VOL: 103, ISSUE: 4, PAGE NO: 34-35
Sue Campbell, MPH, BSc, RGN
Independent health consultant, Uganda
ABSTRACT: Campbell, S. (2007) The process of planning, organising and conducting focus group discussions. www.nursingtimes.net.
ABSTRACT: Campbell, S.(2007) The process of planning, organising and conducting focus group discussions. www.nursingtimes.net.
Public involvement in health decision-making is at the heart of government plans to modernise the NHS. Focus groups provide a mechanism for seeking these views. This article explains when they can be used and how they should be conducted. It also highlights some of their limitations.
The government is committed to reforming the NHS, turning it into a patient-centred service fit for the 21st century. At the heart of this modernisation is the involvement of the public in healthcare decision-making (Farrell, 2004; Chapman, 2002). There are now several examples of the government promoting community consultation on health services priorities and the quality of services (DH, 2001a; 2001b; 2000; 1999).
Consultation, whereby service users are actively engaged in giving feedback on decisions and providing information that is not routinely sought, often uses research-type methods. These include quantitative methods, such as surveys, and qualitative methods, such as focus groups (Billingham et al, 2001).
Benefits of involving service users
Ascertaining service usersÃ?Â’ views Ã?Â’is widely recognised as a powerful way of making change in complex situationsÃ?Â’ (Laws, 2003) because:
- They may offer different perspectives on the issue being addressed;
- They can ensure that the research identified is a priority issue for them;
- They can identify marginalised groups which might otherwise be overlooked.
Participation enables community members to share their perceptions of a problem, find common ground and engage a variety of people in identifying and testing out possible solutions. This process of shared learning can be particularly powerful when local professionals have not felt sufficiently empowered to take action on issue (Laws, 2003; Hanley et al, 2003; Kitzinger, 1995). At the same time, participation can generate a sense of ownership for the service users or research participants and be linked directly to actions at their level (Winch et al, 2000).
Focus group discussions
There are various tools for researching service user views, including interviews, focus groups, documentary sources, observation, questionnaires, ranking exercises and visual methods (Laws, 2003). The Building Strong Foundations Toolkit lists 37 participatory research methodologies prevalent in the UK (Partners in Change, 2002).
Focus group discussions (FGDs) gained popularity in the 1950s as a mechanism for assessing peopleÃ?Â’s opinions about products in the marketplace (Winch et al, 2000). They are able to draw out feelings, beliefs, experiences and reactions (Gibbs, 1997).
Focus groups are particularly useful when:
- In-depth information is needed on how people think about an issue Ã?Â- their reasoning as to why things are as they are and why they hold the views they do (Kitzinger, 1995). They can indicate the range of a communityÃ?Â’s beliefs, ideas or opinions. For example, in exploring user/patient satisfaction, focus groups have provided Ã?Â’rich and meaningfulÃ?Â’ feedback on standards of care (Ridley and Jones, 2002).
Ã?Â? An organisation needs guidance as to what people see as the issues for them when it is setting a framework for larger-scale research. They are a useful tool for designing question guides for individual, in-depth interviews and questions for structured interviews (Kreuger, 1988). They can also be used to evaluate or develop a programme of activities or assess the impact of one (Gibbs, 1997).
- PeopleÃ?Â’s ideas are sought as to how products or services could be improved (Laws, 2003; Winch et al, 2000).
- Data is required on social norms and cultural expectations, such as sexual health and young people. The sexuality of young people is, to a large extent, shaped and influenced by conversations and interactions with peers. The group approach is used to gain a Ã?Â’feelÃ?Â’ for their language, the values it expresses, the range of meanings and to identify areas in which there is agreement or disagreement between members of communities (Ingham and Stone, 2002).
- There is a perceived power differential between participants and decision-makers (Ridley and Jones, 2002; Gibbs, 1997).
- People have similar experiences in relation to the subject under discussion but may lack the confidence to express opinions. For example, FGDs may give women with breast cancer the confidence to speak about their experiences in a way that may not occur in one-to-one interviews. This is particularly the case when the subject under discussion is stigmatising in some way (Laws, 2003).
The research question
Formulating a research question involves breaking down a problem, which can be more challenging than it seems (Kopp, 2001). Chambers (1988) stated that questions should be: simple; specific; realistic; important; capable of being answered; agreed by those who will be involved in any resulting change; capable of being implemented; and, on a subject where change is possible. There is a danger that the results will lack focus and be overwhelming if this step is rushed (Kopp, 2001). As well as talking to colleagues, it is useful to do a thorough search of the literature to find out what is already known about the subject (Laws, 2003).
Once the question has been formulated, the appropriate research method for getting it answered can be identified. The following steps should be followed if the method chosen is a FGD.
Write a brief
Any research needs clear guidelines and the process of writing a brief helps to formulate these and ensure that the research is focused. The brief should include a budget and whether approval will need to be sought from the local ethics committee. The three main areas that must be covered in ethical research with human subjects are: ensuring consent; protecting confidentiality; and, balancing the risk of harm with potential benefit (RCN, 2004).
The RCN Research Society (2004) defined informed consent as Ã?Â’an ongoing agreement by a person to receive treatment, undergo procedures or participate in research, after risks, benefits and alternatives have been adequately explainedÃ?Â’. Its purpose is to ensure people are not deceived or coerced into participating in research. The tape recording and transcribing of FGDs also needs specific consent and recordings must only be used for the purpose for which participants have consented (GMC, 2002).
ParticipantsÃ?Â’ privacy and dignity must be safeguarded. This involves ensuring that personal information given as part of the study is kept confidential and that participants in FGDs maintain confidentiality of information about other people revealed in the discussion (RCN, 2004). Tapes of recorded sessions must be stored securely.
Harm versus benefits
To gain approval from research ethics committees, a study should be reviewed in the light of both its short-term effects and its long-term goals (RCN, 2004).
Identify and train facilitators
Skilled and independent facilitation of the focus group is essential to give credibility to the findings. The structure must be flexible but, at the same time, cover pre-determined areas; this is especially important if there is more than one group.
The facilitator must be able to stimulate group discussions and keep them on course as necessary, without taking a position on anything. He or she should create an atmosphere that is safe and non-judgemental (Ridley and Jones, 2004) and also ensure confidentiality.
The data must be recorded appropriately. Ideally, a second facilitator should record the discussions using a systematic recording form or the session should be taped and transcribed.
During the discussion, the facilitator should not attempt Ã?Â’to support or criticise any response, resolve any issue, address any individual problem or concern, or reach any conclusion. Both concrete information and opinions are relevant. The facilitator should not be concerned if the group is silent at any point. It may be the first time that participants have thought about the issueÃ?Â’ (CPRC, 2003).
The purpose of the interview guide is to provide an overall direction for the discussion. It is not the equivalent of a survey instrument and is not to be followed in detail or even necessarily in order. The guide provides the facilitator with topics and issues that should ideally be covered at some point during the group discussion. It is loosely structured and does not suggest potential responses (Table 1).
A good focus group interview guide consists of 20 questions or less (CPRC, 2003), and proceeds logically from one topic to another and from the general to the specific. The questions should be about things respondents will have information about (Laws, 2003).
Pre-testing the guide with Ã?Â’mockÃ?Â’ focus groups is essential to ensure the questions are clear and stimulate discussion. Several stages of revision may be necessary (CPRC, 2003).
Table 1. Example questions from focus group guide on sexual health services for adolescents, adapted from Ingham and Stone (2002)
Prompts and expansion materials
Awareness of services
Health centres, youth clubs and organisations
Young people’s use of services
Acceptability of young men and women visiting services
Triggers and reasons for attending services
Barriers to attendance
Acceptability of services
Sampling and recruitment
The population groups whose opinions are being sought need to be identified in order to develop a sampling frame. Local contacts can be used to identify suitable participants, but care must be taken to avoid systematic bias and friendship groups. Systematic or random procedures can help prevent this.
Focus groups are generally made up of 6-10 individuals, but some researchers have used as many as 15 and others as few as four (Gibbs, 1997). Often the participants have experiences in common but not always. They may be strangers to each other or drawn from an existing group.
If a group is too heterogeneous, the differences between participants can have a considerable impact on their contributions. If a group is too homogenous, diverse opinions and experiences may not be revealed (Gibbs, 1997).
It is also important that practitioners do not participate in FGDs with current or previous service users as this is unfair to both parties. Efforts also need to be made to ensure the groups are as inclusive as possible. This could involve, for example, providing interpreters if people are not comfortable speaking in English, or using venues with wheelchair access (Hanley et al, 2003). The nature of the research question may require some members of the FDG to have used the service.
Once prospective participants have been selected, they should be contacted by the researcher to assure them of confidentiality and to confirm that they fit within one of the groups for which people are being recruited. The researcher will also need to clarify the participantsÃ?Â’ expectations and confirm whether they are willing to take part (CPRC, 2003).
Incentives to participate will need to be decided and participants informed in advance. Other practicalities include booking the venue and any equipment required, arranging refreshments and organising interpreters or childcare if required. Venues will need to be accessible to the participants, taking account of public transport or car parking. The focus groups should also be timed for the convenience of participants.
Conducting the discussion
Focus groups do not involve a series of individual interviews. The interaction between group members is part of the process and should be encouraged. Everyone should be introduced, and name badges handed out if this will be helpful.
The purpose of the focus group should be explained, along with how long it will take and what feedback participants will receive. Messages about confidentiality should be reinforced. If appropriate, participants should be given time to talk to each other alone.
Members of the group should be seated in such a way that they can all see each other and the discussion should begin with the easier topics. However, it is important to ensure that essential topics are covered towards the beginning of the session (Laws, 2003).
A focus group study may include one meeting with several groups or a few meetings with one group (Gibbs, 1997). Individual sessions usually last 1-2 hours and are followed by a 15-minute debriefing session. During the debriefing, the facilitator should thank participants for their time, summarise what has been said and give the them an opportunity to ask questions or provide feedback (Laws, 2003).
A focus group’s greatest strength is the interaction it allows between the participants. People work together, or argue with each other, to make sense of an issue. It is good to try to preserve this process in the analysis, perhaps by quoting a chunk of text that includes important discussion between participants. Focus groups should not be analysed as if they were a series of individual interviews. In general, it would be inappropriate to add up responses of individuals to a question asked during a group discussion. The group process is likely to influence people, therefore only limited confidence could be placed in those figures. People may not have spoken about an issue simply because someone else had already made the point (Laws, 2003).
Once the discussion is written up with recommendations, it can be given back to the original participants for their comments (Billingham et al, 2001).
Reporting the findings
The report should include a summary of the key findings. Details of the main themes of the research need to be set out under headings, and quotes from the group participants can be included.
The report should be reviewed by a colleague for clarity and relevance before it is disseminated to relevant stakeholders. The final report can also be submitted to the relevant decision-making body in the area for their comments and responses (Billingham et al, 2001).
Disadvantages of focus groups
Their narrow focus is one of the drawbacks of using FDGs. They may be Ã?Â’typicalÃ?Â’ but not necessarily representative, excluding marginalised groups, and it may be hard to reach any generalised conclusions. Participants may not be sufficiently Ã?Â’informedÃ?Â’ about the issues being discussed. Also, running focus groups is time consuming and relatively costly (Ridley and Jones, 2002) (Table 2).
It is important to remember that collecting data and making recommendations does not mean that funding will be available for implementing the proposed changes. This can be frustrating both for the researcher and the communities.
Table 2. Focus groups’ strengths and limitations (Laws, 2003)
This article has highlighted the use of FGDs as a research tool to gain an understanding of health and social care issues. Most research requires information to be gathered from many sources (triangulation). Key steps in preparing for a FGD are to define clearly the question to be addressed and to use an experienced facilitator. Written, informed consent must be gained from the participants to ensure that the research is conducted ethically. Involving as many key stakeholders as possible in the FGD will assist in taking the results forward; conducting the FGD is just the start of a process of change.
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