Our study evaluated the current willingness and cognition toward reporting on travel history to high-risk epidemic regions among the Chinese public, as well as the correlation between their willingness and cognition. A proportion of the public (6.77%) was found to be more inclined to withhold their history, although the majority agreed to report. Nonetheless, considering that any withheld history case can result in unpredictable outcomes, this result already deserves great attention[6–8]. After the emergence of frequent incidences of withheld history, Chinese authorities implemented more severe measures, including several levels of isolation from city to community, rewarding those who provide clues to withholders, and instigating systematic blanket searches in communities[9, 10]. However, in all of these actions the public plays a relatively passive role. Therefore, research into the association between the public’s willingness and cognition to report on travel history is essential for promoting the public's voluntary reporting.
This study discovered several factors associated with the willingness to report on travel history to high-risk epidemic regions. First, is the cognition of benefiting from reporting. Apart from being able to test whether one is infected as soon as possible, a more valuable benefit of timely reporting on travel history, is that it helps to identify other potentially infected patients. The department responsible for epidemic prevention and control would be able to investigate the public transportation that reporters took, the recent events in which they participated, and the number of people that they had been in contact with. This response would allow potentially infected patients to be examined and prevent them from further spreading the virus. The results of the study reflect that the proportion of the public that recognized these benefits demonstrated a greater willingness to report (P < 0.05). However, our research cannot determine whether the reporting behavior of the public could be attributed to egoistic behavior or altruistic behavior. Emphasizing all the benefits of reporting in public advocacy may be the better option for promoting a willingness to report. Furthermore, prospect theory in behavioral economics asserts that people have a mentality of aversion toward loss; their level of sensitivity toward losses and gains are unequal, and the pain they feel in the face of loss is far greater than the joy of gaining. Thus, instead of promoting ‘the benefits of reporting’, the government can promote ‘the risks of not reporting’ in public advocacy to activate the loss-averse mentality in the public and encourage action.
Second, considering the perceived obstacles to reporting, the feelings of stigmatization that reporting brings and the fear of potential quarantine are factors that influence the willingness to report. The proportion of the public that believed reporting would cause stigmatization and feared the quarantine that they may face after reporting expressed a lower level of willingness to report (P < 0.05). The stigmatization and discrimination of potential patients are phenomena that were present since the early stage of epidemic outbreak. Reporting on travel history might cause the reporter to be labeled a potential patient, which lowers their willingness to report. The exaggerated and arbitrary description of risk associated with having a travel history to Wuhan provided by China’s official statements and media reports may also worsen the public’s isolation of people with such an experience, despite it not being the original intention. Thus, social support and social policies should be available for potential patients, including the reporter of travel history, which would alleviate the social stigma attached to the travel history reporter and ease the discriminative atmosphere. The government and media should also draw connections between regions and the infection with discretion to prevent the situation from worsening into regional discrimination. In addition, this study and past studies concur that the public fears restrictive epidemic control measures, such as quarantining[15–17]. On some level, this fear is an extension of the underlying anxiety surrounding an infectious disease with an unknown cause and possible fatal outcome. Members of the public with a travel history would generally be subjected to the prevention and control process of quarantine after reporting, until the incubation period passes without incident. Fear of this has also become one of the factors that impact on the willingness to report. Therefore, effective health education strategies and public risk communication are necessary to allay such fear.
Third, this study showed that the members of the public that agreed that withholding travel history to high-risk epidemic regions would result in legal liability demonstrated a greater willingness to report (P < 0.05). To combat COVID-19, China implemented Class A (the highest level) epidemic prevention and control measures. Each province and city successively implemented first-level responses to the major public health emergency. During this time, all units and individuals were required to comply with epidemic-related measures enforced by disease prevention and control facilities and medical facilities, and truthfully provide relevant information. Deliberately withholding travel history to high-risk regions would result in a conviction for the crime of ‘endangering public security by dangerous means’, based on the severity of the outcome[19, 20]. Shanghai even introduced China’s first COVID-19 legislation: those who evaded quarantine by withholding their travel history would be diligently pursued for applicable legal liability based on the law. Understanding that their action may result in serious consequences enforced by the legal system may suppress the public’s desire to withhold information. Thus, based on the existent legal framework on withholding travel history, the government should further expand public campaigns to explain legal obligations to report on travel history and emphasize the consequences of withholding information.
In investigating the cues that may encourage the public’s reporting of travel history, we found various types of effective cues, with the greatest number of respondents admitting to the effectiveness of hearing about cases where withholders of travel history were punished by law. This outcome could enhance the public’s acknowledgment of the illegality of withholding information, as well as prompt public consideration of law enforcement dynamics. However, this study was unable to provide a conclusion regarding the public’s sensitivity toward different penalties and frequency of hearing cases of people being prosecuted, as well as the threshold that affects their ultimate actions. This aspect would require further exploration in future. Seeing others showing potential symptoms of COVID-19 also encourages individuals to report their travel history, as withholding information increases the concern of negatively impacting others. Epidemiological analysis from the Chinese Center for Disease Control and Prevention shows that there are more than 1,000 cluster COVID-19 cases in the country, 83% of them are family-based, or occurring in common gathering places, such as medical institutions, schools, shopping malls, and factories. Another cue was the public speaking by communities. Thus far, grassroots communities, including rural communities, have played a unique role in China’s epidemic prevention and control as well as in social governance. The power of grassroots leaders made it possible to manage residents of each jurisdiction systematically to monitor the epidemic’s advancement, promote epidemic information, and educate residents on healthy behavior. The community is the public’s direct recipient, processer, and promoter of travel history reports to high-risk epidemic regions, and as such, most members of the public report to their communities first if they have the willingness to report. China’s leader Xi Jinping has commented as follows: ‘The community is the frontline in epidemic prevention and control, and is the most effective line of defense in blocking external infectious sources and containing internal spread’. Under the current situation, where the epidemic is spreading globally, each country can consider mobilizing their communities for prevention and control as China has done—to place the power of prevention and control in the community.
Nevertheless, this study has the following limitations. First, the public’s willingness and cognition toward reporting on travel history to high-risk epidemic regions may change with the course of the epidemic. A cross-sectional study is limited in its usefulness in capturing this type of dynamic change. Future research may consider a longitudinal design. Second, this study only analyzed the effects that socio-demographic characteristics and cognition of reporting travel history had on the willingness to report. There may be other factors affecting the public's willingness to report. Third, considering the cost and convenience of conducting research, this study only selectively investigated a portion of provinces and cities based on the severity of the epidemic outbreak. For more universal results, a study on a larger scale may be necessary.