‘Unfocused groups’: lessons learnt amid remote focus groups in the Philippines

‘Project SALUBONG’ and our research team

The FGDs described in this article were conducted as part of a larger mixed-method study on vaccine hesitancy in the Philippines.23 Using human-centred design, the research examines how families and providers feel about vaccines, how their attitudes and perceptions of vaccines have changed over time, and how individuals feel about an intervention to promote vaccine confidence.

The members of our research team have previously designed, implemented, and evaluated health interventions to address neglected and infectious diseases (eg, childhood pneumonia, leprosy, malaria, helminths, schistosomiasis, etc) across health facilities in the Philippines drawing on a range of qualitative techniques. The two lead authors of this study (MFA and VE), who led the FGDs presented here, have more than two decades of combined experiences moderating or facilitating in-person FGDs.

Choice of platform and preliminary considerations

Our FGDs were initially planned to be conducted in person. However, in March 2020, the Philippines was placed under community lockdown, including movement restrictions in Metro Manila and neighbouring regions (including Calabarzon region, which is our study site).24 This abrupt shift required Filipinos, especially employees and students, to heavily depend on the internet for remote learning and working.25

In this context, and considering the timely nature of our research topic, we decided to shift data collection online. Initially, we considered using Zoom to conduct FGDs as it provides a range of privacy controls and features, and as our team was already familiar with it. However, based on previous experience when conducting remote in-depth interviews (IDIs), we decided to give participants the option to choose among several platforms including: FB messenger, Zoom, Skype and Google Meet.3 Our target participants described a high level of familiarity and general preference for FB Messenger, which made it our top choice.

FBMR, introduced by FB in April 2020, allows users to create a room and invite anyone, with or without an FB account, to join a video call. Designed to compete with other platforms,26 27 FBMR presents an alternative for hosting group calls with up to 50 people, with no limits in terms of call duration and with built-in controls for privacy and security.26 27 With these built-in controls, administrators can lock rooms and remove individual participants. Participants can leave rooms at any time and report rooms to FB administration. However, FBMR lacks end-to-end encryption,28 which is offered by similar applications,29 and poses a number of privacy concerns outlined below (see the ‘Privacy settings and ethical complexities: a word of caution’ subsection below).

Platforms and services provided by FB are highly accessible and accepted in the Philippines. As of January 2020, the Philippines has an estimated 73 million social media users (among a total population of 107 million as of 201930), an 8.6% increase from April 2019,31 with an expected increase to 88 million by 2025.32 Filipinos spend an average of 10 hours a day online (more than any other country) with a rising dependence on mobile internet and smartphones.33 34 Philippine phone network providers offer packages that compel FB usage (ie, free use of FB, but limited to browsing, posting, liking and sharing FB posts, or steeply discounted data packages that entail unlimited use of FB with certain data premiums).35–37 This has resulted in a tremendous spread of FB in the country, which is further accelerated by the efforts of news sources, political actors and social networks to engage directly with people through this platform.38 As at least one prominent observer has noted that in the Philippines, the use of the internet is nearly synonymous with the use of FB.39 40

We conducted a detailed comparison of the two leading potential platforms, FBMR and Zoom (see online supplemental table 1), comparing relevant aspects such as data usage consumption, subscription requirements and fees (which would determine affordability), as well as privacy settings and additional features such as session recording. Based on these considerations and the fact that most participants within our broader study consistently expressed preference for FB as a platform, FBMR emerged as the preferable tool. At the time of writing, we have conducted nine FGDs using FBMR; four with community health workers (n=20; aged 31–60 years), and five with parents (n=27; aged 16–55 years), who have previously refused or accepted vaccines for their children (divided by decision-making pattern).

Preparing and conducting FGDs on FBMR

Prior to shifting FGDs to FBMR, we undertook the following training and preparation exercises for our team: (a) a brief introduction by an information technology (IT) expert (JRG) on FBMR’s features and how to navigate FBMR including how to set preferences for the session, how to invite participants to join and how to be in control during the session; (b) a pilot run within the team via FBMR; and (c) the IT expert mentoring and assisting with the workarounds during the first FGDs. Our experiences in the broader research project with general participant recruitment and data collection preparation are outlined elsewhere3; we therefore focus on setting up and executing FGD sessions (see table 1).

Acquiring consent, recording and storing of data

Participants provided written informed consent individually prior to the FGD; consent forms stated that discussions would take place online. Once participants agreed to participate, they were sent an informed consent form in advance via courier or with the help of local healthcare workers. The process of signing consents was captured during individual recorded FBMR video calls, explaining every part of the consent form and that it would be conducted online using the same platform. The process concluded with a ‘selfie consent’ where the respective participants took a picture while holding their signed consent sheets.3

Video and audio recordings were recorded using Movavi Screen Capture (Movavi, V.11), and a physical audio recorder as backup. All data gathered were anonymised, number coded and stored in password-protected computers, and all data will be destroyed after the study completion and publication of findings.

Notetaker: from ‘passive’ to ‘active’

The role of a notetaker in an in-person FGD is to take detailed notes during the session, and to capture non-verbal cues and information.41 Over the course of our remote FGDs, we experienced several circumstances where the notetaker had to assume a more active role.

From setting up the FGD room to following up with participants after a session’s end, the notetaker oversaw logistics: creating the room, inviting participants, video or audio recording the session, contacting the IT on-call in the event of technological problems during sessions and deleting messages in the in-meeting chat box to prevent participants from taking screen grabs of the conversations in the chat. We found that it was often distracting or intrusive to have an IT person in the FGD (as we felt that it created an imbalance in terms of number of research staff vs number of participants and it was challenging in terms of coordinating staff availability), so our notetaker needed to become conversant on IT troubleshooting. The notetaker was in charge of all in-meeting controls (such as muting participants and removing participants) and followed up with participants who lost connection or had technical problems while the session was underway. Additionally, in cases when the moderator had sudden declines in signal strength or stability, the notetaker stepped in to moderate the discussion. Describing this experience, our notetaker used phrases such as ‘exhausting and stressful’, ‘total madness’, ‘a beautiful disaster’ or ‘like herding cats’.

One limitation of FBMR that transpired during FGDs was that only six participants are visible to the moderator on the computer screen at any time. The notetaker therefore had to assist the moderator in informing who among the other participants wanted to contribute to the discussion. At the end of the meeting, notetakers were responsible for closing the room and the safe keeping of session recordings on top of their typical duties as notetakers (noting non-verbal cues, gauging talking time of participants and following the flow of conversation, etc).

The challenge of recruiting, retaining and engaging participants

Initially, given our preparation efforts, our experiences conducting remote IDIs3 and our proposed workarounds for FGDs, we felt hopeful that remote FGDs were feasible. However, challenges began even at participant recruitment. The recruitment of participants, particularly of parents of under-5 children, and FGD scheduling were considerable challenges. We relied heavily on healthcare workers to identify participants from local communities, but we felt that this was a restrictive approach compared with community canvassing and snowball methods we would normally employ. We repeatedly experienced participants backing out last minute (citing reasons such as the need to tend to their children, not having time or noting that all family members are present at the houses due to community lockdowns). In community-based FGDs, finding families to replace ‘no shows’ can be mitigated by recanvassing a neighbourhood and inviting participants, which is challenging in online engagements. Furthermore, we found that in in-person FGDs, participants are less likely to be no shows or to prematurely depart sessions.

In our remote FGDs, caretakers of small children who signed in from home were especially likely to be distracted. Several mothers described an inability to hear with children present, feedback issues and a temptation to use this ‘alone time’ to check social media updates. FGDs with healthcare workers (even those who are parents of small children) were less often disrupted, which we attribute to the fact that these participants could join from their workplace (in health centres). Across participant types, maintaining interest in the subject matter proved challenging, which participants attributed to technical difficulties that made following the flow of FGDs difficult. We tried to send data bundles, troubleshoot with IT, shorten our guide and simplify our questions, but these did not sufficiently address the problem. We found that we could not gather consensus or further probe on issues because those participants who were not speaking often were not following the conversation. This experience of having trouble maintaining interest and engagement throughout the FGD contrasted sharply with our experiences with remote IDIs3 where participants could be guided one on one through technical troubles, issues in terms of distraction were much lower, and we generally felt that the data quality was on par with in-person endeavours. In this regard, we felt that many of the measures used to show FGD participants that they are being listened to, and that their opinions and insights matter, especially maintaining eye contact and singular focus on the participants, were very challenging in remote FGDs.

Privacy settings and ethical complexities: a word of caution

We appreciate substantive and important debates regarding privacy settings of FB (eg, end-to-end encryption of video calls, data protection and security, fake accounts, etc).42 43 We included steps to mitigate risks and privacy concerns including: (a) screening of the participants prior to invitation (and continuously checking for uninvited participants to be able to remove them immediately, which proved unnecessary in our FGDs); (b) closing the room and deleting in-meeting chats at the end of the session; and (c) creating and communicating ground rules to all participants before the start of the session, that is, no third-party application screen sharing, screen capture or video recording. We acknowledge the possibility that participants may use third-party recording applications to record FGD sessions, or they may screen grab messages amid in-meeting chats. As a precaution, we did not allow participants to type their answers or ideas in the chat (chat replies were allowed only in instances when sound quality was compromised, and clarification was necessary). In general, these concerns mirror ethical and privacy concerns that we view as applicable to all FGDs,16–18 21 where breaches of confidentiality, including unsolicited recording, are possible. Because it is always the responsibility of research teams to take precautions to minimise such risks, we do not view these as fundamental reasons to reject remote FGDs in FBMR.

We are also aware of ethical considerations that relate to identity and identifying features of both FGD participants and the research team. In regard to the former, we recruited participants with the help of community healthcare workers, who established first contact. After confirming (via phone) participants’ desire to partake, and after receiving their permission to contact them via FB Messenger and to confirm their identity via their publicly available FB profile, we reviewed this information to confirm that this appeared to be the same person invited to the data collection activity. This helped us to avoid engagement with fake accounts. Nevertheless, screening participants’ public FB profiles can raise concerns regarding the privacy of these data, and how to systematically limit the consideration of these data to the confirmation of participants’ identity. In terms of our own identity, we decided to use our personal FB Messenger accounts with profile pictures, as we perceived it to be a more authentic and legitimate approach compared with creating an official FB identity for the study. Nevertheless, the existence of an online identity and the manner in which this online persona and presence may affect our engagement with participants and vice versa merit consideration.

In the interest of promoting a sense of ease, we urged participants to consider the following privacy options: (1) create and use a fake account for the FGD (as long as we could verify their accounts prior to the scheduled remote FGD); (2) rename their existing accounts at the start of the session (reverting to their original account name after the close of the session if they wanted); and/or (3) use private browsers in mobile phones to maintain anonymity towards other participants in the session if they do not want to enter the room using their publicly available FB profile.44 However, in the FGDs conducted to date, no participants decided to use one of these suggested anonymity-enhancing approaches.

Limitations and opportunities for further research

We are aware of the controversies surrounding the use of FB to collect people’s personal data.51 52 The current legal discourse around the ownership of private data on social networks (particularly FB) is complicated53 54 and merits discourse that rests beyond the scope of this paper. Our data collection was done via FBMR, with the consent of participants (see informed consent form in online supplemental file 2). We have no knowledge and have found no reliable sources that could outline whether FB records video chats such as those done in FBMR. We ensured, however, that neither the information about the FGD sessions nor information about the participants was posted publicly. The recordings we gathered from the FGD sessions, for the purpose of transcription and data analysis, were recorded using an external application. These video clippings served as data and were therefore accessible to the research team. More practical adaptations could respond to calls for more insight into how we can address overwhelming concerns regarding privacy and confidentiality.