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      Implementation of virtual focus groups for qualitative data collection in a global pandemic

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          Abstract

          Introduction The outbreak of the novel coronavirus disease 2019 (COVID-19) has emerged as a global health threat. COVID-19 has now infected over 20 million people and claimed more than 600,000 lives around the world. 1 These effects have had major repercussions on the healthcare system and revealed ethical dilemmas on resource allocation, 2 anti-Asian sentiment 3 and disproportionally higher mortality rates among African-Americans. 4 The conduct of patient-centered research, particularly those that require face-to-face interactions such as qualitative research, has also been significantly challenged. Focus groups are an important part of qualitative research and is a well-established method for collecting data to explore participants' opinions, experiences, and perspectives. 5 The hallmark of focus groups is to produce data and insights from a group interaction that would be less pronounced in an interview setting. Focus groups are traditionally organized as in-person discussions of a given topic with 6–8 participants and guided by an in-person moderator with audio-recordings for content analysis. Qualitative research is effective for exploring and understanding patient's perceived attitudes, beliefs and emotions regarding illness and healthcare experiences and its use has increased in surgical research. 6 As COVID-19 has forced social distancing, discouraged indoor meetings and reduced financial resources, the ability to conduct in-person focus groups has been questioned. Protocols for recruiting, consenting and working with participants, for example, have all been previously based on assumed in-person interactions. 6 The uncertainty of the duration of this pandemic and the requirements of safety for patients and moderators has forced a decision to adapt these protocols to this new environment or to cease all research activities. With the advent of technologies such a virtual and internet-based meeting platforms, an opportunity now exists to widen the boundaries for conducting qualitative research including with focus groups. According to the U.S. Census Bureau, 89% of American households have a computer with internet access capability. 7 The widespread adoption of technology now supports the potential conduct of virtual focus groups, which may benefit participants with geographical barriers to in-person participation. Early work with remote participants dispersed across Australia suggested that virtual focus groups using web-based video chat platform may be a potential tool to collect qualitative data. 8 Similar work in Sweden has also shown that focus group discussions held online are a feasible mode of qualitative data collection. 9 In the United States, these methods have mostly been described in asynchronous chat formats and virtual focus groups have been limited to small, non-minority and clinically narrow patient populations. 10 The feasibility of conducting virtual focus groups for minority participants and especially those after surgery remain unknown. In this manuscript, we aim to share our experience with the development and implementation of virtual focus groups for a minority surgical population. We will detail the steps for initiating virtual focus groups, describe how the recruitment/training process differs from in-person focus groups and review its advantages and disadvantages. Setup and implementation Before the recruitment process can begin, several adaptations must be made to transition from in-person focus groups to virtual focus groups (Fig. 1 ). First, the research team must decide which online platform will be used to host the virtual meetings. Our team decided to use Zoom (Zoom Video Communications, Inc., San Jose, CA), due its widespread use since the beginning of the pandemic. Based on its broad appeal, our team believed it likely that many participants would be familiar with this tool when approached by our recruitment team. Additionally, given the user-friendly design of the platform, we believed that first-time users could also be easily taught to use the program. Our institution also supports the use of Zoom, providing a professional license which allows unlimited meeting time, HIPAA compliant accounts and technology support. Secondly, adaptations for Institutional Review Board (IRB)-related processes must be made to assure protection of participants in research. This includes modifications of the consent forms, scripts and interview guides to specify that the meeting would be held virtually and that identities would be protected. Finally, written materials that are normally distributed during in-person focus groups for discussions must be prepared differently for virtual group participants. In our experience, this involved mailing material ahead of time for participant reviews and creating PDF files for screen share during the virtual focus groups. Fig. 1 Setup of virtual focus groups. Fig. 1 Similar to in-person focus groups, the recruitment of virtual focus groups starts with a list of potential participants. The recruitment calls, however, must include additional eligibility screener questions inquiring about access to technology. Once the patient agreed to participate, a consent form was then sent using DocuSign (DocuSign Inc., San Francisco, CA). Use of DocuSign has grown steadily in recent years, but the pandemic has led to an acceleration of these type of applications for remote signing and tracking. Similar to Zoom, our institution also supports this technology, allowing consent forms to be sent in a HIPAA compliant manner. Follow-up calls were then made to review the consent form and to provide additional information regarding the use of Zoom and the date of the meeting. We highlight the comparison between processes for in-person groups and virtual groups in Table 1 . Table 1 Design, recruitment, training, and implementation before and after virtual focus groups. Table 1 In-Person Virtual Design •6–8 participants per group•Moderators + co-moderator•Predetermined interview guide •3–4 participants per group•Moderator + co-moderator/tech support•Predetermined interview guide Recruitment •Participants contacted from list of surgical patients•Consent explained and signed at time of the session •Participants contacted from list of surgical patients•Consent explained over phone and sent via email•Must confirm internet and email access Training •Minimal participant training•Review rules with participants at time of focus group •“Zoom Etiquette” training•Instructions to join virtual focus group sent ahead of time•May require family member assistance with joining virtual focus group Implementation •Anonymous names chosen at beginning of the focus group•Written material used during focus groups distributed for discussion and feedback •Anonymous names chosen with each individual while other participants in virtual waiting room•Written material used during focus groups mailed to participants ahead of time and shared on screen share for discussion and feedback•Co-moderator acts as tech support managing wait room, change names, mute individuals For security reasons, all meetings were password protected and a unique invitation was sent to participants individually. At the time of the meeting, all attendees were first sent to a waiting room with a co-host. In the waiting room, the participant identity was confirmed, and their screen name was changed, allowing for confidentiality between participants. Policies for providing incentives to study participants also needed to be adapted. Our institution requires participants to complete and return a W-9 tax form in order to receive gift card incentives. The electronic W-9s were filed by the study coordinator once the participant shared their personal information in the virtual break room. Once all the attendees joined, the meeting was locked, providing an extra layer of security. Although all attendees were instructed to participate with their cameras turned on, the meetings were recorded using audio only, which preserves the identity of the participants while still allowing for acceptable data collection for qualitative analyses. The moderator then proceeded with the group, asking the appropriated questions and following the interview guide. After reaching the end of the questions, the co-host ended the meeting to all participants and the incentive was mailed to them on the following day. Moderator reflections The UAB Minority Health and Health Disparities Research Center (MHRC) was involved with all virtual focus groups at our institution. The MHRC has extensive experience conducting and moderating in-person focus groups but none with virtual focus groups prior to the pandemic. At first, the proposed transition to virtual groups generated concerns over the quality of discussion content that could be collected virtually. Existing literature, however, suggests that similar themes and quality of data are obtained in both online chat and in-person focus group discussions. 11 While our group did not directly compare the quality of virtual focus group discussions to in-person focus group discussions, our moderators did not perceive that any less information was shared in the virtual format when compared to their prior experiences. After conducting six virtual groups, our moderators felt that overall participants were more relaxed online, more eager to share their experiences, and more engaged during the meetings. The role of the primary moderator in facilitating the virtual focus group is similar to their role in leading in-person focus groups. It is the moderator who sets the context, drives the discussion and engages the participants in an interactive conversation. The moderator also creates the tone of the discussion, enabling all the participants to feel comfortable and involved. However, as potential technical and logistical issues are expected with virtual platforms, a co-moderator was required who had several new responsibilities. For traditional in-person focus groups, the co-moderator typically provides in-room logistical support such as signing-in late arrivals, taking notes and distributing incentives. For virtual focus groups, the co-moderator has the new responsibilities of admitting and organizing patients in the virtual waiting room, muting participants who may be unintentionally distracting others and resolving technical problems during the meeting. Therefore, in the virtual setting, the co-moderator acts as technology support for potential problems during the session. Additional issues may also arise with the quality of the video and the audio, which varied based on the internet quality, the device used to connect and the environment surrounding the participant. To minimize this issue, participants were informed of “Zoom etiquette.” This included reminding participants to be alone in a room during the meeting, to disconnect other devices from the Wi-Fi and to avoid outside distractions. Advantages of virtual focus groups Many advantages exist with virtual focus groups. First, individuals may be more likely to participate because virtual focus groups are flexible and participants are able to join from the comfort of their home without commuting. Additionally, an increasing percentage of the population now work from home and with alternative working hours. Virtual focus groups have an advantage because sessions could be scheduled later in the evenings when all participants were free from other commitments. Second, our moderators reflected that participants are more relaxed in their own homes, and thus are more involved in the focus group discussion. We feel that this has resulted in deeper content and substance from each focus group. Third, while in-person focus groups were previously limited to patients who lived within a 30-mile radius of our institution and have a source of transportation, virtual focus groups are newly accessible to participants from any geographic location, participants who do not have access to transportation and participants with busy schedules. In this way, virtual focus groups have allowed for a greatly expanded pool of potential participants. This also allows research teams to recruit patients from locations that may have otherwise been left out of the traditional recruitment process. This is a particularly important consideration when seeking input from vulnerable populations on issues such as health disparities and access to care. Disadvantages of virtual focus groups Several challenges and disadvantages also exist with virtual focus groups. First, some patients are not technologically experienced and may not be used to checking links and messages delivered electronically (e.g., email). As communication and consent processes are moved to internet-based protocols, participants who were not technologically literate required extra attention from our research coordinators, often needing additional phone calls and reminders. Second, virtual groups put a new burden on participants as they are responsible for verifying that Zoom is working on their device. This can delay the start of the focus groups and may have also contributed to the loss of some potential study participants. Third, while we typically aim for 6–8 participants for in-person groups, we decided to limit the target size of the virtual groups to 3–4. This decision was made due to the potential need to troubleshoot technological issues for participants, novelty of the process to our team and uncertainly on how interactions would proceed with too many participants on a virtual platform. Fourth, out of the 23 patients who agreed to participate, 5 (21.7%) participants failed to join the Zoom group due to unforeseen technological issues or difficulty remembering and keeping virtual appointments. Compared to traditional numbers of 6–8 participants per group, this ultimately resulted in smaller focus group sizes although the qualitative data gathered was satisfactory and many participants joined who would not have traditionally participated due to travel distances. Lastly, the technological requirements for online meetings may have also impacted on our ability to recruit older patients and patients who do not have reliable internet access. Despite the increased pool of potential participants, older patients and male patients were less likely to join and participate in our virtual focus groups when compared to in-person focus groups (17.6 vs. 39.5% male and 52.1 vs 57.9 years). 6 This is an important consideration in determining the generalizability of findings from these groups. Early results Our group has had promising results from the use of virtual focus groups. Overall, 23 patients agreed to participate, of which 17 (73.9%) participated in 6 focus group sessions (Table 2 ). Fourteen participants (82.4%) were women, while 3 (17.6%) were men. Nine participants (52.9%) were younger than age 34, and no participants were older than age 64. Six participants (35.3%) graduated high school or obtained their GED as their maximum level of education. One participant (5.9%) had limited health literacy, 5 (29.4%) had marginal, and 11 (64.7%) had adequate health literacy as measured using the Brief Health Literacy Screening Tool (BRIEF). 12 Participants came from all areas of Alabama with an average home distance of 105.1 miles from our institution. Eleven participants (64.7%) lived farther than 30 miles from our institution, with one participant living 580 miles away. Of note, a home distance greater than 30 miles from our institution would have excluded these patients from in-person focus group participation due to travel challenges. Overall, our moderators reflected that participants were eager to participate and gave positive feedback about their experience with the virtual format. Our group was satisfied with the content of the discussion and is now moving forward with the qualitative analysis of the transcripts and planning for future virtual focus groups. Table 2 Virtual focus group participant demographics. Table 2 Sex Female 14 (82.4) Male 3 (17.6) Age 18–24 1 (5.9) 25–34 8 (47.1) 35–44 3 (17.6) 45–54 2 (11.8) 55–64 3 (17.6) Max Education High School Grad or GED 6 (35.3) College 1–3 years 6 (35.3) College Grad 5 (29.4) Annual Household Income $20,000-$39,999 6 (35.3) $40,000-$69,999 1 (5.9) $70,000-$99,999 1 (5.9) Prefer not to say 9 (52.3) Insurance Private 14 (82.4)  Medicaid 2 (11.8) Uninsured 1 (5.9) HL Limited 1 (5.9) Marginal 5 (29.4) Adequate 11 (64.7) Live > 30 miles from institution 11 participants Average living distance from institution 105.1 miles Future directions Virtual focus groups are a promising alternative to in-person focus groups. In our experience, virtual groups are feasible and provide substantial data for qualitative research. Technologies can be leveraged and adapted to ensure that qualitative research continues during the COVID-19 pandemic. The MHRC, which has long conducted in-person focus groups at our institution, is now expanding this new model to other research teams with 25 additional virtual focus groups planned in 2020. Additionally, our team has adapted this model to key informant interviews, which we now administer via similar virtual platforms. While limitations exist, virtual focus groups provide an important and novel method for conducting qualitative research. Disclosures DIC supported in part by K12 HS023009 (2017–2019) and K23 MD013903 (2019–2022).

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          Qualitative research. Introducing focus groups.

          This paper introduces focus group methodology, gives advice on group composition, running the groups, and analysing the results. Focus groups have advantages for researchers in the field of health and medicine: they do not discriminate against people who cannot read or write and they can encourage participation from people reluctant to be interviewed on their own or who feel they have nothing to say.
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            Anti-Asian sentiment in the United States – COVID-19 and history

            In 2020, the South Korean movie Parasite became the only foreign-language film to ever win an Oscar for Best Picture. This historic first mirrors a broader trend towards acceptance and integration of Asian culture in the United States. Yet, despite our innumerable contributions to society, there remains little representation of Asians at the highest levels of government, business, academia, and popular media. Asian Americans are often stereotyped as perpetual foreigners because they are seen as inherently different. 1 This has led to a sense of not fitting in, or “otherness”, as if our membership in America society were conditional. As COVID-19 sweeps the nation, this reality becomes painfully apparent. Asian healthcare workers on the front lines of the pandemic have been subjected to slurs and assaults. Nurses have been spat on, doctors have been told to “go back to f****** China”, and care by staff with “Asian appearances” has been refused. 2 While Chinese people are ostensibly the target, the affected individuals have included Koreans, Filipinos, and other Asian ethnicities. In the midst of the COVID-19 pandemic we see not only a rise in anti-Asian sentiment, but also a recapitulation of history. The earliest Asian immigrants to the United States were brought in during the second half of the 19th century as cheap labor for the mining, agricultural, and railroad industries. They were often forced to work in sub-human conditions, and were cast as scapegoats for multiple outbreaks of smallpox and bubonic plague. 2 The term “yellow peril” was coined in this era to describe the perceived threat of Asian migration to European culture. The West Coast was the epicenter of anti-Asian sentiment and on multiple occasions Asians were driven out of towns or lynched. This activity culminated in the passage of the 1882 Chinese Exclusion Act, the only American law denying immigration and naturalization rights for a single ethnicity, and the 1924 Immigration Act that effectively shuttered immigration from Asian countries. The start of World War II then precipitated one of the greatest injustices of American civil liberties. Americans of Japanese ancestry, the majority of whom were citizens or minors, were forced into concentration camps for most of the war because of their perceived allegiance to the Japanese empire. In the face of injustice, many patriotic Japanese Americans still volunteered for active military service. 3 Immigration reform in the mid-1960s would reopen American borders to Asians, who would become the fastest-growing racial group during the next millennium. 4 These reforms favored a highly-selected group of professionals, leading to an influx of engineers, scientists, and doctors from Asia. This skewed immigration pattern would give rise to the mythology of Asians as the model minority. Asian physicians wound up serving in many rural and underserved communities simply because these places were desperate enough for doctors that they could not discriminate. Despite the vast differences across Asian cultures, we often found ourselves viewed as a single group. This was highlighted by the murder of Vincent Chin in 1982. 5 He was beaten to death by American autoworkers who were upset by the potential loss of their jobs due to Japanese competition. He was targeted because of how he looked although he was of Chinese ancestry, not Japanese, and worked in the American auto industry. His assailants received probation and a small fine. This underscored how Asians of all ethnicities were seen as a single entity when it came to discrimination. In spite of the progress made towards racial justice and equality within the past decades, many Asian Americans have never felt fully accepted in American society and continue to be treated as perpetual foreigners. As anti-Asian sentiment and hate crimes rise in the wake of the COVID-19 pandemic, this perception has become reality. A recent analysis of Twitter and online image-message boards revealed a surge in the use of Sinophobic slurs beginning in late January 2020. 6 Compared to data from before the COVID-19 outbreak in the United States, the authors discovered a shift towards blaming Chinese people for the outbreak on Twitter, and an increasing emergence of novel Sinophobic terms on message boards. On both sites, the terms “virus” and “chink” now appear more frequently alongside the word “Chinese”. Both sites also showed substantial upticks in the use of Sinophobic slurs following references to COVID-19 as the “Chinese virus”. Since the outbreak, the FBI anticipated a rise in hate crimes across the United States citing examples such as the stabbing of an Asian American family, including children ages 2 and 6, whom the assailant believed were spreading COVID-196. Their prediction was confirmed by the Asian Pacific Policy & Planning Council, 7 who documented over 1,000 reports from Asian people of coronavirus discrimination and hate crimes from March 19th to April 1st. Common incidents included verbal harassment, shunning, and physical assault. One report reads: “My kids were at the park with their dad (who is white.) An older white man pushed my 7- year old daughter off of her bike and yelled at my husband to ‘take your hybrid kids home because they're making everyone sick.’” Others have reported strangers spraying them with disinfectant, or burning them with caustic substances. 2 These accounts, along with associations between “Chinese” and “virus”, suggest the emergence of a more sinister phenomenon—namely, the personification of COVID-19 as Asian people. This is especially tragic for Asian healthcare workers, who make up 17% of physicians in active practice and are the most represented ethnic group among foreign-born medical professionals. 2 , 8 The data show a pervasive spread of anti-Asian sentiment in the United States in the wake of the COVID-19 pandemic. History tells us that minority groups are often targeted during periods of global unrest and economic instability. The fear and uncertainty inherent to novel infectious disease, the presumptive origin of COVID-19, and the perpetual foreigner stereotype make Asian Americans especially vulnerable to racism and disease scapegoating. Lest we regress to our historical antecedents, leaders within our society have a responsibility to tamp down on rising xenophobia through thoughtful and humane representation of all people. Although COVID-19 has stoked racial tensions in the United States, it also presents us with an opportunity to rise above these circumstances. We have seen the remarkable resilience of Americans who endure self-isolation and social-distancing to protect the public health. We have also witnessed the awe-inspiring resolve of healthcare providers across specialties who compassionately care for those infected despite working on units staffed by skeleton crews. Each day that passes brings new innovations in medical education and patient care.9, 10, 11, 12 As it turns out, few things unify a population like an endeavor to protect a shared value against a common threat. If we can unite to overcome a pandemic of epic proportions, certainly we can also confront the socioracial issues made manifest by COVID-19. Finally, those driven to discrimination by fear also have something to learn from the virus: it doesn't care what race you are, only that you are human.
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              Using Online Meeting Software to Facilitate Geographically Dispersed Focus Groups for Health Workforce Research

              Focus groups as a data collection method in qualitative research have been used for several decades with great effect. Recent developments in online mechanisms for communication have prompted several researchers to explore alternate means of facilitating focus group participation. However, much of the online focus group literature has explored the use of text-based communication; there are few reports on the application of real-time online video-enabled software. In this article, we seek to inform the growing use of online-meeting software-mediated focus groups by reporting and analyzing its application within the context of a health workforce study among geographically dispersed radiation therapy professionals.
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                Author and article information

                Journal
                Am J Surg
                Am J Surg
                American Journal of Surgery
                Elsevier Inc.
                0002-9610
                1879-1883
                12 October 2020
                12 October 2020
                Affiliations
                [1]Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
                [2]Minority Health & Health Disparities Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
                [3]Division of Preventative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
                Author notes
                []Corresponding author. 1720 2nd Avenue South Birmingham, AL, 35294-0016, USA.
                [1]

                Co-first-authors: Dr. Marques and Dr. Theiss contributed equally as co-first authors.

                Article
                S0002-9610(20)30620-6
                10.1016/j.amjsurg.2020.10.009
                7550163
                33070983
                0f3d29fe-46e8-4119-a960-f552d9813760
                © 2020 Elsevier Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 5 October 2020
                : 7 October 2020
                : 8 October 2020
                Categories
                My Thoughts / My Surgical Pratice

                disparities,focus groups,qualitative research
                disparities, focus groups, qualitative research

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