Focus Groups

ANALYSIS WORKGROUP
Our mission is to foster the improvements in the analysis of health related phenomena among older minority; encourage the development of methods and measures that better capture the health and determinants of health of diverse elders; promote collaboration between RCMAR sites on analysis issues; and disseminate new knowledge in this area.

Focus Groups


Using Focus Groups in Health Disparities Research

Prepared by the Measurement and Methods Core,
Center for Aging in Diverse Communities, University of California San Francisco

Focus groups are widely used and serve multiple purposes in health disparities research.  These include: 1) developing concepts and generating items for a new measure, 2) pretesting existing measures in a diverse group, and 3) developing interventions.  In order to utilize such methods, there also is information on how to conduct focus groups including how to write a focus group guide (open-ended questions) to obtain answers to research questions.  We summarize several key publications that illustrate these four applications.  

(1) KEY ARTICLES ON USING FOCUS GROUPS TO DEVELOP CONCEPTS AND GENERATE ITEMS FOR A NEW MEASURE

Focus groups with diverse populations are of special value in developing new measures to be culturally sensitive and appropriate.  In the formative stage of research, focus groups can help by obtaining the perspectives of persons for whom the concept is relevant.  Focus groups elicit information on how the target respondents think about an issue and articulate it in their own words.  They are especially useful because participants can respond to moderator questions as well as to comments made by other participants.  As such, they allow research to reflect the concerns and issues of those being studied.  Focus groups are especially useful to explore poorly understood and complex phenomena.  Examples are emerging in the literature of how focus group transcripts can be analyzed to generate candidate domains and items for structured surveys on a specific health related topic. 

Daley CM, James AS, Ulrey E, Joseph S, Talawyma A, Choi W.S, Greiner KA, Coe MK. Using focus groups in community-based participatory research: challenges and resolutions. Qual Health Res. 2010; 20(5): 697-706.

The authors describe three focus group studies with American Indians in Kansas and Missouri, using a newly developed method of conducting and analyzing focus groups with community input.  The community members and researchers collaborated to develop guides for the focus group moderators.  Community organizations and their community advisory board conducted recruitment, and the research team trained and employed community members as moderators, assistant moderators, and analysts.  The authors conclude that techniques must be tailored to the community with whom you are working, and is an ongoing effort.

Hughes D, DuMont K. Using focus groups to facilitate culturally anchored research. Am J Community Psychol. 1993;21:775-806.

The authors describe how focus groups were used to formulate a research model and develop instruments in an area with little prior research, namely, work and parenting issues in African American dual-earner families.  The article illustrates how focus groups facilitate culturally sensitive research.  In this context, they were used to understand from participants’ perspectives, how being African American shaped their experiences as employees and parents.  New survey items to assess interpersonal racism and racial socialization also resulted from the focus groups.  Examples are provided on the use of focus groups to develop new items, revise item wording, and pretest the clarity and relevance of existing items. Examples of coding schemes used to identify a smaller number of constructs to summarize a large volume of data are also provided.
 

Kelly JJ, Njuki F, Lane PL, McKinley RK.  Design of a questionnaire to measure trust in an emergency department.  Acad Emerg Med. 2005;12:147-151.

The authors describe the use of focus groups to develop a measure of trust in emergency department physicians and staff.  A literature review and phrases from the focus group transcripts were used to develop an item pool.  Items were refined or dropped based on comments of respondents to the draft survey.  The authors describe criteria used to drop items, and present items that were dropped and retained after psychometric testing.

Krause N. A comprehensive strategy for developing closed-ended survey items for use in studies of older adults. J Gerontol B Psychol Sci Soc Sci. 2002;57B:S263-274.

The author describes the use of focus groups as the first step in a series of qualitative and quantitative stages of development of a measure of religion.  Because a series of focus groups were conducted, the author describes the use of a funnel approach in designing the open-ended questions, in which subsequent groups used to modify questions based on results of early groups.

Nápoles-Springer AM, Santoyo J, Houston K, Perez-Stable EJ, Stewart AL. Patients' perceptions of cultural factors affecting the quality of their medical encounters. Health Expect. Mar 2005;8(1):4-17.

Focus groups were used to identify key domains of cultural competence from the perspective of ethnically and linguistically diverse patients.  Participants were asked the meaning of 'culture' and what cultural factors influenced the quality of their medical encounters. This article provides an example of how to content analyze the transcripts using text units (identifiable continuous verbal utterances) to identify key dimensions using inductive and deductive methods. The findings corroborated aspects of physician cultural competence indicated in the literature but also highlighted aspects not represented in current quality measures.

Nassar-McMillan SC, Borders LD. (2002, March).  Use of focus groups in survey item development. The Qualitative Report, 7(1). Retrieved September 10, 2010, for http://www.nova.edu/ssss/QR/QR7-1/nassar.html

This article illustrates the use of focus groups to develop and refine items for a new structured questionnaire on volunteer work behaviors.  After an initial item list was generated from the literature, focus groups were used to assess the appropriateness of these items for volunteers in mental health services, and to develop new items/uncover new domains.  Participants were asked to listen to each item, indicate whether it was part of their volunteer duties, and provide alternative terminology in cases where items were unclear. This process resulted in a revised draft instrument with reduced items and rewording of items to be appropriate to the target population.

Sarkisian CA, Hays RD, Berry SH, Mangione CM.  Expectations regarding aging among older adults and physicians who care for older adults.  Med Care.2001;39:1025-1036.

Focus groups were used to explore the ways in which older adults conceptualize their expectations of aging, and to compare their expectations of aging with those of physicians who care for older adults.  Data analysis revealed 26 domains of expectations of aging.  Items for the Expectations Regarding Aging Survey were developed from the focus groups by using the exact language of participants to the extent possible.

Willgerodt MA.  Using focus groups to develop culturally relevant instruments.  West J Nurs Res. 2003;25:798-814.

The author discusses the value of using focus groups to develop culturally appropriate instruments in immigrant populations.  She describes a process where transcripts were used to delineate content domains and identify phrases and terms for potential items that preserved the language of participants.  A second round of focus groups was used to elicit feedback on the draft items.  She also describes unique factors that needed to be taken into account in executing the focus groups in an immigrant Chinese community.

Wong ST, Yoo GJ, Stewart AL. Examining the types of social support and the actual sources of support in older Chinese and Korean immigrants.Int J Aging Hum Dev. 2005;61(2):105-121.

Focus groups with older Cantonese and Korean speaking immigrants explored social support domains and sources of support.  Four domains similar to traditional concepts and measures included tangible, information/advice, emotional support, and companionship. They also identified needing language support as relevant for these non-English speaking groups.  This article illustrates how a concept may be understood in a different way than intended when used in diverse groups, as the Chinese and Korean elders defined emotional support in a way not found in the literature on social support.

(2) KEY ARTICLES ON USING FOCUS GROUPS TO PRETEST EXISTING MEASURES

Focus groups (as well as cognitive interview pretests – see “Using Cognitive Interviews to Develop Structured Surveys” annotated bibliography) can be used to determine the relevance and appropriateness of existing measures primarily developed in mainstream populations.  When problems are identified, focus group transcripts can provide information that can help in modifying the measures.

Vogt DS, King DW, King LA. Focus groups in psychological assessment: enhancing content validity by consulting members of the target population. Psychol Assess. 2004;16:231-243.

The authors explain the importance of consulting members of target populations for content validation of existing measures in new populations.  They examine the role of focus groups in the process of adapting measures for diverse populations.  They describe how the focus groups led to the expansion and addition of constructs, the confirmation of existing items, and the identification of relevant quotes that could be used for new items.  The appendices provide examples of detailed definitions of constructs and the focus group guide.

Weech-Maldonado R, Weidmer BO, Morales LS, Hays RS. Cross-cultural adaptation of survey instruments: the CAHPS® experience. Seventh Conference on Health Survey Research Methods (Lynamon ML & Kulke RA, eds). Hyattsville, MD: DHHS Publication No. 01-1013, 2001.

The authors provide recommendations for cross-cultural adaptations of survey instruments using examples from the Consumer Assessment of Health Plans Study (CAHPS®).  Technical equivalence, equivalence in grammar and syntax, is distinguished from conceptual equivalence, absence of differences in meaning and content between two versions of an instrument.  The authors propose a framework that comprises 3 activities: translation; qualitative analysis; and field test and analyses. Focus groups were used to investigate the appropriateness of the CAHPS® survey content for Spanish-speaking Latino patients enrolled in Medicaid.

(3) KEY ARTICLES ON USING FOCUS GROUPS TO DESIGN INTERVENTIONS OR DEVELOP RESEARCH MATERIALS

Occasionally, focus groups are used to help design interventions.  Focus groups can be used as part of a needs assessment process to elicit community input on program priorities, design, and dissemination.

Stewart AL, Grossman M, Bera N, Gillis DE, Sperber N, Castrillo M, Pruitt L, McLellan B, Milk M, Clayton K, and Cassady D.  Multi-level perspectives on diffusing a physical activity promotion program to reach diverse older adults.  J Aging Phys Act. 2006;14(3):270-87.

Focus groups were used to obtain perspectives of multiple community sectors as to how physical activity programs could be diffused into underserved communities.  Focus group guides are described for interviewing community members, coalition members, administrators, service implementers, health care providers, and physical activity instructors.  They were interviewed about attitudes, resources, needs, and barriers to diffusing such programs.

(4) PRACTICAL GUIDES ON METHODS FOR CONDUCTING FOCUS GROUPS

The following resources provide detailed methods for conducting focus groups.

Kruegar RA, Casey MA. Focus Groups: A Practical Guide for Applied Research, 3rd ed.  Thousand Oaks, CA: Sage Publications, Inc., 2002.

Ward H, Atkins J.  From their lives: a manual on how to conduct focus groups of low-income parents.  Institute for Child and Family Policy, Edmund S. Muskie School of Public Health, University of Southern Maine, 2002: http://muskie.usm.maine.edu/focusgroupmanual/manual.htm.

OMNI. Toolkit for Conducting Focus Groups: Adapted from: USAID Center for Development Information and Evaluation. “Conducting Focus Group Interviews.”Performance Monitoring and Evaluation Tips.1996 (10). http://www.omni.org/docs/focusgrouptoolkit.pdf