Spotlight on focus groups

In your practice you have 40 patients with type 2 diabetes who are also obese. You have counseled them extensively regarding diet and exercise. However, you feel that you haven’t made much progress in persuading your patients to make healthy lifestyle changes over the past several years. You have shared your frustration with your colleagues and have discovered that they are similarly frustrated. Realizing that this problem is bigger than you thought, you decide to study it further. You make plans to invite patients to attend a focus group that you will moderate. As you plan your study you wonder, how are focus groups supposed to work?

What are focus groups?

A focus group is a form of qualitative research. Focus groups have long been used in marketing, urban planning, and other social sciences.¹ They were first employed in the early 1940s in an effort to move away from interviewer-dominated research methods and were extensively employed when trying to explore issues of morale among American troops during World War II.² Focus groups have become increasingly popular in health care, especially in the realm of needs assessment.³ The focus group format has also found favour with those doing pilot testing for curricula, program improvement, organizational development, and outcome evaluation.

Essentially, a focus group involves the gathering of a group of people who are asked about their attitudes toward a concept, product, or idea. However, much misconception surrounds the concept of focus groups. It is easy to confuse focus groups with the many other methods of needs assessment and information gathering that involve groups. Public forums, nominal groups (a formal technique, which has been compared to the Delphi method, for identifying, discussing, and ranking issues in a group setting), hearings, task forces, and committees, for example, do not generally possess the defining characteristics of focus groups. Rather, a focus group consists of participants who are guided via a facilitated discussion. A set of open-ended questions initiates focus group discussions. The facilitator can steer the participants back to the focus group questions or go along with the direction of the focus group discussions, depending on the research questions posed. Focus groups concentrate on a clearly defined topic, and efforts are made to gather information and opinions from group members.³ Participants are free to talk with other participants—the setting is intended to be interactive.¹ Focus groups are also clearly defined in size; they are usually composed (depending on varying definitions) of 7 to 10 people.² Table 1 further lists the fundamental elements of focus groups.

Table 1.

Key characteristics of focus groups

CHARACTERISTIC	CRITERIA
Size	Usually 7–10 persons per group Each group is a single unit 2–4 units are often needed
Participants	Need not be randomized Can be homogenous, heterogeneous, or both, depending on the study topic
Group moderator	Trained facilitator Impartial to the study
Setting	Interactive
Data collection	Audiotape and videotape Field notes
Data entry	All communications transcribed verbatim
Data analysis	Should involve a collaborator with qualitative research background

Advantages and disadvantages

As can be inferred from the above description, the focus group format has several advantages: it is relatively inexpensive. What is more, individuals are more likely to provide candid responses. Through facilitated discussion, participants build on each other’s ideas through “piggybacking”; in this way, the focus group is very useful for needs assessment and project evaluation purposes. Given their qualitative nature, focus groups allow researchers to look beyond the facts and numbers that might be obtained via survey methodology—researchers can learn or confirm the meaning behind the facts.^1,3,4

At the same time, focus group methodology has its limitations. The focus group relies heavily on assisted discussion to produce results; consequently, the facilitation of the discussion is critical. The quality of the discussion depends on the skill of the moderator, who should be well trained and preferably from the target population, yet not affiliated with the researchers (to ensure impartiality). Focus group discussions should be audiotaped or videotaped in addition to the recording of field notes. All data should be transcribed verbatim. However, these large volumes of qualitative data might be difficult to analyze. While a focus group format prevents the dangers of a nominal group process, outspoken individuals can “hijack” and dominate a discussion. A further weakness inherent to the focus group format is its participant selection system—participants are self-selected and study results are therefore harder to generalize to the larger population.^1–4

How are focus groups conducted?

To conduct a focus group, a number of steps are suggested. The first is to clarify expectations: what is the purpose of the focus group and what information are you hoping to gather? Participant selection follows. Participants are selected based on common or diverse characteristics, depending on the research question. For example, in the above focus group, only obese patients with diabetes were invited, but there was diversity based on sex, income, and age. After the participants are invited, efforts must also be made to encourage attendance.^1,3,4 It is important to choose a convenient location and to provide reminder notices, e-mails, and telephone calls before the focus group meets.

The questions developed for the focus group must be short, natural, and open-ended. Questions in focus groups have been noted to fall into 5 general categories: opening questions, introductory questions, transition questions, key questions (focusing on the main areas of concern), and concluding questions. Most of the focus group time is devoted to exploring and examining the key questions. In general, focus group discussions are 60 to 90 minutes long. Throughout the session, the moderator must facilitate the discussion and attempt to elicit participation from all members, ensuring that appropriate direction is maintained.

Endnotes

Why do you think it is so difficult for patients with diabetes to follow a specific diet and exercise plan? How do you think diabetes management could be more effective for patients? These questions are complex and without rigid, definable variables. They are answered best by qualitative methods in which the output is rich and textured, so that researchers can learn and confirm the meaning behind the facts. Of the many different qualitative methods, focus group discussions seem suitable, as they can produce useful data, introduce new theories, and illuminate various perspectives. However, as illustrated in the above case study and subsequent discussion, one should not run a study before considering which methodology is the most effective and appropriate to answer the study question. To obtain valid and meaningful results, focus groups must be conducted with a suitably defined purpose, proper structure, and appropriate rigour.