How can we use behavioural science to increase the uptake of the NHS COVID-19 track and trace app in England and Wales?

Felix Naughton and Dorothy Szinay discuss how the uptake of contact tracing apps during the ongoing COVID-19 pandemic could be increased by drawing on what we know about factors that influence people’s uptake of health apps more generally.

From the 24^th September 2020, the NHS COVID-19 track and trace app was made available for use by individuals living in England and Wales.

From a technological point of view, it could be argued that the timing of the COVID-19 pandemic is quite fortunate: smartphone ownership is widespread in the UK and globally, and can act as a powerful tool for containing the spread of the disease. In the UK, around 80% of people currently own a smartphone. Using the phone’s Bluetooth functionality, contact tracing apps (such as the NHS COVID-19 track and trace app) can estimate when and for how long people running the app on their phones spend time together in close proximity. Then, if any of those people test positive for COVID-19, the app can alert those who have spent sufficient time with the infected individual, asking them to self-isolate to reduce the risk of onward transmission.

On paper, the COVID-19 app sounds like a critical tool in the fight against the virus. However, a key factor influencing the impact of a contact tracing app is its adoption rate in the population, i.e., the proportion of people that select to download and run the app on their phones. Contrary to an incorrect assumption that 60% of the population needs to use the app for it to suppress the virus, benefit can still be gained at low levels of adoption. However, the benefit is much greater at higher levels of uptake and ongoing use. As uptake (i.e., downloading and installing an app) is primarily a behavioural issue rather than a technological one, we should draw on behavioural science to better understand factors that influence app uptake and devise strategies to improve it.

Recently, we reviewed all the studies we could identify that investigated psychological and behavioural factors that might influence the uptake of and engagement with health and wellbeing apps. We further conducted an interview study to deepen our understanding. Several important factors were identified. Below, we revisit these factors and consider the implications for the NHS COVID-19 app.

A key factor is app literacy. When individuals have less skill and confidence in their use of apps, they are less likely to install and use them. Although the setup of the NHS COVID-19 app is relatively straightforward, people may still expect it to be complicated to use, which can put them off installing it. The complexity in how the app senses other app users and anonymously alerts them could translate into concerns that using the app will require advanced app skills and competence. It is therefore important that the most vulnerable subgroups in society, including the elderly, receive help to install the app.

Social influence has a big impact on the uptake of apps in general and will likely be an important factor in the uptake of the NHS COVID-19 app. Social influence includes things like other people’s ratings and reviews on app stores, and recommendations from loved ones, friends, health practitioners, and even celebrities. The team that developed the app reports having conducted research with Black and minority ethnic (BAME) communities to find out optimal ways to increase app uptake. One suggestion was to involve influencers within the BAME community in the dissemination of the app. Social influence, however, can be a double-edged sword. Negative reviews on app stores have the potential to undo positive influence. Furthermore, sceptical views or concerns among family and friends could damage uptake intentions. Another type of positive social influence is the use of a credible source: having the app developed by a trusted organisation and endorsed by the NHS and influential scientists and public health organisations, should help increase uptake. Participants in our interview study suggested that the promotion of health apps through a newsletter sent by GPs or family physicians would encourage them to use health and wellbeing apps.

Another factor is the availability of apps. While not having access to an app is an obvious barrier, it is an important one. In the case of the NHS COVID-19 app, while it is availabile in the two major app stores (i.e., for Android and iPhone users), it is not available to the small minority with other types of smartphones. Even among those who can use the compatible app stores, we estimate that 4% of Android users and 25% of iOS users have a phone running an operating system version that is too low to run the COVID-19 app (i.e., below Android version 6 and iOS version 13.5). We know that smartphone ownership is lower among those who are older, and we also anticipate that a larger proportion of older adults own smartphones with older operating systems compared with younger people.

Having adequate user guidance is a factor that can affect both the uptake of and engagement with health and wellbeing apps. For example, understanding QR codes is a requirement for checking into venues using the NHS COVID-19 app. Anecdotal user reports during the piloting phase of the app in Newham, London, suggested that many people didn’t understand how to use QR codes. It is therefore important to provide easy to understand instructions for how to use track and trace apps.

Another perhaps obvious but no less crucial factor is app awareness. Although we live in a world where information can travel fast, advertisements and media reports won’t reach everyone. When it comes to the NHS COVID-19 app, there has been an intensive mass media campaign to raise awareness, which means that many people would have heard about the app. However, the reliance on digital platforms for spreading information about the app might have excluded key groups who typically have low engagement in the online world. As people tend to forget information rapidly, it’s important that efforts to raise app awareness are sustained over time.

The perceived utility of the app was another key factor identified in our review. This includes providing a clear description of what the app does, what it can offer to the user and how it can help the user achieve their goals. One challenge with the NHS COVID-19 app is that its use generally benefits others rather than oneself. Some negative reviews on the app stores have highlighted this. In terms of detailing what the app does, the description clearly describes the features included. In our interview study, we found that highlighting the benefits of the app early on may prompt uptake. For instance, it might be useful to have the message ‘Protect your loved ones. Please download the app’ appear at the start of the app description as opposed to at the end.

Data protection is also an important factor. While the privacy policy for the app is well described, it is not that easy to get to. It is also very important to explain in non-technical language how the anonymity of the users is assured, which is likely to be a barrier to uptake and reduce trust. This has not been helped by the government’s refusal to make the findings of the pilot study public, which has led the Health Foundation to call for greater transparency.

Emotions may also play a role in app uptake. Our review found that curiosity, such as people seeing promotions of the app and feeling curious about trying it, may prompt them to download it. Anxiety was found in our interview study as another reason why individuals may want to use a health app, with the perceived threat of COVID-19 to one’s health or the health of others is a good example of this.

In sum, to maximise the uptake of the NHS COVID-19 track and trace app, evidence from behavioural science suggests the following:

• provide practical support either for enhancing app literacy skills or by providing user guidance
• ensure sustained promotion of the app through multiple channels simultanouesly (i.e., social and digital media, celebrities and influencers, primary care)
• facilitate the experience of relevant emotions when people hear about the app
• highlight the benefits of the app
• ensure transparency about data protection
• explain how anonymity is maintained using non-technical language

Bio:

Felix (@FelixNaughton) is a Health Psychologist and a Senior Lecturer in Health Psychology within the School of Health Sciences, University of East Anglia. He has a key interest in the development and evaluation of mobile phone interventions to promote and support health behaviour change (mHealth), particularly those promoting smoking cessation. He is also the co-lead of the COVID-19 Health Behaviour and Wellbeing Daily Tracker study https://www.uea.ac.uk/groups-and-centres/addiction-research-group/c19-wellbeing-study

Dorothy (@DorothySzinay) is a final year PhD candidate at the at the School of Health Sciences, University of East Anglia. Her research focuses on developing ways to increase the uptake of and engagement with health and wellbeing smartphone apps.