Mixed‐methods exploration of views on choice in a university asymptomatic COVID‐19 testing programme

Abstract Asymptomatic COVID‐19 testing programmes are being introduced in higher education institutions, but stakeholder views regarding the acceptability of mandating or incentivizing participation remain little understood. A mixed‐method study (semi‐structured interviews and a survey including open and closed questions) was undertaken in a case study university with a student testing programme. Survey data were analysed descriptively; analysis for interviews was based on the framework method. Two hundred and thirty‐nine people participated in the study: 213 in the survey (189 students, 24 staff), and 26 in interviews (19 students, 7 staff). There was majority (62%) but not universal support for voluntary participation, with a range of concerns expressed about the potentially negative effects of mandating testing. Those who supported mandatory testing tended to do so on the grounds that it would protect others. There was also majority (64%) opposition to penalties for refusing to test. Views on restricting access to face‐to‐face teaching for non‐participants were polarized. Three‐quarters (75%) supported incentives, though there were some concerns about effectiveness and unintended consequences. Participants emphasized the importance of communication about the potential benefits of testing. Preserving the voluntariness of participation in student asymptomatic testing programmes is likely to be the most ethically sound policy unless circumstances change.

controversial public health powers'. 7 An important feature of the response to COVID-19 has been the introduction of mass testing of asymptomatic individuals, with subsequent isolation of individuals who test positive (and their close contacts). This has been implemented in a range of settings in the UK and elsewhere, but has been controversial. Some of the criticism has focused on questions about the effectiveness of mass testing in reducing COVID-19 transmission, 8 linked to lack of supporting evidence. 9 Others have raised concerns relating to cost 10 and the potential harms associated with false negatives. 11 In higher education settings, where testing has been introduced on a large scale, several of these concerns have been raised specifically. 12 Recent UK Government guidance suggests that higher education institutions can consider incentives for compliance, and disincentives for non-compliance, to enforce COVID-19 public health measures. 13 There is, however, limited evidence about the views of students or staff on these measures. The need for a participatory approach has been emphasized in recent work in empirical ethics, according to which empirical methods can be integrated with ethical analysis to address normative issues. 14 Explicit consideration of how stakeholders might help to guide the development of public health interventions has also been highlighted in a number of public health ethical frameworks. 15 In this context, the need for research into stakeholder views on normative issues relating to asymptomatic COVID-19 testing programmes in higher education institutions-such as the ethical acceptability of different policies to encourage participation-is clear.
In this paper, we report a study of the views of staff and students on choice relating to participation in a student testing programme at a case study university. We sought to examine in particular the acceptability of mandating participation in testing programmes, and the extent to which options that stop short of mandating, such as incentives or penalties, might be seen as legitimate.

| METHODS
The data presented here were collected as part of a wider project on the ethical issues in asymptomatic testing programmes for students in higher education. 16

| Study context
The case-study institution, the University of Cambridge, introduced a programme involving weekly asymptomatic pooled COVID-19 testing of students in October 2020. It is a collegiate university, made up of 31 colleges, which are separate institutions affiliated with the university. The colleges are responsible for providing students with accommodation and catering facilities, and academic and pastoral support. Testing was offered to all students living in college-owned accommodation in October 2020. Its programme was based on obtaining nasal swabs, which were tested by polymerase chain reaction (PCR) in university laboratories. Testing was based around 'households' (typically consisting of 8-10 students, often arranged around a shared kitchen or bathroom), with nasal swabs from individual students all being tested in a pool. If a pooled sample tested positive, students within the household were asked to isolate immediately.
Confirmatory individual testing by PCR then took place. If any of the students within the household tested positive on this confirmatory testing, all in the household were required to isolate for 14 days.
At the time of our study, the testing programme was available to all students living in college-owned accommodation and participation was voluntary for individual students; there was no incentivization or penalization surrounding participation in the testing programme. It is F I G U R E 1 The intervention ladder, reproduced with permission from the Nuffield Council of Bioethics report 16  important to note that this study took place before COVID-19 vaccination was widely available, and the results should be interpreted in this context.

| Study design and data collection
The study used a mixed-method approach (semi-structured interviews and an online survey including Likert-scale and open-ended questions) to gather views of students and staff. We began by developing a provisional ethical framework, drawing on a previously developed example in the area of testing of healthcare staff, 17 and a review of relevant literatures on public health, ethics and screening.
This guided the development of our study instruments and initial analysis of the findings.
We used mass emailing lists to invite students (undergraduate and postgraduate) to participate. Staff (both academic and nonacademic) were invited, also using email, by the colleges in which they worked. Eligible participants were over 18 years old, able to understand and speak English, and were either currently registered University of Cambridge students (any subject or year of study) or a member of staff currently employed by the University of Cambridge or a college.
Emails included full details of the project and an explanation of how to take part. Interested people were asked to register on Thiscovery (https://www.thiscovery.org/about), an online research and development platform created and developed by THIS Institute at the University of Cambridge. They were able to choose to participate in an interview or complete an online survey. All participants provided consent prior to the interview or survey.
Data were collected over a single period running from November 20 to December 11, 2020. The survey was administered using Qualtrics (Supporting Information Appendix S1), and took approximately 15 min to complete. It contained a mixture of closed, open and Likert-scale questions. An initial version of the survey was developed and piloted with 10 students in order to refine the questions.
Only minor changes were made after piloting, which involved altering the wording of questions to make them more understandable to participants.
Semi-structured interviews took place either online using audio-video software or by telephone. Interviews lasted 30-60 min and were conducted using a prompt guide (Supporting Information Appendix S2). The prompt guide was refined through pilot interviews with three students; as with the survey, the main changes that were made after piloting were minor. They concerned the phrasing of questions to enhance clarity and the order of questions to enhance the flow of the interviews. The interviews were transcribed verbatim.
We did not undertake a formal test for theoretical saturation; we instead used the principle of 'information power', which indicated that we have achieved sufficient range and depth of views. 18

| Data analysis
The quantitative closed-ended survey questions were analysed using descriptive statistics, and Likert-scale questions were visualized using diverging stacked bar charts. Our analysis approach for the open-ended survey responses and interview data was broadly based on the framework method. This method allowed multiple analysts to scrutinize the data, comparing views of participants to identify commonalities and divergences.
After familiarizing themselves with the data, two analysts independently coded the first three interview transcripts deductively, using pre-defined codes based on the provisional ethical framework. A group of researchers then scrutinized the work of the two analysts to agree on a set of codes to apply to all transcripts, including an 'other' code to host data that did not fit any of the pre-defined codes. A matrix was then produced by applying this coding framework to all transcripts, in which quotes were organized into codes and copied into an Excel spreadsheet.
A summary was then written for each code, including references to interesting or illustrative quotes. Free-text responses to survey questions were analysed in a similar manner, with the production of a separate matrix and coding summaries for these data.
We integrated the three data types-interview, survey openquestion responses and survey closed question responses-at the interpretation stage of analysis. 19 We discussed patterns arising across our analyses of the three types of data through an iterative process that involved examining all the data for themes, and considering convergence or divergence between sources. Insights from interviews and the survey were given equal priority in the interpretation.

| RESULTS
A total of 239 stakeholders participated in the study: 189 students and 24 staff completed surveys; 19 students and seven staff participated in semi-structured interviews (Table 1). Overall, the interview and survey data did not significantly diverge in their findings, and the results below reflect insights from both datasets.
We present our integrated findings under three themes: views on voluntariness of student participation in the testing programme, 17 THIS Institute. (2020). Testing times: An ethical framework and practical recommendations for COVID-19 testing for NHS workers.

| Views on voluntariness of participation in the student testing programme
Just under two-thirds of survey respondents agreed (40% agreed, 22% strongly agreed) with the statement that asymptomatic testing should be voluntary at the level of the individual student (Table 2).
In both free-text survey responses and interviews, participants who supported voluntary testing cited reasons such as respect for personal liberty and individual choice. This was particularly true for those who conceptualized testing as a medical intervention involving a physically invasive test, one over which individuals should retain the right to choose. In these accounts, preserving individual choice was presented as the predominant ethical consideration. Even when participants strongly supported the view that students should participate in testingfor reasons such as protecting others in the community-some felt that it should still be up to the individual to decide.
Accepting a COVID test involves a physical process of taking swabs, meaning that it is extremely important that each student has the right to consent or decline consent to take part.   My understanding of the legal position here is that you cannot request it in order to be a student, but we could potentially request it both as a landlord and in safeguarding our staff. So, yeah, I would love to make it compulsory, but I think that would be a whole different kettle of fish in trying to enforce that. (I_16_staff) Participants identified potential negative effects of making testing mandatory, for example the potential to change the character of the programme and produce hostility or resentment, even among students who were happy to voluntarily take part.
The principle that students should still be able make a choice, Incentives were seen as more acceptable than penalties: most survey respondents supported their use (42% agreed, 33% strongly agreed; Table 2). In interviews, both staff and students saw small incentives (such as a free coffee) as acceptable. Distinctions were sometimes drawn between the use of small and large incentives; small incentives were seen as more acceptable.
Some strongly welcomed incentives on the grounds of encouraging uptake and also 'thanking' participants for participating in the testing programme (which was conceptualized as an essentially altruistic act).
[I]t's just as a means of acknowledgement or saying that this is something that matters. So making people feel that they're… taking part and their contribution is very much welcomed… It doesn't even need to be a cup of coffee, to be honest, it could be like one sweet, I think, or something like that.
Thanking somebody for an altruistic act is absolutely fine. I don't think large bribes, so I don't think large amounts of funding would be appropriate, but I think a small gift as a thank you is similar to when I give blood. I get a biscuit and a cup of tea. That seems entirely fine and I don't consider that a bribe.

(I_26_staff)
A minority of survey respondents (12%) opposed the use of incentives. Interview and survey free-text data provided insight as to why: some suggested that small incentives might not be very effective in increasing uptake, particularly in students who already had concerns about the programme, and some had concerns that incentives might undermine choice and quality of consent.
Personally, I think that things like a free coffee… would not change most students' opinions who were on the cusp of trying to work out whether or not to do it or not.
I have a hard time agreeing with incentivising students to give consent to the asymptomatic testing because one can then question whether it is truly a consent.
Others described how offering incentives that might be perceived as menial could damage the programme by sending the wrong message about its value and trivialize its importance; instead, students might be more motivated by a desire to act for the good of the community than for a small tangible reward. Necessity-in this case the extent to which a mandatory approach is needed-is also a relevant consideration. According to the principle of the least restrictive means, restrictive measures should only be used where less restrictive means have failed to achieve appropriate ends. 25 This means that policy-makers should not only consider whether a coercive approach is likely to be effective, but also whether it is essentially required. As Childress et al. note, the burden of moral proof lies with proponents of a forcible strategy: they must be able to justify the need for a coercive model above a voluntary one. 26 We found widespread support for the testing programme-99% of survey respondents supported or strongly supported it. 27 Furthermore, at the time of our study, participation in the programme was persistently >75% for eligible students. 28 In this context, it is questionable whether a more restrictive approach is truly necessary for a student asymptomatic testing programme to reach its goal of mini- For participants in our study, being able to choose to do good-rather than being forced, either through the programme being mandated or through threat of punishment-was an important form of respect for their moral agency. In a different but nonetheless relevant context, Brownsword worries that being denied the opportunity to choose to be good may undermine the conditions required for moral community, arguing that the opportunity to lead an authentic moral life takes us to the essence of human dignity. 33 In a similar vein, Buchanan writes, '[o]ther things being equal, a society in which people choose to behave responsibly, rather than being forced against their will… is inherently more desirable'. 34 Opposition to incentives was to some extent similarly grounded in their symbolic status: although the majority of participants supported their use, some worried they could potentially undermine the solidarity-based values of the programme and encourage participation for the wrong reasons. Such views are in keeping with a broader conceptualization of participating in testing as an altruistic endeavour, which is intrinsically valuable for its contributions to public health and does not demand additional remuneration. Sandel has written about the potentially corrupting influence on valuable social norms of incentivizing previously non-monetized practices. 35 The corrosive diminishment of value associated with incentivizing health behaviours has been criticized for its lack of supporting empirical evidence. 36 Although the data we present here are limited, they do provide some support for the idea that incentives might be reasonably opposed on the basis that they may corrupt a contribution with social, rather than monetary value. It is, however, worth considering the difference between a small token, such as a free coffee (which might be viewed as a 'thank you' for participation) and large financial incentives: in our study, some participants explicitly stated that small incentives would be more acceptable than large ones.
It is important not to over-simplify the views that participants in other. The programme we studied used nasal swab-based PCR testing and was based on a pooled testing approach, so the generalizability of our data to programmes using other technologies (e.g. lateral flow tests) is unclear. Potential issues with recruitment and sampling (e.g. bias in the stakeholders who engaged with the study) must be considered; we were unable to assess patterns of nonresponse to our study, and it is possible that our findings are not representative of the views of all students and staff. Differences in the number of participants in student versus staff subgroups precluded statistical analysis for significant differences in their views in the quantitative data. Our study would benefit from replication across a wider variety of student populations in other higher education populations, in particular to clarify the generalizability of our findings.

| CONCLUSION
This study provides empirical support for the principle of the least restrictive means in the context of encouraging participation in an asymptomatic student COVID-19 testing programme: the use of policies that support choice (such as providing information about the testing programme and supporting evidence) should be used in preference to those that restrict choice (such as making participation mandatory or penalizing those who do not participate).
Education and communication that outlines potential community benefits to testing and emphasizes solidarity, while enabling choice and respecting students as moral agents, may be the most optimal strategy for an effective and ethically sound asymptomatic student COVID-19 testing programme. Further evaluation of these con-

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The study instruments (interview guide and questionnaire) are available: This project contains the following files: • Supporting Information Appendix S1-Survey.
Owing to the conditions of the ethical approval for the project, the raw data (transcripts and survey responses) are not available for deposit. This is owing to the sensitive nature of the responses, including their possible political nature, and concerns that it would be difficult to completely de-identify participants (who often gave extensive and specific details about their college and own circumstances in answering questions).
Any requests for access to or use of the data should be made to director@thisinstitute.cam.ac.uk. Access to fully anonymized data for suitable purposes may be granted to bona fide researchers under a data sharing agreement, but must be approved by the relevant ethics committee.