People’s perception of quarantine during the COVID-19 outbreak in Shantou, China

Unprecedented public health measures have been implemented to combat the pandemic outbreak of the 2019 coronavirus disease (COVID-19) in China. The purpose of this research is to identify people’s perception of quarantine during the COVID-19 Methods Semi-structured interviews with 30 participants were conducted, including 15 people who had been quarantined and 15 participants who had not been quarantined during the COVID-19 outbreak in Shantou, Southern China. Interview data were collected from February to March 2020. All interviews were audio-recorded and transcribed verbatim. The transcribed data were coded and analyzed to identify key themes.


Abstract Background
Unprecedented public health measures have been implemented to combat the pandemic outbreak of the 2019 coronavirus disease  in China. The purpose of this research is to identify people's perception of quarantine during the  Methods Semi-structured interviews with 30 participants were conducted, including 15 people who had been quarantined and 15 participants who had not been quarantined during the COVID-19 outbreak in Shantou, Southern China. Interview data were collected from February to March 2020. All interviews were audiorecorded and transcribed verbatim. The transcribed data were coded and analyzed to identify key themes.

Results
Four key themes concerning public health measures emerged: 1) A city-wide lockdown effectively aroused the public's awareness of the seriousness of COVID-19, which was helpful for controlling the pandemic; however, it greatly impacted the economy and individuals' way of life. 2) Hotel quarantine was an effective measure for medical observations. 3) Fear and lack of knowledge of quarantine were the main factors that affected quarantine compliance. 4) Less attention was paid to people's mental health during the pandemic outbreak.

Conclusions
A lockdown and centralized hotel quarantines were effective ways to control the outbreak. Mandatory measures were highly supported. The media should educate the public about COVID-19. Psychological counseling is necessary for people who were quarantined long-term. The ndings have implications for other countries and for emerging infectious diseases in the future.

Background
In December2019, there were several patients with an unknown pneumonia in Wuhan, China. It was soon con rmed that the disease was caused by COVID-19 [1]. Epidemiological investigations suggest that this virus is spread by person-to-person transmission, causing a global health emergency [2][3][4]. The government of Wuhan shut down all public transportation and a city-wide lockdown commenced on January 23, 2020. However, more than ve million residents already left and many of them were infected, which led to the disease being spread across China and other countries [5]. By January 30, COVID-19 was declared a public health emergency of international concern. A total of 113,579 close contacts had been tracked and received medical observation by February 2 [5]. Like other severe acute respiratory syndromes coronavirus (SARS-CoV), most severe patients were symptomatic and identi able, which make quarantining successful [6]. However, some patients infected with COVID-19 were asymptomatic and could spread the virus to other during its incubation period [7]. By February 28, more than 82,000 con rmed cases of COVID-19 had been declared, with more than 2,800 deaths across 46 countries [8].To control the spread of COVID-19, unprecedented public health measures were implemented, including a city-wide lockdown, quarantiningill persons, and social distancing. 5 To effectively quarantine infected individuals and reduce the spread of the pandemic, the Shantou government restricted anyone symptomatic in the pandemic area of Hubei province from having close contact with others for 14 days.
Further, when other people were present, each of them must wear masks. Despite the positive effects of the quarantine, some residents were not compliant with the protective measures. The aim of this study is to understand people's perception and experience of the COVID-19 quarantine providing some suggestions for the improvement of public health measures for future contagious diseases or the same outbreak in other countries.

Study sample
Included individuals were those who currently lived in the downtown area of Shantou. Participants were informed of the study purpose. Thirty-two individuals completed interviews after being recruited through purposive sampling in February-March 2020. One quarantined participant was not strictly quarantined and thus removed from the study. In the non-quarantined group, two people had the same occupation; therefore, we only chose one of them. Finally, 30 individuals were interviewed, including 15 who had been isolated or quarantined (quarantined group) and 15 participants who were not (non-quarantined group).
Participants' characteristics are shown in Table 1.

Data collection
A qualitative research design involving semi-structured in-depth interviews was adopted. Participants were clearly told that they had the right to refuse to answer any questions and withdraw from the study any time. To ensure privacy, participants remained anonymous. All participants provided written consent.
Most interviews were conducted over the phone to reduce the risk of infection. Four participants completed face-to-face interviews with the protection of masks. With participants' permission, all interviews were audio recorded and transcribed verbatim. The interview format allowed participants to speak freely. To ensure interview quality and consistency, one author conducted all interviews. The interview began by asking participants for basic information; describing their perception of the city lockdown, quarantining ill persons, the population's willingness to comply with the quarantine, and the facilitating factors and barriers associated with quarantine; and more speci c questions about their personal experiences. Each interview lasted 30 to 50 minutes

Data analysis
A phenomenological approach was adopted to analyze the interview data. Each interview was independently transcribed verbatim and read several times by two authors to identify recurring patterns and their links to the theoretical framework [9]. Disagreements were resolved by group discussion. The transcribed data were coded and analyzed following the grounded theory approach to identify recurring patterns and create an explanatory framework [10,11] Interview transcripts were repeatedly read by the research team.

Results
Four key themes were identi ed: city-wide lockdown was effective, a hotel quarantine was effective, fear and lack of knowledge of quarantine were the main factors that affected quarantine compliance, and insu cient attention was paid to people's mental health.
First, all participants described their perceptions of the lockdown of Wuhan city. They all agreed that the decision was very wise and necessary. It was unprecedented and caused a widespread panic; however, it was very helpful to try and prevent the pandemic and protect people outside of the city. Two respondents commented on the speci c timing of the lockdown: -medical observer, quarantined group Lastly, concerning participants' mental health, only one participant in the quarantined group had undergone psychological testing. Two participants in the non-quarantined group had completed psychometric measurements for scienti c research. All participants in the non-quarantined group reported they did not need psychological counseling and the participants who were quarantined in hospital or hotel psychological interventions should be available if needed.
This outbreak makes me feel shock and I didn't take any psychological tests. I can adjust by myself and I don't think I need psychological counseling. Participants who were quarantined maybe need psychological counseling; especially the rst line of medical staff-their experiences and emotions might directly affect patients.
-infection management staff, non-quarantined group All the physicians in the quarantined group indicated that they did not need psychological counseling.
Some nurses indicated that proper psychological counseling may help reduce stress. Most quarantined participants believed that a longer isolation period would likely result in increased agitation. In addition, some participants reported being verbally abused and discriminated against. Some media reported that Chinese students and tourists in other countries were also subjected to racist behavior and hate crimes across the world.

Discussion
The in-depth interviews discussed in this study provide participants' perceptions and experiences about quarantine in China during COVID-19. In the recent years, several viral epidemics such as the SARS-CoV, H1N1 in uenza, and the Middle East respiratory syndrome coronavirus (MERS-CoV) struck different parts of the world [12]. Initial public health measures of the outbreak relied heavily on quarantine. We can thus learn many lessons from the previous outbreaks to prevent the spread of COVID-19.
The classic public health measures that were implemented included quarantine and isolation, social distancing, and community containment [5]. A city-wide lockdown was unprecedented in China. While the participants agreed with the lockdown of Wuhan, they felt the situation in Shantou was not dire enough to warrant a lockdown, and that it negatively affected social stability and urban economies [13,14].
Research also demonstrates that sheer population size is the biggest challenge for a owing to a shortage of hospital beds [8].Strong measures taken to restrict the spread of a deadly disease inevitably cause considerable collateral damage [15]. The government had to balance the pros and cons, such as economic losses against the need to contain the spread of a deadly disease, before making the decision.
Other countries may bene t from these decision-making processes if they too experience a COVID-19 outbreak.
Quarantine is one of the most effective measures of controlling communicable disease outbreaks, which was implemented successfully during the SARS epidemic in 2003 [16]. Individuals can be quarantined at home or in a designated facility such as a hotel, cruise ship, or hospital [17].However, an ineffective quarantine may also accelerate the spread of the virus. A recent study reported that the cruise ship Diamond Princess was quarantined for over 14 days; however, the infection rate on board was about four times the rate in Wuhan [18]. Prior studies reported that, without proper preparation and protection, hotels may have hastened the spread of viruses such as SARS in 2003 and H1N1 swine u in 2009 [19][20][21]. It is worth mentioning that we were not aware of any infection caused by hotel quarantine. Many medical observers were quarantined in a hotel in Shantou and all costs were borne by the government. Compared with home and hospital, hotel quarantine seems to solve many problems; e.g., contact with others, the limited number hospital rooms, etc. Staying in a hotel-a person a room-is much safer than home. However, hotel must be strictly sanitized and equipped with su cient medical staff to provide a viable quarantine option for future pandemics.
There is no doubt that mandatory public health measures are essential to combat infectious diseases, especially for new emerging infectious diseases where no vaccine or cure exists [22]. A high compliance rate plays a critical role in a successful quarantine [22]; however, some individuals are reluctant to comply with a quarantine, perhaps owing to uncertainty, scarce information, economic pressure, and a widespread perception of loss of control [23]. One study suggested that income support for individuals in quarantine is essential, and avoiding this issue would hinder emergency responses [22]. Mass media campaigns are strongly needed and should be speci cally tailored for different audiences. Transparency, honesty, and effective health-related communications may improve quarantine compliance [15]. Stakeholder should consider assessing residents' understanding of the virus and effectively educate them to ensure correct understanding [24].
The ndings showed that little attention was pay to mental health during the pandemic in China. Several participants noted that appropriate counseling should be provided, especially for people who are experiencing long-term isolation. Research has demonstrated that a longer duration of quarantine is associated with an increased prevalence of post-traumatic stress disorder (PTSD) [25].though the current physicians stated they did not need psychiatric help, a prior study reported that medical workers that worked during infectious disease outbreaks had a high risk for PTSD [26]. Other research supported our results-when psychological counseling is lacking, communication with family/friends by phone, watching TV, or sur ng the Internet may ease stress during a quarantine [23]. Post-quarantine, those who were isolated often display psychological distress or PTSD symptoms [27][28][29] Therefore, they should be provided with the necessary psychiatric services.

Limitations
This study had several limitations. First, participants were from a designated hospital for COVID-19 treatment, which limits the generalizability of the ndings to other areas; although, we recruited participants with different professions. Second, our inability to conduct all interviews face-to-face limited our ability to detect non-verbal language.

Conclusions
This study documented participants' perceptions and experiences of key public health measures. Although a city-wide lockdown was effective, it should not be implemented lightly. Implementing hotel quarantines also proved effective. To increase quarantine compliance, the government and media should take steps to resolve people's concerns. Availability of data and materials: All these data and materials have not been reported in any other study.
Competing interests: The authors declare that they have no competing interests in this research.

Funding: Not applicable
Authors' contributions: XD was involved in the study conception, design, and data collection. XD and SC conducted data analysis and interpretation, and writing of the manuscript. YZ and SZ participated in data interpretation, and helped to draft the manuscript. XC supervised the study implementation and identi ed the key themes, and critically revised the manuscript. All of authors have read and approved the manuscript