BACKGROUND: Several countries have released digital proximity tracing (DPT) apps to complement manual contact tracing (MCT) for combatting the Sars-CoV-2 pandemic. DPT aims to notify app users about proximity exposures to persons infected with Sars-CoV-2 so that they can self-quarantine. The success of DPT apps depends on user acceptance and DPT embedding into the pandemic mitigation strategy. OBJECTIVE: By searching for media articles published during the first three months after DPT launch, the implementation of DPT in Switzerland was evaluated to inform similar undertakings in other countries. The second aim was to create a link between reported DPT implementation challenges with normalization process theory (NPT) for planning and optimizing complex digital health interventions, which can provide useful guidance for decision-making of DPT design and implementation. METHODS: A Swiss media database was searched for articles on the Swiss DPT app (SwissCovid) published in German or French between 04.07.2020 and 03.10.2020. Topics were extracted and clustered manually from articles that were deemed pertinent in a structured process. Extracted topics were mapped to four NPT constructs, which reflect the flow of intervention development from planning, stakeholder onboarding, and execution to critical appraisal. Coherence constructs describe sense-making by stakeholders, cognitive participation constructs reflect participants' efforts to create engagement with the intervention, collective actions refer to intervention execution and joint stakeholder efforts to make it work, and reflexive monitoring refers to collective risk-benefit appraisals to create improvements. RESULTS: Out of 94 articles deemed pertinent and selected for closer inspection, 38 provided unique information on implementation challenges. Five challenge areas were identified: communication challenges, challenges for DPT to interface with other processes, fear of resource competition with established pandemic mitigation measures, unclear DPT effectiveness, and obstacles for greater user coverage and compliance. Specifically, several articles mentioned unclear DPT benefits to affect commitment and to raise fears among different health system actors regarding resource competition. Moreover, media reports indicated process interface challenges such as delays or unclear responsibilities in the notification cascade, as well as misunderstandings and unmet communication needs from health system actors (including physicians, cantonal health authorities). Finally, reports suggested misaligned incentives, not only for app usage by the public but also for process engagement by other actors in the app notification cascade. These challenges mapped well to the four constructs of NPT, thus providing a framework to contextualize the different DPT implementation challenges and to highlight improvement strategies, namely a better alignment of stakeholder incentives, or stakeholder-specfic communication to address their concerns about DPT. CONCLUSIONS: Early experiences from one of the first adopters of DPT indicate that non-technical implementation challenges may affect DPT-effectiveness. The NPT analysis provides a novel perspective on DPT-implementation and stresses the need for stakeholder inclusion in development and operationalization.
Challenges for non-technical implementation of digital proximity tracing: a media analysis