Conducting Qualitative Research to Respond to COVID-19 Challenges: Reflections for the Present and Beyond

Abstract

The global response to mitigate the spread of the COVID-19 pandemic brought about massive health, social and economic impacts. Based on the pressing need to respond to the crisis, clinical trials and epidemiological studies have been undertaken, however less attention has been paid to the contextualized experiences and meanings attributed to COVID-19 and strategies to mitigate its spread on healthcare workers, patients, and other various groups. This commentary examines the relevance of qualitative approaches in capturing deeper understandings of current lived realities of those affected by the pandemic. Two main challenges associated with the development of qualitative research in the COVID-19 context, namely “time constraints” and “physical distancing” are addressed. Reflections on how to undertake qualitative healthcare research given the evolving restrictions are provided. These considerations are important for the integration of qualitative findings into policies and practices that will shape the current response to the pandemic and beyond.

Following the World Health Organization (WHO)’s declaration of the novel coronavirus disease 2019 (COVID-19) outbreak, the generation, dissemination and exchange of research knowledge has surged to support the effective response and management of this international pandemic (Cucinotta & Vanelli, 2020; Hiscott et al., 2020; WHO, 2020). To date, approximately 4,900 studies and 3,300 systematic reviews addressing various aspects of COVID-19 have been registered in ClinicalTrials.gov and PROSPERO, respectively. This information has allowed scientists, policymakers and public health officials to better grasp the biological and epidemiological properties of the virus, which spreads rapidly, presents differently, and has wide-ranging mortality and morbidity ramifications (Verity et al., 2020). However, as recently noted by Teti and collaborators (2020), COVID-19 has not only physically and clinically impacted people’s lives, but also had important psychosocial consequences (Michie & West, 2020; Michie et al., 2020). Given the possibility that the virus and measures to manage it may extend even up to 5 years (Kissler et al., 2020), the minimal proportion of COVID-19-related qualitative research accounting for psychosocial aspects being carried out at the time this paper was written is alarming. The aim of the present commentary is thus to provide a brief overview of some challenges and opportunities when conducting qualitative health research within the context of the pandemic and to encourage research of this nature to describe, explore and explain the multiple impacts of COVID-19.

The Relevance of Qualitative Research

While COVID-19 is not the first widespread pandemic, its high transmissibility coupled with the often vague and silent symptom profile have challenged medical and public health decision-making strategies to contain the virus (Moghadas et al., 2020). The swift evolution, magnitude and uncertainty associated with the disease have forced public health authorities worldwide to implement massive and rapid measures across the board (Smith & Gibson, 2020). This significant global impact of COVID-19 highlights the importance of considering the context in which, ultimately, people deal with the pandemic. While there is consensus within the scientific and public health communities regarding available evidence-based guidelines about how to contain and prevent transmission (Eccleston-Turner et al., 2019), the implementation of such measures, as well as the associated outcome, has largely depended on the context (Hirschhorn et al., 2020). In fact, there is emerging evidence for disparate responses to the pandemic-related measures due to a combination of social and contextual factors, such as race, income and neighborhood ethnicity (Ryalino, 2020). For instance, although implemented policies regarding physical distancing have been agreed upon and enforced globally, findings demonstrate that people from lower income communities “exhibit less of the social distancing that could buffer against other economic and health impacts of the disease” (Weill et al., 2020, p. 19658), such as pre-existing health conditions and healthcare access. Thus, efforts toward understanding individual and group experiences during the pandemic are warranted to tailor local policy development and implementation. Indeed, if guidelines are transposed from the context and circumstance in which they were generated, they risk not addressing the particularities of the new context in which they are being implemented, nor responding adequately to users’ needs.

Qualitative research is well suited to explore, describe, and explain how changes in policies and practice during the pandemic could be adapted and implemented while addressing healthcare professionals’ and patients’ voices regarding their needs, concerns, and preferences (Chafe, 2017). There are many local examples where healthcare delivery is forced to adapt in response to infection control measures and to ensure adequate healthcare capacity to support the influx of sick patients. For example, to reduce the risk of infection, a nurse may no longer initiate cardiopulmonary resuscitation (CPR) in a deteriorating COVID-19 patient and must wait until the entire code blue emergency team arrives before entering into the patient’s room. Likewise, elective cardiac surgeries were canceled, and unit wards and healthcare teams were redirected for COVID-related care. These changes stemming from the pandemic may be profoundly experienced as distress or resilience by healthcare workers, patients and their families, but remain anecdotal or unexplored in research to date.

Other similar phenomena that emerge as a consequence of the pandemic can be explored with qualitative methods, allowing people to express themselves and share their unique and complex experiences, such as dealing with job loss, isolation, anxiety, physical and mental illness, lack of or reduced support, and caring for family members (Palinkas, 2014). Qualitative research can also provide insight into how individuals and groups perceive and deal with these changes, and better inform a unique and targeted approach to mitigate the negative impacts on society (Gobat et al., 2018; Vindrola-Padros et al., 2020). Moreover, a recent paper by Vindrola-Padros et al. (2020) highlights the crucial contribution of qualitative data in informing evidence-based public health responses and suggests that it is possible and necessary, albeit with some modifications, to address certain challenges that arise. Qualitative research is indeed complimentary to the other types that are currently being conducted, and equally important to ensure an understanding of the various contexts and inform how we respond to the pandemic in the most appropriate way (Vindrola-Padros et al., 2020).

From the thousands of papers already published in 2020 and early 2021, there have only been a small number of qualitative studies addressing specific aspects of healthcare delivery, including one out of Wuhan, China that explored front-line nurses’ experiences treating patients with COVID-19 (Tan et al., 2020). The authors highlighted nurses’ perspectives working in a novel environment, and proposed strategies for nurse managers to ensure the health and safety of their staff and preparedness for future public health emergencies. Another study by a group in the Philippines aimed to share occupational therapists’ voices about their personal and professional experiences, strategies employed, and implications of the pandemic on their work (Sy et al., 2020). In this case, online discussion to delve into reflections on their changing practice was used, revealing feelings of isolation and exclusion, and coming up with ideas to guide sustainable actions in occupational therapy education, practice, and policy. Studies of this nature are needed to enhance reflection around a situation that is not only multi-faceted, but novel.

Conducting Qualitative Research During the Pandemic

As in other areas of society, conducting research amid the COVID-19 pandemic requires adaptation, while ensuring the quality of research is maintained. Overseeing high-quality qualitative research is challenging because quality standards depend on the paradigm in which the inquiry is based, the proposed research strategy, and the object of interest (Sparkes & Smith, 2009). As such, some researchers judge qualitative research quality based on adherence to a set of criteria and standards (e.g., the Consolidated Criteria for Reporting Qualitative Research [COREQ], the Standards for Reporting Qualitative Research [SRQR]; Peditto, 2018), while others view quality as a phenomenon that cannot be strictly attached to methodological rules (Sparkes & Smith, 2009). Although there is debate with regard to the use of standards or alternative methods to judge quality, there is an informal consensus around the fact that consideration must be given to the clarity of the research question, the rigorousness of the research method, and the transparency and completeness of the reporting process (O’Brien et al., 2014). Similarly, trust in the research process is established when the researcher demonstrates an alignment between the different components of the research process, including its epistemology, theory, methodology and methods (Morse, 2015).

Taking a reflexive stance (i.e., engaging in active reflection and disclosure of how and why the researcher comes to certain decisions) is important to ensure trustworthiness. For example, in an ordinary qualitative research endeavor, extensive and intensive in-field time and proximity between participants and researchers are considered key to a trustworthy rendering of complex human phenomenon. However, both of these elements are impeded in the present COVID-19 context due to the urgent need to respond to the pandemic with empirical data and the physical distancing measures implemented on an international scale (Sandars & Goh, 2020). Below, we present our reflection on how qualitative research can be conducted with these considerations in mind. To extend previous literature discussing the use of qualitative research in the context of this pandemic, we: (a) identified two major challenges stemming from COVID-19 associated measures—“time constraints” and “physical distancing,” that may both threaten qualitative research standards; and (b) discussed potential methodological venues to face the aforementioned challenges and ensure high-quality research standards.

Time Constraints

Pressure to produce time-sensitive responses to the pandemic has brought about international collaboration on several projects in order to fast-track massive research. Such research endeavors developed to generate information in a short window of time require faster design, recruitment of participants, and data collection and analysis (Lancaster et al., 2020). This scenario seems to go against both traditional and conservative qualitative research standards that typically required an extended period of time to capture the nature of the phenomenon under study (Denzin & Lincoln, 2018).

In response to time constraints, rapid qualitative research initiatives have recently gained popularity as they have been shown to produce high quality information used to inform decision-making (Johnson & Vindrola-Padros, 2017). Rapid qualitative research is an approach aiming to illuminate a given problem by collecting and analyzing data within a short period of time, ranging from 4–5 days to 6 weeks (Beebe, 2014). Such an approach not only results in time-reduction, but also in a closer and intense analysis of data leading to a potential decrease of required costs and resources (Watkins, 2017). To that end, different strategies such as “mirror studies” that replicate and apply the methodology in the study of sub-cases can enhance and facilitate epidemic-related responses and experiences. As well, the data analysis techniques used for the purposes of rapid qualitative research were studied by Taylor and colleagues (2018) who compared them with generic thematic analysis. After measuring the time needed to complete the two types of analysis, as well as the congruence between the themes identified by each analytic strategy, the scholars confirmed that while the final findings overlapped in around 70%, the completion of rapid analysis required 26.5 less hours.

Despite the aforementioned benefits, certain aspects of rapid qualitative research have been questioned. Methodologically speaking, time is saved by eliminating certain aspects of the research process (e.g., verbatim transcription of interviews), reduction of the natural pace of group discussion, and the additional time burden on the research team and participants (Johnson & Vindrola-Padros, 2017). However, these shortcuts might hinder the exploration and portrayal of complex human and social phenomena and therefore produce less credible findings due to the short-term immersion and interaction of the researcher with the participants (Vindrola-Padros & Johnson, 2020).

While the literature raises the need to address indirect participant burdens in research (Lingler et al., 2014), concerns regarding research duration and time commitments should be considered. Given that the target populations (i.e., frontline health workers, patients and their families, disparate members of society) are already heavily impacted by this pandemic, these concerns are especially relevant. Participatory research approaches might be considered as a possible response to these challenges while acknowledging indirect participants burdens. Participatory research gives voice and space to participants in shaping the research conducted and developing ownership of an advocacy agenda while enhancing the credibility of research findings (Vindrola-Padros, 2021). This is particularly important during a time of significant isolation and uncertainty. Indeed, participant burden has not yet been studied in participants of qualitative research, and given the pandemic context, this could be an opportune moment. The exploration of research burden in quantitative research was undertaken in a recent systematic review of qualitative studies in participants of randomized controlled trials (Naidoo et al., 2020). To reflect on general participant burden, the Perceived Research Burden Assessment (PeRBA) could be used (Lingler et al., 2014), while promoting benefits in engaging in more rapid qualitative approaches (Vindrola-Padros, 2021).

In short, participatory approaches in rapid qualitative research may directly influence how care is delivered, how support is offered to communities and how public health decisions are made in the pandemic context (Burgess et al., 2021). Therefore, while rapid qualitative research proves promising, there still remain aspects of this approach to be further explored and enhanced. Further reflections are needed on how trustworthiness of the data could be maintained, how the data collection could be carried out, and how participatory approaches can be enhanced to promote meaningful trustworthy and credible qualitative research studies.

Physical Distancing

Physical distancing, also referred to as “social distancing,” is a major strategy to reduce the spread of the virus by limiting close contact with others (Galea et al., 2020; WHO, 2020). While the specific behavioral recommendations for physical distancing vary from one jurisdiction to another, they often include avoiding non-essential trips from home, group gatherings and crowded areas (especially if symptomatic or with a confirmed COVID-19 diagnosis), as well as maintaining a minimum distance when in the presence of others (Bonell et al., 2020; WHO, 2020). Further, in some cases, mask or face covering devices are mandatory when in indoor spaces or if the minimum distance cannot be respected, which is usually the case when medical treatments are sought (Greenhalgh et al., 2020). This new reality requires us to rethink certain principles and practices when conducting qualitative research.

As qualitative research strives to understand phenomena that are rooted in the subjective and contextualized experiences of the individuals or groups living it, from the interpretivist and constructivist orientations, typical rules of engagement aim to place the researcher and the researched as close as possible to facilitate building the rapport (Denzin & Lincoln, 2018). Moreover, the researcher is the instrument of data collection, which implies that the relationship established with the participants requires a level of trust, intimacy, and proximity to both access personal and nuanced data, and instill a level of credibility in the research findings (Salmons, 2011). Related to trust is the concept of insider-outsider positionality that is the perception of researcher membership within the population or group of study, and which is contextually dependent (Dwyer & Buckle, 2009). Customary strategies for facilitating rapport include: (a) becoming familiar with the setting prior to first data collection; (b) allowing participants to choose the space for data collection (interviews- in particular); (c) researcher transparency and disclosure about study purpose and rights of the participant; and (d) chatting or informal impromptu interactions that promote familiarization between the researcher and participant, which also give important clues to the setting and context (Creswell, 2018). These instances, due to the intimacy they require, are not only stalwarts of what is considered quality principles for trustworthy and credible qualitative findings, but can also lead to feelings of connectedness (Denzin & Lincoln, 2018). Moreover, these strategies are repeated over time and serve to establish these aims over the long-term. Further, efforts to build rapport go beyond the goal of making participants feel comfortable in sharing their stories but can allow for an equalization of power imbalance in setting the research priority (Anyan, 2013).

Current measures of physical distancing prompt researchers to seek alternative and innovative data-gathering methods that capitalize on technology for synchronous or asynchronous virtual interactions and access to the field. This is evident in the number of crowdsourced documents initiated by the qualitative research community that guide and endorse alternate methods in response to the COVID-19 pandemic (Centre for Critical Qualitative Health Research, 2020; Jowett, 2020). For example, online focus groups (using chat or video) and interviews can be considered in situations where physical proximity is limited (Dodds & Hess, 2021). Additional methods to facilitate qualitative data collection that avoid interaction altogether may include digital text communications, written or video diaries, and photovoice (Lupton, 2020).

Despite their longstanding use and recent spike in popularity, virtual modes of interaction continue to draw concerns with regards to methodological rigor (Weller, 2017), which include potential lack of depth when sharing insights due to the researcher’s restrictions in probing and picking up on nonverbal cues, and lack of contextual data as access to the setting is limited to what is visible through the screen. Thus, even when technology may be an option to address physical distancing, its benefits are not exempted of constraints. More specifically, devices mediating the interaction between the researcher and participant may have an influence on the experience of data collection, especially when compared to traditional approaches in which face-to-face contact is expected (Salmons, 2011). These concerns over use of technology have prompted some to compare traditional methods of data collection (particularly in-person interviews) with technology-based communication (Krouwel et al., 2019; Lo Iacono et al., 2016).

Recent evidence suggests that virtual methods of interaction alter the relationship while still generating in-depth exchanges. For example, in investigating online group interviews with vulnerable populations, Dodds and Hess (2021) found that they were shorter but more substantial than face to face interviews, as participants could interact more equally due to the nature of the virtual interface, and reported feeling comfortable in their own space and in control of the screen. Similarly, participants in online focus groups were often less inhibited and therefore more willing to provide personal thoughts or details (Williams et al., 2012). Moreover, online interactions can be more convenient and may shift power imbalances with more flexibility and control in choosing the time (not limited to office or clinic hours, decreased transportation) and the space (in the house, a coffee shop) as well as offering the possibility to access hard-to-reach groups (King et al., 2014; Williams et al., 2012). On the other hand, there remain significant access issues to broadband internet to support the use of technology in qualitative research, especially in rural and indigenous communities (Canadian Radio-television and Telecommunications Commission, 2020). Therefore, while this approach to data collection may be appropriate in the pandemic context, there are still important accessibility challenges to overcome.

While technology-based interactions for qualitative research may be preferred in the COVID-19 context, some in-person data collection may be unavoidable. By the fall of 2020, the mandatory use of facemasks in community and health settings was mandated in many areas worldwide as an effective means to prevent infection. This has led us to question whether this has an impact on developing trusting relationships when worn by the researcher and participant during an interview. These concerns were similarly expressed by others for healthcare interactions with individuals suffering from hearing loss (Ten Hulzen & Fabry, 2020) or in clinical psychiatric encounters where verbal and non-verbal cues are critical for clear and empathic communication (Mehta et al., 2020). Empirical evidence supports the concern where the use of surgical masks worn by primary care physicians during clinical encounters negatively impacted their patients’ perceived empathy toward them (Wong et al., 2013). Hines and colleagues (2020) reported that healthcare workers expressed worry about the inability for patients and families to see them smile when wearing facial masks. In addition, face coverings are culturally and historically loaded with attached meanings and perceptions about those who wear them (van der Westhuizen et al., 2020). With their use to mitigate past viral outbreaks in China, facemasks were viewed as a psychological symbol of disease (Siu, 2016). As widespread use across multiple contexts is being encouraged or imposed, the perceptions and meanings of facemasks are in evolution (Goh et al., 2020), and this is an important area of future research, particularly within qualitative research interactions.

Finally, traditional qualitative research processes usually involve the development of social relationships through time spent in the research setting, extensive data collection and data analysis methods, all of which are generally time-consuming and therefore considered very costly. At first glance and from the challenges mentioned above, rapid qualitative methods might seem less costly as time needed to develop and maintain social relationships, and to collect, analyze and report data, is reduced. However, while qualitative researchers cannot plan for in-person interaction with research participants and collaborating researchers, there may be costs associated with rapid qualitative research that go beyond monetary. A review of the literature unveiled the fact that there is no research on the relationship between rapid qualitative research and social costs; therefore, we propose the need to address this gap in the context of the COVID-19 pandemic and beyond.

Future Avenues for Qualitative Health Research

As COVID-19 is far from gone, we will endure the changes stemming from this extraordinary context and the long-term impacts of the pandemic. The need for qualitative research during this time cannot be understated to understand peoples’ reactions, emotional responses, behaviors, and perspectives. More specifically, patients’ and families’ voices directly affected by the COVID-19 virus need to be heard, as well as clinicians (e.g., nurses, physicians, and allied health workers) who are on the front lines across healthcare settings. Despite everything that the pandemic has brought, there are also opportunities to grasp, where researchers must innovate and find alternative ways of working together. As a result, there is greater openness in using alternative ways of interacting, including virtual clinical consultations, when mere months ago, this was reserved for certain difficult-to-access groups in society. In qualitative research, where we favored in-person meetings, we have no choice but to adapt to a new way of operating, and our reflections in this article can help guide researchers in this endeavor.

Qualitative research is essential as it allows for in-depth knowledge development through the lens of the ones living the changes, shaped by a unique context. Perspectives from qualitative research acknowledge the local, experiential knowledge as relevant and complimentary to other sources of information (Andersson, 2018). It specifically allows for co-creation of findings embedded in the day-to-day practice of healthcare professionals, thus providing significant practical knowledge, and reducing the gap between practice and theory, unifying the two. Timely knowledge translation is critical to help respond quickly to urgent challenges faced in this pandemic, and for future situations of similar nature. Some reflections with regard to data collection using technology can be extended to considering working with international teams, which could translate to wider possibilities for qualitative researchers: international recruitment of participants, collaborations with expert researchers around the world- a silver lining when having to adapt in such challenging times.

In this reflection, we extended Vindrola-Padros et al.’s (2020) paper summarizing their own in-field research experience during the COVID-19 pandemic by discussing two major challenges, namely time constraints and physical distancing. We hope to have contributed to the existing body of knowledge and highlight the importance of qualitative healthcare research during this time to inform evidence-based public health responses and policy reforms, which will directly impact healthcare workers, patients and families.