General Discussion
To date, studies assessing the public’s willingness to perform COVID-19 self-testing are still limited. To the best of our knowledge, only one study has been conducted during the transition to the endemic phase. In this study, 87.3% of the China population who had never been infected by COVID-19 expressed their willingness to perform COVID-19 self-testing.(30) Other studies conducted during the early or midst of the COVID-19 pandemic reported varying levels of willingness to perform COVID-19 self-testing among their respective populations. For instance, a high willingness rate was reported in South Africa (90.4%),(31) Nigeria (84.1%),(32) Kenya (81.4%),(33) and Greece (79.0%).(17) A slightly lower willingness rate was reported in United Arab Emirates (UAE) (70.3%),(34) while an even lower rate was reported in Indonesia (60.8%) and Brazil (49.1%),(35, 36) respectively.
Similar to China,(30) the public in Malaysia reported a very high willingness for COVID-19 self-testing uptake. Both countries had a high vaccination rate and low community incidence of COVID-19 at the time studies were conducted.(37) The willingness of the public to perform COVID-19 self-testing was considerably higher during the transition to the endemic phase than during the pandemic phase for a few reasons. First, the public had better health literacy regarding COVID-19 self-testing, which can be attributed to the constant provision of information and education by the government through mass media, social media, schools, and healthcare facilities. Second, the public had adopted new health behaviours that required them to live with COVID-19 in the “new norm”. They resumed economic, social, and learning activities as they did before the pandemic, while also getting tested for COVID-19 when necessary. Third, COVID-19 preventive strategies that were associated with less unpleasant experiences were more accepted by the public in the long run, such as hand hygiene and self-testing. On the other hand, strategies like social distancing were associated with mental distress, loss of income, and social rejection,(38) while face mask-wearing caused physical discomfort, communication barriers, and maintenance difficulties.(39) Forth, the COVID-19 immunization program had either not yet started or just commenced in many countries during the early or midst of the pandemic. At that time, the public was more concerned about vaccination and paid less attention to COVID-19 testing.
Several factors have been identified to be associated with a higher willingness to perform COVID-19 self-testing. A higher education level was reported in five studies,(17, 30, 32, 35, 36) full-time employment was reported in four studies,(32, 34–36) residents of rural area was reported in three studies,(31, 33, 35) and older age,(30, 34) female gender,(30, 34) previously investigated for COVID-19,(30, 32) and higher perceived risk of COVID-19 infection were reported in two studies,(30, 32) respectively. Additionally, one study each reported that individuals who stayed with the elderly,(30) previously diagnosed with COVID-19,(34) had been vaccinated against COVID-19,(34) and possessed better knowledge about COVID-19 were more willing to perform COVID-19 self-testing.(30) Those with lower income, limited internet access, and recent experience with non-pharmacological intervention to mitigate COVID-19, such as quarantine, however, were shown to be more reluctant to perform COVID-19 self-testing.(30)
Even though immunization is the most effective measure to mitigate the COVID-19 pandemic, its association with the public’s willingness to perform COVID-19 self-testing has rarely been assessed. In our study, those who had been vaccinated against COVID-19 were eight times more willing to perform COVID-19 self-testing. A higher willingness to perform COVID-19 self-testing was observed among the vaccinated population in UAE, (34) but not in China.(30) The discrepancy could be explained by the fact that COVID-19 vaccination was made compulsory in several places in China, while it was voluntary in Malaysia.(40) Those who were exempted from compulsory COVID-19 vaccination due to health reasons were often still willing to perform COVID-19 self-testing, as reported in our study. On the other hand, individuals who refused to receive the COVID-19 vaccine were less likely to accept or adhere to other health preventive measures, for example, wearing masks, social distancing, and voluntarily getting tested.(41)
The association between previous COVID-19 investigations and the public’s willingness to perform COVID-19 self-testing has only been reported in limited studies. Our respondents who had performed COVID-19 self-testing reported a four-fold higher willingness to undergo the test again. Similarly, in China and Nigeria, individuals who had previously been investigated for COVID-19 also expressed a higher willingness to perform COVID-19 self-testing.(30, 32) Only a small portion of the population in Indonesia (35.1%),(35) South Africa (24.5%),(31) and Kenya (12.2%) had been investigated for COVID-19 at the time of their respective studies.(33) Their willingness to perform COVID-19 self-testing was not affected by their previous investigation experience. The findings of these studies, however, should be interpreted with caution in view of the sample size may not have sufficient statistical power to detect the true difference.
There are several explanations for the factors that significantly affect our respondent’s willingness to perform COVID-19 self-testing. First, the higher willingness among those who have been immunized against COVID-19 can be explained by the psychological domain gradient of the Health Belief Model.(42) Immunized individuals often have a higher perceived susceptibility to and severity of the disease, as well as an understanding of the benefits of preventive measures. Therefore, they are more motivated to engage in other infection-prevention measures, such as voluntary testing for COVID-19.(41) Second, health behaviours during the COVID-19 pandemic are often heavily influenced by past experiences.(43) Those who have previously performed COVID-19 self-testing were more likely to repeat the test again when needed. Third, literature reported women are more likely than men to engage in health behaviours associated with disease prevention,(44) for example, investigated for a disease or risk. Women are also more likely to perceive the COVID-19 pandemic as a serious threat and adopted infection-preventive measures.(45) Fourth, a higher education level is often associated with better economic status, social-psychological support, health behaviours, and access to health care.(46) Higher education attainment also significantly improves health literacy resulting in proactive disease detection and a propensity to make safer health choices.(47) Those with higher education levels, therefore, are more willing to perform COVID-19 self-testing.
The public’s willingness to pay for COVID-19 Ag-RDTs kits closely correlates with their intention to undergo self-testing.(48) The price of the kits, however, can be burdensome for individuals in low- and middle-income countries that have been severely impacted by the COVID-19 pandemic. More than half of the population in Brazil (69.3%),(36) Nigeria (66.8%),(32) Kenya (63.0%),(33) Indonesia (62.1%),(35) and South Africa (61.6%) expressed willingness to pay for COVID-19 self-testing.(31) In Malaysia, the cost of COVID-19 self-testing is fully borne by users. Concerns about the affordability of Ag-RDTs kits were expressed by less than half of our respondents who were hesitant or reluctant to perform COVID-19 self-testing, indicating that the majority found the kits to be affordable. Adherence to recommended actions by authorities following a positive self-testing result is essential to control the spread of COVID-19. Studies have reported that the majority of the public would communicate their results (80.1–97.5%), attend health facilities for post-test counselling (92.8–97.7%), self-isolate (91.4–98.2%), and inform their contact (87.7–90.9%) if their COVID-19 self-testing result turned out positive.(31–33, 35, 36) In our study, almost all respondents who were willing to perform COVID-19 self-testing indicated that they will immediately self-isolate and seek treatment if their test result turned positive, demonstrating a high adherence to the “TRIIS” strategy. Similar to our study, reasons given by individuals who were willing to perform COVID-19 self-testing in other studies included getting the result faster, saving time on travelling and waiting at laboratories, and ensuring privacy.(31, 32)
Strategies for Interventions
First, future strategies to promote COVID-19 self-testing uptake in Malaysia should focus on adults who have not yet been immunized against COVID-19. They can be identified through MySejahtera which records the immunization status of citizens,(6) or social media platforms (such as Facebook and WhatsApp group) that provide inaccurate and misleading information about the COVID-19 vaccine.(49) Information about the importance of self-testing, its benefits, and supporting evidence could be channeled to this group via similar platforms. Second, education materials to promote COVID-19 self-testing should be layman-friendly in order to reach out to people from all walks of life, including those less educated and from rural areas. These materials should be available in multiple languages, including common local languages and dialects. The content should be clear, concise, and free of technical jargon or complex terminology. Third, conducting practical demonstrations in public campaigns, community outreach initiatives, and sharing user testimonials can help encourage individuals who have never tried COVID-19 self-testing to start doing the test. Simple and clear instructions, accompanied by visual aids, can make the learning process easier and more convenient for new users. Providing free test kits, testing incentives, and peer support can also be helpful in promoting uptake.
Fourth, it is important to address false beliefs that act as barriers to COVID-19 self-testing. Specifically, the public should be made aware that individuals infected with COVID-19 are more likely to experience hospitalization, mortality, and long-term complications compared to those with the common flu,(50) and COVID-19 vaccine can reduce the severity of the disease but did not prevent against infection.(51) Fifth, addressing concerns about isolation policy for COVID-19 could help to alleviate hesitations regarding COVID-19 self-testing. For instance, the Malaysian government recently reduced the duration of COVID-19 isolation from seven to five days.(52) Income continuity, incentives, and support for daily living should be provided during the isolation period. Sixth, the advantages of COVID-19 self-testing should be constantly highlighted as part of the education efforts. For instance, self-testing provides faster results and enables early self-isolation to protect family, friends, and colleagues. Oral antivirals such as Paxlovid and Molnupiravir are available in Malaysia, preferably started soon after a diagnosis of COVID-19 and within five days of symptom onset.(53)