key: cord-0969939-30xbx3ym
authors: Varma, Deepthi S.; Young, Mary E.; Kreider, Consuelo M.; Williams, Katherine; Vaddiparti, Krishna; Parisi, Christina; Semeah, Luz M.
title: Practical Considerations in Qualitative Health Research During the COVID-19 Pandemic
date: 2021-09-25
journal: Int J Qual Methods
DOI: 10.1177/16094069211043755
sha: 6965b99b06d872a1f16cab6574adfa80efdfda77
doc_id: 969939
cord_uid: 30xbx3ym

The COVID-19 pandemic has forced both quantitative and qualitative health researchers to adapt and strategize data collection strategies without causing any harm to the participants or researchers. This has resulted in utilizing various types of strategies such as online surveys and synchronous virtual platforms such as Zoom and Webex. This transition from face-to-face to synchronous online platforms has helped in increasing coverage as well as reaching participants who are otherwise unreachable. While quantitative health researchers seem to have made a seamless transition to synchronous online platforms, qualitative health researchers who rely on studying participants in their “real-world-settings” are facing unique challenges with online data collection strategies. This article critically examines the benefits and challenges of implementing qualitative health research studies via synchronous online platforms and provides several practical considerations that can inform qualitative health researchers. It can also assist Institutional Review Board members in reviewing and implementing qualitative health research study protocols in a manner that preserves the integrity, richness, and iterative nature of qualitative research methodology.

Qualitative research is a process of understanding and discovery based on distinct methodological traditions of inquiry that explore social or human experiences. The researcher analyzes words and text, reports detailed views of informants, builds a complex, holistic picture of a phenomenon, and conducts the study in a natural setting (Miles et al., 2020) . The researcher has greater control over the "instrument" for data collection since he or she will modify the questions based on participants' verbal responses and non-verbal behaviors (Agee, 2009; Cresswell, 2007) . Qualitative health research (QHR) is a specialized form of qualitative research that focuses on peoples' experiences with health, illness, healthcare system, and healthcare practice, whereby patients' particular needs regarding privacy and emotionality are taken into account within the research methodology (Morse, 2011) .

As pragmatists (Patton, 2002) and "bricoleurs" (Denzin, 2010) , health researchers have always risen to the challenge of continuing timely and critical studies to impact the health of individuals and communities. An extensive literature review of published articles showed that qualitative health researchers have long been utilizing synchronous and asynchronous online methods to conduct qualitative research. These methods included telephone interviews, e-mails, online chat rooms, Skype interviews, and online meeting rooms (Cater, 2011; Janghorban et al., 2014; Kenny, 2005; Murray, 1995 Murray, , 1997 Sah et al., 2020; Turney & Pocknee, 2005; Tuttas, 2015) . Several of these researchers have also reported on the challenges and benefits of these online platforms. However, the COVID-19 pandemic has forced qualitative health researchers to rapidly adapt their tried and true in-person methods and to explore, innovate, and quickly overcome challenges posed by use of the various available video-conferencing technologies in conducting QHR via synchronous online platforms.

During the last year, to accommodate the pandemic-posed social distancing and other restrictions, researchers began migrating to fully online data collection methods such as virtual focus groups, remote interviews, and online self-report measures and surveys. These strategies seem to be working effectively for quantitative researchers. In the case of survey research, the now commonplace use of online platforms has reduced the burden of traditional barriers to research participation such as travel to the research site, finding childcare, and working around work and/or school schedules.

The use of online technologies has increased anonymity and provided participants the opportunity of responding to a survey at their own leisure and convenience. However, qualitative researchers have found it more difficult to effectively transition methods to an online platform. These researchers agree with the quantitative researchers on the benefits of an online or a remote interface platform; however, qualitative researchers are struggling to adapt and apply the core principles of qualitative research such as integrity and richness in the virtual world. Previous reports on online qualitative health research strategies such as online focus group discussions via synchronous and asynchronous interviewing have reported benefits such as increased coverage of otherwise hard-to-reach populations, opportunity for participants to participate from the comfort of their homes, decreased peer pressure in providing socially desirable responses, and increased flexibility. These reports have also highlighted several challenges such as difficulty observing and recording non-verbal cues from participants, controlling respondent's environment to reduce noise, eliminating distractions, ensuring privacy, and limitations due to the degree of digital literacy of participants during synchronous qualitative data collection (Cater, 2011; Janghorban et al., 2014; Kenny, 2005; Sah et al., 2020; Turney & Pocknee, 2005; Tuttas, 2015) .

At present, in the era of the COVID-19 pandemic and required social distancing, there is an absence of any clear guidelines and practical tips for conducting online QHR. This article is the product of a reflective process and ongoing discussions among the authors, a group of interdisciplinary qualitative health researchers who are members of a regularly scheduled Qualitative Research Colloquium at the Health Science Center of a large public university in the United States.

The methodological decisions described in this article were made in the context of permission from the Institutional Review Board (IRB) to make rapid changes so long as researchers protected the integrity of the research process and maintained the safety and informed consent of participants. The authors, based on their own experiences and extensive literature review, have engaged in ongoing reflective and critical examination of the benefits and challenges of conducting QHR via remote, online environments. This article presents practical considerations that can inform both qualitative researchers and IRB members to review and implement qualitative research protocols in a manner that will preserve the integrity, richness, and iterative nature of qualitative research methodology. We will start by examining the benefits and challenges of implementing a QHR study via an online environment.

As noted in several previous studies, online interviews and focus groups reduce the burden on the participants by allowing them to participate from the comfort of their own homes in a safe environment (Sah et al., 2020; Turney & Pocknee, 2005; Tuttas, 2015) . They need not worry about transportation to the research site and/or securing childcare during the time that they spend with the researchers (Kenny, 2005) . Another advantage from the participants' perspective is their ability to control their anonymity by turning off the video camera, if available, during online interviews or focus group discussions, and/or by using a pseudonym for their on-screen name. This anonymity may provide increased confidence to discuss or disclose information without the fear of being judged by researchers or other participants (Kenny, 2005) . Previous online qualitative studies also have described a lesser degree of "social loafing," or a "synergistic bandwagon effect" compared to a face-to-face focus group discussion (Kenny, 2005; Tuttas, 2015) . This is especially important while researching areas such as HIV/AIDS, substance use, sexual abuse, mental health, or health behaviors. In addition to providing a virus-safe distancing environment, online focus groups may also assist the researchers by increasing the geographical coverage of their participants (Sah et al., 2020) . It helps the researchers to include rural populations and those who live in communities with internet and technology access but are geographically distant from the research site or culturally and linguistically different from the research institutions' culture and language. Expanding abilities to capture diverse perspectives and experiences serves to make the sample more inclusive and the findings more transferable, thus potentially increasing the impact of the studies on social justice.

Finally, online formats may provide a clearer flow of information during focus group discussions, with less cross-talk and participants talking over each other. While we have observed fewer interruptions, arguments, or counter arguments in the online focus group environment, as in previous studies there does appear to be a greater opportunity for participants to provide well-thought-out responses (Kenny, 2005; Turney & Pocknee, 2005; Tuttas, 2015) . It is as if participants' familiarity with remote conferencing technology and accompanying netiquette (e.g., muted microphones and use of chat function to prompt topical shifts) is translated to a perceptively more orderly nature of the online focus groups. However, the mute function also works to mute out participants' immediate agreements, rebuttals, and social conventions for indicating the listener's engagement (e.g., the "uh hum"s). This requires the researcher to be especially attentive to visual cues such as head nods and facial grimaces in response to the dialog.

We have observed that many focus group participants use the long pauses between their own verbal contributions to listen while simultaneously formulating their own response to the original prompt-which, when finally articulated are often notably well thought out. While the online format seems to elicit richer verbal responses than in face-to-face discussions, there is a notably dampened pace and emotional tone to the focus group discussions that, for some participants, can actually foster better "following along." The more orderly nature of the online focus groups requires a slightly different skill set from the facilitator-one that seems more akin to skills required of a panel moderator who must direct or set ground rules for when it is a panelist's turn to speak. Due to the reduction or absence of non-verbal cues and different responsiveness as described above, more attention and concentration may be required from facilitators and co-facilitators during data collection for these focus groups.

Privacy and confidentiality of the information shared by participants from their home with the researcher is a significant challenge for qualitative health researchers whose area of research include HIV/AIDS, sexual abuse, substance use, mental health, stigma, and other sensitive topics. While the presence of other family members in the same room or in close proximity may be discouraged, ultimately, such privacy isfor the most part-out of the researcher's control. Breach of confidentiality may be a higher risk when participants are in the comfort of their home environment, as participants might disclose-or others might overhear-what is being discussed. These issues should be addressed in the informed consent process. Other types of distractions, such as children or family members requiring attention, pets appearing and interrupting, phones ringing, delivery persons or visitors coming to the door, or a myriad of other diversions that are less frequent during a face-to-face setting but commonplace at home, will not be able to be controlled by the researchers when remoting into the participant's environment. These distractions could not only interrupt the flow of discussions, but also could prolong the duration of the interview or discussions.

Moreover, several social and personal elements of the interviews are lost in the absence of face-to-face interactions with the participant during the interviewing process. A qualitative researcher gains meaningful insights from the appearance of the participants, and by observing and recording the non-verbal cues and non-verbal behaviors of individual participants and between the participants (Denham & Onwuegbuzie, 2013; Morgan, 1993) . Online or telephone research without a video camera prevents the researcher from making these observations and capturing cues of their behaviors. Even when a video camera is used, the viewing range is restricted and does not provide the researcher the full context. Though taken for granted, such cues provide important insights into understanding the problem that is being researched (Denham & Onwuegbuzie, 2013) . Additionally, an online interview also sometimes limits reciprocal discussions amongst participants. Several of these shortcomings could be significantly improved by encouraging participants to speak with and respond to all members in the group. However, this will require a skilled qualitative researcher who is cognizant of the limitations of an online focus group discussion and can provide clear guidance on rules of interaction and the order and manner of contributing to the discussions.

Last, when conducting online focus groups or interviews, technological challenges such as availability of equipment, internet service limitations, and hesitation in using new platforms may arise; this might be particularly, but not exclusively, the case with participants from rural or low resource communities. The potential for technology barriers must be prepared for in any online exchanges. Researchers must solve problems on the fly, and monitor the chats for participants with bandwidth, cellular connection, or internet stability problems. Researchers must facilitate the use of textual contributions or call-in functions by participants who do not have adequate bandwidth to use the video function. At times, without the availability of additional research personnel, the focus group facilitator becomes responsible for moderating the discussion while simultaneously monitoring for and eliciting contributions via textual chat as well as providing technical support to participants. Having a co-facilitator or research staff available to manage the logistics of problems with signing in, audio/ video problems, accompanying demographic questionnaires, and compensation distribution, can be most helpful. Additionally, exclusive dependence in an online format could result in the systematic elimination of certain groups of people such as older adults, those less educated, and those who reside in rural areas from research studies. As such, researchers must be careful to mitigate as best as possible such a "digital divide," which could exacerbate already existing health disparities.

Based on the novel and varied experiences obtained while conducting virtual qualitative research studies by the diverse group of authors of this article, below are some pointers that need to be considered by the researchers and the IRB members who review and approve QHR study protocols.

1. The responsibility of researchers to "do no harm" has long been a tenet of ethical research (Kostovicova & Knott, 2020) . Therefore, the qualitative health researcher should ensure privacy and confidentiality by emphasizing that the online interview or focus group be conducted in a private room, to reduce distraction and minimize the chances of others overhearing the conversation with the researcher. Participants could also be provided with a list of best practices, ahead of the research interview, that would minimize distractions and increase privacy. This is especially important in health research studies that collect protected health information and discuss sensitive topics. 2. A welcome page, as recommended by previous studies (Fox et al., 2007) , or at least the creation of a presentation slide, is strongly encouraged where the participants are provided the title and a brief abstract explaining the goals of the study. This could assist the participants to have a clearer understanding of the study as they are waiting for other participants to join the forum. 3. Whenever possible, the researchers must encourage the participants to turn on the camera during the research study. This would help the researchers observe and record the respondent's facial expressions and verbal behaviors as they normally do in an in-person group discussion or interview. 4. The qualitative research study design must explicitly state how the researchers will ensure recruiting people who may not have access or the technical know-how to participate in an online research study. This is important for ensuring representativeness and to avoid increasing the already existing "digital divide" resulting from the disparities in infrastructure, skills, and usage patterns in the communities being studied (Hargittai & Hinnant, 2008) . Lack of attention to these details could also contribute to increasing the health disparity that currently impacts many communities. 5. Researchers should ensure trustworthiness, especially during the time of COVID-19, since many community members are more reluctant to share personal information online with a researcher than during a face-toface interaction. Privacy and confidentiality can be ensured by conducting interviews by sending a link with a passcode to the participant to sign in and establishing a strong rapport by explaining the safeguards before starting the discussions. 6. Researchers must be flexible in their approach since the interview or the data collection session could be interrupted by several technological issues such as poor internet connection, or loss of audio or video. The researcher should be prepared to employ strategies, such as slowing the cadence of their speech or directing participants to communicate via the "chat" function, or utilize the call-in function to ensure preservation of the verbal communications during times when bandwidth is insufficient to support smooth and synchronized audio and visual communications. This is especially important if the researcher is recording the interviews for later transcription and analysis. 7. Most importantly, online interactions do not necessarily allow development of a strong rapport-as is easier to foster with in-person face-to-face interactions-during the brief duration of the synchronous remote interactions. Previous studies have shown that even with extensive preparation before the interviews, each interview is unique and unpredictable; we cannot foresee how the researcher-participant relationship will develop and how this will impact the knowledge we generate (Swauger, 2011; Tuttas, 2015) . Therefore, it is important for all researchers to scale down their expectations regarding what can and cannot be achieved through an online platform. Research protocols and data collection plans need to be developed in consideration of this reality. 8. The circumstances of the COVID-19 pandemic reinforce the need for establishing and maintaining a constant back and forth dialog with the IRB who can serve as an important resource to help ensure the procedures being considered continue to uphold the integrity of the research process and maintain the safety and informed consent of participants. 9. Finally, the researchers should be aware of limitations to providing adequate emotional support to online participants if they strongly experience emotions such as fear, sadness, or anger (Corbin & Morse, 2003) . Researchers should be extra vigilant in detecting any type of distress among the participants and should have a plan of addressing any observed distress articulated in the research protocol. Delving deeply into certain sensitive topics such as deviant or illegal activities that expose the vested interests of powerful persons or persons engaged in coercive, violent, or domineering behaviors, abusive behaviors, and certain religious rituals and practices could arouse powerful emotions among participants. Lack or reduction of reciprocity in an online format could leave the participant uncomfortable and unsupported during or after the interview. These limitations need to be highlighted and addressed in the research protocol, informed consent document, and IRB approval process.

This article aims to highlight several key points to be considered while planning and conducting QHR studies on an online or virtual platform. Health research studies cannot be paused or postponed during a pandemic without important mortality and morbidity implications for the communityimplications that stem from interruptions or a lack of new findings regarding health care and interventions. Many qualitative research methods such as focus group discussions and indepth interviews are frequently conducted as part of pilot studies by quantitative researchers. As such, pausing these research efforts can hinder the start and completion of many types of studies. The COVID-19 pandemic has made us aware of the unpredictability of world events which can force us to think out of the box. As researchers, while we can prepare for several uncertainties, it is important for qualitative health researchers to be prepared to improvise or re-strategize the research process according to the context so that we can continue doing timely, effective, and impactful health research.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Deepthi S. Varma  https://orcid.org/0000-0003-1163-0377

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