Zoom & WhatsApp digital information and communication technologies (ICTs) enhance community engaged research with women immigrants from Mexico

ABSTRACT

This article demonstrates how digital information and communication technologies (ICTs) (Zoom/WhatsApp) unexpectedly and counterintuitively proved to be valuable tools for community-engaged health research when, in the context of the COVID-19 pandemic, they were integrated into a research study testing a peer support group intervention with female immigrants from Mexico. Because of pandemic restrictions, we changed the study protocol to hold meetings remotely via Zoom rather than in person as originally planned. Because we recognized that this would lack some opportunities for participants to interact and develop relationships, we created a WhatsApp chat for each group. Despite challenges for participants to use ICTs and participant-stated preference for in-person meetings, the results demonstrated that participants overwhelmingly endorsed these technologies as promoting access, participation, engagement, and satisfaction. Zoom/WhatsApp created a valuable environment both as a method for conducting research with this population, but also as part of the intervention for immigrant women to support and learn from each other. ICT adaptations have now permanently changed the way we conduct community-engaged health research.

KEYWORDS:

• Information and communication technology (ICT)
• Zoom
• WhatsApp
• community-engaged research
• female Mexican immigrants
• peer support

Introduction

Requirements for social distancing imposed by the COVID-19 pandemic created enormous upheaval in people’s everyday lives. In this context, remote digital information and communication technologies (ICTs) such as Zoom and WhatsApp became valuable as substitutes for in-person interactions. Zoom¹ is a cloud-based, remote conferencing service that allows participants to meet in groups from their devices in separate locations using both video and audio. WhatsApp² is a phone app that provides free messaging using text, voice, or video. Integration of ICTs into novel contexts during the pandemic allowed the maintenance of some level of social connectivity despite restrictions on in-person social interactions.

A significant literature exists describing the ways that immigrants and migrants have used ICTs and social media to create and maintain social networks (e.g., Dekker & Engbersen, 2014; Komito, 2011; Komito & Bates, 2009; Matei & Ball-Rokeach, 2001). In 2018, Kaufmann (2018) suggested that smart phones were an emerging technology that could hold new potential for immigrants and refugees to integrate into new country contexts – an insight that has more than come to pass. In health intervention research, prior to the pandemic, ICT use primarily involved WhatsApp (e.g., Gondwe & Some, 2020; Patel et al., 2018; Trude et al., 2021; Wilson et al., 2022). These studies uniformly found that WhatsApp contributed positively to a variety of health and wellbeing outcomes. In a wellness program for cancer survivors that used Zoom during the pandemic, Jhaveri et al. (2020) found that participation was greatly enhanced.

A common theme in all these studies is that participants endorsed the use of ICTs. ICTs can assist immigrants in obtaining health information. Troubled with finding advice and information through traditional mechanisms in a new country context, Latina immigrants have relied on ICTs to seek answers to questions and to receive the support they cannot obtain elsewhere (Neal & McKenzie, 2011; Whelan, 2007). Latina immigrants have used support groups online to answer their questions. Similarly, during the pandemic, the use of ICTs to conduct research became necessary and studies have demonstrated that ICTs showed promising results and benefits but also require thoughtful implementation in order to address logistical and operational challenges (e.g., Oliffe et al., 2021)

Integrating ICTs into community-engaged research

However, in the context of community-engaged research with individuals from populations that are under-resourced, excluded, or marginalized, the literature on use of ICTs is just beginning to emerge. ICTs are considered inappropriate in some cultures or community contexts, or often not accessible for people from low-income households, and face-to-face interactions are generally assumed to better promote trust-building which is a key component of community engagement (Moore de Peralta et al., 2022). However, in the context of COVID-19, community-engaged research had to adapt. In an editorial by Teti et al. (2021) remarking on the way that COVID-19 was changing the way that we plan, conduct and disseminate participatory research, they highlight the flexibility offered by ICTs as a potential for continued use beyond the pandemic, but they also express concern for being able to ensure the collaborative nature and deep knowledge base that are a hallmark of participatory research with a focus on social justice. Salma and Deena (2021), working with older adult immigrants in Canada, highlight three challenges when working virtually with marginalized and minoritized populations that face particular vulnerabilities: 1) the importance of being able to pivot in response to new contexts, 2) being cognizant of inequities that can emerge in relation to research participation, and 3) making sure to reflect on the well-being of the research team as well as the participants. Tungohan and Catungal (2022) discuss qualitative research with Asian international students and virtual methods adopted during the pandemic from a lens of feminist queer methodology. They emphasized the importance of considering the transnational lives and different/multiple social locations of participants and research team members in the design of the research, and they identify ways that virtual qualitative research, although distinct, is not inherently inferior. In their study of migrating to transnational virtual delivery of a participatory project with domestic workers and asylum-seekers in Hong Kong, Ham et al. (2022) ask “can methods travel the way migrants do?” (p. 1). They identify fragmentation of time and space and the integration of the virtual platform into everyday reality as challenges. Ornelas et al. (2022), used participatory processes to implement a weekly mindfulness-based intervention to prevent and reduce depression and anxiety among Latina immigrants. Their experience is interesting because the intervention was designed to be implemented in person, but because of the pandemic, they had to transition to using a virtual option. They found that attendance was similar across modalities and that participants expressed satisfaction with both.

Similar to Ornelas et al. (2022), here, we discuss results of integrating Zoom and WhatsApp into “Tertulias” (Spanish for “social gatherings”), an anthropologically inspired, community-engaged study to test a culturally and contextually situated peer support group model for reducing social isolation and depression among female Mexican immigrants (Page-Reeves et al., 2019, 2021, 2024). We focus on how this integration impacted study implementation, engagement, and participant experience.

It is clear that the norming of ICTs in research contexts, which previously may have seemed implausible or infeasible, is a lasting legacy of the pandemic. Pragmatic use of ICTs is an adaptation that is not going away, even in community-engaged research. However, data to provide evidence supporting this transformation in relation to the science of engagement are still being generated. Results from community-engaged studies successfully using ICTs to recruit, engage, and retain participants or as part of the delivery of an intervention are lacking. Previous attitudes and assumptions about the primacy of in-person events and structures generally suggested that ICTs and community engagement processes would be antithetical. Given that the transition to using ICTs happened extensively without evidence because of the pandemic, the data presented here offer a unique perspective from a unique moment, but also provide broader insights for community-engaged research study design. Results from this study are interesting because they provide a guide related to the types of things that must be considered when using ICTs in community-engaged research, but they also perhaps open the door to researchers who would not otherwise believe that ICTs would be appropriate. These findings fill a gap in the literature and contribute to the science of engagement.

Materials and methods

In 2007, in Albuquerque, New Mexico, mental health providers who primarily see Mexican immigrant patients became concerned about the number of female patients presenting with social isolation and depression. To address this problem, clinic staff piloted and later worked with researchers at the University of New Mexico (UNM) (Page-Reeves et al., 2019) to enhance an innovative weekly, two-hour, bi-directionally facilitated peer-support group intervention for their female Mexican immigrant patients. Based on promising pilot results (Page-Reeves et al., 2019), the Tertulias study is testing our hypothesis that a peer support group will lead to decreased social isolation and depression, and increased empowerment, resilience, and social connectedness (Page-Reeves et al., 2021). All participant-facing parts of the study are conducted in Spanish.

Sample

Tertulias is designed to have 240 participants (n = 240) in four cohorts of 60/year. Participants are adult female Mexican immigrants (born in Mexico) who live in or near Albuquerque, New Mexico, speak and understand Spanish fluently, and self-report income below 250% of the Federal Poverty Level.

Participants are randomized, using a permuted block design, into an intervention arm or placebo control arm. We are currently in the middle of Y3. Here, we present an interim analysis of data from Y1 and Y2 of the intervention arm (n = 59) focusing on the before/after results of using Zoom and WhatsApp rather than on the study’s primary outcomes between the two arms.

Changing to Zoom and adding WhatsApp

Recruitment for Tertulias began in May 2020 and the first cohort of the intervention began in August 2020. The Tertulias protocol (Page-Reeves et al., 2021) was designed to have weekly in-person group meetings, but because of pandemic restrictions, we re-designed the intervention to use Zoom with added WhatsApp chat groups. Elsewhere we discuss how the pandemic restrictions impacted recruitment and our development of a multimedia recruitment approach (Rodriguez et al., 2022) and overall interim results (Page-Reeves et al., 2024).

As we made the transition to remote meetings, we were concerned that Zoom would not work for this intervention. At that time, few people were familiar with Zoom and it seemed an unlikely-to-succeed idea for a community-engaged study. We were worried about whether women would attend the meetings and that Zoom would not provide the same intimacy for discussion or connectivity between participants that we theorized/anticipated for in-person meetings. To mitigate these concerns, we provide intensive technical assistance to each participant to set up and use Zoom, including the creation of a bilingual, visual Zoom guide for logging on (Appendix A), and we create WhatsApp chat groups so participants can connect with each other outside of the meetings. Additionally, we provide each intervention participant with $30/month to ensure sufficient internet connectivity.

Although prior to the pandemic, ICTs were not common in research unless the specific purpose of an intervention was to test the use of an ICT itself, ICTs, and WhatsApp in particular, were already substantially incorporated into the daily lives of a significant portion of the Mexican population. WhatsApp was considered for use within this intervention because of the regional familiarity with the instant-messaging software. In 2019, Mexico had 57.2 million WhatsApp users – the fifth largest userbase, behind India, Brazil, the United States of America, and Indonesia.³ Within Mexico, WhatsApp had an 87.1% penetration rate – almost 9 in 10 Mexican citizens using WhatsApp.⁴ In 2023, WhatsApp was the most popular instant-messaging application in 63 of 100 countries that were evaluated within a study – including Mexico and several other countries in Latin America.⁵ Both the wide-spread presence and the cost-free opportunity to connect with friends and family, with only the use of a compatible smartphone and internet access – are appealing factors that may play a role in the initiation and continuance of WhatsApp’s prominence amongst Mexicans and Mexican Immigrants.

Security and privacy

In order to make the transition to using Zoom and WhatsApp, we had to ensure participant privacy and obtain requisite permissions. Newman et al. (2021) and Roberts et al. (2021) have highlighted significant ethical considerations of using virtual technologies to conduct research and the need for rigorous security protocols. The UNM Human Research Protections Office (HRPO), and UNM Offices of IT and Privacy and Security conducted a thorough review of our request and granted permission for their use in this study. The consent form indicates that the intervention will be held by Zoom and the possibility of loss of privacy. With the meetings being held by Zoom, the participants generally participate from their homes. We supply participants with earbud-style earphones so that no external person can hear the conversation. In the first meeting, we discuss protocol for privacy with participants. All participants are required to announce themselves when they join the meeting and we do not hold any discussion unless we know that all meeting attendees on the screen are the participants. We have first names-only visible on the screen. Each group selects two “safe” words that are innocuous words like “chocolate” or “flowers.” If a participant is unable to respond to a question or to speak without being overheard, they can just answer with the first safe word and the group understands that they are listening and participating but that they are just not able to contribute at the moment. Following an incident of danger to a participant because of domestic violence, we added the second safe word which is only used to indicate that a participant is unsafe and that we should call the police. We have never had to use the second safe word. We do not audio record the peer support sessions for reasons related to privacy of the content of the sessions. We do audio record and transcribe specific sessions that are for the purpose of the research and that involve evaluation discussion of the intervention, and participants are informed that the recording is being made and they can opt out if they choose to do so.

As noted above, the WhatsApp platform is widely used by Mexican immigrants and their families both in the U.S. and in Mexico. The vast majority of the study participants already use WhatsApp, they are familiar with how it functions, and they have the app on their phone. The WhatsApp platform has an encryption system to protect the privacy of users. Participants are informed on the consent form of the potential risks to privacy that exist when participating in an online chat group – both within the group as all members of the group see the posts, and external from threats to internet security. To the consent form we added an opt-in/opt-out option. Only participants who “opt in” are added to the WhatsApp group. At the first meeting, we also discuss the protocol for use of the chat. WhatsApp language and use is to be with respect and courtesy. No products are allowed to be sold via the WhatsApp. We use the WhatsApp chat to communicate things about trouble shooting access to zoom or reminders for the meetings. For the few who have “opted out,” the study coordinator calls or texts them meeting reminders or other logistical information.

Data collection

We administer a survey at baseline and 12 months that includes questions about Zoom and WhatsApp (Appendix B). We also track attendance at meetings. We gather qualitative data through meeting notes, post-intervention interviews, and documentation of WhatsApp chat streams, participant’s “creative projects” (e.g., story, poem, painting, photograph, recipe, handcraft, etc.) (Appendix C), and group evaluation discussions. Participants also were asked to reflect on their experience in Tertulias and its impact on their lives, including discussion of Zoom and WhatsApp using an innovative participatory evaluation technique called “Ripple Effects Mapping” (REM) (Chazdon et al., 2017; Kollock et al., 2012). From these data, we use XMind 8 Software⁶ to create a visual “map” that describes change, reveals interconnections, and documents complex processes – the “ripples” that happen as a result of the intervention, including capturing and identifying unforeseen or unintended impacts that are difficult to measure using other methods. At a subsequent meeting, we present the map back to participants, incorporate their input to refine the map in real time, and document their thoughts and reactions to the REM process and results. Utilization of REM aligns with equity, feminist, and community-engaged best practices regarding the use of data visualization (Azzam & Evergreen, 2013; D’Ignazio & Bhargava, 2020) as a way to creatively represent complex experiences and capture ideas that are not easily put into words (Furman et al., 2019) which has the power represent reality in new ways and to disrupt existing landscapes of power (D’Ignazio & Bhargava, 2020).

Data analysis

Statistical analysis of survey and attendance data

Descriptive statistics were calculated to summarize responses to four survey questions about Zoom and WhatsApp, and attendance data. These include frequencies and percentages for categorical data, and means, medians, and their respective measures of variability for count and continuous data. SAS 9.4⁷ was used for analyses.

Social network analysis

To measure the structure of and changes in social networks within Tertulias, all intervention participants were asked questions about their relationships within their group at baseline and at follow-up. For each co-member of their group, respondents were asked if they knew this person, could talk to them about personal problems, could ask them for information about resources, do something fun with them, and could ask them for a ride to the doctor. We constructed matrices of directed networks for each of these constructs. We created network visualizations and calculated descriptive metrics using the igraph package in R (Csardi & Nepusz, 2006).

Qualitative data analysis

We reviewed data from meeting notes, interview and evaluation discussion transcripts, WhatsApp chat streams, creative projects, and REM maps. We used a rigorous, disciplined, empirical approach to the analysis according to Hammersley’s (2008) criteria for qualitative research based on plausibility, credibility, and relevance. We followed Gläser and Laudel’s (2013) framework for theory-driven qualitative content analysis. We reviewed the data and identified conceptual categories and patterns related to the domains of inquiry, extracted the data, and developed conceptual summaries. Following review and summary, we coded extracted data internally for systematic subthemes and their domains. We used “constant comparison” (Memon et al., 2017) to explore interconnections between theme/sub-theme categories and to develop an interpretation. We showed participants the REM map created from the evaluation discussion and they provided input for how to refine and understand the map, contributing to interpretation of the data.

Results

Elsewhere, we report overall interim results for the study (Page-Reeves et al., 2024). Results here focus on outcomes specifically related to the integration of Zoom and WhatsApp into the intervention rather than specifically on a more traditional presentation of the outcomes of the study. The lens here is to understand how we integrated Zoom and WhatsApp into the study design and how the use of Zoom and WhatsApp influenced not only the methods of implementing the study but also the way that the participants experienced the intervention – and therefore impacted outcomes. All quotations are English translations from Spanish. We enrolled 59 intervention arm participants. Forty-six responded to the Zoom/WhatsApp questions.

• 57 said they participated in the WhatsApp chats

• 96% said Zoom technology worked “Very Good” or “Good.”

• 98% said the interaction on Zoom was “Very Good” or “Good.”

• 96% said the WhatsApp was “Extremely” or “Very” important.

Technical support

Most participants joined meetings by phone, but a few used tablets or laptops. Technical support was necessary for participants to understand and be able to use Zoom. The bilingual Zoom guide we created (Appendix A) helped participants orient for the first meetings. However, many had trouble logging on and understanding how to operate camera, mute, and chat functions. In general, participants needed a great deal of assistance and frequent trouble-shooting before and during each meeting.

Financial support

We had anticipated that some participants would have difficulty participating because of lack of access to a device or to the internet. We did not find that participants had difficulty due to lack of a device. The main challenge was with internet connectivity, especially in Y1. Connectivity issues interrupted service and reduced the ability of some to participate. In other cases, participants were not able to speak because the bandwidth of their connection badly distorted their voice or made communication with and/or participation by a participant impossible. Because we provided intervention arm participants $30/month internet support, participants experiencing internet issues were generally able to increase their data to be able to participate. Participants reported that having internet financial support was extremely important for allowing them to participate.

Skills

We noticed a distinct change in participants’ ease and skill over time when using Zoom. Many participants had an initial apprehension with technology, especially with Zoom. However, by the end of each year, participants developed fluidity. We also saw a difference between Y1 and Y2, with Y2 participants starting with a higher level of knowledge, skill, and confidence. Participants said, “When we first started, I was scared to touch anything or push any button, I learned that it is actually easy and now I’m very competent.” And “The technology started out as an obstacle but I learned how to overcome that.”

Technology

Through the process of learning how to use Zoom and by participating in weekly Zoom meetings, participants reported that the experience changed the way that they interface with technology. This had impact beyond the study in the lives of participants – the “radiant” impacts as demonstrated visually in the REM map (Appendix D). Participants said:

• “I was really happy to learn how to use Zoom because it has allowed me to connect with other people in my life!”

• “Learning how to use Zoom motivated me to take an accounting class remotely.”

• “Learning more about modern technology made me feel as if I am not being left behind.”

• “Learning to navigate Zoom was an experience that opened my eyes to the world of technology. Zoom opened-up a whole new world for us.”

Engagement

The median number of Tertulias sessions attended was 30. The median percentage of Tertulias sessions attended was 76% (Q1 to Q3: 56% to 88%). Several participants stated that they would not have been able to continue with the study if it had been conducted in-person.

Participants lamented that the meetings could not occur in person, especially in relation to developing social connections and sharing food. In the evaluation discussion, one participant said, “It’s not the same as in person, we can’t see each other in the same way, we can’t share food.” Other participants commented on negative differences: “I can’t express myself on camera! It changed the experience.” However, participants reported that despite being disappointed that they could not gather in-person or share food, Zoom actually enhanced/increased participation. One participant said, “I’m always really surprised at how well it works [to have meetings by Zoom]. I’m very happy. It has surpassed my expectations.” Other participants said:

• “Without this, we wouldn’t have been able to meet as often or with all the people, but by Zoom it has benefited everyone because we all had flexibility.”

• “It is better by Zoom because right now I’m working but I can still be on the screen.”

• “Zoom was very practical because it was a way to be able to incorporate the meetings with our daily lives – otherwise it would have been really difficult.”

• “I don’t have a car, so Zoom is a way for me to be able to join the group.”

The fact that Zoom allows participants a great deal of flexibility compared to traveling to and attending a two-hour weekly meeting was key to making it feasible for most participants to participate. It was very common for participants to be cooking dinner or driving during the meeting. A number attended from work because of schedule conflicts (e.g., folding clothes as a laundromat attendant, caregiving for an elder or children, house cleaning, food prep in a restaurant). A few routinely transitioned from work, to car, to home during the meeting. Two participants attended from the hospital when a family member was ill, and two while traveling. Participants felt very comfortable being able to attend from home and that made it an enjoyable experience. Participants said: “It was easier to join the Tertulias because of the comfort of being at home.” And, “It is more comfortable and so much easier [by Zoom]. This electronic way is very easy. It is as if we are in person.”

Social connections

Participants reported that they experienced the Tertulias meetings in an incredibly deep and meaningful way, and that attending by Zoom had contributed rather than detracted from this. One of the creative projects (Appendix C) from Y1 visually captures the Zoom screen context, but also her experience of participation. Participating by Zoom also impacted the way that participants socialize. A number said that being able to listen to so many women with such diverse life histories and perspectives through the Zoom screen taught them the value of listening, being accepting, and being tolerant. One participant described the experience saying, “It made us imagine the world differently (‘un imagine imaginatoria’) – and it gave us an opportunity to experiment and experience different things.” For nearly all of the participants, the experience was not only significant and meaningful, but in some ways life-changing. Participants said:

• “The Zoom screen allows us to see each other in a different way.”

• “It was a new experience. You don’t have to get dressed up. It is just a time for women friends. I don’t think this would have happened in person.”

• “Seeing that I can make friends virtually has made me realize that I would like to do more of this and make more friends this way.”

Participants agreed that being able to see each other on screen during the meetings was very important for creating social connection and intimacy. One participant said, “seeing the faces creates trust.” Another participant said, “I could see expressions and connected with people even though I don’t know them – but even when the people didn’t have their camera on, I recognize their voices.” Flexibility of the camera was equally important – we encouraged use of the camera, but participants could choose to have it off. Most participants who turned their cameras off were still engaged, and they would unmute to participate, as needed. Discussions during group sessions demonstrated that everyone was generally paying attention and participating, regardless of camera use.

Less obviously, the camera also allowed the group to peek inside other participants’ homes. Participants felt that this added a personal dimension to the experience that brought them into other participants’ personal spaces. One participant said, “I really like being able to see everyone in their homes and their own spaces, it makes us transcend the screen.” Some discussed how they always got ready for the meeting with excitement and anticipation – it motivated and encouraged them to dress up. However, others felt the opposite – that the security and comfort of being at home let them appear in the group in a more relaxed way, without having to dress up or put on makeup, and that Zoom promoted less formality and more closeness among the group. One participant said, “We see each other less fixed-up and maybe in our pajamas. To have this trust, really, it helps to be by Zoom and it has facilitated the process more.”

One participant said that she felt like it was so much easier to tell things to the group that she had never told anyone before because she felt safe in her house, and because she was participating by phone and could only see one person at a time on the screen, it did not feel like everyone was looking at her. Participants said:

• “Normally, I can’t talk or add to a conversation, but here in these meetings by Zoom, we all get a turn to speak and the others get muted.”

• “I see that it is easier to say how I feel by screen rather than in person.”

• “I think it would have been harder to get close to each other in-person in the same way and to share our thoughts and feelings.”

• “I would never have been able to share what I shared in person. I was easier because I felt like I was alone in my house and just talking to my device by Zoom.”

Real time connection

Zoom connected participants in a new way in real time. One participant described that “I could share things right at the moment they were happening in my house.” In one instance, a participant got into an argument with her husband during the meeting and muted herself and turned off the camera. When she turned the camera back on, she was in her car and told us that the incident had become violent and she had fled. The group rallied to support her with heartfelt advice and thoughts, helping her talk through what she needed to do next. Subsequent to the call, the facilitators assisted her in getting help from a domestic violence shelter and a restraining order, and over the next couple of weeks, she filed for divorce.

Chats

The team used WhatsApp to send logistical information, reminders, and login information. Participants used the chat for cheerful salutations, words of encouragement or support, sharing/celebrating accomplishments, sharing news, information, and resources, and asking advice or connection to resources. Only two participants opted not to be included in a chat group because of a lack of time or complicated technology.

The WhatsApp chat groups were extremely active; in Y1 alone, there were 3,386 messages posted. Some became active with participants introducing themselves and interacting a couple of weeks before the Tertulias meetings began. There were some who posted more than a dozen times a day, and those who were less active, but the vast majority participated regularly at least in some form. Participants told us that the everyday WhatsApp communications encouraged them to participate, and that the communication function was a key feature. Participants said: “It made us more connected – faster – between everyone.” And, “We communicated easier, whatever thing was communicated.”

Participants told us how WhatsApp had increased their social connectedness, saying:

• “WhatsApp gave us the tool to connect.”

• “It made us more connected faster and between everyone.”

• “The WhatsApp messages and having the weekly meeting gave me the motivation to get up each day and to confront what was ahead.”

Qualitative analysis of conversations over WhatsApp revealed an evolution in the nature and characteristics of chat posts. At first, conversations revolved around logistics and simple courtesies. Participants said things like:

• “Unfortunately, I will not be able to make it to the meeting on Monday, I have a medical appointment.”

• “It is not letting me enter [the zoom meeting].”

• “Have a beautiful weekend.”

However, as time went on, the chat stream changed to include more personal sentiments, intimate thoughts, and advice:

• “I am praying for L – and her family’s health.”

• “I hope everything turns out well, if you need anything I am here.”

• “You know that for whatever you need I am here, let me know. Is someone with you?”

Between greetings, emoticons, and media, they also began sharing their emotions, secrets, guilt, and insecurities.

Beyond the chat

Participants planned several gatherings on their own using WhatsApp. One group coordinated a food distribution. One of the participants discovered a local store was giving away free groceries. She posted information with pictures of what she received on the chat, encouraging others to go, but the food at the store ran out too quickly. The participant who posted the information offered to share what she had received with her “virtual friends” and gave food to many of them.

Participants also organized a potluck, drive-thru birthday party through WhatsApp and were very excited about this both before and after the event. The day of the event, there was a snowstorm, but everyone still dropped off a dish. The organizer divided the food and re-distributed it in to-go containers. They ate the meal remotely, but together, during the Zoom meeting and were particularly happy that they succeeded in holding the event despite inclement weather and the pandemic restrictions on social gatherings. This same group also decided they needed more in-person interactions and coordinated coffee using WhatsApp on several subsequent occasions.

Connection to resources

As described below, informational support networks increased during the intervention. Information and resources were shared at meetings, but that was also a key function of the WhatsApp Chat group. Participants were eager to share with the group about resources and information they discovered. A plethora of resources and opportunities such as COVID-19 vaccination sites, state-funded financial support, COVID-19-related unemployment benefits and guidance, home remedies, food distribution times/locations, and scholarships for children were posted in the chat. Participants offered to personally deliver supplies, food, and home remedies to those in need, such as those quarantined with COVID-19, or those who had hospitalized family members.

The immediacy of WhatsApp provided an in-the-moment resource that allowed participants to learn about or access resources when they needed them urgently or for a short window when limited resources were available, or to provide support and encouragement to a participant who was having a crisis such as the hospitalization and death of a participant’s husband from COVID-19. One participant said, “Through technology [WhatsApp], I was able to get help from the group instantly.”

Social network analysis

Figure 1 displays sociograms of relationships between participants in one of the Tertulias groups at the beginning of the study and 12 months later, regarding who in the group they felt they could ask for a ride to the doctor. Each lettered circle represents one respondent, and the directional lines connect respondents to the person they felt they could ask for a ride. At baseline, only a small number of respondents knew one another, and so the networks began mostly empty: on average only 8% of all possible relationships existed in the groups (i.e., edge density) in terms of knowing each other. At the end, most participants not only knew one another, but also identified many members of their group as sources of support: on average 47% of the relationships in the group were identified as someone who could be asked for transportation to the doctor. This was observed for all of the forms of social support measured, including information about needed resources, transportation to the doctor, discussing personal problems, and doing something fun. At 12 months, all groups were composed of dense networks of mutual support.

Figure 1. Sociograms of transportation-to-the-doctor support among participants in a Tertulias group, (a) pre- and (b) post-intervention. Letters represent the same individual participants across both sociograms.

Discussion

The counter-intuitiveness of our results

Zoom and WhatsApp were only integrated into the Tertulias study because COVID-19 restrictions prohibiting in-person encounters required us to do so. We had no other option if we intended to conduct the study. When the pandemic began, we believed these technologies would not be useful or appropriate for community-engaged research and we never would have considered using them. Robotham et al. (2016) describe the existence of a “digital divide.” The ICT landscape is marked by dynamics that reflect and reproduce existing social, economic, political, cultural, and geographic fault lines. When we were confronted with transitioning to Zoom, we believed it would be foreign and inaccessible for participants, that participants would experience Zoom as cold and antiseptic, that remote interaction would not engender the intimacy and connection that we anticipated with in-person meetings, that it would be very challenging to get participants to show up to Zoom meetings, and that everyone would prefer to have the meetings in-person. Although WhatsApp is widely used among the participants and their families, and we added it hoping it might provide some way for participants to interact outside of the structured 2-hour zoom screen meeting time, we did not believe that forming a WhatsApp chat group with a bunch of women who do not know each other would be that effective in the context of creating intimacy in the study. These beliefs reflected both the team’s biases and personal experiences, and also input from our team members and advisory board members who are female immigrants from Mexico and what they believed would be true about the women we were recruiting to participate.

Although at the beginning of each cohort year, participants lamented that the meetings could not occur in person, counter-intuitively, and much to our surprise, from the very beginning of the study, the use of ICTs has proven to be extremely valuable and in reality, essential to the success of the intervention. The fact that ICT technology played an important role in the intervention was demonstrated widely across our mixed-method data.

Because we recognized that integrating ICTs into this intervention was novel, in 2020 when we revised the study protocol to use Zoom and WhatsApp instead of in-person meetings, we had the foresight to add evaluation questions about the use of ICTs into the post-survey, evaluation discussion, and interviews. This meant that we obtained systematic data to inform our understanding of what happened when we used these technologies and how participants experienced them. The results of the survey demonstrate that participants overwhelmingly endorsed the use of ICTs, with responses ranging from 96% to 98% being positive or extremely positive.

Technical and financial supports were necessary and important for participation

An important finding from the perspective of community-engaged research, we learned that significant support from the team was essential to make ICTs work in this intervention. At the time we started the intervention, almost none of our participants had ever used Zoom and members of our team were only starting to become proficient, so Zoom was unfamiliar and technically challenging. We anticipated we would need to provide substantial technical support, and this was validated. We also learned that the financial support for internet connectivity we provided was essential. When we made the decision to launch the intervention remotely using Zoom, we knew that the “digital divide” is a huge issue in New Mexico where 39.6% of the population does not have internet service—one of the highest rates in the country.⁸ Lack of access to a device (e.g., phone, tablet, or computer) or to internet connection can be a huge barrier. This was particularly important since part of our inclusion criteria was that participants are from low-income households. We discovered that having a device was not an issue – the main challenge was with internet connectivity, especially in the Y1 cohort. When we launched the project by Zoom, we recognized that it would likely be a problem for participants to have sufficient internet bandwidth to use the Zoom platform without audio and visual disturbances. Moreover, we were concerned about the amount of data that Zoom uses and that participation would inflict a cost on participants if they were on limited data plans. To mitigate this potential harm, we provided intervention participants the $30/month stipend to support their internet capacity. We were not paying them to participate. We were making sure that participation did not enact a financial burden and that they had sufficient internet connection to be able to actually participate. Our data demonstrate that the stipend was important, and some participants would not have been able to connect without it. These are important lessons for community-engaged research design intending to use ICTs, although the post-pandemic context in which people are now comfortable with and have had to use Zoom and other platforms could make this need less important in the future.

New skills and a changed relationship with technology

Participants’ ability to use and feel comfortable using Zoom changed dramatically over time. We saw a distinct difference between the Y1 Cohort (2020–2021) and the Y2 Cohort (2021–2022) which punctuated different COVID-19 pandemic contexts. Because many participants in Y2 had the experience of visiting doctors and facilitating children’s schooling remotely during the first year of the pandemic, our team noticed a clear difference in knowledge and skills in Y2. The technology was not as alien, it was much easier for them, and they were not as afraid to use it.

The acquisition of skill and experience using Zoom changed the way that the lives of participants interface with technology. Learning how to utilize Zoom in the context of the pandemic was not simply mastering a new skill, but mastering a relevant new skill that is useful for staying updated and engaged in the current social and technological context. Through participation by Zoom, participants increased confidence utilizing ICTs and digital resources and developed new skill sets. Participants reflected on this process positively and focused on what they gained rather than on what it cost them to learn. For some, this change was transformative in other areas of their lives as they utilized these skills or the self-confidence they discovered beyond the boundaries of the study.

Zoom enhanced engagement, participation, and social connectivity

We had anticipated that it would be difficult, but more likely impossible, to have deep engagement with participants or to create a mechanism and environment for engagement between participants via Zoom. Participants told us that they felt the same way at the beginning. However, our data demonstrate that not only was this not the case, but rather, participants reported that despite being disappointed that they could not gather in-person for the meetings or share each other’s food, Zoom actually enhanced and increased participation, and as one participant noted, “surpassed expectations.” Over both years, attendance was high, and participants reported that the accessibility and ease of participation created by Zoom was a major factor allowing them to participate, compared to the unlikelihood of them being able to participate had the intervention been implemented in-person as originally planned. Zoom was key to making it feasible for most participants to participate in the study at all. Factors that contributed to this had to do with the fact that Zoom allows participants a great deal of convenience, flexibility, and comfort compared to traveling to and attending a two-hour weekly meeting. Being able to participate from home was reported to be not only convenient, but comfortable and comforting. Additionally, despite some expressed disappointment at not being able to meet in-person, to our surprise, many indicated that after they got used to it, they preferred to meet by Zoom.

As mentioned above, we had anticipated that meeting remotely, the structured nature of a Zoom meeting on a screen, and the lack of opportunity for individual women to get to know each other outside of the screen would have a significant negative impact on the development of social connections between participants – which we would have otherwise hypothesized would have occurred in the context of in-person meetings. However, these assumptions were not reflected in our data. Participants overwhelmingly expressed the extent to which their zoom experiences were meaningful, connecting, impactful, and even life-changing. Moreover, and possibly more surprisingly, participant reports demonstrate that the technological layer imposed by the Zoom platform was actually positive, rather than detracting from the experience. These qualitative data are supported by both the high level of attendance and the results from the social network analysis which show that the participants formed dense connections of support and socialization within their Tertulias groups, and that the connections made (such as being able to ask for a ride to the doctor) were relatively intense and intimate. Participants reported the different ways that their Tertulias experience had deep and cascading impacts on other areas of their lives, including on the way that they socialize with others outside of the study.

We were interested to learn that participants felt that the Zoom screen itself and the use of the Zoom camera were both important to the success of the intervention and their engagement with it. Being able to see each others’ faces contributed to trust-building and made it possible for participants to share intimate thoughts and experiences. In addition, because almost none of the participants used a Zoom background filter, the entire group always had a view into the homes and lives of the participants. Notably, participants reported that this made the Zoom gatherings more intimate but that it also contributed to the feeling of being able to escape their own narrow worlds.

It was also notable to find that the Zoom screen and the “distance” of participating remotely created a “safe” space for sharing intimate thoughts, feelings, and experiences. Many participants discussed how being in the group via a screen, especially from their phones, had a sort of emotional buffering effect during moments of sharing traumatic experiences or intimate thoughts and feelings, and that participants experienced this in a positive way. Zoom provided an extra level of anonymity that made participants feel like they were talking either to themselves or to one other person, when in reality everyone in the group could hear and consider what they had to say. One participant said that she felt like it was so much easier to tell things to the group that she had never told anyone before because she felt safe in her house, and because she was participating by phone and could only see one person at a time on the screen, it did not feel like everyone was looking at her. The anonymity of social media (e.g., blog posts, chat groups, etc.) or of the Catholic confessional can allow people space to reveal personal information that they would not do otherwise, but we discovered that even though the participants were not “anonymous” to the group, the fact of being remote made participants feel that there was less stigma, shame, and social pressure than would have happened in person.

However, as one anonymous reviewer of this paper suggested a point well taken, the “real time connection” provided by the Zoom screen cannot be romanticized – as was demonstrated by the domestic violence situation described above. The intimacy of being able to look into people’s homes is “also a view into the (gendered) politics that shape the spaces from where participants are joining … an illustration that the spaces where people are joining from are not blank slates but are intensely political spaces. The example also complicates, in a very poignant way, the argument about Zoom being a ‘safe’ space” merely because it is from home.

The serendipity of the WhatsApp afterthought

WhatsApp was a last-minute addition when we were transitioning to the Zoom platform, made at the suggestion of one of our team members. As indicated above, we added WhatsApp, thinking it would help mitigate what we imagined would be weaknesses of Zoom-based social interaction. With the chat groups becoming operational and utilized so frequently and so quickly immediately when we started the study, we noted that the addition of WhatsApp had exceeded our expectations. Even more so than anticipated, WhatsApp enhanced social connectivity among participants but also connection to information and resources – all of which are dimensions of social isolation. Despite its addition as an afterthought, WhatsApp became an integral component of the intervention.

The simplicity of the WhatsApp phone-based app technology and the functionality of the platform contributed to its usefulness and success. Part of our decision to use WhatsApp was our recognition that WhatsApp is a culturally appropriate technology in the immigrant community. Because WhatsApp allows communication across country borders without charge, WhatsApp is used widely by immigrants all over the world. Moreover, the ability to create chat groups provides a way for extended networks of people to be connected/interconnected. As such, the vast majority of participants either already had the WhatsApp app on their phones and were completely fluent and comfortable with WhatsApp as a form of communication, and for the few who did not, it was not a completely alien concept.

The ease of use and multidimensional communication features of the WhatsApp technology increased the communication capacity and impact of the chat. Being easy to use meant that the few participants who were unfamiliar with WhatsApp were quickly able to adapt and learn. Communicating information to participants was simple using WhatsApp, and it also worked well for long-term, easily accessible storage of information such as important dates or resources mentioned during weekly meetings. Time-sensitive information was communicated and disseminated rapidly. However, information can also be stored in the chat for as long as needed and some participants commented that they were keeping that information to reference in the future. WhatsApp allowed participants to post, read, and respond to messages whenever they had time or interest. They saw it as a safe and trusted personal outlet for writing about how their day was, asking how other people's days were, asking questions, asking for favors, etc.

The simple power of “hello” and “how are you?”

As clearly demonstrated in the over 3,000 chat posts in Y1 alone, WhatsApp provided a mechanism for the participants to become engaged with each other beyond the confines of the Tertulias Zoom meetings. WhatsApp gave the participants the ability to create connectivity on their own terms, and the regularity and consistency of communication created by WhatsApp transformed participants’ quotidian social practice. In our analysis of the WhatsApp chat streams, we identified a pattern of simple “Buenos dias/Good morning” and “Cómo estás/How are you?” Participants reported that these casual daily check-ins and greetings were crucial to their mental and emotional health by giving them a sense of belonging and connectedness. In the evaluation discussions, participants indicated that this was extremely powerful in decreasing feelings of isolation on a day-to-day basis. The continuity of communication throughout the week, even if just casual conversations or checking in, meant a great deal to participants and aided in reducing feelings of loneliness and not having friends. It was quite remarkable that simple daily reminders of belonging to a group of people who care about you and your well-being helped participants to feel included and valued, elevated their mood, and relieved their sense of isolation.

Conclusions

This study is of how an aspect of the intervention (the use of Zoom & WhatsApp) impacted the methods we used to implement the intervention and the way it was experienced by participants, but it also impacted outcomes. The reason for us wanting to report on this is because of the dramatic difference that we saw between what we anticipated when we were required to institute the use of these technologies versus what we saw happening and experienced as we implemented the intervention, and in the evaluation of these technologies by participants. These counter-intuitive results felt notable to us, and we wanted to share them with others interested in conducting community-engaged research. The discussion here is designed to present the contrast between our sense at the beginning of the pandemic that using these technologies would actually lead to failure of the intervention and what happened.

We demonstrate how ICTs created a valuable environment for female immigrants from Mexico to support and learn from each other in the context of a community-engaged research study testing a social isolation support group model for reducing social isolation and depression. Participants were able to connect with each other and provide encouragement and resources despite having never met face-to-face. These findings provide evidence of the potential for ICTs to be used in community-engaged research. Despite previous positioning of ICTs as culturally and contextually inappropriate for community-engaged research contexts, this study demonstrates that ICTs can be used effectively.

Our starting assumption that it would be challenging, if not impossible, to translate the intervention to Zoom was not borne out by either the experience of implementing the study or the data. The COVID-19 pandemic challenged us to adapt in ways that have permanently changed us. Importantly, our findings are not just about how the use of ICTs changed the way we implemented a research study. Instead, using multi-dimensional data, including REM which helped us to document the “ripples” that happened as a result of the intervention, we discovered that the change was much deeper. Participants learned new skills and developed new perspectives that will continue to impact their lives and the lives of others in their social orbits in an ongoing way. Over the past two years, it has become clear that participation in the Tertulias groups would have been much more challenging for participants if we had used the original in-person format, and we now believe we would have had much less success in having intensive, ongoing participation from so many women, especially those who live far apart, or hold one or more jobs.

Zoom and WhatsApp complemented each other. Participants acknowledged that something was lost over Zoom, but for most, the convenience of online superseded and transcended the lack of physical interaction and face-to-face conversation. The Zoom format is conducive to simultaneously working, completing household tasks, or caring for children while attending group sessions. Holding the Tertulias by Zoom greatly increased the ability for several busy women with multiple time commitments and work and family responsibilities to be able to meet consistently. WhatsApp provided an easy-to-use, convenient, and continuously available platform for creating connectivity in an ongoing, quotidian way, and participants were able to use it (or not) to create engagement according to their own rules and schedules. Using ICTs, the participant can modulate the extent of participation based on the current demands of the environment at home or the participant’s energy level. WhatsApp provided something inherently different, but complementary and equally essential to the weekly meetings and the success of the intervention in relation to improving feelings of isolation and loneliness. WhatsApp arguably had an amplifying effect on the sense of community provided in the weekly Zoom sessions by allowing for continued, quotidian communication beyond the screen and outside of meeting hours.

At the onset of the COVID-19 pandemic, quarantine prohibition regarding in-person social interaction promoted the use of ICTs in a variety of contexts including health care, education, work, and social settings, but also in health research. However, the reality of the digital divide makes using ICTs in community-engaged research complex. Attention needs to be paid to issues of access and knowledge. At the same time, evidence from multiple studies, including this one, demonstrates that if designed to do so, ICTs can promote equity and address disparities. ICTs can decrease a variety of costs to both participants and investigators, decrease problems and expenses related to accessibility, and increase ease of participation, retention, and engagement.⁹

Referring to both Zoom groups and WhatsApp chat groups; participants used the phrase “we are a group” (“somos un grupo”) rather than “we are in a group.” Given that one of the primary outcomes of the intervention is to reduce social isolation, this is a transformative result. Moreover, we have seen how this transformation is reflected in the participants themselves as described in their quotes above. The use of ICTs in Tertulias upended our assumptions about technology, community-engaged research, and our participants, and for many, the knowledge and experience have become a gateway that has opened up a whole new world that has led them to obtain certification and work as Community Health Workers (CHWs) or to take Zoom-based classes in business and accounting. ICTs have proven to be useful both as a method for conducting community-engaged research with this population, but also as part of the intervention. The power and simplicity of the integrative, quotidian social practice demonstrated in this study was impressive and offers insights for future interventions to improve health outcomes with marginalized populations and in low-resource environments.

Ethics statement

The study was approved by the Human Research Protections Office of the University of New Mexico. Written informed consent was obtained from all participants.

Acknowledgments

We would like to thank all of the women who participated in the aspect of the study discussed here. We would also like to thank the six members of our Community Advisory Board and the 6 members of our Data Safety Management Board (DSMB) who have provided insights and recommendations that have helped us as we implement this study. Additionally, we would like to thank our partner organizations, the Hopkins Center for Children and Families and its parent organization, Centro Sávila, and One Hope Centro de Vida Health Center and its parent organization, East Central Ministries.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10705422.2024.2351935

Additional information

Funding

This research was funded by the National Institute on Minority Health and Health Disparities, #1R01MD014153-01, and supported by an award from the National Center for Advancing Translational Sciences #UL1TR001449. Bearer is partially funded by The Harvey Family Endowment.

Notes

1. https://zoom.us

2. https://www.whatsapp.com/features

3. eMarketer Editors. (2019, September 23). WhatsApp is becoming a key driver of mobile messaging growth. eMarketer. https://www.insiderintelligence.com/content/whatsapp-is-becoming-a-key-driver-of-mobile-messaging-growth#

4. Ceci, L. (2023, September 25). WhatsApp penetration rate among global messaging app users as of April 2022, by country. Statista.https://www.statista.com/statistics/1311229/whatsapp-usage-messaging-app-users-by-country/

5. March, L. (2023, January 31). Most popular messaging apps worldwide 2023. Similarweb. https://www.similarweb.com/blog/research/market-research/worldwide-messaging-apps

6. https://www.xmind.app/xmind8-pro/

7. www.sas.com

8. Broadband Search (accessed March 2024). Internet service in New Mexico. https://www.broadbandsearch.net/service/new-mexico#:~:text=Despite%20this%20accessibility%2C%20a%20startling,highest%20rates%20in%20the%20country.&text=Population%20with%20faster%20than%201%20Gbps%20available.&text=Population%20with%20only%20100%20Mbps%20speeds%20or%20less%20available.&text=Population%20with%20only%2025%20Mbps%20speeds%20or%20less%20available.

9. Fei, J., Sadye Wolff, J., Hotard, M., Ingham, H., Khanna, S., Lawrence, D., Tesfaye, B., Weinstein, J., Yasenov, V., & Hainmueller, J. (2022, May). Automated chat application surveys using WhatsApp: Evidence from panel surveys and a mode experiment (Working Paper No. wp2015). https://kingcenter.stanford.edu/publications/working-paper/automated-chat-application-surveys-using-whatsapp-evidence-panel-surveys