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Exploring the psychosocial consequences of mandatory quarantine during the COVID-19 pandemic in Hong Kong

Disclaimer

This article is part of a research project for which I received full ethical approval. The findings herein are the voices of 150 Hong Kong residents who took part in this study, all of whom gave their full consent. As a qualitative researcher, one is supposed to bracket one’s own personal opinion so as not to bias the findings. This I tried to do. But to be honest, I found this very difficult to do. And so, if I have not included or misinterpreted some of the voices, I apologise, it was my full intention to keep to the narrative of the respondents as they gave them. In this report, I offer you my interpretation of 150 surveys and 14 interviews on the psychosocial consequences of mandatory quarantine in Hong Kong.

 Introduction

Until quite recently, quarantine was considered anachronistic, a measure used in previous eras to contain the spread of diseases.  Although often used interchangeably, quarantine and isolation are actually different terms. Quarantine refers to separating and restricting the movement of people who have potentially been exposed to a contagious disease to ascertain if they become unwell, in order to reduce the risk of transmission to others. Isolation, however, is used for contagious individuals that require separation from those who are not infected. The COVID-19 pandemic has resulted in governments implementing disease containment measures such as school closures, social distancing, and quarantine measures.

While we receive regular information and statistics on the number of COVID-19 cases, deaths and whether the cases are local or imported, little is known of the psychosocial consequences of those in quarantine in Hong Kong. Previous research has found that those undergoing quarantine are at an increased risk of negative psychosocial outcomes such as Post Traumatic Stress Disorder (PTSD), depression and anxiety; many of which can be long-lasting [1, 2]. Other studies identified a range of psychological consequences of quarantine including anger, fear, grief, numbness, confusion and insomnia, with increased quarantine duration correlating positively to higher levels of adverse mental health issues. This has led researchers suggesting that policy makers should perhaps consider voluntary quarantine, emphasising altruistic reasons for self-isolating, arguing that having a sense of altruism could mitigate the mental health consequences of quarantine.

Hong Kong has not experienced the mass lockdowns that have taken place in other countries during the COVID-19 pandemic, however there are mandatory measures in place for those that test positive and for those deemed to be ‘risky’. Anyone that tests positive for COVID-19 is isolated in a government hospital (even if asymptomatic), while for those ‘close contacts’, it is mandatory to enter government quarantine facilities for 14-days. Furthermore, mandatory quarantine measures for returning residents have become increasingly draconian; from 14 days home quarantine legislated from mid-March 2020, to 14 days mandatory hotel quarantine in October 2020, to the current Designated Quarantine Hotel Scheme which mandates that, aside from residents returning from China, Taiwan and Macao, all other inbound residents are required to undergo 21 days mandatory quarantine at designated quarantine hotels [3]. This is despite the fact the World Health Organisation [4] recommends 14-days quarantine from last exposure to a confirmed case, based upon research showing that the incubation period of COVID-19 is on average 5-6 days (although could be as long as 14-days). [5]

Without a doubt, Hong Kong has managed to keep the numbers of COVID-19 cases low, not an easy feat in such a densely populated city. In fact at the time of writing, there have been 11,727 people that have tested positive for COVID-19, of which 11 325 have recovered and 209 deaths have been recorded. What is interesting is to put this into perspective and compare the number of deaths from COVID-19 with influenza-related deaths from previous years, eg. for the 2018/19 influenza season there were 356 influenza related deaths. [6]

Following the severe acute respiratory syndrome (SARS) coronavirus epidemic in 2003 (which most Hong Kong residents remember well), researchers developed a framework of values and principles, outlining the importance of a bioethical input in decision-making during pandemics. [7]  A number of countries e.g. New Zealand, developed their own framework which formed the basis of their response to COVID-19 (see Table 1).

Table 1. Ethical framework to guide decision-making during pandemics. Adapted from [8]

Ethical Value Associated Actions
Inclusiveness To include those who will be affected by the decision, taking into account people from all cultures and communities, taking all stakeholders contributions seriously and aiming for acceptance of an agreed decision-making process.
Openness and Transparency Decisions should be open to scrutiny and the basis for decisions is explained. Information should be effectively disseminated to all stakeholders and these parties should be clearly informed where to go for further communication
Reasonableness Decisions are based on evidence, principles, and values that are agreed upon and made by those who are credible and accountable.
Responsiveness Decisions should be revisited and revised as new information emerges. Stakeholders should be given opportunities to voice concerns about decisions.
Accountability Ensure mechanisms are in place to guarantee that ethical decision-making is sustained.

Similarly, WHO guidelines suggest that before governments implement quarantine, they should communicate why this measure is needed, provide clear, up-to-date and consistent guidance about quarantine measures and constructive engagement with communities if these measures are to be accepted. The WHO Director-General stated that “all countries must strike a fine balance between protecting health, preventing economic and social disruption, and respecting human rights” [9]   Alas, anecdotal accounts from both print and social media on the impact that mandatory quarantine is having on HK residents, suggests a lack of common sense, compassion and humanity in dealing with quarantine measures [10-12].  While these measures may have been successful in keeping the numbers of COVID cases low, the psychosocial consequences of mandatory quarantine in Hong Kong has not been explored. It was for this reason that I decided to conduct a research study.

RESEARCH FINDINGS

Effects of quarantine on overall mental wellbeing

Effects of quarantine on general health

Effects of quarantine on sleep

 Word Cloud illustrating respondents’ experiences of quarantine (most frequently used words are depicted bolder and bigger)

As expected in qualitative research, existing political ideologies and individual differences resulted in different opinions and experiences, from those who believe that COVID-19 is merely a conspiracy theory, to those who feel that mandatory quarantine is a social responsibility. Survey responses and interviews suggest that those quarantining at home fared better than those in hotels, government quarantine or isolated in hospital; with those that quarantined for 21-day experiencing the greatest negative effects. Overall though, it was the lack of reasonableness, inclusivity, openness and transparency that seemed to cause most of the adverse mental health outcomes.

Reasonableness:

The ethical value framework above suggest that decisions should be based on evidence, principles, and values that are agreed upon by all stakeholders [8].  While most of the respondents supported the need for quarantine measures to reduce the spread of COVID-19, there was an unanimous agreement that 21-days hotel quarantine was unreasonable.

This was clear from the survey responses:

  • I don’t mind having to quarantine to protect the city and it think it’s effective but the third week is just cruel and unnecessary.
  • Quarantine is reasonable, however, given virus incubation period, 21 days hotel quarantine is unnecessary, it’s not only a waste of money, time and is a huge mental challenge.

 A number of respondents were more vocal in their survey responses:

  • …lock people up for 21 days with no scientific basis. It is heinous and likely a violation of the Basic Law
  • 21 days is unnecessary and not supported by data
  • 21 days in a hotel is inhumane

This sentiment was echoed by most of those interviewed, with one interviewee questioning the need for quarantine after being tested negative…  “I felt really felt angry… we tested negative, we have no symptoms, why are we being locked up? What are they achieving by doing this? Who are they protecting?”  Concerns that these ‘draconian’ measures  are “not connected to real science” have left them feeling fearful, with many questioning their future in Hong Kong.

Overwhelming, home quarantine was what most respondents felt was a reasonable measure during the COVID-19 pandemic. Some respondents opted to stay at a hotel rather than put their families at risk, but it was this autonomous decision-making process that mitigated adverse mental health issues. Several of those that quarantined at home stated categorically that they would not mentally cope with hotel quarantine or hospitalisation, while for many, quarantining at home, in a familiar space, gave them the opportunity to do chores and  relax without guilt.

Home quarantine is still the best especially for people who have a home and are living alone.. I’ve been on unpaid leave and paying for a hotel is really not helping the financial aspect.

Yeah, I think that things have got stricter and as a result, quarantine now is something to be almost feared. Whereas when I was doing it, I felt it was my responsibility as a parent. As a citizen coming back from Hong Kong. So I felt that there was more freedom over what I chose to do as well.

Although only a few respondents in this study underwent quarantine in the government quarantine camps, the experience was “hellish” for many [12], with reports of children as young as 2 years old being separated from their families. These stringent measures are bound to have adverse effects on mental health as previous research has suggested [1].  Moreover, the hospital experience of one interviewee left them traumatised“ I just can’t imagine going through that again…One thing I could do is I could quarantine at home. But just don’t lock me up again. You know, I haven’t been bad. I haven’t done anything wrong. I don’t deserve to be in a prison. You know, I feel I deserve humanity. I deserve care…..”

When asked what measures they felt would be helpful to minimise the risk of transmission, while minimising mental health issues, the majority of responses incorporated mask wearing, hand sanitising and social distancing measures as reasonable:

Mask wearing (HKers good at this) Every other seat made unavailable on public transport and no standing allowed (HK govt has deliberately shied away from this one). It’s nonsense to have strict social distancing rules but allow people to be packed in close together on trains and buses.

Masking up, social distancing where possible (not really possible in HK), washing hands, and just staying clean, BE RESPONSIBLE. Maybe have a trustworthy government who actually understands the people instead of implementing silly quarantine extension periods.

Interestingly, in a study exploring attitudes towards quarantine conducted after the SARS epidemic, the authors found that 81% of Hong Kong respondents favoured quarantining of those suspected of having being exposed to the disease, although only 54% remained in favour for mandatory quarantine [12].  This supports the suggestion that having a sense of altruism could mitigate the negative impact of quarantine on mental health [13].

Inclusivity:

The ethical framework mentioned above advises that all those who will be affected by the measures should be included in the decision-making process, taking into account people from all cultures and communities, and that an acceptance of an agreed decision-making process should be attempted. Inclusivity was certainly not something felt by respondents in this study. As the word cloud illustrates, many respondents felt a sense of incarceration, particularly when the government or hotel staff did not provide any support.  There were numerous parallels drawn between the hotel quarantine experience and being imprisoned. Many argued that being in prison was preferable compared with lack of fresh air, exercise, sunshine and substandard food in some hotels. Respondents referred to feeling as though they were ‘criminals’,  ‘undesirables’, ‘untouchables’ and not human. This was clear from many of the survey responses:

I felt that I wasn’t treated as a human being, from the treatment on arrival in the airport to every time government people contacted me, I was treated as a number and nobody take care of my wellbeing, nutrition, etc.

I think the govt doesn’t care about mental well-being. If they did, they would make sure the food was suitable and everyone’s rooms were appropriate for 21 days solitary confinement. People without windows will struggle so much.

This entire idea is baseless. A crime against humanity. Locking up healthy people, no sunlight and fresh air to breathe…

So I’m all for doing quarantine. I don’t have a problem with doing quarantine. I have a problem with doing quarantine when you are treated as a convict.

 For a number of respondents, how they were treated in hotels, quarantine camps and hospitals had a direct effect on their mental wellbeing as the following quotes suggest:

‘Yeah. I think there must be a correlation between your mental health and how well, or not, you think you were treated. Because the families that have been split up were the families that had some sort of trauma as a result of quarantine. I think their mental health issues must be exacerbated enormously. So that I’m sure if you look at people’s views of what quarantine were, the ones that say it was the worst, were probably the ones with the medical health issues in the long term.’

The whole thing about hotel quarantine for 21 days, is they actually treat you like you’re a prisoner….I suddenly thought, ‘No-ones actually phoned me up to see if I’m still alive, let alone if I’m well or not.’

Despite media reports highlighting the stringent measures and conditions of quarantine, many people felt that they were not heard [14]. Follow-up interviews shared this sentiment suggesting that: “I’m pretty sure the Hong Kong government are seeing the feedback etc., but I don’t think they’re really taking any action. But I’m pretty sure they’re seeing what we’re seeing. Even the hotels. They’re noticing what we’re saying about it, but they are not really taking actions on it.”

Those that had some connection with their hotel staff experienced less adverse psychological effects than those who were not given any support. This is corroborated by previous research that shows how important feeling integral to society is for mental wellbeing during quarantine [15]. In this regard, the online HK quarantine support group was instrumental for many to feel included and connected, even if only through a shared narrative.

Openness and Transparency:

Although the framework for pandemic planning suggests that decisions should be open to scrutiny and the basis for these decisions explained [8], most people felt that there was a lack of openness and transparency around HK quarantine measures. This lack of transparency and openness led to respondents seeking information elsewhere, citing evidence to support conspiracy theories. One respondent stated that it felt as though the quarantine measures were “designed to deter people from travelling and punish them for doing so” while another stated that ‘Yeah, there’s a lack of transparency. There is inequality in the system for sure. And that kind of gnaws at you a little bit.’ There were numerous comments and suggestions made suggesting that public health authorities provide a rationale for the quarantine measures based on scientific data, particularly the decision to enforce a 21-day quarantine.

  • Firstly, follow the science…21 days quarantine is completely unnecessary.
  • 21 days quarantine is not substantiated. Use data to confirm the need.

People felt that while there was some information on the government website, it was not effectively disseminated, with many relying heavily on the HK Quarantine Support Group for information. Moreover, the constantly changing regulations left people feeling uncertain and powerless, resulting in many losing trust in the government. One interviewee stated that

“I think the government has really lost its legitimacy in completely failing to rationalise what it’s doing here.”

The lack of openness and transparency was evident in those undergoing government quarantine as well as those who tested positive and were admitted to hospital. One participant found it particularly frustrating trying to get information on what her tests were for and nobody would tell her. She felt that “…..it’s really like you take away everything that makes us human. You lock us in. You have zero communication. The communication that you do have is not only non-productive.” This was echoed by many people who were taken in to government quarantine camps where little to no explanation was given as to the science behind the decision making.

Most people would agree that justification for quarantine measures should be based on science, but it should also be equally informed by the values, preferences and practices of the affected communities [16].  A lack of trust in the authorities affects how people process and interpret health messages and advice. Transparency and open communication not only mitigates the adverse psychosocial effects of quarantine but could also result in a greater likelihood that the public will accept and adhere to the recommendations made, particularly if they are reasonable and if the public have been included in the decision-making process.

 Silver Linings and Measures to Mitigating Mental Health Issues

Respondents were asked about the best aspects of, and whether there were any silver linings to, their quarantine experience. While most felt there were absolutely none, some people mentioned that quarantine (mostly those that quarantined at home) gave them time to slow down, to enjoy their own company, and to complete low priority tasks. Quite a few mentioned that quarantine was an opportunity for ‘me time’ and others felt a sense of accomplishment in completing 21-days quarantine.

Netflix was a ‘go-to’ for many and most people were grateful for technology, particularly social media to feel connected. One interviewee reflected that “… we are actually very lucky to go through this pandemic at this time in that technology has enabled us to maintain contact”.

While some people developed a deeper appreciation for fresh air, friends, family and freedom, the most common positive to emerge was the support and the kindness of strangers from the online support group, which was for many an important component in mitigating mental health issues. Respondents were also asked what their most helpful tool or daily practice was to mitigate mental health issues and the following word cloud illustrates their responses. A daily routine, meditation, family and friends proved to be useful for most respondents.

Word cloud illustrating practices used to mitigate mental health issues

While many people relied on family and friends for support, the online HK Quarantine Support Group proved to be an incredible source of support for many respondents, with an appreciation of the shared narrative of ‘incarceration’; many finding humour in the substandard food some hotels provided. Members of the group were able to provide guidance and support, with some offering therapy services to members suffering panic attacks and claustrophobia.

Most respondents acknowledged that quarantine was bound to have a psychological impact, however some found that they were able to adjust their mindset before entering quarantine, and actually make the experience a positive one.

There are other people like me who found it a positive experience. I feel a part of the problem is everyone speaks about it as being a ‘prison term’ – this is the first mistake. Entering into the hotel with the right mindset is the first thing to do.

One interviewee engaged the help of a life coach prior to going into quarantine, which was very helpful. Another interviewee who had quarantined several times revealed that they “…learned about the tips I have used to stay sane in quarantine. And by staying sane, I choose those words carefully because to me, so much of the quarantine is a mental battle as much as it is physical.”

Several respondents opted to quarantine in hotels rather than put their family at risk by quarantining at home, with one interviewee stating that “I think even if I was given a choice, I would choose to be quarantined in a hotel. Again, just because I have children…”.  This implies that if people were given a choice, they would most likely use logic and/or altruism and voluntarily quarantine. This prosocial behaviour was echoed in the survey, with one respondent referring to quarantine as a social responsibility to make sure I am Covid -free to leave the hotel. Knowing others will do the same too”. The findings in this study suggest that most people are conscientious towards public health and are compliant with regulations, although there are the few who feel they are above the law and thus alter the status quo for the community.

There was also evidence of  altruism in an interviewee who was participating in the hospital COVID study stating that… for the greater good of man, I’ve got no problem with doing a trial.” Altruism was particularly evident in an online group, the HK quarantine support group, where members delivered groceries, gave advice and provided support for one another at no cost.

Respondents were asked for suggestions on how policy makers could assist mental wellbeing during quarantine. Aside from the recurring theme of making quarantine shorter and allowing home quarantine, responses included access to fresh air, exercise, decent food and being allowed out once a day. Most respondents reported that unless they specifically sought help, there was no follow up by government officials as to their wellbeing, no recommendations for any mental health support system, nor was there any offer of access to counsellors or psychologists.

The findings from this study echo the sentiments of a recent review article on how to reduce the psychological impact of quarantine [1]. The authors of this review concluded that:

  • Information is key: people who are quarantined need to understand the situation
  • Effective and rapid communication is essential
  • Supplies (both general and medical) need to be provided
  • The quarantine period should be short and the duration should not be changed unless in extreme circumstances
  • Most of the adverse effects come from the imposition of a restriction of liberty; voluntary quarantine is associated with less distress and fewer long-term complications
  • Public health officials should emphasise the altruistic choice of self-isolating

Conclusion:

This research project has shed light on the perspectives and experiences of HK residents towards quarantine measures. Given the need to balance public safety with human rights, this study highlights the need for reasonableness, inclusiveness, openness and transparency when making decisions regarding quarantine measures in order to mitigate negative psychosocial consequences. There are implications of these findings for policy makers, health authorities and governments to arrange humanistic quarantine measures and to incorporate the ethical values framework in their decision-making process.

Key Points:

  • It is imperative that there is a risk-benefit analysis in weighing up the need to prevent the spread of COVID-19 versus the psychological consequence of quarantine.
  • HK residents should be informed about the need for quarantine, the science behind the decisions and should be well supported during this period.
  • Depriving people of their freedom for longer than is necessary has long term detrimental consequences and requires careful handling by health authorities and governments.
  • Perhaps relying on altruism and not enforcing quarantine could also help to alleviate the mental health issues associated with quarantine.
  • If these measures are necessary, they need to be implemented with compassion and psychological support should be made available for people during and after quarantine.

Acknowledgements

The author would like to thank the participants who joined this study and particularly the admin of the HK quarantine support group on Facebook, without whom this project would have not taken place.

Declaration of conflict of interest

The author declared no potential conflict of interests with respect to the research, authorship and/or publication of this article.

Funding

The author received no funding for this research, authorship and/or publication of this article.

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