WhatsApp as a medium to collect qualitative data among adolescents: lessons learned and considerations for future use

Introduction

In order to understand the dynamics surrounding adolescents’ access to and use of contraception, perspectives of youth themselves must be considered. In Malawi, where 22% of married and 52% of unmarried sexually active women between the ages of 15–19 report an unmet need for family planning (National Statistical Office/Malawi and ICF, 2017), more detailed data on adolescents’ contraceptive barriers, needs and preferences can help bridge the gap between adolescents who want to prevent pregnancies but do not use contraception. Technology may provide an avenue for collecting this ASRH data and with added anonymity. Although anonymity can be compromised when using online methods, technology platforms do present an opportunity for youth to engage with other participants and facilitators on sensitive subjects such as ASRH, without having to make personal statements in face-to-face discussions.

WhatsApp is a mobile messaging technology widely used in many areas of the world, including Africa, which allows users to send images, text, video and voice messages; and conduct individual or group conversations¹ (Kumar & Sharma, 2017). As WhatsApp has become a popular medium for communication (Rosenfeld et al., 2018), examples have emerged of the platform being used in health care and public health². WhatsApp has been employed to conduct supportive supervision with community health care workers, reduce rural health worker feelings of isolation and recent nursing graduates’ fears about transitioning to professional life, improve communication between consulting and emergency physicians, support delivery of out-of-hours pharmacy services, and bolster medical education programs (Ajuwon et al., 2018; Copestake et al., 2020; Gulacti et al., 2016; Henry et al., 2016; Pimmer et al., 2017; Pimmer et al., 2019; Pimmer, 2015; Raiman et al., 2017; Rathbone et al., 2020; Willemse, 2015; Willemse et al., 2019). WhatsApp has also been utilized to help deliver public health interventions, including a bed net campaign in Mozambique, HIV counseling for men who have sex with men in Peru, and for sending health information to new parents in South Africa³ (Arroz et al., 2019; Bayona et al., 2017). However, there are few recorded examples of WhatsApp being used for research in public health (Chen & Neo, 2019; Fardousi et al., 2019). The use of WhatsApp focus group discussions (FGDs) for a 2019 waste management study in Singapore indicated the potential for using the platform for health research, while underscoring the need to further develop mobile messaging as a qualitative research method (Chen & Neo, 2019). Another study published in 2019 utilized WhatsApp to conduct remote interviews exploring health workers’ perceptions in a conflict zone. The study commented on issues such as internet connectivity and confidentiality concerns as factors that impacted the ability to conduct interviews via WhatsApp (Fardousi et al., 2019).

In June 2018, VillageReach used WhatsApp to conduct FGDs with Malawian youth on the topic of contraceptive needs and preferences, as part of a larger study funded by the Bill & Melinda Gates Foundation entitled Youth-led Contraceptive Knowledge Generation and Design. WhatsApp was selected as a tool for eliciting information from adolescents because the mobile messaging application is popular among sub-populations of Malawian youth⁴ (Matto & Kazungu, 2018), thereby offering researchers a chance to test whether or not the platform could offer an innovative approach to obtaining sensitive information from young people who may be uncomfortable sharing such information in traditional face-to-face FGDs.

Approach

Our approach was guided by principles of community based participatory research (CBPR), working with youth to design methods and instruments to explore the research questions (Leung et al., 2004). Six Malawian youth researchers (YRs), aged 22-to 25 and from the target districts, were recruited to facilitate the WhatsApp FGDs. The YR position was posted on local job boards and newspapers and resulted in over 500 applications, of which 23 applicants were interviewed. The interviews covered past experience and how applicants would handle hypothetical data quality and research ethics scenarios. A scoring rubric was completed by the interview panel and scores were used to select the six YRs for hire. Facilitation training for the YRs lasted four days and included study background, research ethics, FGD logistics, and role as moderator. Just prior to WhatsApp data collection we hosted a four-hour refresher training devoted to the WhatsApp technology and how to moderate in that context. Following the training, YR’s worked with VillageReach staff to finalize eight scenarios depicting context-relevant ASRH situations to generate discussion in the FGD sessions.

Scenarios were derived through brainstorms with YRs, who drew upon insights gathered from methods used in the larger study design that preceded the WhatsApp FGDs (full design not described here but can be requested from authors). Scenarios included situations for the participants to react to and expound on, such as a scenario in which a married teen couple has young children and one partner would like to start using contraception, while another scenario described two teens who decide to have sex for the first time and use contraception, and how that discussion might unfold.

To recruit WhatsApp FGD participants the study team met with youth network community leaders and district youth officers to describe the research and target group. These community contacts then reached out to local youth groups, purposively selecting potential participants who fit the age and geographic sampling criteria. In-person WhatsApp FGD participants (n=96) were loaned a WhatsApp-enabled phone for one hour to allow for their participation in the FGD. In-person focus groups were mixed gender, stratified by marital status, urban/rural locality, and geographic region (or district); there were eight participants per FGD.

Remote WhatsApp FGD participants (n=38) did not gather at a central location; rather they used their own WhatsApp-enabled smartphones to respond to the weekly facilitated scenarios as they continued with their daily activities. Remote groups were mixed with regard to participant gender, marital status, and urban/rural locality, and were only stratified by geographic region. Northern, central and southern region remote sessions had 9, 11, and 16 participants, respectively.

Participants provided written informed consent. Those participating in the in-person FGDs with study phones were in the same room and therefore knew who was participating in the discussion overall, but their specific responses were fully anonymous given that the phone numbers associated with their contributions were linked to the study phones and not personal devices. Participants in remote sessions used their own phones and thus responses were linked to their phone numbers. The consent form made this clear and encouraged participants to remove identifying features from their WhatsApp profile during the participation in the sessions. Participants were also asked not to share their name, address, and other personal information in the chats, and were instructed not to contact any of the participants outside the context of the group discussion. Potential participants were informed that researchers could not prevent this from happening, but that researchers would remove anyone from the chat who was not following the guidelines, and that participants could block messages from such participants.

WhatsApp FGDs consisted of a YR sharing an ASRH scenario, and then managing the virtual discussion with posed questions and probing. Participants were able to message directly with the YR if they did not want to share something with the full group. A VillageReach staff member was present at each in-person session and was included in each remote group to provide support to the YRs if needed.

Debriefing sessions between VillageReach staff and YRs were held either in-person or by phone following each FGD in which the team iteratively discussed their observations and experiences and built consensus on what worked, what did not work and lessons learned for future use of WhatsApp FGDs. Specifically, YRs were asked to reflect on: “what were the key takeaways from the group’s discussion? (including debates, powerful statements)”, “what feedback did participants have? (either on the content of the discussion or more generally around process),” “what worked well in facilitating that should be repeated?,” “what should be changed or improved about how the session was facilitated?” and “other.” Findings from these prompts were documented as debriefing summaries and approved by all debriefing session participants.

Fifteen WhatsApp FGDs were conducted, either as in-person (12) or remote (3) sessions. In-person WhatsApp FGDs were conducted at a specific time and location, such as youth clubs, sports facilities, schools or health centers, for approximately one hour. Remote FGDs convened several times each week over the period of one month, ranging from discussions totaling three hours to 10 hours each week. The amount of time dedicated each week depended on participant and facilitator availability and level of engagement throughout the week. Participants were male and female Malawian adolescents, aged 15–19 (n=134). Sessions occurred in three target geographic regions across Malawi (northern, central and southern). The study was reviewed and received approval from the Malawi National Health Sciences Research Committee (Protocol Number: 17/05/1813). In-person participants were given transport reimbursement, while those in the remote FGDs and using personal phones were compensated with 500MB of airtime data. Participants in remote sessions were given an additional 500MB of data as needed during the course of their participation.

Lessons learned

Applying WhatsApp mobile messaging technology to facilitate FGDs yielded important learnings about the strengths and limitations of this methodology; these have been organized into learnings related to data collection, data quality and data analysis. These learnings may be useful to other researchers attempting to use WhatsApp as a means of data collection.

Considerations for future use

While there are benefits to the WhatsApp FGD methodology, there are considerations that may complicate data collection in comparison to other qualitative methods. The approach requires certain logistics such as access to power sources to keep phones charged as well as WIFI or stable mobile data network connection to ensure FGDs run smoothly, and ensuring these pre-conditions exist requires planning. Additionally, the methodology may not be conducive to every demographic and as elaborated elsewhere, requires target populations to have some level of smartphone literacy, which should be considered when sampling populations with low rates of smart phone ownership (Chen & Neo, 2019).

Costs associated with WhatsApp FGDs (providing devices, data) may prohibit use of the platform for research in health. However, with a projected increase in smartphone ownership⁵ paired with introduction of low-cost WhatsApp bundles by some sub-Saharan mobile network operators, more people have access to this platform and other social media than ever before⁶. WhatsApp may also be a more cost-effective option in some circumstances, as it allows researchers to collect data on an ongoing basis without traditional costs such as hall rentals, transportation reimbursement to participants, etc.

Regardless of cost, this methodology may be more convenient for researchers and participants in some cases, particularly if aiming to engage the same cohort over time. The method may also be better positioned to reach the adolescent audience due to the technology’s flexibility, convenience and portability, and expanding familiarity of the WhatsApp platform (and of smartphones, generally) in adolescent sub-populations across Africa⁷. Further, the amount of detail and insights youth contributed in discussions indicates that the anonymity offered by WhatsApp FGDs may be an important factor in youth feeling comfortable to share sensitive information, especially in social environments like Malawi where adolescents place a high value on keeping sexual behavior hidden from elders, parents and peers (Limaye et al., 2012; Munthali et al., 2006).

Researchers who plan to use this technology should carefully consider the study design and any implications. For instance, researchers may want to clearly articulate to participants the ways the platform could be used in terms of whether voice recordings, photos/emoticons, text are all allowed, or if participants should only use the text feature, for example. Such guidelines may have implications for the resulting data format and ease of analysis, as well as how comfortable participants are sharing and the amount and nuance of information shared. Additionally, researchers should consider whether participants will be required to have access to their own smartphones to participate or if devices will be provided, and the resulting trade-offs around cost, representativeness of the sample, etc.

Conclusions/discussion

WhatsApp provides an alternative platform for researchers when eliciting information from adolescents on sensitive topics. The tool has both advantages and disadvantages associated with data collection, data quality and analysis, which should be considered prior to using WhatsApp for FGDs. The potential of this methodology is to allow researchers to collect in-depth and granular qualitative data and is a strength of the approach when working with challenging topics or stigmatized populations, who may be particularly concerned participating in more visible forms of data collection such as in person FGDs or in-depth interviews. Adolescents indicated feeling comfort using WhatsApp to share their perspectives on sensitive topics. Additionally, the opportunity to collect qualitative data over a longer period of time allows researchers to collect a great quantity of data as well as offers the potential for in-depth nuanced data as participants have more time to gain confidence and trust with the researchers and fellow participants.

By utilizing mobile messaging technologies, such as WhatsApp, health researchers may be better able to connect to adolescent experiences in ways reflecting contemporary youth culture and communication preferences. This in turn, could enhance the visibility of youth perspectives in health research and help improve the effectiveness of youth-targeted public health interventions.

As the use of WhatsApp grows to support health sector projects, there is a need to elevate more examples of lessons learned to drive technology to address the challenges faced using the tool. It will also be important to promote successes so researchers can consider whether it is a suitable platform for their work. As technology is applied in new ways in research, it is critical that the research community establishes guidelines for addressing ethical considerations, such as recruitment of diverse perspectives given a growing digital divide (Afrobarometer, 2022), and considerations around data privacy to be able to fully inform research participants of the risks and benefits to prior to participating in research through platforms such as WhatsApp.