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International Journal of Disaster Risk Reduction 64 (2021) 102516

Available online 19 August 2021 2212-4209/© 2021 Elsevier Ltd. All rights reserved.

Six Cs of pandemic emergency management: A case study of Taiwan’s initial response to the COVID-19 pandemic

Li-Yin Liu a, Wei-Ning Wu b,*, David A. McEntire c

a Department of Political Science, University of Dayton, Address: 300 College Park, Dayton, OH, 45469, USA b Institute of Public Affairs Management, National Sun Yat-sen University, Address: No.70 Lien-hai Rd., Kaohsiung, 80424, Taiwan c College of Health and Public Service (CHPS), Utah Valley University, Address: 800 W University Pkwy, Orem, UT, 84058, USA

A R T I C L E I N F O

Keywords: COVID-19 Cognition Confidence Coproduction Emergency response

A B S T R A C T

A review of the disaster literature indicates that emergency responses to pandemics are often understudied; the current COVID-19 crisis provides an important opportunity to improve awareness and understanding about this and other contagious and disruptive diseases. With this in mind, this study examines Taiwan’s response to COVID-19 because it was successful in spite of a high probability of contagion. The paper first explores the assertion that cognition, communication, collaboration, and control are vital for effective disaster response; it then indicates the need to consider two additional Cs: confidence (trust of government’s competency) and coproduction (public participation in disaster transmission prevention). The paper also conducts a qualitative descriptive study of the Taiwan government’s response timeline with examples of each of these concepts in action. To further illustrate the need for the two additional Cs, survey data illustrate how public confidence serves as a pivot between government’s COVID-19 response and citizen coproduction in COVID-19 transmission prevention.

1. Introduction

Taiwan has set an example for other countries in how its government has coped with COVID-19 and should be studied comprehensively to improve the understanding of emergency management [1–4]. On January 31, 2020, as the coronavirus disease (COVID-19) began spreading from China, a report, based on air travel between Taiwan and China, predicted Taiwan would have the second-highest case count in the world. However, this prediction did not become reality. By April 27, 2020, from 61,684 tests, there were only 429 confirmed cases (only 55 of which were local, not imported, infections) and 6 deaths in Taiwan (statistics retrieved from the Taiwan Centers for Disease Control (CDC) on April 27, 2020). This brings up two very important questions: What emergency response mechanisms did Taiwan implement to contain the outbreak of COVID-19? How is the emergency response to a pandemic different from other hazard responses?

Using Taiwan’s COVID-19 pandemic response as a case study, this research argues that effective responses to public health emergencies, such as pandemics, require more than just an emphasis on the traditional four Cs of a government’s actions—cognition, communication, collab- oration, and control (see Ref. [5] for cognition, communication, and

control; see Ref. [6] for collaboration). Instead, citizen cop- roduction/compliance of disease prevention, and public confidence in government’s competency may be equally as crucial as the traditional four Cs of emergency management. Specifically, the traditional four Cs of emergency management are necessary but insufficient for coping with disasters related to public health. A government needs to utilize the four Cs to carry out necessary steps and cope with the uncertainty, but even then, policies related to the four Cs cannot be executed effectively and efficiently without public confidence and the willingness to coproduce in the process, especially in democratic countries. Several emergency management studies in psychology and sociology have identified citi- zens’ trust in government as a key determinant for public compliance to emergency policies [7–10]. While emergency management and the four Cs have received significant attention, public confidence and willingness to coproduction/comply are relatively understudied in the field of public sector emergency management compared to psychology and so- ciology. Most importantly, there are only a few existing studies inves- tigating the interaction between the traditional four Cs (government action) and the two additional Cs (citizen perspective).

With this in mind, the following study seeks to explore the impor- tance of the six Cs (the four traditional Cs plus coproduction and

* Corresponding author. E-mail addresses: [email protected] (L.-Y. Liu), [email protected] (W.-N. Wu), [email protected] (D.A. McEntire).

Contents lists available at ScienceDirect

International Journal of Disaster Risk Reduction

journal homepage: www.elsevier.com/locate/ijdrr

https://doi.org/10.1016/j.ijdrr.2021.102516 Received 29 March 2021; Received in revised form 13 July 2021; Accepted 16 August 2021

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confidence) in response to a pandemic emergency by focusing on Tai- wan’s initial response. Moreover, using evidence collected through an online survey to comprehensively understand how and why people in Taiwan are willing to comply and be confident in the government’s actions, this study highlights how the Taiwanese government’s cogni- tion, collaboration, communication, and control strategies increased public confidence in government, which in turn increased citizens’ willingness to coproduce in non-pharmaceutical interventions and comply with the government’s regulations. Therefore, a qualitative descriptive study will be utilized to discuss how the Taiwanese gov- ernment used the traditional four Cs of emergency management to contain the spread of COVID-19, while the quantitative analysis of the survey responses will be used to demonstrate the importance of the two additional Cs related to the public perspective.

2. Literature review

The COVID-19 pandemic has incentivized governments around the world to redesign emergency management policy and to redirect re- sources in order to cope with the rapid, unpredictable spread of the virus. Scholars indicate that governments, in their attempts to contain the outbreak, are adopting many mechanisms to increase public awareness and encourage disaster prevention [11,12]. Countries have adopted public management tools, including open access on COVID-19 cases (all confirmed, suspected, and reported cases can be found on governmental websites); public sanitation education (the importance of handwashing, mask-wearing, and social distancing); and prevention polices through symptom identification and contact tracing, while others focus on promoting and supporting collaboration and resource mobilization to strengthen the capacity and resilience of their own health prevention systems [13,14]. But it is also important to note that citizens should be responsible for following government COVID-19 preventative recommendations [15,16]. Most of the existing COVID-19 literature focuses on the actions initiated by public agents, such as health departments and medical agencies [17], but such an approach largely ignores the important roles the public can play in the governance process of epidemic prevention [18,19].

The public role in governance is crucial because emergency man- agement has an important impact on regional capacity of disaster response, can supplement and complement emergency service delivery, and can hold government accountable for emergency response. For example, in many countries, civil organizations and citizens have been exerting pressure on governments for increased accountability and maintenance of public reports to explain COVID-19 outbreaks [20,21]. Ever-rising public expectations for COVID-19 relief results in an enduring motivation for governments to continually adjust their re- sponses on the basis of assessments of the risks in different locations and situations [22,23]. These pressures reflect public concern, which in turn has encouraged governments to keep responding to contain COVID-19.

Studies on traditional influenza management emphasize communi- cation strategies through social media during high-uncertainty events [24] to provide sufficient information to the public, which enables the public to take personal responsibility for disease prevention. These recent studies also identify citizens’ willingness to accept government recommendations and their compliance with health prevention policies as a significant facilitator of disease prevention [25,26]. The public can contribute to epidemic prevention in several ways, including self-health monitoring and mask use, and as both users and producers of risk in- formation [27,28]. Although the existing studies provide some funda- mental public health emergency response strategies for governments to respond to COVID-19 [29–32], and have increasingly focused on the importance of incorporating citizens in influenza preparedness, miti- gation, response, and prevention [33,34], these studies do not link together the government-initiated action and the role of the public and are insufficient to help government cope with challenges from COVID-19 [34]. The response to COVID-19 is different from traditional

influenza management efforts because the period of a pandemic is significantly more extended than that of other hazards and should be categorized as an extreme context in which several extreme events are likely to occur and result in intolerable consequences. Thus, more research on the role of the public is needed.

Therefore, to comprehensively study the strategies of containing COVID-19, we not only focus on government-initiated action and the public’s role in disease prevention, but we also connect both concepts by investigating how a government’s actions can result in public confidence in government, willingness to coproduce, and compliance with policy.

3. Theory: the six Cs of pandemic emergency responses

As previous studies have illustrated, cognition, communication, collaboration, and control are the four key elements in emergency response both practically and theoretically [5,35]. However, emergency management related to public health emergencies such as pandemics is relatively understudied. The distinction between pandemic emergencies and other hazards can be significant. All disasters require not only government efforts but public participation to increase the probability of success. However, a resilient pandemic response plan requires even further citizen coproduction in transmission prevention because taking non-pharmaceutical interventions and precautionary activity are equally, and in some respects even more, essential [36,37]. Merely relying on government-initiated actions (the traditional four Cs), which has been widely adopted by many countries to cope with COVID-19, may not be enough to generate effective outcomes. All disease control mechanisms and non-pharmaceutical interventions cannot be imple- mented effectively without public acceptance and coproduction or public confidence. In other words, coproduction and public confidence are essential to coping with public health emergencies such as the pandemic. From the existing literature, we first briefly explain the importance of the six Cs of pandemic response and then state our hy- potheses related to the two additional Cs.

3.1. Cognition

Cognition is a “C” that has different manifestations among the public and government. Cognition is defined as “the capacity to recognize the degree of emerging risk” [5]; p.189). From the public’s perspective, being cognizant of public health threats will increase emergency pre- paredness and encourage the public to use non-pharmaceutical in- terventions [37,38]. Thus, the level of public cognition of a problem’s severity is positively associated with public compliance and production of disease prevention.

From the government’s perspective, failing to understand the magnitude of the disaster leads to more serious consequences, such as failing to initiate the necessary response and taking steps for disaster mitigation [5,39–41]. Failure at this early stage may hinder the efforts of emergency response because an early and aggressive response is critical when attempting to contain an epidemic outbreak [42]. Moreover, cognition of a problem’s severity by the government should not be based merely on perception; instead, proper assessment and identification with evidence are needed to build effective communication with the public [43,44]. Thus, without cognition, effective emergency manage- ment policy will likely not be carried out. Missing the timing for con- taining the spread can lead to larger scale disaster.

3.2. Communication

Communication in a pandemic response affects how the public per- ceives and reacts to the virus because “[r]isk must be well-publicized to inspire personal protective actions” [45]; p.16). Thus, transparent, up-to-date, and accurate information through many communication channels is essential to raising awareness of the problem’s severity and the need for public sanitation. Also, the effectiveness of

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non-pharmaceutical interventions and emergency preparedness de- pends heavily on the success of public education and information communication [38,46]. In contrast, inadequate communication can lead to anxiety and “public fatigue about respiratory infection commu- nications and a blunting of advice messages on non-pharmaceutical in- terventions” [44]; p.14). Therefore, ensuring information quality (transparency and accuracy) and sufficient quantity (that is frequent and up-to-date) are key elements of pandemic emergency communication.

3.3. Collaboration

The capacity to cope with the uncertainty of disease control and the broader emergency response far exceeds the expectations of what a single agency can deal with or be trained to handle [6]. Thus, inter- governmental, interdepartmental, and intersectional collaboration are essential to combine actors’ capacities in order to create an effective network. Moreover, leaders—including elected officials, political ap- pointees, public managers, civil servants, and leaders from private and nonprofit organizations—need to share the joint goal, support the transboundary cooperation, and grant one another certain levels of au- tonomy to facilitate effective emergency response collaboration [47,48]. An effective response to a pandemic requires a government to utilize collaboration within governmental agencies and with other sectors in order to secure and distribute necessary resources effectively and efficiently.

3.4. Control

Bureaucratic control was considered a crucial approach for emer- gency management early on, but overly bureaucratized control in emergency management has been criticized for having a negative impact on emergency response [31,49–51]. In the context of this paper, control is not defined as bureaucratic control; instead, it is defined as the capacity to focus on essential tasks and the shared goal of preventing further disaster impacts [5]. From a public health emergency perspec- tive, control includes the initiation and implementation of institutional regulatory policies—social distancing policies, case identifications [52], mass screenings, foreign entry suspension [53], and sanitation product distribution mechanisms—as well as surveillance between community members (non-institutional), to ensure the government and the public health system have the capacity to contain a disease outbreak.

3.5. Coproduction

Although an informed and dedicated governmental approach to emergency management is considered vital, a failure to incorporate the public as a coproducer in public health response is likely to result in social disruption and ineffectiveness of epidemic control [54]. Disease prevention and preparedness cannot be effective if residents refuse to adopt the precautionary strategies [38].

The view of the public as partner is the core of coproduction and emphasizes the importance and functions of the public in service coproduction, which states that citizens can make up for the lack of service-delivery capacity of public organizations [55]. Citizens are ex- pected to have a civic responsibility and a moral imperative to assist government and to follow the guidelines and commands of government. The willingness to comply is the first and most necessary step for a proactive citizen coproduction.

Citizen-initiated coproduction is viewed as a potential source of governmental capacity [56]. Engaging the public as a coproducer to pandemic planning is important for transparency and improving compliance with public health orders [57]. This, in turn, improves government capacity to contain the outbreak of the disease [54]. Moreover, the public can play an important role in emergency man- agement processes because most often the first response to disaster is from citizens, and most citizens are viewed as partners of government

and called on as “citizen journalists” to offer information about the places they live to other collaborative participants [58,59].

In this study we define coproduction as not only the voluntary action taken by citizens as preventive disease control, such as taking non- pharmaceutical interventions, but also the inclusion of the initial and essential element of coproduction—citizen compliance with govern- ment policy on COVID-19.

3.6. Confidence

Public confidence is related to the public’s evaluations of the effec- tiveness of governmental actions and activities, especially whether government would perform its designated role based on the public’s expectations [60,61]. Public confidence in government competency serves as a pivot point between government’s pandemic response and citizens’ compliance and coproduction behavior. Previous studies have shown that public confidence in government increases compliance and cooperative behavior with emergency response policy initiated by the government [62]. And confidence also increases the public’s willingness to coproduce [63]. Thus, the level of confidence in a government’s competency has a positive impact on citizen compliance and citizen-initiated coproduction (Hypothesis 1).

Because public confidence is hypothesized to be a crucial determi- nant for citizen compliance and citizen-initiated coproduction, factors that increase public confidence in government are important issues for emergency response. Scholars have indicated that citizens’ satisfaction of perceived government performance is associated with confidence in government’s competency [64]. Catastrophic events regularly affect public confidence in governments. If governments cope with cata- strophic events effectively, the public confidence will increase [65]. For example, studies related to the terrorist attack on the World Trade Center in the United States have found that public confidence increased after the terrorist events [66]. On the contrary, if a government does not respond to catastrophes effectively, public satisfaction and confidence in the government’s action will inevitably decrease [67,68]. Thus, citizens’ satisfaction level of a government’s emergency response performance, including a government’s cognition, communication, collaboration, and control strategies, has a positive impact on public confidence in that government’s emergency response competency (Hypothesis 2).

We use both qualitative and quantitative analyses to comprehen- sively analyze the Taiwanese experience to test the six Cs. Specifically, the qualitative analysis focuses on thoroughly investigating how the Taiwanese government utilizes the traditional four Cs in their response to COVID-19 strategies, while the quantitative analysis aims to examine the two additional Cs and test Hypotheses 1 and 2.

4. Qualitative case analysis: cognition, communication, collaboration, control and the initial experiences in Taiwan

In this section, we conduct a qualitative descriptive study (a type of qualitative analysis) of the Taiwan government’s COVID-19 response timeline in relation to the global events, using this as evidence to illustrate the presence of these traditional four Cs. All information pro- vided in the qualitative descriptive study was collected from the following agencies’ daily press briefings—Taiwan Centers for Disease Control (CDC), the Executive Yuan, Ministry of Foreign Affairs, the Ministry of Education, and the Presidential Office (see Fig. 1 for a more detailed timeline and Table 1 for how these government actions corre- spond to the traditional four Cs framework).

4.1. Period 1 (~January 20, 2020): risk recognition and preparation

Cognition. This study uses the timing of the Taiwan government’s initiation of response actions and the aggressiveness of these action in comparison with COVID-19 global events to infer the government’s cognition. Drawing lessons from the SARS outbreak in 2003, Taiwan has

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been very careful with its approach to the COVID-19 pandemic [1]. In fact, Taiwan CDC started implementing onboard screenings of all direct flights arriving from Wuhan, China, on December 31, 2019, which was before the World Health Organization (WHO) received the report on the novel coronavirus [69]. Moreover, before the first confirmed case entered Taiwan on January 21, the CDC hosted a meeting of experts on the establishment of testing and reporting criteria, began hosting daily press briefings, organized an advisory committee in preparation for a possible outbreak, reinforced screening practices at the airports and seaports, sent medical experts to Wuhan, China, to obtain more infor- mation, announced travel warnings, and activated the Central Epidemic Command Center (CECC) for Severe Special Infectious Pneumonia to coordinate cross-departmental tasks in response to the new virus [70]. Moreover, the president delegated the coordinating power to the com- mander of CECC to coordinate with other agencies directly [71], which enabled collaboration to be facilitated with fewer bureaucratic procedures.

Although few cases had been confirmed outside China and no human-to-human transmission was evident at this time, the Taiwan government was cognizant of the risk the virus could pose to the public and immediately initiated an aggressive response before most countries and regions [1].

4.2. Period 2 (January 21 to February 6): rapid and aggressive response

Most COVID-19 response mechanisms were initiated and mobilized during this period (between the first confirmed cases and first outbreak outside China on February 6) in Taiwan.

Communication with the Public. The CECC continued daily press briefings, provided COVID-19 updates, and corrected misinformation. The CDC also quickly revised its website and collaborated with social media platforms to provide daily updates and correct information. Sanitation education, such as handwashing and mask training, was made available in all public transportation stations [1]. Elected officials

Fig. 1. Chronology of Taiwan Government’s responses to COVID-19.

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and administrative agency leaders also worked together to ensure in- formation credibility and consistency. Information regarding COVID-19 and public sanitation was given to leaders of the CECC and the vice-president, who was a prominent epidemiologist [72]. Other elected officials and political appointees were responsible for releasing carefully crafted information to decrease public concerns, such as ensuring the supply of essential groceries and personal protection equipment (PPE) and assistance for economic stability [73].

Control (Elevated). The government began evacuating Taiwanese nationals from Wuhan, China, through charter flights and required evacuees to stay at designated sites for a 14-day isolation. All confirmed cases were required to be hospitalized regardless of the severity of the symptoms and to provide itineraries for the previous 14 days, while an investigation was conducted on the source of infection and contacts

were identified. All relevant human contacts of confirmed cases were subjected to 14-day home quarantines. People subjected to home quarantine were required to enroll in a GPS tracking system with local police to ensure the effectiveness of home quarantine [74]. To prevent PPE shortages, the Taiwan government suspended exports of surgical and N-95 masks and centralized the distribution of masks [75,76].

Collaboration (Intersectoral). To distribute masks, the Taiwanese government collaborated with NHI-contracted pharmacies to sell masks under a name-based rationing system on February 6, 2020 [77]. The Digital Ministry also collaborated with citizens to develop “Mask Map” apps to assist in purchasing [78]. On February 5, the Taiwan govern- ment collaborated with more than 20 private corporations to recruit a “national mask team” to build 60 surgical mask production lines. Within six weeks, the team assembled 60 production lines, which normally

Fig. 1. (continued).

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would have taken four to six months to complete [79]. Collaboration (Intergovernmental). Most Taiwanese residents

enroll in single-payer National Health Insurance (NHI) and carry NHI cards that provide physicians access to a comprehensive medical

condition database. The CDC in Taiwan had been collaborating with the National Immigration Agency on entry screening, mandating arriving passengers’ self-reported health information, and the integration of NHI and Custom and Immigration databases enabled doctors to pinpoint

Fig. 1. (continued).

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high-risk patients during clinical visits [80]. The CDC also collaborated with the Ministry of Foreign Affairs on suspending travelers from and to China, based on the epidemic situation. The CDC also coordinated with

the Ministry of Education to defer the start date of the school semester [81]. In addition, to ensure community surveillance, the central gov- ernment collaborated with local governments (counties and villages) on

Fig. 1. (continued).

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community members’ health condition reporting, correction of misin- formation, and public sanitation education [82].

Information transparency through various communication channels, intergovernmental and intersectional collaboration, and effective

implementation of control mechanisms facilitated during this period enhanced the government emergency response capacity. Moreover, these mechanisms also created a solid foundation for the following periods.

Fig. 1. (continued).

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4.3. Period 3 (February 7 to March 12): capacity enhancement

With outbreaks occurring globally, the Taiwanese government continued to expand and build upon the mechanisms it had already established.

Control and Communication. The CECC continued to closely

monitor the COVID-19 outbreak worldwide in order to update travel advisories and trace all high-risk groups and their possible contacts. It also expanded the testing criteria to people with foreign travel history or with contact history and provided guidelines for large-scale gatherings. Moreover, quarantine requirements were elevated: asymptomatic trav- elers arriving from outbreak areas were subjected to strict home-based

Fig. 1. (continued).

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quarantine, and special taxi services were launched at the airports for passengers subjected to home quarantine. Positive per-diem compen- sation (NT$1000/US$33.33) was provided for 14 days for those sub- jected to quarantine, and there were negative sanctions for those violating quarantine orders (NT$150,000/US$5000 fine for violators). Additionally, recovered patients could not leave the hospital until passing three health tests [83].

Collaboration. The mask production collaboration boosted Taiwan’s production capacity from 4 million to 10 million masks daily, which increased the name-based mask purchasing quota; 303 local district public health centers joined the distribution of the name-based mask rationing system. Moreover, the CECC launched the Mask Online Ordering System and began collaborating with convenience stores for online order pickups. Relief and Restoration was implemented by other government agencies to address the economic impact caused by COVID- 19 under the Special Act on COVID-19 [84]. The Ministry of Education also collaborated with the Environmental Protection Administration to disinfect schools for the new semester [85].

During this period, the COVID-19 outbreak occurred in other coun- tries, such as South Korea, Iran, and Italy. These continuing response actions effectively kept the confirmed cases under 400 in Taiwan.

Table 1 Example Taiwanese government strategies corresponding to traditional four Cs.

4Cs Time Example Strategies

Cognition Period 1 (~January 20, 2020)

The government’s cognition, drawing lessons from the SARS outbreak in 2003.

Control Period 1 (~January 20, 2020)

Taiwan CDC started implementing onboard screenings of all direct flights arriving from Wuhan, China, on December 31, 2019.

Period 2 (January 2 to February 6)

(1) The government began evacuating Taiwanese nationals from Wuhan, China, through charter flights and required evacuees to stay at designated sites for a 14-day isolation. (2) All confirmed cases were required to be hospitalized regardless of the severity of the symptoms, and all relevant human contacts of confirmed cases were subjected to 14-day home quarantine. (3) Taiwanese residents were required to enroll in single-payer National Health Insurance (NHI) and carry NHI cards linked to comprehensive medical condition database.

Period 3 (February 7 to March 12)

Asymptomatic travelers arriving from outbreak areas were subjected to strict home-based quarantine.

Period 4 (March 13 to March 31)

(1) After the WHO declared COVID-19 a pandemic, the Taiwanese government suspended entry for non-Taiwanese nationals and banned airline transit through the island nation. (2) All returning travelers were required to conduct 14-day home quarantines, and recommended suspending large indoor and outdoor gatherings to prevent cluster infections. (3) The punishment for quarantine violators increased.

Period 5 (April 1 to May 1)

(1) The CECC imposed social distancing measures. A new policy on mask wearing in public transportation was issued; violators to be fined up to NT$15,000 (US $500). (2) Inbound travelers from Europe and the Americas after April 4 must voluntarily present documents for home quarantine requirements before boarding. (3) All businesses on the footprint list were asked to conduct two-day disinfection procedures.

Communication Period 1 (~January 20, 2020)

On January 21, the CDC hosted a meeting of experts on the establishment of testing and reporting criteria, began hosting daily press briefings, and organized an advisory committee in preparation of a possible outbreak.

Period 2 (January 21to February 6)

(1) The CECC continued daily press briefings and collaborated with social media platforms to provide daily updates and to correct misinformation. (2) People subjected to home quarantine were required to enroll in a GPS tracking system to enable local police to ensure the effectiveness of home-quarantine. (3) Emphasis was placed on information transparency through multiple communication channels and intergovernmental and intersectional collaboration.

Period 5 (April 1 to May 1)

(1) Warnings are sent out through the Public Warning System to people who have been in contact with suspected COVID-19 cases. (2) SMS messages are sent every day to track the health status of people

Table 1 (continued )

4Cs Time Example Strategies

quarantined through the Public Warning System.

Collaboration Period 1 (~January 20, 2020)

The Central Epidemic Command Center (CECC) for Severe Special Infectious Pneumonia was activated to coordinate cross-departmental tasks in response to the new virus.

Period 2 (January 21to February 6)

(1) Elected officials and political appointees were responsible for releasing carefully crafted information to decrease public concerns. (2) The Taiwanese government collaborated with NHI-contracted pharmacies to sell masks under a name- based rationing system on February 6, 2020. (3) GPS tracking system was adopted for reporting citizens’ home quarantine. (4) The Digital Ministry also collaborated with citizens to develop “Mask Map” apps to assist in purchasing. (5) The central government collaborated with local governments (counties and villages) on community member’s health condition reporting, correction of misinformation, and public sanitation education.

Period 3 (February 7 to March 12)

(1) Special taxi services were launched at the airports for passengers subjected to home quarantine. (2) The mask production collaboration among chain suppliers boosted Taiwan’s production capacity from 4 million to 10 million masks daily. (3) 303 local district public health centers joined the distribution of name-based mask rationing system.

Period 4 (March 13 to March 31)

The official Outbreak Prevention Works Instruction enhanced collaboration among public agencies and private corporations.

Period 5 (April 1 to May 1)

The CECC collaborated with Line Taiwan and HTC Corporation’s healthcare unit to launch a Disease Containment Expert system.

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4.4. Period 4 (March 13 to March 31): control mechanism elevation

After the WHO declared COVID-19 a pandemic, several control mechanisms were elevated in Taiwan. The Taiwanese government sus- pended entry for non-Taiwanese nationals and banned airline transit through the island nation.

Control: In response to the global outbreak, the CECC began con- ducting retrospective COVID-19 testing for travelers arriving in Taiwan from March 3 to March 14, requiring all returning travelers to conduct 14-day home quarantines, and recommended suspending large indoor and outdoor gatherings to prevent cluster infections. The punishment for quarantine violators went up to a NT$1 million (US$33,300) fine with mandatory quarantine at designated sites [86].

Collaboration. To ensure effective quarantine practices, the Taiwa- nese CDC [87] released the official Outbreak Prevention Works In- struction to formalize the collaboration between the central government, local governments, religious groups, community volunteer groups, health centers, and schools to correct misinformation and arrange local civil affairs personnel to implement home quarantine procedures. This increased the implementation of formal control and generated non-institutional control mechanisms, such as community surveillance, in undertaking non-pharmaceutical interventions. The collaboration on mask distribution remained ongoing: in mid-March, 15 more private corporations joined the production, which continued to increase the mask purchasing quota for NHI holders [73].

As the result of the pandemic declaration, the number of returning Taiwanese nationals rapidly increased, as did confirmed imported cases. Yet, because of the early preparedness, no mass community transmission occurred in Taiwan.

4.5. Period 5 (April 1 to May 1): global pandemic continued

Control. To prevent community transmission during the Tomb Sweeping Festival (TSF) a four-day national holiday, the CECC imposed social distancing measures. A new policy on mask wearing in public transportation was issued; violators would be fined up to NT$15,000 (US $500). The CECC also urged people who visited crowded places to conduct 14-day self-health management and sent out warnings through the Public Warning System (also an example of Communication). Moreover, incoming passengers who provided incorrect personal infor- mation on the health declaration notice could be fined up to NT $150,000 (US$5000). Inbound travelers who had visited Europe and the Americas after April 4 were to voluntarily present documents for home quarantine requirements before boarding [88].

Communication (Channels Upgraded). The CECC collaborated with Line Taiwan and HTC Corporation’s healthcare unit to launch a Disease Containment Expert system to track people in home quarantine and began to send SMS messages every day to track the health status of people who were quarantined. Those quarantining at home could reply to the messages to report their health condition. Moreover, on April 18, three naval officers, who were on a vessel, tested positive for COVID-19. The navy immediately called back 744 navy personnel, including those who were on other vessels, to conduct mass testing and immediate quarantine [89]. The central government immediately collaborated with county governments, quarantining people they had contacted, and used text messages to release the footprints (tracking) of all confirmed cases. All businesses on the footprint list were asked to conduct two-day disinfection procedures [70].

There is evidence of the effectiveness of the Taiwanese government’s COVID-19 response; April 28, 2020, marked the 100th day Taiwan had been coping with COVID-19, and despite the TSF and navy incidents, 14 days passed without any new confirmed cases. Moreover, Taiwan now not only has the capacity to contain the COVID-19 spread in the country but has also begun to donate nearly 10 million surgical masks to coun- tries in need to cope with the cross-boundary challenges.

5. Quantitative data analysis: determinants of public confidence and coproduction

5.1. Methodology

To explore public satisfaction with the Taiwan government’s response to COVID-19 and test Hypotheses 1 and 2, we conducted an online survey. IRB for the research and the survey was submitted on April 5, 2020 (expedited review) and was approved by the University of Dayton Institutional Review Board on April 6, 2020. The survey was distributed by posting the survey link on social media platforms widely used in Taiwan [90,91], including Facebook, Line, Dcard, and PTT (both Dcard and PTT are similar to reddit in Taiwan) between April 9 and April 17, 2020. Users of these social media took the survey or shared the survey link voluntarily (N = 1972). When survey participants clicked the link, participants were immediately informed that the survey was completely anonymous; it did not gather nor present the respondents’ IP address or location data in the results. Additionally, respondents were informed that this survey was solely for academic research and in no way affiliated with a government agency. Researchers’ university affil- iations and the institution granting the IRB approval were also disclosed in the consent form.

Post-stratification was applied to reduce the sample bias. Post- stratification weight was created on the basis of gender and age. The comparison between the weighted and unweighted gender and age distribution is presented in Table 2. Generally, there are more female than male participants; around 50% of the participants were between 30 and 44 years old.

Respondents were asked to rate their level of satisfaction with gov- ernment actions regarding communication, collaboration, and cognition as well as their preferred level of government control. Respondents were also asked to rate their confidence in the government’s competency, the level of personal responsibilities taken, and their willingness to comply with relevant regulations. Two mediator analyses were conducted through Stata 15 (see Table 3 for survey questions). The first mediator analysis examines the indirect effect of government’s cognition, control, communication, collaboration efforts on the public’s willingness to coproduce in containing COVID-19 with the level of public confidence as a mediator. The second mediator analysis examines the indirect effect of government’s cognition, control, communication, collaboration efforts on the public’s willingness to comply with COVID-19 related regulations with the level of public confidence as a mediator. Control variables included gender, age, income, party affiliation, education level, marital status, and whether the respondent had children. Descriptive statistics for control variables are presented in Table 4.

6. Results

According to the survey, more than 90% of the respondents were

Table 2 Survey respondents’ age and gender distribution.

Unweighted Weighted

Age Less than 20 (at least 18) 6.52% 3.05% 20–24 7.22% 8.20% 25–29 6.42% 8.73% 30–34 13.29% 8.65% 35–39 19.81% 10.66% 40–44 17.15% 10.72% 45–49 9.48% 9.63% 50–54 7.82% 9.86% 55–59 6.22% 9.91% 60–64 3.76% 8.84% 65 or Older 2.31% 11.74%

Gender Male 36.92% 50.46% Female 62.68% 49.23% Unspecified 0.40% 0.31%

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satisfied with the government’s cognition, communication, and collab- oration mechanisms; were confident of the government’s competency; and preferred stricter government regulations. Moreover, 99% reported they had engaged in non-pharmaceutical interventions to prevent dis- eases control and were willing to sacrifice personal freedom to comply with relevant policy (see Table 5).

As Table 6 presents, public satisfaction with the government’s cognition, communication, and collaboration mechanisms were

positively associated with public confidence in the government’s com- petency in coping with the COVID-19 pandemic (showing that Hy- pothesis 2 is partially valid). But this does not directly affect citizen compliance and coproduction. Public confidence in government’s COVID-19 response competence, as hypothesized, has had a positive association with citizen compliance and coproduction (Hypothesis 1 Valid). In other words, public confidence in government has served as a pivot point between government’s COVID-19 response and citizens’ disease prevention efforts. Moreover, public cognition and the public’s preferred level of government control mechanisms also have had a positive impact on coproduction and citizen compliance. However, re- spondents’ preferences for control level was not associated with their level of confidence in government, but directly increased their willing- ness to coproduce and comply.

7. Discussion

Unless there were serious legal consequences for non-compliance, many governments were unable to produce an effective COVID-19 response because they failed to boost citizens’ confidence in their ac- tions [15], which in turn decreased the public’s willingness to coproduce

Table 3 Measurement/indicators.

Indices/Variables Measurements/Indicators Cronbach’s Alpha

Communication Daily press briefing .79 Public sanitation education Source of infection

Collaboration Mask production .80 Mask distribution Interdepartmental (horizontal) Intergovernmental (vertical)

Control Travel advisory warning .79 Entry limitation Tracking system Quarantine (high-risk) Quarantine (businessperson and students) Quarantine (travel) Name-based rationing system Fine

Cognition Aggressive response .82 Early warning

Confidence Confidence in government competency

NA

Public Cognition COVID-19 severity .65 Global news Confirmed cases in Taiwan SARS experience

Coproduction (Non- pharmaceutical interventions)

Social distancing ,80 Prevent crowed places Mask wearing Handwashing Prevent eating out

Coproduction (Compliance) Comply with regulation .83 Comply with quarantine rule

Table 4 Descriptive statistics for control variables.

Weighted Percentage

Marital Status Married 50.37% Other 49.62%

Have Child? Have at Least One Child 57.30% No Children 42.70%

Party Affiliation KMT 11.29% DPP 30.63% People First Party 0.12% New Power Party 3.68% Taiwan State Building Party 4.40% Taiwan People’s Party 4.42% Others or No Party Affiliation 45.64%

Income less than NTD 28,000 10.06% NTD 28,001–39,000 15.48% NTD 39,001–49,000 13.42% NTD 49,001–59,000 13.16% NTD 59,001–69,000 12.07% NTD 69,001–80,000 12.57% NTD 80,001–93,000 6.51% More than NTD 93,000 16.75%

Education No Education 0.59% High School and Under 23.63% College Degree 38.15% Master’s Degree 29.88% Ph.D. Degree 7.75%

Table 5 Descriptive statistics for the six Cs.

Indices/Variables Measurements/ Indicators

Percentage of Response

Dissatisfied and Strongly Dissatisfied

Neutral Satisfied and Strongly Satisfied

Communication Daily press briefing 2.80% 3.24% 93.96% Public sanitation education

3.12% 3.35% 93.53%

Source of infection 8.51% 7.41% 84.18% Collaboration Mask production 4.57% 4.68% 90.76%

Mask distribution 8.45% 5.29% 86.25% Interdepartmental (horizontal)

6.46% 9.74% 83.81%

Intergovernmental (vertical)

3.36% 27.46% 69.14%

Control Travel advisory warning

1.66% 42.83% 55.51%

Entry limitation 1.86% 51.22% 46.94% Tracking system 1.50% 56.61% 41.89% Quarantine (high- risk)

1.74% 61.8% 36.45%

Quarantine (businessperson and students)

1.49% 47.47% 51.04%

Quarantine (travel) 1.54% 44.63% 53.83% Name-based rationing system

22.47% 74.39% 3.14%

Fine 2.02% 3.53% 94.46% Cognition Aggressive response 3.27% 8.41% 88.32%

Early warning 2.61% 4.26% 93.13% Confidence Confidence in

government competency

3.50% 6.33% 90.18%

Public Cognition COVID-19 severity 0.74% 1.85% 97.41% Global news 9.46% 11.54% 79.00% Confirmed cases in Taiwan

0.47% 1.78% 97.75%

SARS experience 1.69% 8.29% 90.03% Coproduction

(Non- pharmaceutical interventions)

Social distancing 0.97% 4.12% 94.91% Prevent crowed places

0.90% 3.87% 95.23%

Mask wearing 0.47% 2.52% 97.01% Handwashing 0.28% 2.37% 97.35% Prevent eating out 5.65% 13.54% 80.82%

Coproduction (Compliance)

Comply with regulation

0.24% 1.84% 97.92%

Comply with quarantine rule

0.00% 1.64% 0.00%

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and comply. The case of Taiwan’s initial response to the COVID-19 pandemic provides valuable theoretical and practical contributions. In practice, according to the initial COVID-19 pandemic response experi- ence in Taiwan, public health emergencies require more than government-initiated communication, collaboration, and control ac- tions. Effective responses are also based on government and public cognition, public confidence in government, and citizen coproduction.

The results show, to successfully contain the spread of COVID-19, governments need to encourage citizens to have an active role in the COVID-19 pandemic and not just be passive public service consumers. To encourage coproduction and increase public confidence (the two additional Cs), governments first have to utilize the traditional four Cs to increase their emergency management performance and boost public confidence. Moreover, the traditional four Cs can remove barriers to citizen responsibility in disease prevention. For example, if a govern- ment does not provide transparent, high-quality, consistent, and up-to date COVID-19 and public sanitation information, it will be difficult for the public to understand the severity of the pandemic and disease prevention mechanisms or to understand and comply with govern- mental regulations. In addition, if the government does not collaborate with other sectors to secure non-pharmaceutical interventions, it will be extremely difficult for the public to obtain them. In other words, the traditional four Cs are essential to boost the additional two Cs presented in this study; the additional two Cs are then essential to ensure that the four Cs initiated by government are effective.

This study also provides several theoretical contribution. The Taiwan experience highlights the importance of cognition. Although this study only focuses on the initial stage, it highlights the importance of studying a country’s early action in response to possible large scale catastrophes. Due to the 2003 SARS experience, both the Taiwanese government and the public are more cognizant of epidemic threats [2]. When COVID-19 was discovered but not yet to an epidemic level in late 2019, the Taiwanese government had initiated a series of precautionary actions, which set up the foundation to cope with the threats of this global pandemic. For example, when the first outbreak took place in Taiwan in

the middle of May 2021, the daily confirmed cases in Taiwan started to decrease in the middle of June 2021 and continued to drop to around 30 in early July 2021 without full lockdowns or mass vaccinations. The effectiveness of containing the outbreak reveals the resilience of the early infrastructure.

Moreover, this study connects the traditional 4Cs (cognition, communication, collaboration, and control) and the two additional Cs (coproduction and confidence) into a comprehensive theoretical framework. Specifically, Cognition, Control, Communication [5], Collaboration [6], Confidence, and Coproduction were all important concepts in public health emergency management studies. However, the existing studies typically focus on some of these concepts rather than attempting to establishing the connection between these six concepts. Based on these previous theories, we developed a theoretical framework to predict and exam how the government’s action interacts with citi- zens’ risk preparedness and response behaviors.

8. Conclusion

On the basis of the qualitative descriptive study, the effectiveness of Taiwan’s initial COVID-19 response should be attributed to its cognition that triggered the actions on quality and quantity of communication (transparent information, misinformation correction, daily briefing, and numerous channels), collaboration (mask production, interdepart- mental and intersectoral efforts), and institutional control (mask ra- tioning system, strict quarantine, retrospective investigation, and entry suspension). Even though negative and positive incentives are associ- ated with the Taiwan government’s control mechanism, without strict lockdown/social distancing rules, government actions alone are insuf- ficient to contain the spread of COVID-19. Therefore, the Taiwan experience has shown that its citizens’ coproduction on transmission preventions, such as voluntary use of non-pharmaceutical interventions and willingness to comply, and non-institutional control, such as com- munity surveillance, increase the peer pressure for community members to take non-pharmaceutical interventions, and are equally essential. Moreover, while the convenience sample of the online survey creates certain inferential limitations, the evidence collected reveals that the proactive risk-recognized capacity (cognition) and communication and collaboration mechanisms taken by the Taiwan government can indi- rectly increase citizen production and compliance through the effect of public confidence in government’s COVID-19 response competencies and public cognition among the Taiwanese online users.

As with every study, this research also poses some limitations that can be improved by future research. First, government cognition can be better measured by interviewing core decision makers. Future studies can conduct a series of focus group interviews or semi-structured in- terviews to obtain direct information from decision makers in the Taiwanese government.

Second, the nonrandom social media sample is not representative of the entire population. Although we have applied post-stratification sampling, the bias of representation cannot be completely eliminated. Specifically, the survey excluded the population that did not use social media; individuals above 65 were underrepresented in the sample. Moreover, participants who opted into the survey might differ from social media users who decided not to opt-in. However, according to recently published studies, a significant number of individuals, espe- cially people under 65 years old, obtain COVID-19 information through social media and also express their opinions on these social media platforms [92–97]. But it is worthwhile to quickly capture public opinions of COVID-19 responses in Taiwan by recruiting participants from social media during the early stage of the pandemic. Future studies can conduct surveys that use random sampling in order to better capture the public’s reaction to COVID-19 and eliminate the possible differences between volunteer respondents and non-respondents. Moreover, through a survey with random-sampling, we can better understand whether non-social-media users are more likely to take preparedness

Table 6 Mediator analysis.

Confidence

Communication .181** Collaboration .209*** Control -.076 Gov. Cognition .380*** Female -.073* Age -.003 Income .002 Education -.017 Kid .056 Married .033 KMT -.089 _cons 1.438 R-squared .44

Coproduction Compliance

Confidence .095*** .168*** Public Cognition .432*** .426*** Communication .035 .032 Collaboration .050 .043 Control .168*** .161*** Gov. Cognition -.022 .028 Female -.148*** -.028 Age .017*** -.002 Income .001 -.010* Education .005 .006 Kid .036 .036 Married .028 .003 KMT .019 .035 _cons 1.150 1.031 R-squared .43 .34

*p < .05; **p < .01; ***p < .001.

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measures. To further understand the interaction between the six Cs, future

research can conduct experiments to test how a government’s pandemic response strategies, such as communication mechanisms, increase the willingness of citizens to coproduce. A comparative study that uses the six Cs as the main framework is also encouraged to investigate the interconnection among all Cs. Most importantly, incorporating the interaction between government actions and the public’s perspective will be crucial for future studies on public health emergency management.

Data Availability Statement: Some or all data, models, or code generated or used during the study are proprietary or confidential in nature and may only be provided with restrictions. (Anonymized data of the survey distributed through social media, N = 1,972, may be provided).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

Many thanks to Nicholas A. Oesterling and Rikki Morris for all their assistance in data organization and in formatting this paper.

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