Feasibility and Ethical Considerations for Conducting Online versus In-person Interviews for a Qualitative Study

The COVID-19 pandemic has had a significant impact on the field activities of researchers.[1] While many researchers have had to pause their on-site research activities for an unknown period, others decided to modify their research methodologies through ‘moving research online’ and using online platforms to conduct surveys and interviews to accommodate physical distancing.[2] In particular, the use of online interviews grew substantially during the pandemic, with video conferencing often regarded as the most feasible and cost-efficient alternative to in-person interviews.[3] In the wake of the pandemic, much of the evidence on the use and benefits of online interviewing with patient participants comes from high-income countries.[4-9] While evidence from low- and middle-income countries (LMICs) suggests that conducting online interviews with providers and program stakeholders is feasible,[10,11] there is limited evidence on using online interviews for patient participants and key informants due to a number of practical, ethical and privacy concerns.[12] Carter etal. also emphasise the significance of attending ethical, technical and social considerations in online qualitative research.[2] Reñosa etal. caution that online qualitative research may pose challenges to accessing and enrolling participants from areas where telephone or internet access is limited.[9] Thus, the concept of ‘moving qualitative research online’ is sometimes not feasible in LMICs and requires researchers to explore alternatives. Cooper, James and Busher research suggests that online interviews offer methodological flexibility in social science research, but they caution that this approach should not be seen as an ‘easy option’. Instead, it should be chosen only when researchers can justify its suitability for their particular studies.[13,14] In one of our qualitative research projects, we conducted and analysed 36 semi-structured in-person interviews with 15 pregnant women at high risk for pre-eclampsia and 21 key informants, including clinicians, nurses, maternal, neonatal and child health specialists and digital health experts. The aim was to explore perceived needs, requirements and preferences for designing a telemonitoring program in Pakistan. The protocol for the needs assessment study was published in BMC Reproductive Health.[15] The findings of the study have been recently published in JMIR formative research.[16] The study received approval from the Aga Khan University Ethical Review Committee (2020-2153-8519), the Institutional Review Board of Jinnah Postgraduate Medical Centre (44379) and the University of Toronto Research Ethics Board (30635). The interview transcripts were analysed using the conventional content analysis. Participants were receptive to the telemonitoring programme, recognizing numerous benefits such as early detection of pregnancy complications, timely treatment, convenience, cost-effectiveness, an enhanced sense of control over their health care, improved continuity of care and a reduction in clinical workload. One of the limitations of this study is that it involved in-person interviews with patient participants at the hospital during the pandemic. This commentary contributes to an emerging evidence base by reflecting on this qualitative research project to highlight practical, ethical and privacy considerations associated with conducting online qualitative interviews with beneficiaries in LMICs. It will also draw upon our experience of conducting in-person patient interviews in Pakistan during the pandemic to highlight challenges and mitigation strategies associated with safely conducting in-person qualitative interviews in LMICs during a pandemic. Rather than presenting guidelines, this commentary seeks to spark an essential conversation amongst public health scholars, practitioners and qualitative researchers grappling with the challenges of conducting online qualitative interviews with patient participants from LMICs during the pandemic. Practical, Ethical and Privacy Considerations Social science researchers often do not prefer online interviewing for various reasons: It offers limited opportunities to build strong rapport and relationships with the study participants;[17] graduate students and early career researchers are unable to gain first-hand experience of fieldwork, which provides essential insights that cannot be captured through online methods;[3,18] it is more challenging when researching sensitive topics with vulnerable participants;[18] and it has ethical implications, as online interviews tend to hinder patient privacy and confidentiality.[13,19] Although online interviews in LMICs share many of these general challenges, several additional challenges of online qualitative research exist that are unique to the LMIC context. There is limited research that thoroughly examines the practical, ethical and privacy issues involved in designing and conducting virtual qualitative research.[3] First, inadequate technological infrastructure and limited access to technology in LMICs present practical challenges for conducting online qualitative research with patient participants. Irani etal. and O’connor etal.’s studies articulated that researchers face difficulty in setting up online interviews with participants with poor access to technological infrastructure.[20,21] The limited access to digital technologies amongst patient participants in LMICs is sometimes compounded by sociocultural barriers which can impact the inclusion of participants who are women, such as patriarchal family systems, resistance from family members to participants’ use of technology and other cultural norms that hinder women from accessing the required digital technology and their ability to decide to participate.[22] In our qualitative study on exploring high-risk pregnant women’s needs and preferences regarding telemonitoring, online interviews were not feasible since most pregnant women did not have individual access to mobile phones due to cultural norms (i.e. men-owned and carried mobile phones). Our prior field experience highlighted the necessity of in-person interactions in such contexts, where cultural norms and technological limitations impede online engagement. It was anticipated that pregnant women in our study would face difficulties in participating in online qualitative interviews due to these socio-cultural constraints. In such instances, some qualitative researchers might find it feasible to train local staff who can conduct the research and provide a data set for analysis. Second, the lack of access to online technologies and limited digital competencies amongst patient participants raises ethical and equity considerations for online qualitative research. Although online interviews can help overcome geographical isolation and support disadvantaged groups, they can also inadvertently exclude those who lack access to the necessary technology. Moreover, the remote recruitment method can unfairly exclude individuals with limited ability to use online technologies and impose significant burdens and stress on patient participants who feel inexperienced with technology.[2] In addition, securing informed consent for online interviews can be difficult, as researchers must account for the participant’s access to and proficiency with the technology necessary to submit a signed consent form remotely.[23,24] Furthermore, the online consent-taking process does not allow two-way communication between the researcher and the participant, which is particularly important for participants with low literacy who require the researcher to read the consent form and answer questions in real time.[23] In our fieldwork experience, we found that in-person consent procedures were crucial in ensuring participants fully understood their rights and the study’s purpose, which was often compromised in online settings. The involvement of local stakeholders might benefit in designing ethical clearance forms using a co-designing approach and obtaining clearances from at-risk populations. In our qualitative needs assessment study, pregnant women had limited capacity to provide consent through online modalities. Considering equity issues in online qualitative research, our study conducted in-person interviews with pregnant women to enable the inclusion of pregnant women who lack access to online modalities and have limited digital literacy. Carter etal.’s practical application paper on ‘conducting online qualitative research’ also emphasises that equity should be a key consideration in online qualitative research, as online methods can enhance participation opportunities for some while excluding others.[2] Third, the pandemic raises several privacy considerations for conducting online interviews with at-risk patient participants in LMICs.[13] Ensuring patients’ privacy and confidentiality during online interviews is challenging because at-risk patients would likely be participating in the interviews from their own homes.[25] Carter etal.’s paper highlights that online qualitative interviews introduce unique privacy risks, such as researchers potentially observing and hearing participants’ domestic environments and the use of various communication platforms requiring profile information, which can compromise participants’ anonymity.[2] Our experience in the field during the pandemic underscored the importance of privacy in research, as many participants felt uneasy sharing sensitive information from their homes. In our qualitative needs assessment study, online interviews were not possible since high-risk pregnant women lacked private spaces for participating in virtual interviews. Based on the prior field experience, it was anticipated that high-risk pregnant women would likely be participating in the online interviews from home and may feel uncomfortable sharing their perspectives due to privacy issues. The Experience of Conducting In-person Patient Interviews Our decision to conduct in-person qualitative interviews with pregnant women was shaped by the above challenges associated with online qualitative research in LMICs. While in-person interviews with pregnant women provided an opportunity to address many of the above-highlighted challenges, the prospect of conducting in-person patient interviews during a pandemic presents its own set of challenges. These include difficulties related to on-site recruitment of patient participants due to pandemic restrictions, the inability to involve caregivers in patient participant interviews and the risk of exposing high-risk pregnant women to the COVID-19 virus during in-person interviews at the hospital. These three challenges are discussed below in the context of our research study. For our study, we originally intended to have the research coordinator present in a very busy public sector hospital to recruit pregnant women for in-person interviews, but this was found to be impossible due to the pandemic restrictions. Instead, hospital nurses were asked to assist in identifying and recruiting eligible pregnant women for in-person interviews. Once a potential participant was identified, the nurses contacted the research coordinator, who then promptly visited the clinic to obtain consent and conduct the in-person interviews. A similar strategy was used by Namageyo–Funa etal. for in-person recruitment for hard-to-reach participants and involved a gatekeeper to facilitate the identification of potential participants from the patient waiting area while they waited for several hours to see their health care provider.[26] Our study intended to involve caregivers during patient interviews to capture their perspectives on the perceived requirements of a telemonitoring program for pregnant women at high risk for pre-eclampsia.[27] However, due to COVID-19 visitation restrictions, it was not possible to involve caregivers during patient participant interviews. Janesick’s methodological paper on ‘choreography of qualitative research design’ suggests that ‘the qualitative researcher must be ready to reschedule schedules and interview times, add or subtract observations or interviews, and even rearrange terms of the original agreement’.[28] Our team rearranged the terms of the original research protocol and did not involve caregivers during patient interviews to adhere to COVID-19 precautions. However, our study acknowledged this limitation and recognised that caregiver involvement would have benefited this qualitative inquiry in several ways, including an understanding of the shared narrative about pregnant women’s needs and preferences for the telemonitoring program. Finally, to help mitigate the risk of exposing pregnant women to COVID-19 during in-person interviews, the interviews were conducted with eligible pregnant women only if they were visiting the hospital for their regular antenatal visits.[13] However, this still resulted in the pregnant women spending extra time at the hospital, which could have increased their risk of contracting COVID-19. While the hospital had guidelines for safely providing clinical care during COVID-19, there were no specific guidelines for conducting research activities in the clinical setting amid COVID-19. To ensure the safety of both patient participants and the research coordinator during in-person interviews, pregnant women and the research coordinator were provided with all recommended personal protective equipment, including face masks and shields, hand sanitizers, gloves and gowns, to minimise the risk of COVID-19 transmission during data collection. In addition, the in-person patient interviews were conducted in a separate room near the hospital outpatient area, to ensure physical distancing and patients’ privacy and confidentiality during interviews.[13] Conclusion In shifting to online qualitative research, public health researchers must be sensitive to the practical, ethical and privacy considerations associated with conducting online interviews during a pandemic. Our adaptations to qualitative methods might prove useful for other researchers who are interested in conducting qualitative studies with patients in LMICs, especially during a pandemic. This commentary serves as a call for careful reflection on the impact of equity issues and bias during online qualitative research which can arise due to technological or socio-cultural circumstances of patient participants, as well as on how to mitigate safety concerns during in-person interviews. Future research should be conducted to explore alternatives to online qualitative interviews for particular patient groups to address challenges that are unique to the LMIC context. In addition, there is a need to develop guidelines and best practices related to when and how to conduct online and in-person qualitative interviews amid outbreaks in LMICs to support qualitative researchers in reshaping their projects and methodologies. While the focus of this piece is on LMICs, many of these insights may have implications for other resource-limited settings where in-person interviews seem to be the only option. Data availability statement All data relevant to the study are included in the article. Ethics approval The work was approved by the Aga Khan University ethical review committee (2020-2153-8519), the Jinnah Post Graduate Medical Center institutional review board (44379) and the University of Toronto research ethics board (30635).

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