conducted, such a study has not been conducted yet in Qatar. At the same time, even though several studies on EHTERAZ were conducted, the public’s perception of the application was not assessed. The present study will contribute to the current body of knowledge by closing the identified gap.