Societal impacts of Covid-19

Case study: Reflections on running public involvement focus groups on the societal impacts of Covid-19 during a period of changing Covid-19 restrictions from October to December 2021

By Katherine Baker, Imperial Patient Experience Research Centre (PERC) Public Involvement Officer & Anna Carnegie (Co-PPI Lead, HPRU Modelling and Health Economics, Community Manager & Project Coordinator, London School of Health and Tropical Medicine

Background

Established in April 2020, the NIHR Health Protection Research Unit in Modelling and Health Economics (HPRU MHE) is led by Professor Neil Ferguson and has a core mission to develop novel analytical and computational tools to improve public health. The NIHR HPRU MHE is a partnership between UK Health Security Agency (HAS) and Imperial College London, in collaboration with London School of Hygiene & Tropical Medicine (LSHTM). Imperial College London also hosts the NIRH Imperial Patient Experience Research Centre (PERC) which is a core facility of the Imperial Biomedical Research Centre (BRC) undertaking research on research and providing advice and support for public involvement and engagement.

What did you do?

We held focus groups with members of the public to inform the design of a Discrete Choice Experiment on Covid-19 restrictions which is being delivered by the HPRU MHE to inform public health policy regarding future infectious disease outbreaks.

What is a discrete choice experiment?

A discrete choice experiment is used to identify people’s preferences (for example, about the features they would like to see in a contact tracing app) without directly asking them to state their preferred options. People are typically presented with a series of alternative hypothetical scenarios containing a number of variables. They are then asked to state their preference between 2 or 3 competing scenarios, each of which consists of a combination of these variables. Surveys usually have 5-10 choices or ‘tasks’ to be completed and through the choices made, people’s preferences are revealed.

The focus groups

During November and December 2021 we hosted 6 virtual public involvement focus groups, made up of 3 different groups who met twice, 2 weeks apart, from 5.30 to 6.30pm. The first of the two sessions explored the broad societal impacts of Covid-19 and restrictions, while the second focused on translating some of these themes into the format of a discrete choice experiment. Over the period of time when these focus groups were held:

• Government Covid-19 restrictions and guidelineswere changing rapidly to try and anticipate what would happen over Christmas 2021 and into the new year.
• A new Covid-19 variant of concern had also been designated by the World Health Organisation (Omicron)
• Stories began to emerge of rule breaking within the seat of government.

While the focus groups were not planned to coincide with these constantly changing contexts, they provided ‘a moment in time’ for reflection for both the participating members of the public and those working on Covid-19 research.

The focus group discussions brought together a diverse group of members of the public to give their perspectives on the societal impacts of Covid-19 and restrictions. Focus group attendees were asked what they thought about:

• restrictions in the community,
• shopping,
• travelling at the time of the focus group (i.e. November/December 2021) and in the future; and
• whether they felt the current restrictions were appropriate.

Who we involved and how we found them?

We approached recruitment to the focus groups in the following ways:

• advertising on the VOICE platform (to which Imperial has a licence); and
• by sending out emails to existing Imperial mailing lists
• social media.

The mailing lists included the Imperial’s Young Person’s Advisory Network (17 to 25 years) and those who had expressed an interest in the work of HPRU MHE following public involvement workshops hosted to inform the HPRU MHE PPIE Strategy.

The focus groups consisted of 23 individuals in total with a split between the genders of 70% Female, 22% Male, 4% Non-Binary, 4% Trans. The age range was from 19 – 65, with an average age of 34. Public involvement can often skew towards those who are older and retired.

The ethnic diversity of the session was also very important to us, in light of the disproportionate impact that Covid-19 has had on ethnic minority communities within the UK. Those attending identified as White British, African, Black, Bangladeshi, Other White background, White/Asian, Indian, Pakistani, Berber and White/Black British, with over 50% being from ethnic minority communities.

Due to the national reach of the HPRU MHE’s research and the virtual nature of the focus groups, we were able to cast a wide geographical net which included those from across the UK. There have been a number of inequalities highlighted and made worse by the pandemic and geographical location can play a role in this.

The changing context around us

Whilst we were asking questions during focus group 1b (see Table 2 below) about the level of restrictions and how contributors felt that the public would respond to these, the UK government announced ‘Plan B’ was coming into action. This included a new communication strategy about the level of risk that we faced for Covid-19, legally mandating face coverings and the re-introduction of the ‘work from home’ message. The Omicron variant was identified in the UK days after the first set of focus groups. Also during the course of the focus groups, the first news reports emerged of parties and socialising within No.10 Downing Street during lockdowns.

Table 1. Summary of Covid-19 announcements that the government and media made during the time when the series of focus groups were running

Impact on focus groups of the changing restrictions

The first three focus group sessions (1a, 2a and 3a) took place before the announcement that Omicron was a ‘variant of concern’. Whilst the Delta variant was mentioned within the first round of focus groups (1a, 2a, and 3a) there was a wider focus on ‘Covid-19’ as a whole rather than specific variants. Attendees responded positively to the idea of restrictions if it meant there was less pressure on the NHS and a reduction in sickness and death however attendees were still wary of travel and a couple mentioned that they would not be travelling any time soon.

After the third focus group session ended (3a), the facilitators discussed the emergence of the new Omicron variant including: how to respond to questions on it, how would contributors react to this news and whether this would cause changes in people’s responses to the question on restrictions.

In the two weeks between all the sessions, Omicron’s global impact grew with new travel restrictions brought in by many nations. These measures went further than what had been discussed in the first set of focus groups (1a, 2a and 3a) and so we wondered if this would have an effect on asking about what attendees’ thought about appropriate levels of restrictions.

During this time, news also broke of parties being held within Downing Street by those working in government and elected officials. News outlets, paper and social media painted a picture of fury from members of the public which we were concerned could again influence the opinions of the those attending the focus groups.

How staff prepared for attendees’ responses

The facilitators and PPIE staff met before the sessions to discuss how we would counsel potentially angry and upset public contributors but also keep the groups on track to answer the questions. This also led to our own reflection about the changes happening around us as we had to reconcile gathering information that was important to our work alongside the emotional reaction to the news. The value of having the opportunity to speak to colleagues about our emotional response to the new restrictions and controversies gave us time to process this information before discussing the topics with members of the public.

How the attendees’ responded

As the focus group attendees were interested in health research, those who joined were aware of the changing restrictions but also receptive to the fact that the discussion had to keep on topic and that the facilitators’ would bring the discussion back to the planned questions.  The sessions generally kept on track with only a couple of comments made about the relevance of the focus group questions as new restrictions were already being implemented rather than being a hypothetical. There was some evidence that the changing context and growing concern posed by Omicron caused some attendees to change their viewpoint on what restrictions they considered acceptable. The use of “vaccine passports” for travel, dining and entertainment was one example. Focus group attendees were reflective about the fact that their views had evolved in light of the increased threat posed by the disease.

Advice for undertaking public involvement when the context is changing around you

An activity that involves asking questions about a public health situation that is constantly developing as the sessions are being run will always be tricky to negotiate. It will depend upon the sensitivity of the topic and the attitudes of those attending the session, along with the confidence and experience of those facilitating.

We would advise reflecting on the expectations of the session and how facilitators might react when potentially challenged on sensitive and emotive topics. When it comes to public health it is always good to be aware of the most up-to date news and to what information members of the public may also have access. 

So, what’s next?

Following the focus groups, researchers at LSHTM designed a discrete choice experiment using the perspectives gathered from the focus groups. The experiment was piloted by LSHTM staff and public contributors who attended the sessions and revised on the basis of their feedback.

The next step is to roll out the final discrete choice experiment to a representative sample of the UK population, as well as in two additional countries within Europe (Belgium and Switzerland). The results from the experiment will help to inform governments and public health authorities about the restrictions that members of the public deem acceptable when there is a large-scale disease outbreak.