{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T05:18:19Z","timestamp":1787807899185,"version":"build-2784847793"},"reference-count":50,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T00:00:00Z","timestamp":1787788800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Precise measurement of sensitive public health outcomes is often limited by underreporting, stigma, and social desirability bias. These challenges can affect estimates of COVID-19 infection and vaccine hesitancy, leading to incomplete evidence for surveillance and public health decision-making. This study examined the use of privacy-preserving stratified randomized response models (SRRMs) to improve the estimation of sensitive health information in a population-based setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We conducted a cross-sectional quantitative survey in Punjab, Pakistan, during June-August 2021. A total of 1,200 participants were recruited using simple random sampling with replacement within a stratified design, with equal allocation to urban (\n                      <jats:italic>n<\/jats:italic>\n                      = 600) and rural (\n                      <jats:italic>n<\/jats:italic>\n                      = 600) populations. Privacy-preserving SRRM-I and SRRM-II procedures were applied to estimate underreported outbreak cases and vaccine hesitancy while reducing response bias related to confidentiality concerns. Estimates were compared with directly reported responses, and precision was assessed using the percentage relative efficiency (PRE).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The empirical estimates reflect the June\u2013August 2021 survey period in Punjab, Pakistan. Estimated outbreak prevalence was higher than directly reported prevalence in both urban and rural populations, indicating underreporting of infection. In urban areas, directly reported COVID-19 cases (10.5%) were lower than privacy-preserving estimates obtained using SRRM-I and SRRM-II (15.3% and 17.4%). In rural areas, directly reported cases (13.7%) were also lower than the corresponding estimates (16.7% and 19.5%). Vaccine hesitancy estimates were also higher under the privacy-preserving procedures (26.3% reported vs. 27.4% and 27.2%), although the difference was considerably smaller than for outbreak cases. All PRE values exceeded 100, indicating improved efficiency relative to the benchmark models. These findings suggest that conventional self-reporting underestimates sensitive public health outcomes, particularly where disclosure concerns are present.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Privacy-preserving SRRM frameworks can improve the estimation of sensitive public health outcomes, including outbreak underreporting and vaccine hesitancy. The advantage of the two-stage design was most pronounced for the more sensitive outcome, indicating that the truthful-reporting parameter should be matched to the perceived sensitivity of the outcome under study. In settings where respondents are reluctant to disclose health-related information, such methods can strengthen surveillance data quality and support more reliable public health planning and policy decisions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1854347","type":"journal-article","created":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T04:27:30Z","timestamp":1787804850000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Breaking barriers in health surveillance: privacy-preserving techniques for tracking vaccine hesitancy and disease outbreaks in Pakistan"],"prefix":"10.3389","volume":"14","author":[{"given":"Muhammad Imran","family":"Shahid","sequence":"first","affiliation":[{"name":"College of Political Science and Public Administration, Henan Normal University","place":["Xinxiang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Han","family":"Wanqu","sequence":"additional","affiliation":[{"name":"College of Political Science and Public Administration, Henan Normal University","place":["Xinxiang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Faiza","family":"Shah","sequence":"additional","affiliation":[{"name":"College of Political Science and Public Administration, Henan Normal University","place":["Xinxiang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kunpeng","family":"Ai","sequence":"additional","affiliation":[{"name":"College of Political Science and Public Administration, Henan Normal University","place":["Xinxiang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,27]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1064","DOI":"10.1177\/00491241251345463","article-title":"An optimal stratification method for addressing nonresponse bias in Bayesian adaptive survey design","volume":"55","author":"Ma","year":"2025","journal-title":"Sociol Methods Res"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1754","DOI":"10.1093\/jamia\/ocae148","article-title":"Impact of response bias in three surveys on primary care providers' experiences with electronic health records","volume":"31","author":"Hendrix","year":"2024","journal-title":"J Am Med Inf Assoc"},{"key":"B3","doi-asserted-by":"publisher","first-page":"1008","DOI":"10.1016\/j.jadohealth.2025.03.004","article-title":"Are adolescents sensitive about sensitive data? Exploring student concerns about privacy, confidentiality, and data use in health research","volume":"76","author":"Soneson","year":"2025","journal-title":"J Adolesc Health"},{"key":"B4","doi-asserted-by":"publisher","first-page":"20552076251343959","DOI":"10.1177\/20552076251343959","article-title":"Data privacy in healthcare: global challenges and solutions","volume":"11","author":"Conduah","year":"2025","journal-title":"Digit Health"},{"key":"B5","doi-asserted-by":"publisher","first-page":"2523","DOI":"10.1186\/s12889-024-19819-6","article-title":"Prevalence estimates for COVID-19-related health behaviors based on the cheating detection triangular model","volume":"24","author":"Hsieh","year":"2024","journal-title":"BMC Public Health"},{"key":"B6","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1186\/s12874-025-02702-2","article-title":"Evaluating the accuracy of survey data: a case study of COVID-19 vaccination rates in Germany","volume":"25","author":"von","year":"2025","journal-title":"BMC Med Res Methodol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"127346","DOI":"10.1016\/j.vaccine.2025.127346","article-title":"Timeliness and completeness of serial routine vaccinations among 8062 rural children in southwest China during the COVID-19 pandemic: a multi-stage stratified cluster sampling survey in 1094 villages","volume":"61","author":"Hu","year":"2025","journal-title":"Vaccine"},{"key":"B8","doi-asserted-by":"publisher","first-page":"841842","DOI":"10.3389\/fpubh.2022.841842","article-title":"COVID-19 vaccine hesitancy in Pakistan: a mini review of the published discourse","volume":"10","author":"Khalid","year":"2022","journal-title":"Front Public Health"},{"key":"B9","doi-asserted-by":"publisher","first-page":"326","DOI":"10.3390\/electronics14020326","article-title":"A randomized response framework to achieve differential privacy in medical data","volume":"14","author":"Ioannidis","year":"2025","journal-title":"Electronics"},{"key":"B10","doi-asserted-by":"publisher","first-page":"17138","DOI":"10.1038\/s41598-025-02033-8","article-title":"Calibrated optional randomized response techniques for efficient and robust estimation of quantitative sensitive variables","volume":"15","author":"Audu","year":"2025","journal-title":"Sci Rep"},{"key":"B11","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12874-025-02692-1","article-title":"Utilizing stratified double response techniques in public health investigations to optimize privacy and efficiency via sensitive data estimation","volume":"25","author":"Shahid","year":"2025","journal-title":"BMC Med Res Methodol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"341","DOI":"10.1007\/s00184-009-0234-7","article-title":"Unbiased estimators of mean, variance and sensitivity level for quantitative characteristics in finite population sampling","volume":"71","author":"Huang","year":"2010","journal-title":"Metrika"},{"key":"B13","doi-asserted-by":"publisher","first-page":"800","DOI":"10.1177\/0049124119882469","article-title":"Zero-truncated binomial distribution as a randomization device","volume":"51","author":"Zapata","year":"2022","journal-title":"Sociol Methods Res"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e0293628","DOI":"10.1371\/journal.pone.0293628","article-title":"A comparative study of randomized response techniques using separate and combined metrics of efficiency and privacy","volume":"18","author":"Azeem","year":"2023","journal-title":"PLoS ONE"},{"key":"B15","doi-asserted-by":"publisher","first-page":"701","DOI":"10.1080\/09720510.2016.1142726","article-title":"Improved randomized response models in additive scrambling","volume":"19","author":"Shahid","year":"2016","journal-title":"J Stat Manag Syst"},{"key":"B16","doi-asserted-by":"publisher","first-page":"351","DOI":"10.2991\/jsta.d.191112.001","article-title":"Improved randomized response in optional scrambling models","volume":"18","author":"Hussain","year":"2019","journal-title":"J Stat Theory Appl"},{"key":"B17","doi-asserted-by":"publisher","first-page":"5967","DOI":"10.1080\/03610918.2020.1788587","article-title":"An improved randomized response model for simultaneous estimation of means of two quantitative sensitive variables","volume":"51","author":"Kumar","year":"","journal-title":"Commun Stat Simul Comput"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1595","DOI":"10.2147\/RMHP.S294731","article-title":"Study to alter the nuisance effect of non-response using scrambled mechanism","volume":"14","author":"Singh","year":"2021","journal-title":"Risk Manag Healthc Policy"},{"key":"B19","first-page":"165","article-title":"Variance estimation using randomized response technique","volume":"18","author":"Gupta","year":"2020","journal-title":"Revstat Stat J"},{"key":"B20","doi-asserted-by":"publisher","first-page":"633","DOI":"10.1007\/s00362-009-0273-1","article-title":"A class of estimators for quantitative sensitive data","volume":"52","author":"Diana","year":"2011","journal-title":"Stat Pap"},{"key":"B21","doi-asserted-by":"publisher","first-page":"4034","DOI":"10.1080\/03610926.2011.638427","article-title":"Generalized scrambling in quantitative optional randomized response models","volume":"42","author":"Gupta","year":"2013","journal-title":"Commun Stat. Theory Methods"},{"key":"B22","doi-asserted-by":"publisher","first-page":"506","DOI":"10.1080\/15598608.2017.1415175","article-title":"A unified measure of respondent privacy and model efficiency in quantitative RRT models","volume":"12","author":"Gupta","year":"2018","journal-title":"J Stat Theory Pract"},{"key":"B23","doi-asserted-by":"publisher","first-page":"2727","DOI":"10.1080\/03610918.2021.1914092","article-title":"A mixture binary RRT model with a unified measure of privacy and efficiency","volume":"52","author":"Lovig","year":"2023","journal-title":"Commun Stat Simul Comput"},{"key":"B24","doi-asserted-by":"publisher","first-page":"19913","DOI":"10.1038\/s41598-023-45427-2","article-title":"Efficient estimation of population variance of a sensitive variable using a new scrambling response model","volume":"13","author":"Saleem","year":"2023","journal-title":"Sci Rep"},{"key":"B25","doi-asserted-by":"publisher","first-page":"e35852","DOI":"10.1016\/j.heliyon.2024.e35852","article-title":"A new unified measure for evaluation of randomized response techniques","volume":"10","author":"Azeem","year":"2024","journal-title":"Heliyon"},{"key":"B26","volume-title":"Does School Matter for Early Childhood Education? Assessing Cognitive and Wider Development of Children in the Province of Punjab, Pakistan and State of Gujarat, India","author":"Siddiqui","year":"2022"},{"key":"B27","doi-asserted-by":"publisher","first-page":"13882","DOI":"10.1002\/mma.9295","article-title":"Using the exponential function of scrambling variable in quantitative randomized response models","volume":"46","author":"Azeem","year":"2023","journal-title":"Math Methods Appl Sci"},{"key":"B28","first-page":"71","article-title":"A sprightly mathematical model in the presence of scrambled responses","volume":"16","author":"Bhat","year":"2025","journal-title":"Int. J. Nonlinear Anal. Appl"},{"key":"B29","doi-asserted-by":"publisher","first-page":"3617","DOI":"10.3390\/math12223617","article-title":"A ratio estimator for the mean using a mixture optional enhance trust (MOET) randomized response model","volume":"12","author":"Gupta","year":"2024","journal-title":"Mathematics"},{"key":"B30","doi-asserted-by":"publisher","first-page":"1337","DOI":"10.1007\/s00125-019-4905-2","article-title":"Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials","volume":"62","author":"Jenum","year":"2019","journal-title":"Diabetologia"},{"key":"B31","doi-asserted-by":"publisher","first-page":"127","DOI":"10.53391\/mmnsa.2022.011","article-title":"An efficient application of scrambled response approach to estimate the population mean of the sensitive variables","volume":"2","author":"Zahid","year":"2022","journal-title":"Math Model Numer Simul Appl"},{"key":"B32","doi-asserted-by":"publisher","first-page":"1261","DOI":"10.1007\/s11336-024-10000-x","article-title":"Modeling evasive response bias in randomized response: cheater detection versus self-protective no-saying","volume":"89","author":"Sayed","year":"2024","journal-title":"Psychometrika"},{"key":"B33","doi-asserted-by":"publisher","first-page":"1759","DOI":"10.1186\/s12889-021-11814-5","article-title":"Population preferences and attitudes towards COVID-19 vaccination: a cross-sectional study from Pakistan","volume":"21","author":"Tahir","year":"2021","journal-title":"BMC Public Health"},{"key":"B34","doi-asserted-by":"publisher","first-page":"2299","DOI":"10.1186\/s12889-022-14553-3","article-title":"COVID-19 vaccination acceptance in underserved urban areas of Islamabad and Rawalpindi: results from a cross-sectional survey","volume":"22","author":"Kazmi","year":"2022","journal-title":"BMC Public Health"},{"key":"B35","doi-asserted-by":"publisher","first-page":"1112","DOI":"10.1186\/s12889-023-15905-3","article-title":"COVID-19 vaccine hesitancy and attitudes in Pakistan: a cross-sectional phone survey of major urban cities","volume":"23","author":"Khan","year":"2023","journal-title":"BMC Public Health"},{"key":"B36","doi-asserted-by":"publisher","first-page":"1583","DOI":"10.3390\/vaccines10101583","article-title":"Assessment of attitudes and intentions towards COVID-19 vaccines and associated factors among general populations of Pakistan: a cross-sectional study","volume":"10","author":"Khattak","year":"2022","journal-title":"Vaccines"},{"key":"B37","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1186\/s12879-023-08305-w","article-title":"COVID-19 vaccine hesitancy and social contact patterns in Pakistan: results from a national cross-sectional survey","volume":"23","author":"Quaife","year":"2023","journal-title":"BMC Infect Dis"},{"key":"B38","doi-asserted-by":"publisher","first-page":"1661379","DOI":"10.3389\/fpsyg.2025.1661379","article-title":"The impact of work concerns on teaching effectiveness: a structural equation modeling and multiple regression analysis in Chinese private universities","volume":"16","author":"Liang","year":"2025","journal-title":"Front Psychol"},{"key":"B39","doi-asserted-by":"publisher","first-page":"703","DOI":"10.3390\/app15020703","article-title":"Quaternion-based fast SMC\u2013PD cross-domain tracking control for coaxial hybrid aerial\u2013underwater vehicle under oceanic disturbances","volume":"15","author":"Lu","year":"2025","journal-title":"Appl Sci"},{"key":"B40","first-page":"533","article-title":"The evolution of sensitive data estimation: dual response frameworks for enhanced privacy","volume":"14","author":"Honghe","year":"2026","journal-title":"Liberte J"},{"key":"B41","first-page":"547","article-title":"The future of sensitive data estimation: Privacy-preserving dual response models for reliable results","volume":"14","author":"Wanqu","year":"2026","journal-title":"Liberte J"},{"key":"B42","doi-asserted-by":"publisher","first-page":"53839","DOI":"10.1038\/s41598-026-53839-z","article-title":"Leveraging randomized response frameworks to enhance sensitive data acquisition: implications for data regarding public health","volume":"16","author":"Shah","year":"2026","journal-title":"Sci Rep"},{"key":"B43","doi-asserted-by":"publisher","first-page":"30929","DOI":"10.1038\/s41598-024-81579-5","article-title":"Understanding the impact of COVID-19 on quality of life using surveys and Mendelian randomization","volume":"14","author":"Jiang","year":"2024","journal-title":"Sci Rep"},{"key":"B44","doi-asserted-by":"publisher","first-page":"e139881","DOI":"10.5812\/jjcdc-139881","article-title":"Effect of COVID-19 and air pollution on the risk factors attributed to COPD, cardiovascular, and respiratory diseases","volume":"13","author":"Nikmanesh","year":"2024","journal-title":"Jundishapur J Chronic Dis Care"},{"key":"B45","doi-asserted-by":"publisher","first-page":"301","DOI":"10.1007\/s40620-024-02161-w","article-title":"mRNA vaccine against SARS-CoV-2 response is comparable between patients on dialysis and healthy controls after adjustment for age, gender and history of COVID-19 infection","volume":"38","author":"Rostoker","year":"2024","journal-title":"J Nephrol"},{"key":"B46","doi-asserted-by":"publisher","first-page":"700","DOI":"10.3390\/v13040700","article-title":"Long-COVID and post-COVID health complications: an up-to-date review on clinical conditions and their possible molecular mechanisms","volume":"13","author":"Silva Andrade","year":"2021","journal-title":"Viruses"},{"key":"B47","doi-asserted-by":"publisher","DOI":"10.1101\/2024.02.21.24303099","article-title":"Modeling the relative influence of socio-demographic variables on post-acute COVID-19 quality of life","author":"Menkir","year":"2024","journal-title":"medRxiv"},{"key":"B48","doi-asserted-by":"publisher","first-page":"e13949","DOI":"10.1111\/jsr.13949","article-title":"Pre-existing sleep problems as a predictor of post-acute sequelae of COVID-19","volume":"33","author":"Schilling","year":"2024","journal-title":"J Sleep Res"},{"key":"B49","doi-asserted-by":"publisher","first-page":"1382","DOI":"10.3390\/vaccines11081382","article-title":"Impact of a COVID-19 outbreak in an elderly care home after primary vaccination","volume":"11","author":"Mauriz","year":"2023","journal-title":"Vaccines"},{"key":"B50","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1186\/s12982-025-00695-3","article-title":"Estimating the local-level child full polio vaccination rates in Ethiopia using a hierarchical Bayes small area estimation approach","volume":"22","author":"Yilema","year":"2025","journal-title":"Discov Public Health"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1854347\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T04:27:32Z","timestamp":1787804852000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1854347\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,27]]},"references-count":50,"alternative-id":["10.3389\/fpubh.2026.1854347"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1854347","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,27]]},"article-number":"1854347"}}