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 Table of Contents  
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 5-10

Combating New Challenge in Coronavirus Disease-2019 Management: Assessment of Factors Affecting Testing Refusal

Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission12-Jan-2021
Date of Decision06-Feb-2021
Date of Acceptance08-Feb-2021
Date of Web Publication01-Apr-2022

Correspondence Address:
Dr. Arun Kumar Yadav
Associate Professor, Department of Community Medicine, Armed Forces Medical College, Pune-411040, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_9_21

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Background: The coronavirus disease-2019 (COVID-19) pandemic has introduced new ethical challenges in the care of patients and people who may have been exposed to severe acute respiratory syndrome coronavirus-2 or have mild to moderate COVID-19. Refusal to get tested for COVID-19 and having poor adherence to infection prevention protocols are the areas of concern for the ongoing pandemic. Such situations increase the risk of infection to other patients and staff. The factors affecting testing refusal were studied with the help of the Google questionnaire. Methodology: The cross-sectional survey tool was developed and distributed after pilot testing. The study population was selected using mix sampling method, snowball, and random sampling using the mobile number of the participants. All the participants were informed about the purpose of the study and included after taking consent. Results: Of the 176 study participants, the majority were male (112, 63.6%), with a mean age of 37.2 years (standard deviation 10.4). Forty-one (23.3%) were health-care workers and 74 (42.1%) were private company employees. Seventy-one (40.3%) refused to get tested for COVID-19 when asked whether they will get tested in the presence of any COVID-19 symptoms and 81 (46.8%) refused to get tested in the absence of any symptoms. Conclusion: Health policy-makers should utilize the study results to formulate the policy regarding any future pandemic to reduce the level of stigma associated with an unknown disease. These clarifications and excuses asked to the study participants are meant to provide a deeper understanding to address the pandemic better.

Keywords: Coronavirus, coronavirus disease-2019, pandemic, severe acute respiratory syndrome coronavirus-2

How to cite this article:
Kansara N, Kumar S, Yadav AK. Combating New Challenge in Coronavirus Disease-2019 Management: Assessment of Factors Affecting Testing Refusal. J Mar Med Soc 2022;24, Suppl S1:5-10

How to cite this URL:
Kansara N, Kumar S, Yadav AK. Combating New Challenge in Coronavirus Disease-2019 Management: Assessment of Factors Affecting Testing Refusal. J Mar Med Soc [serial online] 2022 [cited 2022 Dec 1];24, Suppl S1:5-10. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/5/342391

  Introduction Top

The world is witnessing a pandemic of unprecedented scale; the strategy to combat the pandemic of coronavirus disease-2019 (COVID-19) has evolved along the lines of a pandemic. However, testing of the susceptible individuals for the diagnosis of COVID-19 remains the single most important strategy to measure and contain the spread in any geographical area. Escalation of testing, isolation, and contact tracing is identified as the core elements of the pandemic management.[1] In an effort to contain the pandemic, the countries worldwide have invested heavily to increase the testing capacity. The WHO is leading global partnerships to aid low- and middle-income countries in upscaling the testing facilities.[2],[3]

Reverse transcription polymerase chain reaction testing for COVID-19 is the key aspect of contact tracing, and it is the only mode to reveal whether the flu-like symptoms is due to influenza or severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Not only testing but also positivity rate is equally important, as a positivity rate of more than 5%, is considered as greater community transmission.[4] Mitigation of the spread of SARS-Cov-2 in the cities, regions, states, and countries can only be done by the acceptance of physical distancing norms and wearing masks with or without government's legal enforcement.[5] The consequences of testing positive for COVID-19 may discourage some people from testing. If tested positive for COVID-19, then it implies that individuals cannot leave their homes due to quarantine, cannot return to their work, or spend time with their families. After a COVID-19 outbreak in March 2020, when pandemic hit cruise ship Grand Princess, travelers were quarantined at a California military base and when diagnostic testing was offered for COVID-19, 568 (66%) of 858 passengers denied to get themselves tested.[6] Rendering to news reports, some travelers feared that undertaking testing or getting positive results could extend their quarantine period and postpone their chances to return home.

People might refuse COVID-19 testing due to fear of receiving infection if they have to travel for testing. People might concern about the discomfort caused due to the collection of specimen (e.g., nasopharyngeal/oropharyngeal swabbing). Distrust upon the government may be also one of the causes for refusal to get tested. The unknown factors about the disease create myths, rumors, and fear among the people, which subsequently nurtures the social stigma.[7] It is always essential for any ministry to communicate the well-structured criteria for COVID-19 testing, a majority of people may not aware about the fact that whether their symptoms or lack of symptoms make them suitable for testing or not.[8] Testing for high-risk contacts, symptomatic individuals, and travelers is being done by multiple government agencies. The present testing strategy is witnessing a new challenge in the form of testing refusal by the individuals.[9] The government of India has enforced the Epidemic Act 1897 and the Disaster Management Act 2005 to ensure cooperation from the general public.[10] The states have to adopt legal means to get the test done for such individuals.[11] However, these intimidating measures are at conflict with medical ethics, particularly the patient autonomy. Therefore, we need to have a rational approach to overcome the challenge of testing refusal.

The first step to adopt the rationale approach is to identify the reasons for testing refusal. This study attempts to find out the factors affecting the test-seeking behavior of the individuals and suggest appropriate practical solutions to mitigate testing refusal.

  Methodology Top

The present study was conducted using a cross-sectional study design. The data collection tool was developed by the authors and pretested on 20 participants, which were later excluded from the analysis. The questionnaire was suitably modified after the pilot testing. Considering the need for physical distancing and to reach a wider population, the questionnaire used was converted to Google form and the link was sent to all the participants on their E-mails or mobile phone. The questionnaire used was bilingual, in Hindi as well as English. The participants were requested to complete the questionnaire after reading the information sheet sent along with the questionnaire. To reduce the chances of missing data due to incomplete filling of the questionnaire, all the questions were marked as mandatory. Moreover, the questionnaire was kept concise to reduce the time used to complete the same.

The study population was randomly selected. The sampling technique used was a mix of snowball and random sampling using the mobile number of participants. Random number table was used to generate a three-digit random number. This three-digit random number generated was looked for in the mobile contacts of the authors, the first person appearing on the contact list using this three-digit number was chosen as the participant. Afterward, every participant was given a three-digit random number, and similarly, they were asked to choose a contact of theirs. This was continued till the sample size was reached.

All the participants were duly informed about the purpose of the study and were included in the study after they consented. Ethical clearance was obtained from the Institutional Ethical Committee. The data were collated in MS Excel. Descriptive statistics were conducted to create the summary tables for variables, and cross-tabulation analysis was performed using the Chi-square tests to examine the distribution of characteristics of COVID-19 testing behavior with respondents' sociodemographic characteristics. The data were analyzed using StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX, USA: StataCorp LLC. P < 0.05 was considered as statistically significant.

  Results Top

The present study was conducted between 21 October 2020 and 20 November 2020. Of the 176 participants, majority were male (112, 63.6%). The mean age of the study participants was 37.2 with the standard deviation of 10.4. Of the 176 participants, 41 (23.3%) were health-care workers. Majority of the study participants were private company employee (74, 42.1%) and 22 (12.5%) were unemployed. Majority of the study participants had educational qualification as postgraduate and above (86, 48.9). Of 176 study participants, 54 (31.2%) did not have stable income during the pandemic and 29 (16.5%) had ailments in any form. 36 (20.5%) participants were tested for COVID-19 in this study [Table 1].
Table 1: Sociodemographic characteristics of the participants

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When study participants were asked “If you have any of the symptoms which you think are due to COVID-19 would you get yourself tested?,” 71 (40.3%) participants refused to get tested for COVID-19. Furthermore, when asked “will you get tested if you don't have symptoms but told by someone?,” 81 (46.8%) participants refused for COVID-19 testing.

[Table 2] shows common misconceptions with COVID-19 testing and their relationship with demographic variables. When the study participants were asked about getting admission to the hospital against wish, the majority denied getting admitted (89, 50.56%). Majority of them was male (56, 62.9%). When asked about the fear of losing job, total 22 (12.5%) out of 176 participants replied as “Yes/Maybe” and the majority of them were < 30 years of age-group. When asked about the behavior change of their friends/relatives after their positive COVID-19 status 91 (51.7%) replied as “Yes/Maybe.” 24 (13.6%) participants replied as “Yes,” when asked about workplace discrimination, and 17 (9.7%) had fear of isolation.
Table 2: Common misconceptions with COVID-19 testing and their demographic transition

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Of 176 study participants, 18 (10.22%) would blame others for their positive COVID-19 status and when asked, “If you are tested negative, will you still wear a mask while going out of your house?” the majority of the participants' reply was “Yes” (172, 97.7%). Moreover, when asked about social distancing, a similar trend was seen (170, 96.6%).

[Figure 1] shows the attitude toward COVID-19 testing. Likert scale was used to assess the attitude toward COVID-19 testing in various scenarios. The study participants were asked whether they will go to a COVID testing facility even if they have no symptoms because they want to be reassured that their practice of wearing a mask, social distancing, and hand hygiene are keeping them from being infected, 81 (46%) participants disagreed/strongly disagreed. When they were asked that they will go to a COVID testing facility to set a good example for others, 103 (58.52%) disagreed/strongly disagreed the fact. When the study participants asked about whether they will go to a COVID testing facility even if they have no symptoms for their peace of mind that they are COVID-free, 97 (55.11%) were disagree/strongly disagree. Only 36 (20.45%) agreed/strongly agreed regarding the fact that they will report for COVID-19 testing just to be sure that they do not have the disease even if there are no symptoms present. One hundred and twenty-three (69.88%) disagreed/strongly disagreed when asked that they will report for COVID-19 testing as it is free without any presence of symptoms.
Figure 1: Attitude towards coronavirus disease-2019 testing

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  Discussion Top

Our study has revealed the factors associated with the unwillingness to undergo COVID-19 testing. Responses suggested that common misconceptions associated with COVID-19 testing were alteration in the behavior of their friends/relatives followed by admission in the hospital against wish, workplace discrimination, fear of isolation, and losing a job. In the study conducted by McGowan et al. in Bangladesh, the top most cited reason was fear among the population followed by not believing in the COVID-19 disease.[12]

Patient autonomy, a key pillar of medical ethics, is overridden by competing interests in exceptional circumstances like in the case of COVID-19 where protecting others from communicable disease is the public interest.[9] Policy-makers should develop safety guidelines that should protect the autonomy of the patients. SARS-CoV-2 is considered as a serious contagious disease and many countries have enforced various public health acts. In the context of the risks due to COVID-19 to others, untested individuals are treated and considered as if they are infected with COVID-19.

Health-care workers are frequently being tested for SARS-CoV-2 to lessen risks of nosocomial infection and to appraise the need for isolation.[13] Patients and staff should not be differentiated but as per the contact tracing policy and guidelines by NCDC, high-risk contacts were also tested irrespective of presence or absence of symptoms.[14] Our study results reveal that 16 (9.09%) study participants were afraid that their job will be lost after their positive COVID-19 status. The cascading effects of nationwide lockdown are seen on the economy as well as the health of India.[15] In addition, it was observed that lockdown measures affected approximately 400 million informal workers, who are the poorest and most marginalized members of society and having the least socioeconomic volume to fight the pandemic without labor and income. Finally, it leads to profound poverty and starvation.[16]

In the present study, males were afraid of job loss more than females due to COVID-19 testing. Women's capacity to resist economic losses is less than their male counterparts. In the UK, the report showed that mothers were 1.5 times more likely than fathers to have lost or quit their jobs within the quarantine period,[17] This fact showed that lockdown measures can be considered unsuccessful because of its undesirable social implications and aggravation of health inequalities. That's why it is worth noticing that lockdown measures taken were political as well as economical emergencies.[18]

Epidemiologic evidence has confirmed that presymptomatic and asymptomatic carriers can transmit the virus, and this fact has driven the current pandemic.[19],[20] High rates of household transmission were seen among the family members, where there is the inadequate wearing of masks and social distancing is followed. It has been documented in a study that 382 children were exposed to SARS-CoV-2, of whom 76% became infected. To control an ongoing pandemic, testing is the only answer to identify as many people who are spreading infection as swiftly as possible, so they can be isolated and their contacts can be identified and quarantined.

To address the stigma associated with COVID-19 testing, our collective efforts should be centralized toward multi-disciplinary research and policy efforts. These study results are aimed to explore stigma associated with COVID-19 testing and to suggest sufficient and effective interventions with the common consensus of researchers, clinicians, and policy-makers rather than focusing on individual.[21]


The study has given an insight into the factors associated with COVID-19 testing refusal in India. The main limitation of the study is sampling size, so the study results cannot be generalized. Even because of the sampling method underprivileged population of India may not have been able to participate in the study. However, the present study has given the results due to the normal human tendency to react toward COVID-19 pandemic which is usually expected due to unknown disease.

  Conclusion Top

This study tried to view factors associated with COVID-19 testing refusal of the people of India. The perspective toward COVID-19 testing seen among the study participants is rational, even when they appear otherwise. They are shaped by the goals and needs of the individual, whether this is to avoid fear, anxiety or to live by important life values. Although maximum factors were tried to get evaluated by a questionnaire, there are many other forms of psychological explanation that can be used to address these particular reasons for refusal toward testing. These explanations are meant to deliver a more significant hypothetical concept to a subjective topic to address the ongoing pandemic better. There is an urgent felt need to explore these human psychological changes with qualitative and quantitative studies for a better understanding of the behavioral changes which are specific to ongoing COVID-19 pandemic. These results can direct us to better formulate the policies and help us to prepare better for future similar pandemics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Global Partnership to Make Available 120 Million Affordable, Quality COVID-19 Rapid Tests for Low- and Middle-Income Countries. Available from: https://www.who.int/news/item/28-09-2020-global-partnership-to-make-available-120-million-affordable-quality-covid-19-rapid-tests-for-low--and-middle-income-countries. [Last accessed on 2021 Jan 08].  Back to cited text no. 2
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  [Figure 1]

  [Table 1], [Table 2]


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