focus group study research methods

Chapter 12. Focus Groups

Introduction.

Focus groups are a particular and special form of interviewing in which the interview asks focused questions of a group of persons, optimally between five and eight. This group can be close friends, family members, or complete strangers. They can have a lot in common or nothing in common. Unlike one-on-one interviews, which can probe deeply, focus group questions are narrowly tailored (“focused”) to a particular topic and issue and, with notable exceptions, operate at the shallow end of inquiry. For example, market researchers use focus groups to find out why groups of people choose one brand of product over another. Because focus groups are often used for commercial purposes, they sometimes have a bit of a stigma among researchers. This is unfortunate, as the focus group is a helpful addition to the qualitative researcher’s toolkit. Focus groups explicitly use group interaction to assist in the data collection. They are particularly useful as supplements to one-on-one interviews or in data triangulation. They are sometimes used to initiate areas of inquiry for later data collection methods. This chapter describes the main forms of focus groups, lays out some key differences among those forms, and provides guidance on how to manage focus group interviews.

Focus Groups: What Are They and When to Use Them

As interviews, focus groups can be helpfully distinguished from one-on-one interviews. The purpose of conducting a focus group is not to expand the number of people one interviews: the focus group is a different entity entirely. The focus is on the group and its interactions and evaluations rather than on the individuals in that group. If you want to know how individuals understand their lives and their individual experiences, it is best to ask them individually. If you want to find out how a group forms a collective opinion about something (whether a product or an event or an experience), then conducting a focus group is preferable. The power of focus groups resides in their being both focused and oriented to the group . They are best used when you are interested in the shared meanings of a group or how people discuss a topic publicly or when you want to observe the social formation of evaluations. The interaction of the group members is an asset in this method of data collection. If your questions would not benefit from group interaction, this is a good indicator that you should probably use individual interviews (chapter 11). Avoid using focus groups when you are interested in personal information or strive to uncover deeply buried beliefs or personal narratives. In general, you want to avoid using focus groups when the subject matter is polarizing, as people are less likely to be honest in a group setting. There are a few exceptions, such as when you are conducting focus groups with people who are not strangers and/or you are attempting to probe deeply into group beliefs and evaluations. But caution is warranted in these cases. [1]

As with interviewing in general, there are many forms of focus groups. Focus groups are widely used by nonresearchers, so it is important to distinguish these uses from the research focus group. Businesses routinely employ marketing focus groups to test out products or campaigns. Jury consultants employ “mock” jury focus groups, testing out legal case strategies in advance of actual trials. Organizations of various kinds use focus group interviews for program evaluation (e.g., to gauge the effectiveness of a diversity training workshop). The research focus group has many similarities with all these uses but is specifically tailored to a research (rather than applied) interest. The line between application and research use can be blurry, however. To take the case of evaluating the effectiveness of a diversity training workshop, the same interviewer may be conducting focus group interviews both to provide specific actionable feedback for the workshop leaders (this is the application aspect) and to learn more about how people respond to diversity training (an interesting research question with theoretically generalizable results).

When forming a focus group, there are two different strategies for inclusion. Diversity focus groups include people with diverse perspectives and experiences. This helps the researcher identify commonalities across this diversity and/or note interactions across differences. What kind of diversity to capture depends on the research question, but care should be taken to ensure that those participating are not set up for attack from other participants. This is why many warn against diversity focus groups, especially around politically sensitive topics. The other strategy is to build a convergence focus group , which includes people with similar perspectives and experiences. These are particularly helpful for identifying shared patterns and group consensus. The important thing is to closely consider who will be invited to participate and what the composition of the group will be in advance. Some review of sampling techniques (see chapter 5) may be helpful here.

Moderating a focus group can be a challenge (more on this below). For this reason, confining your group to no more than eight participants is recommended. You probably want at least four persons to capture group interaction. Fewer than four participants can also make it more difficult for participants to remain (relatively) anonymous—there is less of a group in which to hide. There are exceptions to these recommendations. You might want to conduct a focus group with a naturally occurring group, as in the case of a family of three, a social club of ten, or a program of fifteen. When the persons know one another, the problems of too few for anonymity don’t apply, and although ten to fifteen can be unwieldy to manage, there are strategies to make this possible. If you really are interested in this group’s dynamic (not just a set of random strangers’ dynamic), then you will want to include all its members or as many as are willing and able to participate.

There are many benefits to conducting focus groups, the first of which is their interactivity. Participants can make comparisons, can elaborate on what has been voiced by another, and can even check one another, leading to real-time reevaluations. This last benefit is one reason they are sometimes employed specifically for consciousness raising or building group cohesion. This form of data collection has an activist application when done carefully and appropriately. It can be fun, especially for the participants. Additionally, what does not come up in a focus group, especially when expected by the researcher, can be very illuminating.

Many of these benefits do incur costs, however. The multiplicity of voices in a good focus group interview can be overwhelming both to moderate and later to transcribe. Because of the focused nature, deep probing is not possible (or desirable). You might only get superficial thinking or what people are willing to put out there publicly. If that is what you are interested in, good. If you want deeper insight, you probably will not get that here. Relatedly, extreme views are often suppressed, and marginal viewpoints are unspoken or, if spoken, derided. You will get the majority group consensus and very little of minority viewpoints. Because people will be engaged with one another, there is the possibility of cut-off sentences, making it even more likely to hear broad brush themes and not detailed specifics. There really is very little opportunity for specific follow-up questions to individuals. Reading over a transcript, you may be frustrated by avenues of inquiry that were foreclosed early.

Some people expect that conducting focus groups is an efficient form of data collection. After all, you get to hear from eight people instead of just one in the same amount of time! But this is a serious misunderstanding. What you hear in a focus group is one single group interview or discussion. It is not the same thing at all as conducting eight single one-hour interviews. Each focus group counts as “one.” Most likely, you will need to conduct several focus groups, and you can design these as comparisons to one another. For example, the American Sociological Association (ASA) Task Force on First-Generation and Working-Class Persons in Sociology began its study of the impact of class in sociology by conducting five separate focus groups with different groups of sociologists: graduate students, faculty (in general), community college faculty, faculty of color, and a racially diverse group of students and faculty. Even though the total number of participants was close to forty, the “number” of cases was five. It is highly recommended that when employing focus groups, you plan on composing more than one and at least three. This allows you to take note of and potentially discount findings from a group with idiosyncratic dynamics, such as where a particularly dominant personality silences all other voices. In other words, putting all your eggs into a single focus group basket is not a good idea.

How to Conduct a Focus Group Interview/Discussion

Advance preparations.

Once you have selected your focus groups and set a date and time, there are a few things you will want to plan out before meeting.

As with interviews, you begin by creating an interview (or discussion) guide. Where a good one-on-one interview guide should include ten to twelve main topics with possible prompts and follow-ups (see the example provided in chapter 11), the focus group guide should be more narrowly tailored to a single focus or topic area. For example, a focus might be “How students coped with online learning during the pandemic,” and a series of possible questions would be drafted that would help prod participants to think about and discuss this topic. These questions or discussion prompts can be creative and may include stimulus materials (watching a video or hearing a story) or posing hypotheticals. For example, Cech ( 2021 ) has a great hypothetical, asking what a fictional character should do: keep his boring job in computers or follow his passion and open a restaurant. You can ask a focus group this question and see what results—how the group comes to define a “good job,” what questions they ask about the hypothetical (How boring is his job really? Does he hate getting up in the morning, or is it more of an everyday tedium? What kind of financial support will he have if he quits? Does he even know how to run a restaurant?), and how they reach a consensus or create clear patterns of disagreement are all interesting findings that can be generated through this technique.

As with the above example (“What should Joe do?”), it is best to keep the questions you ask simple and easily understood by everyone. Thinking about the sequence of the questions/prompts is important, just as it is in conducting any interviews.

Avoid embarrassing questions. Always leave an out for the “I have a friend who X” response rather than pushing people to divulge personal information. Asking “How do you think students coped?” is better than “How did you cope?” Chances are, some participants will begin talking about themselves without you directly asking them to do so, but allowing impersonal responses here is good. The group itself will determine how deep and how personal it wants to go. This is not the time or place to push anyone out of their comfort zone!

Of course, people have different levels of comfort talking publicly about certain topics. You will have provided detailed information to your focus group participants beforehand and secured consent. But even so, the conversation may take a turn that makes someone uncomfortable. Be on the lookout for this, and remind everyone of their ability to opt out—to stay silent or to leave if necessary. Rather than call attention to anyone in this way, you also want to let everyone know they are free to walk around—to get up and get coffee (more on this below) or use the restroom or just step out of the room to take a call. Of course, you don’t really want anyone to do any of these things, and chances are everyone will stay seated during the hour, but you should leave this “out” for those who need it.

Have copies of consent forms and any supplemental questionnaire (e.g., demographic information) you are using prepared in advance. Ask a friend or colleague to assist you on the day of the focus group. They can be responsible for making sure the recording equipment is functioning and may even take some notes on body language while you are moderating the discussion. Order food (coffee or snacks) for the group. This is important! Having refreshments will be appreciated by your participants and really damps down the anxiety level. Bring name tags and pens. Find a quiet welcoming space to convene. Often this is a classroom where you move chairs into a circle, but public libraries often have meeting rooms that are ideal places for community members to meet. Be sure that the space allows for food.

Researcher Note

When I was designing my research plan for studying activist groups, I consulted one of the best qualitative researchers I knew, my late friend Raphael Ezekiel, author of The Racist Mind . He looked at my plan to hand people demographic surveys at the end of the meetings I planned to observe and said, “This methodology is missing one crucial thing.” “What?” I asked breathlessly, anticipating some technical insider tip. “Chocolate!” he answered. “They’ll be tired, ready to leave when you ask them to fill something out. Offer an incentive, and they will stick around.” It worked! As the meetings began to wind down, I would whip some bags of chocolate candies out of my bag. Everyone would stare, and I’d say they were my thank-you gift to anyone who filled out my survey. Once I learned to include some sugar-free candies for diabetics, my typical response rate was 100 percent. (And it gave me an additional class-culture data point by noticing who chose which brand; sure enough, Lindt balls went faster at majority professional-middle-class groups, and Hershey’s minibars went faster at majority working-class groups.)

—Betsy Leondar-Wright, author of Missing Class , coauthor of The Color of Wealth , associate professor of sociology at Lasell University, and coordinator of staffing at the Mission Project for Class Action

During the Focus Group

As people arrive, greet them warmly, and make sure you get a signed consent form (if not in advance). If you are using name tags, ask them to fill one out and wear it. Let them get food and find a seat and do a little chatting, as they might wish. Once seated, many focus group moderators begin with a relevant icebreaker. This could be simple introductions that have some meaning or connection to the focus. In the case of the ASA task force focus groups discussed above, we asked people to introduce themselves and where they were working/studying (“Hi, I’m Allison, and I am a professor at Oregon State University”). You will also want to introduce yourself and the study in simple terms. They’ve already read the consent form, but you would be surprised at how many people ignore the details there or don’t remember them. Briefly talking about the study and then letting people ask any follow-up questions lays a good foundation for a successful discussion, as it reminds everyone what the point of the event is.

Focus groups should convene for between forty-five and ninety minutes. Of course, you must tell the participants the time you have chosen in advance, and you must promptly end at the time allotted. Do not make anyone nervous by extending the time. Let them know at the outset that you will adhere to this timeline. This should reduce the nervous checking of phones and watches and wall clocks as the end time draws near.

Set ground rules and expectations for the group discussion. My preference is to begin with a general question and let whoever wants to answer it do so, but other moderators expect each person to answer most questions. Explain how much cross-talk you will permit (or encourage). Again, my preference is to allow the group to pick up the ball and run with it, so I will sometimes keep my head purposefully down so that they engage with one another rather than me, but I have seen other moderators take a much more engaged position. Just be clear at the outset about what your expectations are. You may or may not want to explain how the group should deal with those who would dominate the conversation. Sometimes, simply stating at the outset that all voices should be heard is enough to create a more egalitarian discourse. Other times, you will have to actively step in to manage (moderate) the exchange to allow more voices to be heard. Finally, let people know they are free to get up to get more coffee or leave the room as they need (if you are OK with this). You may ask people to refrain from using their phones during the duration of the discussion. That is up to you too.

Either before or after the introductions (your call), begin recording the discussion with their collective permission and knowledge . If you have brought a friend or colleague to assist you (as you should), have them attend to the recording. Explain the role of your colleague to the group (e.g., they will monitor the recording and will take short notes throughout to help you when you read the transcript later; they will be a silent observer).

Once the focus group gets going, it may be difficult to keep up. You will need to make a lot of quick decisions during the discussion about whether to intervene or let it go unguided. Only you really care about the research question or topic, so only you will really know when the discussion is truly off topic. However you handle this, keep your “participation” to a minimum. According to Lune and Berg ( 2018:95 ), the moderator’s voice should show up in the transcript no more than 10 percent of the time. By the way, you should also ask your research assistant to take special note of the “intensity” of the conversation, as this may be lost in a transcript. If there are people looking overly excited or tapping their feet with impatience or nodding their heads in unison, you want some record of this for future analysis.

I’m not sure why this stuck with me, but I thought it would be interesting to share. When I was reviewing my plan for conducting focus groups with one of my committee members, he suggested that I give the participants their gift cards first. The incentive for participating in the study was a gift card of their choice, and typical processes dictate that participants must complete the study in order to receive their gift card. However, my committee member (who is Native himself) suggested I give it at the beginning. As a qualitative researcher, you build trust with the people you engage with. You are asking them to share their stories with you, their intimate moments, their vulnerabilities, their time. Not to mention that Native people are familiar with being academia’s subjects of interest with little to no benefit to be returned to them. To show my appreciation, one of the things I could do was to give their gifts at the beginning, regardless of whether or not they completed participating.

—Susanna Y. Park, PhD, mixed-methods researcher in public health and author of “How Native Women Seek Support as Survivors of Intimate Partner Violence: A Mixed-Methods Study”

After the Focus Group

Your “data” will be either fieldnotes taken during the focus group or, more desirably, transcripts of the recorded exchange. If you do not have permission to record the focus group discussion, make sure you take very clear notes during the exchange and then spend a few hours afterward filling them in as much as possible, creating a rich memo to yourself about what you saw and heard and experienced, including any notes about body language and interactions. Ideally, however, you will have recorded the discussion. It is still a good idea to spend some time immediately after the conclusion of the discussion to write a memo to yourself with all the things that may not make it into the written record (e.g., body language and interactions). This is also a good time to journal about or create a memo with your initial researcher reactions to what you saw, noting anything of particular interest that you want to come back to later on (e.g., “It was interesting that no one thought Joe should quit his job, but in the other focus group, half of the group did. I wonder if this has something to do with the fact that all the participants were first-generation college students. I should pay attention to class background here.”).

Please thank each of your participants in a follow-up email or text. Let them know you appreciated their time and invite follow-up questions or comments.

One of the difficult things about focus group transcripts is keeping speakers distinct. Eventually, you are going to be using pseudonyms for any publication, but for now, you probably want to know who said what. You can assign speaker numbers (“Speaker 1,” “Speaker 2”) and connect those identifications with particular demographic information in a separate document. Remember to clearly separate actual identifications (as with consent forms) to prevent breaches of anonymity. If you cannot identify a speaker when transcribing, you can write, “Unidentified Speaker.” Once you have your transcript(s) and memos and fieldnotes, you can begin analyzing the data (chapters 18 and 19).

Advanced: Focus Groups on Sensitive Topics

Throughout this chapter, I have recommended against raising sensitive topics in focus group discussions. As an introvert myself, I find the idea of discussing personal topics in a group disturbing, and I tend to avoid conducting these kinds of focus groups. And yet I have actually participated in focus groups that do discuss personal information and consequently have been of great value to me as a participant (and researcher) because of this. There are even some researchers who believe this is the best use of focus groups ( de Oliveira 2011 ). For example, Jordan et al. ( 2007 ) argue that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues. So although I do not recommend the beginning qualitative researcher dive into deep waters before they can swim, this section will provide some guidelines for conducting focus groups on sensitive topics. To my mind, these are a minimum set of guidelines to follow when dealing with sensitive topics.

First, be transparent about the place of sensitive topics in your focus group. If the whole point of your focus group is to discuss something sensitive, such as how women gain support after traumatic sexual assault events, make this abundantly clear in your consent form and recruiting materials. It is never appropriate to blindside participants with sensitive or threatening topics .

Second, create a confidentiality form (figure 12.2) for each participant to sign. These forms carry no legal weight, but they do create an expectation of confidentiality for group members.

In order to respect the privacy of all participants in [insert name of study here], all parties are asked to read and sign the statement below. If you have any reason not to sign, please discuss this with [insert your name], the researcher of this study, I, ________________________, agree to maintain the confidentiality of the information discussed by all participants and researchers during the focus group discussion.

Signature: _____________________________ Date: _____________________

Researcher’s Signature:___________________ Date:______________________

Figure 12.2 Confidentiality Agreement of Focus Group Participants

Third, provide abundant space for opting out of the discussion. Participants are, of course, always permitted to refrain from answering a question or to ask for the recording to be stopped. It is important that focus group members know they have these rights during the group discussion as well. And if you see a person who is looking uncomfortable or like they want to hide, you need to step in affirmatively and remind everyone of these rights.

Finally, if things go “off the rails,” permit yourself the ability to end the focus group. Debrief with each member as necessary.

Focus Groups – Steps, Examples and Guide

Table of Contents

Focus Group

Definition:

A focus group is a qualitative research method used to gather in-depth insights and opinions from a group of individuals about a particular product, service, concept, or idea.

The focus group typically consists of 6-10 participants who are selected based on shared characteristics such as demographics, interests, or experiences. The discussion is moderated by a trained facilitator who asks open-ended questions to encourage participants to share their thoughts, feelings, and attitudes towards the topic.

Focus groups are an effective way to gather detailed information about consumer behavior, attitudes, and perceptions, and can provide valuable insights to inform decision-making in a range of fields including marketing, product development, and public policy.

Types of Focus Group

The following are some types or methods of Focus Groups:

Traditional Focus Group

This is the most common type of focus group, where a small group of people is brought together to discuss a particular topic. The discussion is typically led by a skilled facilitator who asks open-ended questions to encourage participants to share their thoughts and opinions.

Mini Focus Group

A mini-focus group involves a smaller group of participants, typically 3 to 5 people. This type of focus group is useful when the topic being discussed is particularly sensitive or when the participants are difficult to recruit.

Dual Moderator Focus Group

In a dual-moderator focus group, two facilitators are used to manage the discussion. This can help to ensure that the discussion stays on track and that all participants have an opportunity to share their opinions.

Teleconference or Online Focus Group

Teleconferences or online focus groups are conducted using video conferencing technology or online discussion forums. This allows participants to join the discussion from anywhere in the world, making it easier to recruit participants and reducing the cost of conducting the focus group.

Client-led Focus Group

In a client-led focus group, the client who is commissioning the research takes an active role in the discussion. This type of focus group is useful when the client has specific questions they want to ask or when they want to gain a deeper understanding of their customers.

The following Table can explain Focus Group types more clearly

How To Conduct a Focus Group

To conduct a focus group, follow these general steps:

Define the Research Question

Identify the key research question or objective that you want to explore through the focus group. Develop a discussion guide that outlines the topics and questions you want to cover during the session.

Recruit Participants

Identify the target audience for the focus group and recruit participants who meet the eligibility criteria. You can use various recruitment methods such as social media, online panels, or referrals from existing customers.

Select a Venue

Choose a location that is convenient for the participants and has the necessary facilities such as audio-visual equipment, seating, and refreshments.

Conduct the Session

During the focus group session, introduce the topic, and review the objectives of the research. Encourage participants to share their thoughts and opinions by asking open-ended questions and probing deeper into their responses. Ensure that the discussion remains on topic and that all participants have an opportunity to contribute.

Record the Session

Use audio or video recording equipment to capture the discussion. Note-taking is also essential to ensure that you capture all key points and insights.

Analyze the data

Once the focus group is complete, transcribe and analyze the data. Look for common themes, patterns, and insights that emerge from the discussion. Use this information to generate insights and recommendations that can be applied to the research question.

When to use Focus Group Method

The focus group method is typically used in the following situations:

Exploratory Research

When a researcher wants to explore a new or complex topic in-depth, focus groups can be used to generate ideas, opinions, and insights.

Product Development

Focus groups are often used to gather feedback from consumers about new products or product features to help identify potential areas for improvement.

Marketing Research

Focus groups can be used to test marketing concepts, messaging, or advertising campaigns to determine their effectiveness and appeal to different target audiences.

Customer Feedback

Focus groups can be used to gather feedback from customers about their experiences with a particular product or service, helping companies improve customer satisfaction and loyalty.

Public Policy Research

Focus groups can be used to gather public opinions and attitudes on social or political issues, helping policymakers make more informed decisions.

Examples of Focus Group

Here are some real-time examples of focus groups:

A tech company wants to improve the user experience of their mobile app. They conduct a focus group with a diverse group of users to gather feedback on the app’s design, functionality, and features. The focus group consists of 8 participants who are selected based on their age, gender, ethnicity, and level of experience with the app. During the session, a trained facilitator asks open-ended questions to encourage participants to share their thoughts and opinions on the app. The facilitator also observes the participants’ behavior and reactions to the app’s features. After the focus group, the data is analyzed to identify common themes and issues raised by the participants. The insights gathered from the focus group are used to inform improvements to the app’s design and functionality, with the goal of creating a more user-friendly and engaging experience for all users.
A car manufacturer wants to develop a new electric vehicle that appeals to a younger demographic. They conduct a focus group with millennials to gather their opinions on the design, features, and pricing of the vehicle.
A political campaign team wants to develop effective messaging for their candidate’s campaign. They conduct a focus group with voters to gather their opinions on key issues and identify the most persuasive arguments and messages.
A restaurant chain wants to develop a new menu that appeals to health-conscious customers. They conduct a focus group with fitness enthusiasts to gather their opinions on the types of food and drinks that they would like to see on the menu.
A healthcare organization wants to develop a new wellness program for their employees. They conduct a focus group with employees to gather their opinions on the types of programs, incentives, and support that would be most effective in promoting healthy behaviors.
A clothing retailer wants to develop a new line of sustainable and eco-friendly clothing. They conduct a focus group with environmentally conscious consumers to gather their opinions on the design, materials, and pricing of the clothing.

Purpose of Focus Group

The key objectives of a focus group include:

Generating New Ideas and insights

Focus groups are used to explore new or complex topics in-depth, generating new ideas and insights that may not have been previously considered.

Understanding Consumer Behavior

Focus groups can be used to gather information on consumer behavior, attitudes, and perceptions to inform marketing and product development strategies.

Testing Concepts and Ideas

Focus groups can be used to test marketing concepts, messaging, or product prototypes to determine their effectiveness and appeal to different target audiences.

Gathering Customer Feedback

Informing decision-making.

Focus groups can provide valuable insights to inform decision-making in a range of fields including marketing, product development, and public policy.

Advantages of Focus Group

The advantages of using focus groups are:

In-depth insights: Focus groups provide in-depth insights into the attitudes, opinions, and behaviors of a target audience on a specific topic, allowing researchers to gain a deeper understanding of the issues being explored.
Group dynamics: The group dynamics of focus groups can provide additional insights, as participants may build on each other’s ideas, share experiences, and debate different perspectives.
Efficient data collection: Focus groups are an efficient way to collect data from multiple individuals at the same time, making them a cost-effective method of research.
Flexibility : Focus groups can be adapted to suit a range of research objectives, from exploratory research to concept testing and customer feedback.
Real-time feedback: Focus groups provide real-time feedback on new products or concepts, allowing researchers to make immediate adjustments and improvements based on participant feedback.
Participant engagement: Focus groups can be a more engaging and interactive research method than surveys or other quantitative methods, as participants have the opportunity to express their opinions and interact with other participants.

Limitations of Focus Groups

While focus groups can provide valuable insights, there are also some limitations to using them.

Small sample size: Focus groups typically involve a small number of participants, which may not be representative of the broader population being studied.
Group dynamics : While group dynamics can be an advantage of focus groups, they can also be a limitation, as dominant personalities may sway the discussion or participants may not feel comfortable expressing their true opinions.
Limited generalizability : Because focus groups involve a small sample size, the results may not be generalizable to the broader population.
Limited depth of responses: Because focus groups are time-limited, participants may not have the opportunity to fully explore or elaborate on their opinions or experiences.
Potential for bias: The facilitator of a focus group may inadvertently influence the discussion or the selection of participants may not be representative, leading to potential bias in the results.
Difficulty in analysis : The qualitative data collected in focus groups can be difficult to analyze, as it is often subjective and requires a skilled researcher to interpret and identify themes.

Characteristics of Focus Group

Small group size: Focus groups typically involve a small number of participants, ranging from 6 to 12 people. This allows for a more in-depth and focused discussion.
Targeted participants: Participants in focus groups are selected based on specific criteria, such as age, gender, or experience with a particular product or service.
Facilitated discussion: A skilled facilitator leads the discussion, asking open-ended questions and encouraging participants to share their thoughts and experiences.
I nteractive and conversational: Focus groups are interactive and conversational, with participants building on each other’s ideas and responding to one another’s opinions.
Qualitative data: The data collected in focus groups is qualitative, providing detailed insights into participants’ attitudes, opinions, and behaviors.
Non-threatening environment: Participants are encouraged to share their thoughts and experiences in a non-threatening and supportive environment.
Limited time frame: Focus groups are typically time-limited, lasting between 1 and 2 hours, to ensure that the discussion stays focused and productive.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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What Is a Focus Group?

Saul Mcleod, PhD

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A focus group is a qualitative research method that involves facilitating a small group discussion with participants who share common characteristics or experiences that are relevant to the research topic. The goal is to gain insights through group conversation and observation of dynamics.

a focus group of people sat on chairs in a circle. one person is making notes on a clipboard.

In a focus group:

A moderator asks questions and leads a group of typically 6 to 12 pre-screened participants through a discussion focused on a particular topic.
Group members are encouraged to talk with one another, exchange anecdotes, comment on each others’ experiences and points of view, and build on each others’ responses.
The goal is to create a candid, natural conversation that provides insights into the participants’ perceptions, attitudes, beliefs, and opinions on the topic.
Focus groups capitalize on group dynamics to elicit multiple perspectives in a social environment as participants are influenced by and influence others through open discussion.
The interactive responses allow researchers to quickly gather more contextual, nuanced qualitative data compared to surveys or one-on-one interviews.

Focus groups allow researchers to gather perspectives from multiple people at once in an interactive group setting. This group dynamic surfaces richer responses as participants build on each other’s comments, discuss issues in-depth, and voice agreements or disagreements.

It is important that participants feel comfortable expressing diverse viewpoints rather than being pressured into a consensus.

Focus groups emerged as an alternative to questionnaires in the 1930s over concerns that surveys fostered passive responses or failed to capture people’s authentic perspectives.

During World War II, focus groups were used to evaluate military morale-boosting radio programs. By the 1950s focus groups became widely adopted in marketing research to test consumer preferences.

A key benefit K. Merton highlighted in 1956 was grouping participants with shared knowledge of a topic. This common grounding enables people to provide context to their experiences and allows contrasts between viewpoints to emerge across the group.

As a result, focus groups can elicit a wider range of perspectives than one-on-one interviews.

Step 1 : Clarify the Focus Group’s Purpose and Orientation

Clarify the purpose and orientation of the focus group (Tracy, 2013). Carefully consider whether a focus group or individual interviews will provide the type of qualitative data needed to address your research questions.

Determine if the interactive, fast-paced group discussion format is aligned with gathering perspectives vs. in-depth attitudes on a topic.

Consider incorporating special techniques like extended focus groups with pre-surveys, touchstones using creative imagery/metaphors to focus the topic, or bracketing through ongoing conceptual inspection.

For example

A touchstone in a focus group refers to using a shared experience, activity, metaphor, or other creative technique to provide a common reference point and orientation for grounding the discussion.

The purpose of Mulvale et al. (2021) was to understand the hospital experiences of youth after suicide attempts.

The researchers created a touchstone to focus the discussion specifically around the hospital visit. This provided a shared orientation for the vulnerable participants to open up about their emotional journeys.

In the example from Mulvale et al. (2021), the researchers designated the hospital visit following suicide attempts as the touchstone. This means:

The visit served as a defining shared experience all youth participants could draw upon to guide the focus group discussion, since they unfortunately had this in common.
Framing questions around recounting and making meaning out of the hospitalization focused the conversation to elicit rich details about interactions, emotions, challenges, supports needed, and more in relation to this watershed event.
The hospital visit as a touchstone likely resonated profoundly across youth given the intensity and vulnerability surrounding their suicide attempts. This deepened their willingness to open up and established group rapport.

So in this case, the touchstone concentrated the dialogue around a common catalyst experience enabling youth to build understanding, voice difficulties, and potentially find healing through sharing their journey with empathetic peers who had endured the same trauma.

Step 2 : Select a Homogeneous Grouping Characteristic

Select a homogeneous grouping characteristic (Krueger & Casey, 2009) to recruit participants with a commonality, like shared roles, experiences, or demographics, to enable meaningful discussion.

A sample size of between 6 to 10 participants allows for adequate mingling (MacIntosh 1993).

More members may diminish the ability to capture all viewpoints. Fewer risks limited diversity of thought.

Balance recruitment across income, gender, age, and cultural factors to increase heterogeneity in perspectives. Consider screening criteria to qualify relevant participants.

Choosing focus group participants requires balancing homogeneity and diversity – too much variation across gender, class, profession, etc., can inhibit sharing, while over-similarity limits perspectives. Groups should feel mutual comfort and relevance of experience to enable open contributions while still representing a mix of viewpoints on the topic (Morgan 1988).

Mulvale et al. (2021) determined grouping by gender rather than age or ethnicity was more impactful for suicide attempt experiences.

They fostered difficult discussions by bringing together male and female youth separately based on the sensitive nature of topics like societal expectations around distress.

Step 3 : Designate a Moderator

Designate a skilled, neutral moderator (Crowe, 2003; Morgan, 1997) to steer productive dialogue given their expertise in guiding group interactions. Consider cultural insider moderators positioned to foster participant sharing by understanding community norms.

Define moderator responsibilities like directing discussion flow, monitoring air time across members, and capturing observational notes on behaviors/dynamics.

Choose whether the moderator also analyzes data or only facilitates the group.

Mulvale et al. (2021) designated a moderator experienced working with marginalized youth to encourage sharing by establishing an empathetic, non-judgmental environment through trust-building and active listening guidance.

Step 4 : Develop a Focus Group Guide

Develop an extensive focus group guide (Krueger & Casey, 2009). Include an introduction to set a relaxed tone, explain the study rationale, review confidentiality protection procedures, and facilitate a participant introduction activity.

Also include guidelines reiterating respect, listening, and sharing principles both verbally and in writing.

Group confidentiality agreement

The group context introduces distinct ethical demands around informed consent, participant expectations, confidentiality, and data treatment. Establishing guidelines at the outset helps address relevant issues.

Create a group confidentiality agreement (Berg, 2004) specifying that all comments made during the session must remain private, anonymous in data analysis, and not discussed outside the group without permission.

Have it signed, demonstrating a communal commitment to sustaining a safe, secure environment for honest sharing.

Berg (2004) recommends a formal signed agreement prohibiting participants from publicly talking about anything said in the focus group without permission. This reassures members their personal disclosures are safeguarded.

Develop questions starting general then funneling down to 10-12 key questions on critical topics. Integrate think/pair/share activities between question sets to encourage inclusion. Close with a conclusion to summarize key ideas voiced without endorsing consensus.

Krueger and Casey (2009) recommend structuring focus group questions in five stages:

Opening Questions:

Start with easy, non-threatening questions to make participants comfortable, often related to their background and experience with the topic.
Get everyone talking and open up initial dialogue.
Example: “Let’s go around and have each person share how long you’ve lived in this city.”

Introductory Questions:

Transition to the key focus group objectives and main topics of interest.
Remain quite general to provide baseline understanding before drilling down.
Example: “Thinking broadly, how would you describe the arts and cultural offerings in your community?”

Transition Questions:

Serve as a logical link between introductory and key questions.
Funnel participants toward critical topics guided by research aims.
Example: “Specifically related to concerts and theatre performances, what venues in town have you attended events at over the past year?”

Key Questions:

Drive at the heart of study goals, and issues under investigation.
Ask 5-10 questions that foster organic, interactive discussion between participants.
Example: “What enhances or detracts from the concert-going experience at these various venues?”

Ending Questions:

Provide an opportunity for final thoughts or anything missed.
Assess the degree of consensus on key topics.
Example: “If you could improve just one thing about the concert and theatre options here, what would you prioritize?”

It is vital to extensively pilot test draft questions to hone the wording, flow, timing, tone and tackle any gaps to adequately cover research objectives through dynamic group discussion.

Step 5 : Prepare the focus group room

Prepare the focus group room (Krueger & Casey, 2009) attending to details like circular seating for eye contact, centralized recording equipment with backup power, name cards, and refreshments to create a welcoming, affirming environment critical for participants to feel valued, comfortable engaging in genuine dialogue as a collective.

Arrange seating comfortably in a circle to facilitate discussion flow and eye contact among members. Decide if space for breakout conversations or activities like role-playing is needed.

Refreshments

Coordinate snacks or light refreshments to be available when focus group members arrive, especially for longer sessions. This contributes to a welcoming atmosphere.
Even if no snacks are provided, consider making bottled water available throughout the session.
Set out colorful pens and blank name tags for focus group members to write their preferred name or pseudonym when they arrive.
Attaching name tags to clothing facilitates interaction and expedites learning names.
If short on preparation time, prepare printed name tags in advance based on RSVPs, but blank name tags enable anonymity if preferred.

Krueger & Casey (2009) suggest welcoming focus group members with comfortable, inclusive seating arrangements in a circle to enable eye contact. Providing snacks and music sets a relaxed tone.

Step 6 : Conduct the focus group

Conduct the focus group utilizing moderation skills like conveying empathy, observing verbal and non-verbal cues, gently redirecting and probing overlooked members, and affirming the usefulness of knowledge sharing.

Use facilitation principles (Krueger & Casey, 2009; Tracy 2013) like ensuring psychological safety, mutual respect, equitable airtime, and eliciting an array of perspectives to expand group knowledge. Gain member buy-in through collaborative review.

Record discussions through detailed note-taking, audio/video recording, and seating charts tracking engaged participation.

The role of moderator

The moderator is critical in facilitating open, interactive discussion in the group. Their main responsibilities are:

Providing clear explanations of the purpose and helping participants feel comfortable
Promoting debate by asking open-ended questions
Drawing out differences of opinion and a range of perspectives by challenging participants
Probing for more details when needed or moving the conversation forward
Keeping the discussion focused and on track
Ensuring all participants get a chance to speak
Remaining neutral and non-judgmental, without sharing personal opinions

Moderators need strong interpersonal abilities to build participant trust and comfort sharing. The degree of control and input from the moderator depends on the research goals and personal style.

With multiple moderators, roles, and responsibilities should be clear and consistent across groups. Careful preparation is key for effective moderation.

Mulvale et al. (2021) fostered psychological safety for youth to share intense emotions about suicide attempts without judgment. The moderator ensured equitable speaking opportunities within a compassionate climate.

Krueger & Casey (2009) advise moderators to handle displays of distress empathetically by offering a break and emotional support through active listening instead of ignoring reactions. This upholds ethical principles.

Advantages and disadvantages of focus groups

Focus groups efficiently provide interactive qualitative data that can yield useful insights into emerging themes. However, findings may be skewed by group behaviors and still require larger sample validation through added research methods. Careful planning is vital.

Efficient way to gather a range of perspectives in participants’ own words in a short time
Group dynamic encourages more complex responses as members build on others’ comments
Can observe meaningful group interactions, consensus, or disagreements
Flexibility for moderators to probe unanticipated insights during discussion
Often feels more comfortable sharing as part of a group rather than one-on-one
Helps participants recall and reflect by listening to others tell their stories

Disadvantages

Small sample size makes findings difficult to generalize
Groupthink: influential members may discourage dissenting views from being shared
Social desirability bias: reluctance from participants to oppose perceived majority opinions
Requires highly skilled moderators to foster inclusive participation and contain domineering members
Confidentiality harder to ensure than with individual interviews
Transcriptions may have overlapping talk that is difficult to capture accurately
Group dynamics adds layers of complexity for analysis beyond just the content of responses

Goss, J. D., & Leinbach, T. R. (1996). Focus groups as alternative research practice: experience with transmigrants in Indonesia. Area , 115-123.

Kitzinger, J. (1994). The methodology of focus groups: the importance of interaction between research participants . Sociology of health & illness , 16 (1), 103-121.

Kitzinger J. (1995). Introducing focus groups. British Medical Journal, 311 , 299-302.

Morgan D.L. (1988). Focus groups as qualitative research . London: Sage.

Mulvale, G., Green, J., Miatello, A., Cassidy, A. E., & Martens, T. (2021). Finding harmony within dissonance: engaging patients, family/caregivers and service providers in research to fundamentally restructure relationships through integrative dynamics . Health Expectations , 24 , 147-160.

Powell, R. A., Single, H. M., & Lloyd, K. R. (1996). Focus groups in mental health research: enhancing the validity of user and provider questionnaires . International Journal of Social Psychiatry , 42 (3), 193-206.

Puchta, C., & Potter, J. (2004). Focus group practice . Sage.

Redmond, R. A., & Curtis, E. A. (2009). Focus groups: principles and process. Nurse researcher , 16 (3).

Smith, J. A., Scammon, D. L., & Beck, S. L. (1995). Using patient focus groups for new patient services. The Joint Commission Journal on Quality Improvement , 21 (1), 22-31.

Smithson, J. (2008). Focus groups. The Sage handbook of social research methods , 357-370.

White, G. E., & Thomson, A. N. (1995). Anonymized focus groups as a research tool for health professionals. Qualitative Health Research , 5 (2), 256-261.

Download PDF slides of the presentation ‘ Conducting Focus Groups – A Brief Overview ‘

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Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

P. Gill 1 &
J. Baillie 2

British Dental Journal volume 225 , pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

You have full access to this article via your institution.

Determinants of behaviour and their efficacy as targets of behavioural change interventions

Interviews in the social sciences

A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

Introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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World Leaders in Research-Based User Experience

Focus Groups 101

July 31, 2022 2022-07-31

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It is no secret that the field of user experience often favors objective, observational research methods over subjective, attitudinal methods. After all, when something is observed, with proof that it has actually happened, it can be hard to argue against it. However, it takes more than observational research to truly empathize and understand the full complexity of a person’s experience, which includes emotional experiences, mindsets, values, and belief systems. Since there is no other way to gather this data (at the writing of this article, mind reading with neural implants is not possible) researchers must use attitudinal methods to solicit the thoughts and opinions of target customers. A focus group is one of these methods.

Definition: A focus group is a qualitative, attitudinal research method in which a facilitator conducts a meeting or workshop (typically about 1–2 hours long) with a group of 6–9 people to discuss issues and concerns about their experiences with a product or service. The term “focus” relates to the role of the facilitator, who maintains the group’s focus on certain topics during discussions.

Traditionally, focus groups have been a market-research method, used to get a sense of some aspect of a product, service, or concept. In these settings, the focus would typically be on certain words, graphics, videos, or other noninteractive media. All participants are presented with the media as a group and then prompted to provide their thoughts to the facilitator and the rest of the group.

Generally speaking, focus groups can provide useful information about your customers’ overall opinions and their impressions of a product or service.

Focus groups are notoriously problematic and often improperly used. Here are some of their limitations:

They do not provide detailed insights on usability. People will comment on what is shown or remembered and offer opinions, so, by their nature, focus groups cannot provide any objective information on behavior when using a product or service. Thus, they cannot provide detailed usability insights, which would be best found with a usability test or field study . Even if there are some usability insights uncovered when presenting a design, products are almost never used by a whole committee; they’re used individually.
People don’t always know what they will do or what will MOST benefit them in the future. In many focus groups, participants are asked whether they would use a particular product. But users do not always do what they say they will do. So, while it’s helpful to listen to customers’ concerns, preferences, or requests for features or product offerings — especially to uncover unmet user needs — the requests themselves are not always going to be the best solutions to address customers’ needs in a systematic and prioritized way.
Negativity bias often results in people more readily recalling what was bad about an experience (particularly if it was not a great one), which can skew the discussion negatively for everyone else.
The peak-end rule can cause people to overly focus on the most memorable and most recent moments, at the expense of other possibly more-meaningful ones.
Priming can cause participants to overemphasize an aspect of their experience, because it so happened that someone else mentioned it and made them remember it.
Group dynamics may impact how much (or how little) people share. Strong personalities in the group may affect what and how much is shared. Depending on the focus group’s format, it may disproportionately represent the opinions of those who are more talkative or quick to answer. Groupthink is also more likely to occur in these settings if only verbal contributions are given attention. To paraphrase my colleague Sarah Gibbons : a poorly run focus group can be a great way to pay 9 people for the opinions of three.

Given these limitations, focus groups should NOT be utilized in the following contexts:

Evaluating a design’s usability
Evaluating workflows
Creating a list of design requirements
Determining a UI’s impact on emotions
Quantifying satisfaction or other sentiments

Despite these shortcomings, there are some good reasons to consider a focus group:

Participants with similar goals or perspectives can build on each other’s responses or recall experiences in greater detail. Sometimes during interviews, a participant might have trouble recalling all the details of an experience. However, hearing another participant mention something related may trigger the recollection of an important detail, which would otherwise get skimmed over in an interview.
They can help teams clarify users’ mental models and language (vocabulary) around the problem space during discovery phases , before conducting further research. While you should generally run a pilot study for most research studies anyway, a focus group can help researchers rework a research plan or facilitator guide with language that could be more user-centered.
They are a time-efficient method for the researcher. Rather than dedicate 9–12 hours interviewing 6–9 individual participants, a researcher can dedicate 1–2 hours to gather the perspectives of 6–9 people at the same time. It can be a quick way to learn from many people and perspectives (and certainly a 100% improvement to conducting no research at all). These can be especially time-efficient if the researcher is facilitating the focus group online rather than in person.
When run properly, they can yield rich qualitative insights due to a format similar to semistructured interviews . Unlike questionnaires — which can sometimes limit the level of detail covered — focus groups give facilitators the flexibility to explore topics in which the participants are interested. This format is especially useful if the team is still in early stages of product development and trying to discover new information about the problem space.

Given these benefits, focus groups are BEST utilized in the following contexts:

Early discovery research to gauge customer familiarity or interest in a concept and initial impressions
Understanding users’ mental models and expectations
Cocreation workshops with sponsored customers

It’s fair to say that focus groups are often unfairly maligned, considering the many benefits they can yield with relatively less time commitment compared to other methods. The key to reaping these benefits and mitigating limitations is to use a combination of other research methods (like other behavioral or attitudinal methods), and having a strong research plan.

Here are the key things to consider when planning your focus group:

1. Recruit participants that are representative of your target audience(s).

Who do you want to learn about? What specific segment of users are you interested in? Even if your user is “everybody,” use personas , archetypes , or jobs-to-be-done to identify key recruiting criteria . Recruiting is a tricky balance of finding similar user motivations and goals (not demographics) while inviting a mix of backgrounds to reduce bias from other sources — such as having an overly westernized sample when studying a global offering.

2. Note potential sources of bias from the focus group’s structure.

Note who is not included, and why, for consideration during analysis and when strategizing future research. Is it a different segment that’s intentionally excluded? Lack of response? Lack of interest/trust? Bias is difficult to totally eliminate, but awareness of sources of bias can help during analysis and might inform future research. For example:

With online focus groups, there may be potential participants who are excluded from participating (be it due to a poor internet connection, lack of a desktop device, or low literacy in certain digital tools). Thus, they may not be able join a video chat or, if they do join, they may be less likely to participate when using an unfamiliar online-meeting tool or whiteboard platform for the first time.
With in-person focus groups, it’s fair to assume that the study will only involve participants from the immediate commutable vicinity (i.e., within the city or state), especially if travel is not funded by the study or if insufficient notice is provided for those commuting from further distances.
Is your focus group accessible? This is relevant for both in-person and online focus groups. Can disabled participants get into the facility and participate readily? Can nonverbal participants contribute?

3. Treat your focus group like a workshop . Make participants comfortable with participating, verbally or nonverbally.

As you plan your agenda for the focus group, remember that most of your participants likely do not know each other and will be asked to speak honestly, potentially revealing information that may make them feel vulnerable or unlike others. Some people may do it, others may not. Consider having the following in your focus group:

It gives a structured way for participants to build rapport with the facilitator and with each other.
It builds participants’ confidence, in themselves and in the format (particularly if you’re using online-meeting tools or digital whiteboards). Note: Do not “break the ice” with highly personal or sensitive topics, which will likely cause participants to withdraw instead. (In fact, those types of answers are probably not going to come easily in a focus-group format, even with the most “warmed up” group. These types of questions are better suited to 1:1 interviews).
Both written and verbal participation opportunities As with any other UX workshop , offer multiple methods of engagement (verbal and nonverbal) to encourage maximum participation and contribution. This ensures that less vocal or nonnative speakers feel comfortable contributing. You can also use the diverge–converge technique to maximize participation while decreasing bias potential. Note: If covering sensitive topics, offer an anonymous way to contribute (or, again, consider a different, more-private method altogether).

4. Have a (written) plan and guide.

Construct your prompts in advance to avoid leading or biasing participants. As with semistructured interviews, focus-group questions should use the funnel technique : be open-ended and broad at the beginning and progressively build detail and specificity with concepts as the conversation progresses. On a related note: remember to frame followup questions both positively and negatively to avoid leading participants, particularly when the conversation may naturally skew in one of these directions.

Focus groups don’t accurately predict future behavior. However, they can help gauge attitudes and guide future exploration, thus avoiding wasted research time. Still, they should be considered a starting point to further research, rather than a validation step. The good news? If your focus-group participants are willing, not only will you have their input to guide your further research, you may also have a group of customers willing and able to test what you create to further guide your design.

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Qualitative Research:...

Qualitative Research: Introducing focus groups

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Peer review
Jenny Kitzinger , research fellow a
a Glasgow University Media Group, Department of Sociology, University of Glasgow, Glasgow G12 8LF

This paper introduces focus group methodology, gives advice on group composition, running the groups, and analysing the results. Focus groups have advantages for researchers in the field of health and medicine: they do not discriminate against people who cannot read or write and they can encourage participation from people reluctant to be interviewed on their own or who feel they have nothing to say.

This is the fifth in a series of seven articles describing non-quantitative techniques and showing their value in health research

**FIGURE OMITTED**

Rationale and uses of focus groups

Focus groups are a form of group interview that capitalises on communication between research participants in order to generate data. Although group interviews are often used simply as a quick and convenient way to collect data from several people simultaneously, focus groups explicitly use group interaction as part of the method. This means that instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another: asking questions, exchanging anecdotes and commenting on each other's experiences and points of view. 1 The method is particularly useful for exploring people's knowledge and experiences and can be used to examine not only what people think but how they think and why they think that way.

Focus groups were originally used within communication studies to explore the effects of films and television programmes, 2 and are a popular method for assessing health education messages and examining public understandings of illness and of health behaviours. 3 4 5 6 7 They are widely used to examine people's experiences of disease and of health services. 8 9 and are an effective technique for exploring the attitudes and needs of staff. 10 11

The idea behind the focus group method is that group processes can help people to explore and clarify their views in ways that would be less easily accessible in a one to one interview. Group discussion is particularly appropriate when the interviewer has a series of open ended questions and wishes to encourage research participants to explore the issues of importance to them, in their own vocabulary, generating their own questions and pursuing their own priorities. When group dynamics work well the participants work alongside the researcher, taking the research in new and often unexpected directions.

Group work also helps researchers tap into the many different forms of communication that people use in day to day interaction, including jokes, anecdotes, teasing, and arguing. Gaining access to such variety of communication is useful because people's knowledge and attitudes are not entirely encapsulated in reasoned responses to direct questions. Everyday forms of communication may tell us as much, if not more, about what people know or experience. In this sense focus groups reach the parts that other methods cannot reach, revealing dimensions of understanding that often remain untapped by more conventional data collection techniques.

Some potential sampling advantages with focus groups

Do not discriminate against people who cannot read or write

Can encourage participation from those who are reluctant to be interviewed on their own (such as those intimidated by the formality and isolation of a one to one interview)

Can encourage contributions from people who feel they have nothing to say or who are deemed “unresponsive patients” (but engage in the discussion generated by other group members)

Tapping into such interpersonal communication is also important because this can highlight (sub)cultural values or group norms. Through analysing the operation of humour, consensus, and dissent and examining different types of narrative used within the group, the researcher can identify shared and common knowledge. 12 This makes focus groups a data collection technique particularly sensitive to cultural variables—which is why it is so often used in cross cultural research and work with ethnic minorities. It also makes them useful in studies examining why different sections of the population make differential use of health services. 13 14 For similar reasons focus groups are useful for studying dominant cultural values (for example, exposing dominant narratives about sexuality 15 ) and for examining work place cultures—the ways in which, for example, staff cope with working with terminally ill patients or deal with the stresses of an accident and emergency department.

The downside of such group dynamics is that the articulation of group norms may silence individual voices of dissent. The presence of other research participants also compromises the confidentiality of the research session. For example, in group discussion with old people in long term residential care I found that some residents tried to prevent others from criticising staff—becoming agitated and repeatedly interrupting with cries of “you can't complain”; “the staff couldn't possibly be nicer.” On the one hand, such interactions highlighted certain aspects of these people's experiences. In this case, it showed some resident's fear of being “punished” by staff for, in the words of one woman, “being cheeky.” On the other hand, such group dynamics raise ethical issues (especially when the work is with “captive” populations) and may limit the usefulness of the data for certain purposes (Scottish Health Feedback, unpublished report).

However, it should not be assumed that groups are, by definition, inhibiting relative to the supposed privacy of an interview situation or that focus groups are inappropriate when researching sensitive topics. Quite the opposite may be true. Group work can actively facilitate the discussion of taboo topics because the less inhibited members of the group break the ice for shyer participants. Participants can also provide mutual support in expressing feelings that are common to their group but which they consider to deviate from mainstream culture (or the assumed culture of the researcher). This is particularly important when researching stigmatised or taboo experiences (for example, bereavement or sexual violence).

Focus group methods are also popular with those conducting action research and those concerned to “empower” research participants because the participants can become an active part of the process of analysis. Indeed, group participants may actually develop particular perspectives as a consequence of talking with other people who have similar experiences. For example, group dynamics can allow for a shift from personal, self blaming psychological explanations (“I'm stupid not to have understood what the doctor was telling me”; “I should have been stronger—I should have asked the right questions”) to the exploration of structural solutions (“If we've all felt confused about what we've been told maybe having a leaflet would help, or what about being able to take away a tape recording of the consultation?”).

Some researchers have also noted that group discussions can generate more critical comments than interviews. 16 For example, Geis et al, in their study of the lovers of people with AIDS, found that there were more angry comments about the medical community in the group discussions than in the individual interviews: “perhaps the synergism of the group ‘kept the anger going’ and allowed each participant to reinforce another's vented feelings of frustration and rage. 17 A method that facilitates the expression of criticism and the exploration of different types of solutions is invaluable if the aim of research is to improve services. Such a method is especially appropriate when working with particular disempowered patient populations who are often reluctant to give negative feedback or may feel that any problems result from their own inadequacies. 19

Conducting a focus group study

Sampling and group composition.

Focus group studies can consist of anything between half a dozen to over fifty groups, depending on the aims of the project and the resources available. Most studies involve just a few groups, and some combine this method with other data collection techniques. Focus group discussion of a questionnaire is ideal for testing the phrasing of questions and is also useful in explaining or exploring survey results. 19 20

Although it may be possible to work with a representative sample of a small population, most focus group studies use a theoretical sampling model (explained earlier in this series 21 ) whereby participants are selected to reflect a range of the total study population or to test particular hypotheses. Imaginative sampling is crucial. Most people now recognise class or ethnicity as important variables, and it is also worth considering other variables. For example, when exploring women's experiences of maternity care or cervical smears it may be advisable to include groups of lesbians or women who were sexually abused as children. 22

Most researchers recommend aiming for homogeneity within each group in order to capitalise on people's shared experiences. However, it can also be advantageous to bring together a diverse group (for example, from a range of professions) to maximise exploration of different perspectives within a group setting. However, it is important to be aware of how hierarchy within the group may affect the data (a nursing auxiliary, for example, is likely to be inhibited by the presence of a consultant from the same hospital).

The groups can be “naturally occurring” (for example, people who work together) or may be drawn together specifically for the research. Using preexisting groups allows observation of fragments of interactions that approximate to naturally occurring data (such as might have been collected by participant observation). An additional advantage is that friends and colleagues can relate each other's comments to incidents in their shared daily lives. They may challenge each other on contradictions between what they profess to believe and how they actually behave (for example, “how about that time you didn't use a glove while taking blood from a patient?”).

It would be naive to assume that group data are by definition “natural” in the sense that such interactions would have occurred without the group being convened for this purpose. Rather than assuming that sessions inevitably reflect everyday interactions (although sometimes they will), the group should be used to encourage people to engage with one another, formulate their ideas, and draw out the cognitive structures which previously have not been articulated.

Finally, it is important to consider the appropriateness of group work for different study populations and to think about how to overcome potential difficulties. Group work can facilitate collecting information from people who cannot read or write. The “safety in numbers factor” may also encourage the participation of those who are wary of an interviewer or who are anxious about talking. 23 However, group work can compound difficulties in communication if each person has a different disability. In the study assessing residential care for the elderly, I conducted a focus group that included one person who had impaired hearing, another with senile dementia, and a third with partial paralysis affecting her speech. This severely restricted interaction between research participants and confirmed some of the staff's predictions about the limitations of group work with this population. However, such problems could be resolved by thinking more carefully about the composition of the group, and sometimes group participants could help to translate for each other. It should also be noted that some of the old people who might have been unable to sustain a one to one interview were able to take part in the group, contributing intermittently. Even some residents who staff had suggested should be excluded from the research because they were “unresponsive” eventually responded to the lively conversations generated by their coresidents and were able to contribute their point of view. Communication difficulties should not rule out group work, but must be considered as a factor.

RUNNING THE GROUPS

Sessions should be relaxed: a comfortable setting, refreshments, and sitting round in a circle will help to establish the right atmosphere. The ideal group size is between four and eight people. Sessions may last one to two hours (or extend into a whole afternoon or a series of meetings). The facilitator should explain that the aim of focus groups is to encourage people to talk to each other rather than to address themselves to the researcher. The researcher may take a back seat at first, allowing for a type of “structured eavesdropping.” 24 Later on in the session, however, the researcher can adopt a more interventionist style: urging debate to continue beyond the stage it might otherwise have ended and encouraging the group to discuss the inconsistencies both between participants and within their own thinking. Disagreements within groups can be used to encourage participants to elucidate their point of view and to clarify why they think as they do. Differences between individual one off interviews have to be analysed by the researchers through armchair theorising; differences between members of focus groups should be explored in situ with the help of the research participants.

The facilitator may also use a range of group exercises. A common exercise consists of presenting the group with a series of statements on large cards. The group members are asked collectively to sort these cards into different piles depending on, for example, their degree of agreement or disagreement with that point of view or the importance they assign to that particular aspect of service. For example, I have used such cards to explore public understandings of HIV transmission (placing statements about “types” of people into different risk categories), old people's experiences of residential care (assigning degrees of importance to different statements about the quality of their care), and midwive's views of their professional responsibilities (placing a series of statements about midwive's roles along an agree-disagree continuum). Such exercises encourage participants to concentrate on one another (rather than on the group facilitator) and force them to explain their different perspectives. The final layout of the cards is less important than the discussion that it generates. 25 Researchers may also use such exercises as a way of checking out their own assessment of what has emerged from the group. In this case it is best to take along a series of blank cards and fill them out only towards the end of the session, using statements generated during the course of the discussion. Finally, it may be beneficial to present research participants with a brief questionnaire, or the opportunity to speak to the researcher privately, giving each one the opportunity to record private comments after the group session has been completed.

Ideally the group discussions should be tape recorded and transcribed. If this is not possible then it is vital to take careful notes and researchers may find it useful to involve the group in recording key issues on a flip chart.

ANALYSIS AND WRITING UP

Analysing focus groups is basically the same as analysing any other qualitative self report data. 21 26 At the very least, the researcher draws together and compares discussions of similar themes and examines how these relate to the variables within the sample population. In general, it is not appropriate to give percentages in reports of focus group data, and it is important to try to distinguish between individual opinions expressed in spite of the group from the actual group consensus. As in all qualitative analysis, deviant case analysis is important—that is, attention must be given to minority opinions and examples that do not fit with the researcher's overall theory.

The only distinct feature of working with focus group data is the need to indicate the impact of the group dynamic and analyse the sessions in ways that take full advantage of the interaction between research participants. In coding the script of a group discussion, it is worth using special categories for certain types of narrative, such as jokes and anecdotes, and types of interaction, such as “questions,” “deferring to the opinion of others,” “censorship,” or “changes of mind.” A focus group research report that is true to its data should also usually include at least some illustrations of the talk between participants, rather than simply presenting isolated quotations taken out of context.

Tapping into interpersonal communication can highlight cultural values or group norms

This paper has presented the factors to consider when designing or evaluating a focus group study. In particular, it has drawn attention to the overt exploitation and exploration of interactions in focus group discussion. Interaction between participants can be used to achieve seven main aims:

To highlight the respondent's attitudes, priorities, language, and framework of understanding;

To encourage research participants to generate and explore their own questions and develop their own analysis of common experiences;

To encourage a variety of communication from participants—tapping into a wide range and form of understanding;

To help to identify group norms and cultural values;

To provide insight into the operation of group social processes in the articulation of knowledge (for example, through the examination of what information is censured or muted within the group);

To encourage open conversation about embarrassing subjects and to permit the expression of criticism;

Generally to facilitate the expression of ideas and experiences that might be left underdeveloped in an interview and to illuminate the research participant's perspectives through the debate within the group.

Group data are neither more nor less authentic than data collected by other methods, but focus groups can be the most appropriate method for researching particular types of question. Direct observation may be more appropriate for studies of social roles and formal organisations 27 but focus groups are particularly suited to the study of attitudes and experiences. Interviews may be more appropriate for tapping into individual biographies, 27 but focus groups are more suitable for examining how knowledge, and more importantly, ideas, develop and operate within a given cultural context. Questionnaires are more appropriate for obtaining quantitative information and explaining how many people hold a certain (pre-defined) opinion; focus groups are better for exploring exactly how those opinions are constructed. Thus while surveys repeatedly identify gaps between health knowledge and health behaviour, only qualitative methods, such as focus groups, can actually fill these gaps and explain why these occur.

Focus groups are not an easy option. The data they generate can be as cumbersome as they are complex. Yet the method is basically straightforward and need not be intimidating for either the researcher or the researched. Perhaps the very best way of working out whether or not focus groups might be appropriate in any particular study is to try them out in practice.

Qualitative study design: Focus groups

Qualitative study design
Phenomenology
Grounded theory
Ethnography
Narrative inquiry
Action research
Case Studies
Field research
Focus groups
Observation
Surveys & questionnaires
Study Designs Home

Focus Groups

Focus groups bring individuals from the study population together in a specific setting in order to discuss an issue as a group. The discussion generates research data.

Focus groups typically have these features:

Four to ten participants meeting for up to two hours
A facilitator or facilitators to guide discussion using open-ended questions
An emphasis on the group talking among itself rather than to the facilitator
Discussion is recorded and then transcribed for analysis by researchers

Researchers conduct several individual focus group meetings to produce a series. The number of focus groups in the series depends on the study’s aim, methods and resources.

Focus groups use a group setting to generate data different to that obtained in a one-to-one interview. The group context may allow for better examination of beliefs, attitudes, values, perspectives, knowledge and ideas.

Focus groups can be useful in action research methodology and other study designs which seek to empower research participants. Focus groups are also useful in multimethod studies utilising different forms of data collection.

Quick way to collect data from several people
Produces data unique to group setting (e.g. teasing, arguing and non-verbal behaviour) due to the interaction between participants. This is a unique feature of focus groups.
Unlike written questionnaires, focus groups don’t rely on participant literacy to generate data
Can encourage participation from marginalised groups
Can facilitate discussion of stigmatised or counter-cultural topics due to feeling of mutual support among focus group participants
Can generate more critical comments than individual interviews. This is valuable for research aimed at improving products or services.
Can be used to validate findings from quantitative research methods by providing a deeper understanding that statistics cannot.

Limitations

Individual perspectives that dissent from the focus group’s majority may remain hidden due to overriding behavioural or cultural norms, or a desire to be seen as conforming.
Confidentiality of individual responses is compromised due to the existence of the group
Only applicable when the population of interest has shared social and cultural experience or share common areas of concern.
Group discussion does not provide enough depth for researchers to understand experiences, especially in comparison to in-depth interviews.
Data is representative of the range of views in a population, not the prevalence of such views.
The facilitator has a strong effect on the focus groups behaviour and can therefore influence the extent to which issues or views are explored.
Data analysis is usually very time consuming due to the quantity produced.

Example questions

What are the experiences, needs and wishes of mothers who received midwifery care at tertiary hospitals in Victoria, Australia?
How useful is the patient perspective for the creation of an information information booklet for patients with liver cancer?
What factors influence nursing students' development of end-of-life communication skills?

Example studies

Harrison, M., Ryan, T., Gardiner, C., & Jones, A. (2017). Psychological and emotional needs, assessment, and support post-stroke: a multi-perspective qualitative study . Top Stroke Rehabil, 24 (2), 119-125. doi: 10.1080/10749357.2016.1196908

Shilubane, H. N., Ruiter, R. A., Bos, A. E., Reddy, P. S., & van den Borne, B. (2014). High school students' knowledge and experience with a peer who committed or attempted suicide: a focus group study . BMC Public Health, 14 , 1081. doi: 10.1186/1471-2458-14-1081

Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. (2012). The meaning of "aging in place" to older people . Gerontologist , 52(3), 357-366. doi: 10.1093/geront/gnr098

Kitzinger, J. (1995). Qualitative research: introducing focus groups . BMJ, 311 (7000), 299. doi: 10.1136/bmj.311.7000.299

Rice, P. L., & Ezzy, D. (1999). Qualitative research methods: a health focus . South Melbourne, Australia: Oxford University Press.

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Next: Observation >>
Last Updated: Apr 8, 2024 11:12 AM
URL: https://deakin.libguides.com/qualitative-study-designs

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3 Writing Focus Group Methods

Published: January 2014
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This chapter begins with a description of the challenges in writing the methods section of a focus group report. It then describes the purpose and content of the methods section, providing guidance on what to include in the methods section, why each component is important, and suggestions on how to write each part. It uses examples of extracts from published focus group research to demonstrate how particular aspects of the methods section can be written. It also outlines common pitfalls in writing the methods section and how to overcome these pitfalls.

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Research Design Review

A discussion of qualitative & quantitative research design, strengths of the focus group method: an overview.

The following is a modified excerpt from Applied Qualitative Research Design: A Total Quality Framework Approach (Roller & Lavrakas, 2015, pp. 111-112).

A dynamic group discussion will often stimulate spontaneous ideas and personal disclosures that might otherwise go unstated in an IDI.
A relaxed, interactive, as well as a supportive (e.g., homogeneous) group environment can be conducive to discussing sensitive topics (e.g., a discussion of the immigration process among recent Chinese immigrants to the United States).
As participants exchange opinions, they consider their own views in relation to others’—which may encourage participants to refine their thoughts. In this way the group interaction gives the researcher insight into how people think about the topic(s) being studied and on what basis opinions may change. For example, in a focus group with college students who are considering various study-abroad programs, some participants might change their criteria for selecting one program over another after hearing other participants’ considerations. This discussion would help the researcher identify the important aspects of study-abroad programs that may impact students’ decision making.

Participant interaction, or the social aspect of focus group discussions, can be a particularly important advantage when conducting research with vulnerable and underserved population segments . For instance, women’s studies researchers such as Wilkinson (1999) believe that focus groups offer feminist psychologists an important research approach over other psychological research methods because they (a) come “closer to everyday social processes” (p. 227) and are less “artificial” than other methods; (b) are highly interactive, which “produces insights that would not be available outside the group context” (p. 229); and (c) reduce the moderator’s “exploitation” of the research by shifting control of the discussion to the participants. Other researchers have found the social nature of focus group discussions to be conducive to investigating societal constraints and health needs among Emirati women (Bailey, 2012; Winslow, Honein, & Elzubeir, 2002).

There are two other important strengths of the group discussion method: (1) it allows for the presence of observers , especially in the face-to-face (in-person and sometimes video) mode; and (2) it increases the likelihood that a wide range of attitudes, knowledge, and experiences will be captured in one group session. Whereas most qualitative research methods can conceivably accommodate observers, observers tend to take on a particularly engaged and active role in group interviewing. Face-to-face focus groups are traditionally conducted at a facility equipped with a one-way mirror (and online video group platforms also offer a client backroom), behind which members of the research team can view and hear the discussions. (Note: Group participants are informed of the presence of observers prior to the discussion.) Viewers often include people affiliated with the research sponsor who have a vested interest in learning firsthand about the attitudes and behavior of members of the target population. In addition to gaining clarity on participants’ wants and needs, observers can be helpful in redirecting the discussion on the spot, if necessary, when participants make unanticipated comments that introduce a new way of thinking about the research topic. In these situations, it is important to be able to change course in the research or otherwise pursue new lines of questioning as unanticipated insights emerge from the discussions.

The range of opinions and behavior that can be represented in any one focus group is another important strength of the method because such a range is a factor in finding the “surprising insights” mentioned above. Even the most homogeneous group of participants will relate different experiences and thoughts, thereby giving the researcher an awareness and appreciation of the extent of divergent views on a particular issue. Unlike the IDI method that requires many separate interviews to uncover the spectrum of perspectives related to the subject matter, group discussions offer a time- and often cost-efficient method for revealing differing viewpoints.

Bailey, D. C. (2012). Women and Wasta: The use of focus groups for understanding social capital and Middle Eastern women. Retrieved from The Qualitative Report website: http://www.nova.edu/ssss/QR/QR17/bailey.pdf

Wilkinson, S. (1999). Focus groups: A feminist method. Psychology of Women Quarterly , 23 (2), 221–244.

Winslow, W. W., Honein, G., & Elzubeir, M. A. (2002). Seeking Emirati women’s voices: The use of focus groups with an Arab population. Qualitative Health Research , 12 (4), 566–575. https://doi.org/10.1177/104973202129119991

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Best Practices for Agile UX Research

In the past five years, the Ad Council’s digital team has conducted more than 250 studies for a wide range of campaigns with our partner Feedback Loop . These studies have complimented our other methods of research: focus groups, moderated UX research and communications checks, to name a few.

With Feedback Loop we’ve identified five best practices for agile UX research.

1. Get curious about your audience

All great research starts with curiosity. Ask yourself: What do I think I know about my audience? What am I unsure about? Getting curious early on helps you build empathy for your audience. It also helps you identify your biases and assumptions. To learn more about cognitive biases that impact design, check out David Dylan Thomas ’s book, Design for Cognitive Bias, and his podcast, The Cognitive Bias Podcast . You can also check out our interview with him .

2. Identify your assumptions

The challenge with assumptions is you might not know you’re making them. Developing awareness about assumptions you make is a skill anyone can cultivate. Pressure test what you think you know: Do I know this because of testing we did? Have we done a recent landscape review? Assumptions you identify can inform your learning objectives.

3. Define your learning objective

Your learning objective is what you want to learn from a study. Learning objectives should ladder up to higher level goals. Consider: What decisions do you need to make based on results? Which stakeholders need to be involved in test creation and results?

4. Determine the best time and way to test

The project life cycle of a digital product includes different phases. To figure out the best time to test and which method to use, ask yourself: What stimulus is needed to answer my questions? Do we need to know what people think and feel? Or what they do? Read “ When to Use Which User-Experience Research Methods ” by Christian Rohrer on Nielsen Norman Group’s website for a comprehensive landscape of user research methods to reference.

5. Create action standards before you test

This best practice is one we’re experimenting with, thanks to Feedback Loop’s advice. Action standards are commitments to action that you will take depending on the results of your test. This could look like the team agreeing that if 20% or more of respondents are confused by creative, you’ll create alternatives. The key to this one is determining what threshold you find acceptable for your learning objectives in advance and following through after the fact.

If you get curious, identify assumptions, and define your learning objectives early on, you can test earlier in the project life cycle and prevent problems that need to be fixed later (when it’s more costly and difficult to do so). I have joked before that the research cycle should be a pattern of testing, learning, acting and celebrating, because with each research-based decision, you’re creating value for your company and your audience. That’s always worth celebrating!

For more on this, check out the webinar we recently presented about our learnings, including case studies from our campaigns.

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Open Access

Peer-reviewed

Research Article

The development and structural validity testing of the Person-centred Practice Inventory–Care (PCPI-C)

Contributed equally to this work with: Brendan George McCormack, Paul F. Slater, Fiona Gilmour, Denise Edgar, Stefan Gschwenter, Sonyia McFadden, Ciara Hughes, Val Wilson, Tanya McCance

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery/Sydney Nursing School, The University of Sydney, Camperdown Campus, New South Wales, Australia

Roles Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliation Institute of Nursing and Health Research, Ulster University, Belfast, Northern Ireland

Roles Data curation, Investigation, Methodology, Writing – review & editing

Affiliation Division of Nursing, Queen Margaret University, Edinburgh, Scotland

Roles Data curation, Formal analysis, Writing – review & editing

Affiliation Nursing and Midwifery Directorate, Illawarra Shoalhaven Local Health District, New South Wales, Australia

Roles Data curation, Methodology, Validation, Writing – review & editing

Affiliation Division of Nursing Science with Focus on Person-Centred Care Research, Karl Landsteiner University of Health Sciences, Krems, Austria

Roles Data curation, Investigation, Validation, Writing – review & editing

Affiliation Prince of Wales Hospital, South East Sydney Local Health District, New South Wales, Australia

Roles Conceptualization, Formal analysis, Methodology, Validation, Writing – original draft, Writing – review & editing

Brendan George McCormack,
Paul F. Slater,
Fiona Gilmour,
Denise Edgar,
Stefan Gschwenter,
Sonyia McFadden,
Ciara Hughes,
Val Wilson,
Tanya McCance

Published: May 10, 2024
https://doi.org/10.1371/journal.pone.0303158
Reader Comments

Person-centred healthcare focuses on placing the beliefs and values of service users at the centre of decision-making and creating the context for practitioners to do this effectively. Measuring the outcomes arising from person-centred practices is complex and challenging and often adopts multiple perspectives and approaches. Few measurement frameworks are grounded in an explicit person-centred theoretical framework.

In the study reported in this paper, the aim was to develop a valid and reliable instrument to measure the experience of person-centred care by service users (patients)–The Person-centred Practice Inventory-Care (PCPI-C).

Based on the ‘person-centred processes’ construct of an established Person-centred Practice Framework (PCPF), a service user instrument was developed to complement existing instruments informed by the same theoretical framework–the PCPF. An exploratory sequential mixed methods design was used to construct and test the instrument, working with international partners and service users in Scotland, Northern Ireland, Australia and Austria. A three-phase approach was adopted to the development and testing of the PCPI-C: Phase 1 –Item Selection : following an iterative process a list of 20 items were agreed upon by the research team for use in phase 2 of the project; Phase 2 –Instrument Development and Refinement : Development of the PCPI-C was undertaken through two stages. Stage 1 involved three sequential rounds of data collection using focus groups in Scotland, Australia and Northern Ireland; Stage 2 involved distributing the instrument to members of a global community of practice for person-centred practice for review and feedback, as well as refinement and translation through one: one interviews in Austria. Phase 3 : Testing Structural Validity of the PCPI-C : A sample of 452 participants participated in this phase of the study. Service users participating in existing cancer research in the UK, Malta, Poland and Portugal, as well as care homes research in Austria completed the draft PCPI-C. Data were collected over a 14month period (January 2021-March 2022). Descriptive and measures of dispersion statistics were generated for all items to help inform subsequent analysis. Confirmatory factor analysis was conducted using maximum likelihood robust extraction testing of the 5-factor model of the PCPI-C.

The testing of the PCPI-C resulted in a final 18 item instrument. The results demonstrate that the PCPI-C is a psychometrically sound instrument, supporting a five-factor model that examines the service user’s perspective of what constitutes person-centred care.

Conclusion and implications

This new instrument is generic in nature and so can be used to evaluate how person-centredness is perceived by service users in different healthcare contexts and at different levels of an organisation. Thus, it brings a service user perspective to an organisation-wide evaluation framework.

Citation: McCormack BG, Slater PF, Gilmour F, Edgar D, Gschwenter S, McFadden S, et al. (2024) The development and structural validity testing of the Person-centred Practice Inventory–Care (PCPI-C). PLoS ONE 19(5): e0303158. https://doi.org/10.1371/journal.pone.0303158

Editor: Nabeel Al-Yateem, University of Sharjah, UNITED ARAB EMIRATES

Received: January 26, 2023; Accepted: April 20, 2024; Published: May 10, 2024

Copyright: © 2024 McCormack et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because of ethical reason. Data are available from the Ulster University Institutional Data Access / Ethics Committee (contact via email on [email protected] ) for researchers who meet the criteria for access to confidential data

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Person-centred healthcare focuses on placing the beliefs and values of service users at the centre of decision-making and creating the context for practitioners to do this effectively. Person-centred healthcare goes beyond other models of shared decision-making as it requires practitioners to work with service users (patients) as actively engaged partners in care [ 1 ]. It is widely agreed that person-centred practice has a positive influence on the care experiences of all people associated with healthcare, service users and staff alike. International evidence shows that person-centred practice has the capacity to have a positive effect on the health and social care experiences of service users and staff [ 1 – 4 ]. Person-centred practice is a complex health care process and exists in the presence of respectful relationships, attitudes and behaviours [ 5 ]. Fundamentally, person-centred healthcare can be seen as a move away from neo-liberal models towards the humanising of healthcare delivery, with a focus on the development of individualised approaches to care and interventions, rather than seeing people as ‘products’ that need to be moved through the system in an efficient and cost-effective way [ 6 ].

Person-centred healthcare is underpinned by philosophical and theoretical constructs that frame all aspects of healthcare delivery, from the macro-perspective of policy and organisational practices to the micro-perspective of person-to-person interaction and experience of healthcare (whether as professional or service user) and so is promoted as a core attribute of the healthcare workforce [ 1 , 7 ]. However, Dewing and McCormack [ 8 ] highlighted the problems of the diverse application of concepts, theories and models all under the label of person-centredness, leading to a perception of person-centred healthcare being poorly defined, non-specific and overly generalised. Whilst person-centredness has become a well-used term globally, it is often used interchangeably with other terms such as ’woman-centredness’ [ 9 ], ’child-centredness’ [ 10 ], ’family-centredness’ [ 11 ], ’client-centredness’ [ 12 ] and ’patient-centredness’ [ 13 ]. In their review of person-centred care, Harding et al [ 14 ] identified three fundamental ‘stances’ that encompass person-centred care— Person-centred care as an overarching grouping of concepts : includes care based on shared-decision making, care planning, integrated care, patient information and self-management support; Person-centred care emphasising personhood : people being immersed in their own context and a person as a discrete human being; Person-centred care as partnership : care imbued with mutuality, trust, collaboration for care, and a therapeutic relationship.

Harding et al. adopt the narrow focus of ’care’ in their review, and others contend that for person-centred care to be operationalised there is a need to understand it from an inclusive whole-systems perspective [ 15 ] and as a philosophy to be applied to all persons. This inclusive approach has enabled the principles of person-centredness to be integrated at different levels of healthcare organisations and thus enable its embeddedness in health systems [ 16 – 19 ]. This inclusive approach is significant as person-centred care is impossible to sustain if person-centred cultures do not exist in healthcare organisations [ 20 , 21 ].

McCance and McCormack [ 5 ] developed the Person-centred Practice Framework (PCPF) to highlight the factors that affect the delivery of person-centred practices. McCormack and McCance published the original person-centred nursing framework in 2006. The Framework has evolved over two decades of research and development activity into a transdisciplinary framework and has made a significant contribution to the landscape of person-centredness globally. Not only does it enable the articulation of the dynamic nature of person-centredness, recognising complexity at different levels in healthcare systems, but it offers a common language and a shared understanding of person-centred practice. The Person-centred Practice Framework is underpinned by the following definition of person-centredness:

[A]n approach to practice established through the formation and fostering of healthful relationships between all care providers , service users and others significant to them in their lives . It is underpinned by values of respect for persons , individual right to self-determination , mutual respect and understanding . It is enabled by cultures of empowerment that foster continuous approaches to practice development [ 16 ].

The Person-centred Practice Framework ( Fig 1 ) comprises five domains: the macro context reflects the factors that are strategic and political in nature that influence the development of person-centred cultures; prerequisites focus on the attributes of staff; the practice environment focuses on the context in which healthcare is experienced; the person-centred processes focus on ways of engaging that are necessary to create connections between persons; and the outcome , which is the result of effective person-centred practice. The relationships between the five domains of the Person-centred Practice Framework are represented pictorially, that being, to reach the centre of the framework, strategic and policy frames of reference need to be attended to, then the attributes of staff must be considered as a prerequisite to managing the practice environment and to engaging effectively through the person-centred processes. This ordering ultimately leads to the achievement of the outcome–the central component of the framework. It is also important to recognise that there are relationships and there is overlap between the constructs within each domain.

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https://doi.org/10.1371/journal.pone.0303158.g001

In 2015, Slater et al. [ 22 ] developed an instrument for staff to use to measure person centred practice- the Person-centred Practice Inventory- Staff (PCPI-S). The PCPI-S is a 59-item, self-report measure of health professionals’ perceptions of their person-centred practice. The items in the PCPI-S relate to seventeen constructs across three domains of the PCPF (prerequisites, practice environment and person-centred processes). The PCPI-S has been widely used, translated into multiple languages and has undergone extensive psychometric testing [ 23 – 28 ].

No instrument exists to measure service users’ perspectives of person-centred care that is based on an established person-centred theoretical framework or that is designed to compare with service providers perceptions of it. In an attempt to address this gap in the evidence base, this study set out to develop such a valid and reliable instrument. The PCPI-C focuses on the person-centred processes domain, with the intention of measuring service users’ experiences of person-centred care. The person-centred processes are the components of care that directly affect service users’ experiences. The person-centred processes enable person-centred care outcomes to be achieved and include working with the person’s beliefs and values, sharing decision-making, engaging authentically, being sympathetically present and working holistically. Based on the ‘person-centred processes’ construct of the PCPF and relevant items from the PCPI-S, a version for service users was developed.

This paper describes the processes used to develop and test the instrument–The Person-centred Practice Inventory-Care (PCPI-C). The PCPI-C has the potential to enable healthcare services to understand service users’ experience of care and how they align with those of healthcare providers.

Materials and methods

The aim of this research was to develop and test the face validity of a service users’ version of the person-centred practice inventory–The Person-centred Practice Inventory-Care.

The development and testing of the instrument was guided by the instrument development principles of Boateng et al [ 29 ] ( Fig 2 ) and reported in line with the COSMIN guidelines for instrument testing [ 30 , 31 ]. An exploratory sequential mixed methods design was used to construct and test the instrument [ 29 , 30 ] working with international partners and service users. A three-phase approach was adopted to the development and testing of the PCPI-C. As phases 1 and 2 intentionally informed phase 3 (the testing phase), these two phases are included here in our description of methods.

https://doi.org/10.1371/journal.pone.0303158.g002

Ethical approval

Ethics approval was sought and gained for each phase of the study and across each of the participating sites. For phase 2 of the study, a generic research protocol was developed and adapted for use by the Scottish, Australian and Northern Irish teams to apply for local ethical approval. In Scotland, ethics approval was gained from Queen Margaret University Edinburgh Divisional Research Ethics Committee; in Australia, ethics approval was gained from The University of Wollongong and in Northern Ireland ethics approval was gained from the Research Governance Filter Committee, Nursing and Health Research, Ulster University. For phase 3 of the study, secondary analysis of an existing data set was undertaken. For the original study from which this data was derived (see phase 3 for details), ethical approval was granted by the UK Office of Research Ethics Committee Northern Ireland (ORECNI Ref: FCNUR-21-019) and Ulster University Research Ethics Committee. Additional local approvals were obtained for each partner site as required. In addition, a data sharing agreement was generated to facilitate sharing of study data between European Union (EU) sites and the United Kingdom (UK).

Phase 1 –Item selection

An initial item pool for the PCPI-C was identified by <author initials to be added after peer-review> by selecting items from the ‘person-centred processes’ sub-scale of the PCPI-S ( Table 1 ). Sixteen items were extracted, and the wording of the statements was adjusted to reflect a service-user perspective. Additional items were identified (n = 4) to fully represent the construct from a service-user perspective. A final list of 20 items was agreed upon and this 20-item questionnaire was used in Phase 2 of the instrument development.

https://doi.org/10.1371/journal.pone.0303158.t001

Phase 2 –Instrument development and refinement

Testing the validity of PCPI-C was undertaken through three sequential rounds of data collection using focus groups in Scotland, Australia and Northern Ireland. The purpose of these focus groups was to work with service users to share and compare understandings and views of their experiences of healthcare and to consider these experiences in the context of the initial set of PCPI-C items generated in phase 1 of the study. These countries were selected as the lead researchers had established relationships with healthcare partners who were willing to host the research. The inclusion of multiple countries provided different perspectives from service users who used different health services. In Scotland, a convenience sample of service users (n = 11) attending a palliative care day centre of a local hospice was selected. In Australia a cancer support group for people living with a cancer diagnosis (n = 9) was selected and in Northern Ireland, people with lived experience who were attending a community group hosted by a Cancer Charity (n = 9) were selected. All service users were current users of healthcare and so the challenge of memory recall was avoided. The type of conditions/health problems of participants was not the primary concern. Instead, we targeted persons who had recent experiences of the health system. The three centres selected were known to the researchers in those geographical areas and relationships were already established, which helped with gaining access to potential participants. Whilst the research team had potential access to other centres in each country, it was evident at focus group 3 that no significant new issues were being identified from the participants and thus we agreed to not do further rounds of refinement.

A Focus Group guide was developed ( Fig 3 ). Participants were invited to draw on their experiences as a user of the service; particularly remembering what they saw, the way they felt and what they imagined was happening [ 32 ]. The participants were invited to independently complete the PCPI-C and the purpose of the exercise was reiterated i.e. to think about how each question of the PCPI-C reflected their own experiences and their answers to the questions. Following completion of the questionnaire, participants were asked to comment on each question in the PCPI-C (20 questions), with a specific focus on their understanding of the question, what they thought about when they read the question, and any suggestions to improve readability. The focus group was concluded with a discussion on the overall usability of the PCPI-C. Each focus group was audiotaped and the audio recordings were transcribed in full. The facilitators of the focus group then listened to the audio recordings, alongside the transcripts, and identified the common issues that arose from the discussions and noted against each of the questions in the draft PCPI-C. Revisions were made to the questions in accordance with the comments and recommendations of the participants. At the end of the analysis phase of each focus group, a table of comments and recommendations mapped to the questions in the instrument was compiled and sent to the whole research team for review and consideration. The comments and recommendations were reviewed by the research team and amendments made to the draft PCPI-C. The amended draft was then used in the next focus group until a final version was agreed. Focus group 1 was held in Scotland, focus group 2 in Australia and focus group 3 in Northern Ireland. Table 2 presents a summary of the feedback from the final focus group.

https://doi.org/10.1371/journal.pone.0303158.g003

https://doi.org/10.1371/journal.pone.0303158.t002

A final stage of development involved distributing the agreed version of the PCPI-C to members of ‘The International Community of Practice for Person-centred Practice’ (PcP-ICoP) for review and feedback. The PcP-ICoP is an international community of higher education, health and care organisations and individuals who are committed to advancing knowledge in the field of person-centredness. No significant changes to the distributed version were suggested by the PcP-ICoP members, but several members requested permission to translate the instrument into their national language. PcP-ICoP members at the University of Vienna, who were leading on a large research project with nursing homes in the region of Lower Austria, agreed to undertake a parallel translation project as a priority, so they could use the PCPI-C in their research project. The instrument was culturally and linguistically adapted to the nursing home setting in an iterative process by the Austrian research team in collaboration with the international research team. Data were collected through face-to-face interviews by trained research staff. Residents of five nursing homes for older persons in Lower Austria were included. All residents who did not have a cognitive impairment or were physically unable to complete the questionnaire (because of ill-health) (n = 235) were included. 71% of these residents (N = 167) managed to complete the questionnaire. Whilst in Austria, formal ethical approval for non-intervention studies is not required, the team sought informed consent from participants. Particular attention was paid throughout the interviews to assure ongoing consent of residents by carefully guided conversations.

Phase 3: Testing structural validity of the PCPI-C

The aim of this phase was to test the structural validity of the PCPI-C using confirmatory factor analysis with an international sample of service users. The PCPI-C comprises 20 items measured on a 5-point scale ranging from ‘strongly disagree’ to ‘strongly agree. The 20 items represent the 5 constructs comprising the final model to be tested, which is outlined in Table 3 .

https://doi.org/10.1371/journal.pone.0303158.t003

A sample of 452 participants was selected for this phase of the study. The sample selected comprised two groups. Group 1 (n = 285) were service users with cancer (breast, urological and other) receiving radiotherapy in four Cancer Treatment Centres in four European Countries–UK, Malta, Poland and Portugal. These service users were participants in a wider SAFE EUROPE ( www.safeeurope.eu ) project exploring the education and professional migration of therapeutic radiographers in the European Union. In the UK a study information poster with a link to the PCPI-C via Qualtrics © survey was disseminated via UK cancer charity social media websites. Service user information and consent were embedded in the online survey and presented to the participant following the study link. At the non-UK sites, hard copy English versions of the surveys were available in clinical departments where a convenience sampling approach was used, inviting everyone in their final few days of radiotherapy to participate. The ‘DeepL Translator’ software (DeepL GmbH, Cologne, Germany) was used to make the necessary terminology adaptions for both the questionnaire and the participant information sheet across the various countries. Fluent speakers based in the participating sites and who were members of the SAFE EUROPE project team confirmed the accuracy of this process by checking the accuracy of the translated version against the original English version. Participants were provided with study information and had at least 24 hours to decide if they wished to participate. Willing participants were then invited to provide written informed consent by the local study researcher. The study researcher provided the hard copy survey to the service user but did not engage with or assist them during completion. Service users were informed they could take the survey home for completion if they wished. Completed surveys were returned to a drop box in the department or returned by post (data collected May 2021-March 2022). Group 2 were residents in nursing homes in Lower Austria (n = 125). No participating residents had a cognitive impairment and were physically able to complete the questionnaire. Data were collected through face-to-face interviews by trained research staff (data collected January 2021-March 2021).

Statistical analysis

Descriptive and measures of dispersion statistics were generated for all items to help inform subsequent analysis. Measures of appropriateness to conduct factor analysis were conducted using The Kaiser-Meyer-Olkin Measures of Sampling Adequacy and Bartletts Test of Sphericity. Inter-item correlations were generated to examine for collinearity prior to full analysis. Confirmatory factor analysis was conducted using maximum likelihood robust extraction testing of the 5-factor model.

Acceptable fit statistics were set at Root Mean Square Estimations of Approximation (RMSEA) of 0.05 or below; 90% RMSEA higher bracket below 0.08; and Confirmation Fit Indices (CFI) of 0.95 or higher and SRMR below 0.05 [ 33 – 35 ]. Internal consistency was measured using Cronbach alpha scores for factors in the accepted factor model.

The model was re-specified using the modification indices provided in the statistical output until acceptable and a statistically significant relationship was identified. All re-specifications of the model were guided by principles of (1) meaningfulness (a clear theoretical rationale); (2) transitivity (if A is correlated to B, and B correlated to C, then A should correlate with C); and (3) generality (if there is a reason for correlating the errors between one pair of errors, then all pairs for which that reason applies should also be correlated) [ 36 ].

Acceptance modification criteria of:

The items to first order factors were initially fitted.
Correlated error variance permitted as all items were measuring the same unidimensional construct.
Only statistically significant relationship retained to help produce as parsimonious a model as possible.
Factor loadings above 0.40 to provide a strong emergent factor structure.

Factor loading scores were based on Comrey and Lee’s [ 37 ] guidelines (>.71 = excellent, >.63 = very good, >.55 = good, >.45 = fair and >.32 = poor) and acceptable factor loading given the sample size (n = 452) were set at >0.3 [ 33 , 38 ].

Results and discussion

Demographic details.

The sample of 452 participants represented an international sample of respondents drawn from across five countries: UK (14.6% n = 66), Portugal (47.8%. n = 216), Austria (27.7%, n = 125), Malta (6.6, n = 30) and Poland (3.3%, n = 15). Table 4 outline the demographic characteristics of the sample. The final sample of 452 participants provides an acceptable ratio 33 of 22:1 respondent to items.

https://doi.org/10.1371/journal.pone.0303158.t004

The means scores indicate that respondents scored the items neutrally. The measures of skewness and kurtosis were acceptable and satisfied the conditions of normality of distribution for further psychometric testing. Examination of the Kaiser Meyer Olkin (0.947) and the Bartlett test for sphericity (4431.68, df = 190, p = 0.00) indicated acceptability of performing factor analysis on the items. Cronbach alpha scores for each of the constructs confirm the acceptability and unidimensionality of each construct.

Examination of the correlation matrix between items shows a range of between 0.144 and 0.740, indicating a broadness in the areas of care the questionnaire items address, as well as no issues of collinearity. The original measurement model was examined using maximum likelihood extraction and the original model had mixed fit statistics. All factor loadings (except for items 11 and 13) were above the threshold of 0.4 ( Table 3 ). Six further modifications were introduced into the original model based on highest scored modification indices until the fit statistics were deemed acceptable ( Table 5 for model fit statistics and Fig 4 for items correlated errors). Two item correlated error modifications were within factors and 4 between factors. The accepted model factor structure is displayed in Fig 4 .

https://doi.org/10.1371/journal.pone.0303158.g004

https://doi.org/10.1371/journal.pone.0303158.t005

Measuring person-centred care is a complex and challenging endeavour [ 39 ]. In a review of existing measures of person-centred care, DeSilva [ 39 ] identified that whilst there are many tools available to measure person-centred care, there was no agreement about which tools were most worthwhile. The complexity of measurement is further reinforced by the multiplicity of terms used that imply a person-centred approach being adopted without explicitly setting out the meaning of the term. Further, person-centred care is multifaceted and comprises a multitude of methods that are held together by a common philosophy of care and organisational goals that focus on service users having the best possible (personalised) experience of care. As DeSilva suggested, “it is a priority to understand what ‘person-centred’ means . Until we know what we want to achieve , it is difficult to know the most appropriate way to measure it . (p 3)” . However, it remains the case that many of the methods adopted are poorly specified and not embedded in clear conceptual or theoretical frameworks [ 40 , 41 ]. A clear advantage of the study reported here is that the PCPI-C is embedded in a theoretical framework of person-centredness (the PCPF) that clearly defines what we mean by person-centred practice. The PCPI-C is explicitly informed by the ‘person-centred processes’ domain of the PCPF, which has an explicit focus on the care processes used by healthcare workers in providing healthcare to service-users.

In the development of the PCPI-C, initial items were selected from the Person-centred Practice Inventory-Staff (PCPI-S) and these items are directly connected with the person-centred processes domain of the PCPF. The PCPI-S has been translated, validated and adopted internationally [ 23 – 28 ] and so provides a robust theoretically informed starting point for the development of the PCPI-C. This starting point contributed to the initial acceptability of the instrument to participants in the focus groups. Like DeSilva, [ 39 ] McCormack et al [ 42 ] and McCormack [ 41 ] have argued that measuring person-centred care as an isolated activity from the evaluation of the impact of contextual factors on the care experienced, is a limited exercise. As McCormack [ 41 ] suggests “ Evaluating person-centred care as a specific intervention or group of interventions , without understanding the impact of these cultural and contextual factors , does little to inform the quality of a service . ” (p1) Using the PCPI-C alongside other instruments such as the PCPI-S helps to generate contrasting perspectives from healthcare providers and healthcare service users, informed by clear definitions of terms that can be integrated in quality improvement and practice development programmes. The development of the PCPI-C was conducted in line with good practice guidelines in instrument development [ 29 ] and underpinned by an internationally recognised person-centred practice theoretical framework, the PCPF [ 5 ]. The PCPI-C provides a psychometrically robust tool to measure service users’ perspectives of person-centred care as an integrated and multi-faceted approach to evaluating person-centredness more generally in healthcare organisations.

With the advancement of Patient Reported Outcome Measures (PROMS) [ 43 , 44 ], Patient Reported Experience Measures (PREMS) [ 45 ] and the World Health Organization (WHO) [ 15 ] emphasis on the development of people-centred and integrated health systems, greater emphasis has been placed on developing measures to determine the person-centredness of care experienced by service users. Several instruments have been developed to measure the effectiveness of person-centred care in specific services, such as mental health [ 45 ], primary care [ 46 , 47 ], aged care [ 48 , 49 ] and community care [ 50 ]. However only one other instrument adopts a generic approach to evaluating services users’ experiences of person-centred care [ 51 ]. The work of Fridberg et al (The Generic Person-centred Care Questionnaire (GPCCQ)) is located in the Gothenburg Centre for Person-centred Care (GPCC) concept of person-centredness—patient narrative, partnership and documentation. Whilst there are clear connections between the GPCCQ and the PCPI-C, a strength of the PCPI-C is that it is set in a broader system of evaluation that views person-centredness as a whole system issue, with all parts of the system needing to be consistent in concepts used, definitions of terms and approaches to evaluation. Whilst the PCPI-S evaluates how person-centredness is perceived at different levels of the organisation, using the same theoretical framework and the same definition of terms, the PCPI-C brings a service user perspective to an organisation-wide evaluation framework.

A clear strength of this study lies in the methods engaged in phase 2. Capturing service user experiences of healthcare has become an important part of the evaluation of effectiveness. Service user experience evaluation methodologies adopt a variety of methods that aim to capture key transferrable themes across patient populations, supported by granular detail of individual specific experience [ 43 ]. This kind of service evaluation depends on systematically capturing a variety of experiences across different service-user groups. In the research reported here, service users from a variety of services including palliative care and cancer services from three countries, engaged in the focus group discussions and were freely able to discuss their experiences of care and consider them in the context of the questionnaire items. The use of focus groups in three different countries enabled different cultural perspectives to be considered in the way participants engaged with discussions and considered the relevance of items and their wording. The sequential approach enabled three rounds of refinement of the items and this enabled the most relevant wording to be achieved. The range of comments and depth of feedback prevented ‘knee-jerk’ changes being made based on one-off comments, but instead, it was possible to compare and contrast the comments and feedback and achieve a more considered outcome. The cultural relevance of the instrument was reinforced through the translation of the instrument to the German language in Austria, as few changes were made to the original wording in the translation process. This approach combined the capturing of individual lived experience with the systematic generation of key themes that can assist with the systematic evaluation of healthcare services. Further, adopting this approach provides a degree of confidence to users of the PCPI-C that it represents real service-user experiences.

The factorial validity of the instrument was supported by the findings of the study. The modified models fit indices suggest a good model fit for the sample [ 31 , 34 , 35 ]. The Confirmation Fit Indices (CFI) fall short of the threshold of >0.95. However, this is above 0.93 which is considered an acceptable level of fit [ 52 ]. Examination of the alpha scores confirm the reliability (internal consistency) of each construct [ 53 ]. All factor loadings were at a statistically significant level and above the acceptable criteria of 0.3 recommended for the sample size [ 38 ]. All but 2 of the loadings (v11 –‘ Staff don’t assume they know what is best for me’ and v13 – ‘My family are included in decisions about my care only when I want them to be’ ) were above the loadings considered as good to excellent [ 37 ]. At the level of construct, previous research by McCance et al [ 54 ] showed that all five constructs of the person-centred processes domain of the Person-centred Practice Framework carried equal significance in shaping how person-centred practice is delivered, and this is borne out by the approval of a 5-factor model in this study. However, it is also probable that there is a degree of overlap between items across the constructs, reflected in the 2 items with lower loadings. Other items in the PCPI-C address perspectives on shared decision-making and family engagement and thus it was concluded that based on the theoretical model and statistical analysis, these 2 items could be removed without compromising the comprehensiveness of the scale, resulting in a final 18-item version of the PCPI-C (available on request).

Whilst a systematic approach to the development of the PCPI-C was adopted, and we engaged with service users in several care settings in different countries, further research is required in the psychometric testing of the instrument across differing conditions, settings and with culturally diverse samples. Whilst the sample does provide an acceptable respondent to item ratio, and the sample contains international respondents, the model structure is not examined across international settings. Likewise, further research is required across service users with differing conditions and clinical settings. Whilst this is a limitation of this study reported here, the psychometric testing of an instrument is a continuous process and further testing of the PCPI-C is welcomed.

Conclusions

This paper has presented the systematic approach adopted to develop and test a theoretically informed instrument for measuring service users’ perspectives of person-centred care. The instrument is one of the first that is generic and theory-informed, enabling it to be applied as part of a comprehensive and integrated framework of evaluation at different levels of healthcare organisations. Whilst the instrument has good statistical properties, ongoing testing is recommended.

Acknowledgments

The authors of this paper acknowledge the significant contributions of all the service users who participated in this study.

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This paper is in the following e-collection/theme issue:

Published on 10.5.2024 in Vol 11 (2024)

Facilitators of and Barriers to the Use of a Digital Self-Management Service for Diagnostic Testing: Focus Group Study With Potential Users

Authors of this article:

Original Paper

Kyma Schnoor 1, 2 , MSc ;
Esther P W A Talboom-Kamp 1, 2, 3 , MBA, MD, PhD ;
Muamer Hajtić 4 , MSc ;
Niels H Chavannes 1, 2 , MD, PhD ;
Anke Versluis 1, 2 , PhD

1 Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands

2 National eHealth Living Lab, Leiden University Medical Center, Leiden, Netherlands

3 Zuyderland, Sittard-Geleen, Netherlands

4 Department of Medical informatics, University of Amsterdam, Amsterdam, Netherlands

Corresponding Author:

Kyma Schnoor, MSc

Department of Public Health and Primary Care

Leiden University Medical Center

Hippocratespad 21

Netherlands

Phone: 31 71526 8433

Email: [email protected]

Background: Health care lags in digital transformation, despite the potential of technology to improve the well-being of individuals. The COVID-19 pandemic has accelerated the uptake of technology in health care and increased individuals’ willingness to perform self-management using technology. A web-based service, Directlab Online, provides consumers with direct digital access to diagnostic test packages, which can digitally support the self-management of health.

Objective: This study aims to identify the facilitators, barriers, and needs of Directlab Online, a self-management service for web-based access to diagnostic testing.

Methods: A qualitative method was used from a potential user’s perspective. The needs and future needs for, facilitators of, and barriers to the use of Directlab Online were evaluated. Semistructured focus group meetings were conducted in 2022. Two focus groups were focused on sexually transmitted infection test packages and 2 were focused on prevention test packages. Data analysis was performed according to the principles of the Framework Method. The Consolidated Framework for Implementation Research was used to categorize the facilitators and barriers.

Results: In total, 19 participants, with a mean age of 34.32 (SD 14.70) years, participated in the focus groups. Important barriers were a lack of privacy information, too much and difficult information, and a commercial appearance. Important facilitators were the right amount of information, the right kind of tests, and the involvement of a health care professional. The need for a service such as Directlab Online was to ensure its availability for users’ health and to maintain their health.

Conclusions: According to the participants, facilitators and barriers were comprehension of the information, the goal of the website, and the overall appearance of the service. Although the service was developed in cocreation with health care professionals and users, the needs did not align. The users preferred understandable and adequate, but not excessive, information. In addition, they preferred other types of tests to be available on the service. For future research, it would be beneficial to focus on cocreation between the involved medical professionals and users to develop, improve, and implement a service such as Directlab Online.

Introduction

Society is changing, and the world is becoming increasingly digital [ 1 ]. Health care lags in digital transformation, despite the potential of technology to improve the well-being of individuals [ 1 , 2 ]. The COVID-19 pandemic accelerated the development and use of technology in health care, also referred to as eHealth, with more digital consultations and increased use of home monitoring [ 3 , 4 ]. Furthermore, the COVID-19 pandemic, among others, has increased the need and willingness of individuals to perform self-management [ 5 - 7 ]. In patients with chronic diseases, self-management strategies are often used to support patients in dealing with treatment and lifestyle changes [ 8 ]. In addition, self-management strategies can be used to support individuals with home diagnostic tests [ 9 ]. The concept of self-management aligns with this positive health definition: “health as the ability to adapt and self-manage in the face of social, physical, and emotional challenges” [ 10 , 11 ].

eHealth can be used in 3 stages of laboratory diagnostic testing. The first stage is triage and advice on diagnostic testing, the second stage is the testing itself (ie, at home or a facility), and the third stage is the communication of the test results to the user. A systematic review by Versluis et al [ 9 ] showed that web-based diagnostic testing services were positively evaluated and preferred over clinic-based testing. However, most of the evaluated services only offered tests to detect sexually transmitted infections (STIs) [ 9 ].

eHealth services can support self-management, for example, with web-based services that support behavior and lifestyle changes (eg, Liva Healthcare) [ 12 ] and with websites where individuals can obtain health information (eg, Thuisarts.nl) [ 13 ]. In addition, there are multiple apps to support patients with chronic conditions such as hypertension, diabetes, or lower back pain [ 14 - 16 ].

In the Netherlands, a web-based service called Directlab Online (Saltro, part of Unilabs) offers individuals direct access to laboratory diagnostic tests independent of a health care provider [ 17 ]. It is a so-called direct-to-consumer platform. Directlab Online gives individuals direct digital access to diagnostic testing based on a triage that aligns with medical guidelines. Unlike the services identified in the systematic review by Versluis et al [ 9 ], Directlab Online offers a variety of diagnostic tests, for example, diagnostic tests for STIs, COVID-19, and vitamin deficiencies, as well as testing for health-related questions concerning fatigue and the prevention of heart disease. The results and the information on the website can give individuals insight into their health, which could support and motivate them to adopt healthier behaviors [ 12 ]. In addition, it supports users to be better informed about their health without the interference of a health care professional, which can lead to more efficient and accessible care [ 18 ]. Packages to test the health of individuals align with the patient-centered care approach, which can lead to a better quality of care [ 19 ]. Patient-centered care aims to empower patients to take charge of their health and actively participate in their health care [ 20 ]. Another term used is person-centered care, which is similar but does not solely focus on disease-related aspects, aligning better with the positive health definition [ 21 ].

To completely harness the potential and significance of Directlab Online, prioritizing high-quality and user-friendly service is paramount. Delving into the barriers and facilitators individuals encounter when using the service could provide invaluable insights, facilitating the enhancement of its user-friendliness and effectiveness. For example, known factors in dermatology that could influence the uptake of a digital service are, among others, financial aspects and accessibility for a digital service [ 22 ]. In a study by Vergouw et al [ 23 ], facilitators of and barriers to digital services for older adults in primary care were researched. Nonfamiliarities with web-based environments appeared to be a barrier, and efficiency was seen as an important facilitator for using a digital service in primary care [ 23 ]. In the review of STI testing by Versluis et al [ 9 ], concerns regarding complicated language and data handling insecurities were also discovered for ordering an STI test on the web. To our knowledge, no research has been conducted on facilitators, barriers, and needs of a direct-to-consumer platform that offers direct access to multiple diagnostic tests and web-based results. Identifying the needs, facilitators, and barriers will help determine what is necessary to optimize the use and improve the implementation of those services. This can give insight into the potential future directions for developing such services.

This study aims to identify the facilitators of and barriers to using a service such as Directlab Online and to identify the needs regarding direct digital access to diagnostic testing. To achieve this, focus groups were conducted. Half of the focus groups focused on STI test packages and the other half on prevention test packages. STI tests and prevention test packages are the most ordered test packages on Directlab Online. The focus is on potential users, that is, those who have not used Directlab Online before, because we are interested in capturing people’s first impression of the service.

The Service: Directlab Online

Directlab Online is a Dutch, web-based service available for everyone, through which diagnostic tests can be ordered on the web [ 17 ]. The service was developed by a multidisciplinary innovation team of a diagnostic company (Saltro, part of Unilabs) and was launched in 2016 [ 24 , 25 ]. The process of using the service is presented in Figure 1 . First, individuals undergo a web-based triage, based on medical guidelines, to determine whether the diagnostic tests are relevant and, if applicable, which tests are relevant. Second, individuals can order and buy associated tests. Depending on the diagnostic tests ordered, a self-sampling kit is sent to the individual’s home address, or an appointment is scheduled at a blood collection center or a laboratory for collecting a blood sample. Once the laboratory receives the collected specimen, high-quality analyses are conducted. The results of the tests are communicated through a web-based, secure patient portal. Furthermore, deviating results are communicated to the patient’s general practitioner but only if the patient has authorized it. The triage was based on medical guidelines, and the diagnostic test packages were developed in cocreation with general practitioners and tested by them and laboratory specialists referred to as health care professionals. Diagnostic test packages consist of different parameters for diagnostic testing. For example, a test package for cholesterol measures the following parameters: low-density lipoproteins, high-density lipoproteins, triglycerides, and total cholesterol. Multimedia Appendix 1 provides a complete overview of the test packages that could be ordered on Directlab Online during the focus group meetings. Table 1 provides an overview of the prevention and STI test packages that were part of the discussions with the focus groups.

a Blood sample needed for diagnostics; HbA 1c : hemoglobin A 1c .

b Urine sample needed for diagnostics.

c These tests are not available any more on Directlab Online after the service update.

d Blood sample needed for diagnostics collected by self-sampling.

e Oral, anal, vaginal, or urine sample needed for diagnostic tests.

Study Design and Participants

Focus group meetings were conducted with potential users of the service. As the Directlab Online service offers a wide variety of test packages, we focused on 2 specific categories (ie, prevention test and STI test packages). These test packages were ordered most frequently. Half of the focus groups focused on STI test packages, and the other half focused on the prevention test packages. The general inclusion criteria for the focus groups were speaking Dutch and not having used Directlab Online earlier. In addition, there were specific inclusion criteria to ensure that the sociodemographic characteristics of the participants in the focus groups were consistent with the characteristics of the target population of the test packages. Notably, a specific inclusion criterion for the focus group about STI testing was that the participants were aged between 18 and 30 years. The specific inclusion criterion for the focus groups about prevention test packages was that the participants were aged between 18 and 65 years. It is important to note that there were no specific health or disease requirements to participate. Focus group meetings were held until data saturation was reached.

Ethical Considerations

The study was declared to not fall within the scope of the Dutch Medical Research Involving Human Subjects Act by the Leiden University Medical Center Medical Ethics Committee (N21.101).

Procedure and Data Collection

The recruitment period started on October 25, 2021, and lasted until February 20, 2022. Participants were recruited via different web-based channels (eg, LinkedIn [LinkedIn Corporation] and Facebook [Meta platforms, Inc]). Individuals were invited to contact KS via email when interested. Then, KS sent them more information. In addition, questions were asked regarding their birth year and if they could understand Dutch. A few date options for web-based meetings were sent if the individual met the inclusion criteria. When individuals could participate, they received an email with the date and time, a link to the Zoom (Zoom Video Communications) platform where the meeting would be conducted (on the web), and a link to a web-based informed consent form, which they were asked to sign before participation. All participants had the right to withdraw at any moment. The focus group meetings occurred between January 10 and March 2, 2022, in the presence of MH and KS [ 26 ]. KS led the focus groups, and MH managed the time and assisted with technical issues. The focus group meetings were in a semistructured format, following a predefined topic list with open-ended questions to leave space for discussion ( Multimedia Appendix 2 ). First, general questions were asked regarding using eHealth to see how familiar participants were with eHealth. Second, participants were provided 10 minutes to view the website of Directlab Online and navigate through the website on a computer or mobile phone; no further instructions were given. When time was up, questions were asked regarding the website in general (eg, the first impression, whether they needed help when using the website, and whether they found the website attractive). While navigating the website, they had the option to write down notes or vocalize their impressions, expressing their observations, preferences, and feelings about the website [ 27 ]. Third, participants were instructed to go through Directlab Online, do some triages, and look at their test advice. Notably, we allowed participants to navigate through the process as normal users would. Hence, they were required to peruse informational materials, undergo a triage process involving medical inquiries concerning their symptoms, and obtain guidance regarding testing. Subsequently, questions were asked regarding the triage service, facilitators of and barriers to using Directlab Online, and the participants’ needs for such a service. At the end of the focus groups, they received a digital gift card of €25 (US $27).

Data Analysis

All focus group meetings were audio recorded for subsequent analyses and were transcribed (intelligent) verbatim. When the transcripts were completed, the audio records were deleted. Two reviewers, MH and KS, conducted the qualitative data analysis according to the principles of the Framework Method [ 28 ]. The Framework Method is a systematic and flexible approach commonly used for the thematic analysis of health research semistructured interview data [ 29 ]. The method combines deductive and inductive techniques, which align with the aim of the study to identify specific issues regarding the use of Directlab Online and leave space to identify needs and opportunities that have not been formulated a priori. First, open coding was performed independently by the 2 reviewers, KS and MH. The interview data were coded using the software Atlas.ti 22 (Atlas.ti 22 Scientific Software Development). Second, the codes were compared between the 2 reviewers. Third, the codes were grouped into categories, resulting in the analytical framework. Fourth, for identifying the facilitators and barriers, the Consolidated Framework for Implementation Research (CFIR) was used [ 30 ]. The framework is widely used for the content analysis of qualitative data regarding the factors influencing implementation success [ 30 ]. Furthermore, the framework is comprehensive and makes it convenient to systematically study a wide array of facilitators and barriers [ 31 ]. In addition, using this framework made it possible to compare the findings and transfer them to other implementation studies [ 32 ]. The CFIR is a theory-driven model and comprises five domains: (1) the innovation domain, (2) the outer setting domain, (3) the inner setting domain, (4) the individuals’ domain, and (5) the implementation process [ 30 , 33 ]. Identified facilitators and barriers were placed within the CFIR domains. Final themes were achieved via discussion and consensus between researchers KS and MH.

Participant Characteristics

Data saturation was reached after forming 4 focus groups with 19 participants. The characteristics of the participants are shown in Table 2 . The participants were aged 20 to 61 (mean 34.32, SD 14.70) years. The number of male (9/19, 47%) and female (10/19, 53%) participants was almost equal. The focus group meetings lasted around 90 minutes per group.

Age differed over the 2 different focus groups, as aligned with the target population of the diagnostic test packages. Overall, the experiences and choices of the focus groups regarding the website were the same. Therefore, in most cases, the focus group results were discussed together. When the results differed between the 2 groups, this was specified. Different themes around usability, facilitators, barriers, and needs emerged from the data and are elaborated in subsequent sections.

a Groups 1 and 3 focused on sexually transmitted infection packages, and groups 2 and 4 focused on prevention packages.

Facilitators of and Barriers to the Uptake of Innovation

The identified barriers and facilitators were categorized specifically into the following 3 CFIR domains: innovation domain, outer setting domain, and individuals domain. The other 2 domains of the CFIR (ie, inner setting and implementation process) did not align with the facilitators and barriers mentioned by the participants and were therefore not discussed. Table 3 provides insight into the most essential and changeable facilitators and barriers identified. Therefore, it is not an exhaustive list of all potential barriers and facilitators that influenced the service uptake. It is notable that certain factors can be considered as a facilitator and barrier. For example, financial costs are frequently mentioned as a factor affecting the willingness to use digital health services [ 33 ]. When there are high user costs, it is a barrier; however, low costs can be considered a facilitator. The identified facilitators and barriers are explained in detail and explained per domain in subsequent sections.

Facilitators and Barriers in the Innovation Domain

Innovation source.

Participants mentioned different factors that were related to the innovation source of the innovation domain. These factors mainly influenced the credibility and trustworthiness in a positive (ie, facilitator) or negative (ie, barrier) way. First, the website’s commercial appearance were the most frequently mentioned barriers that influenced its reliability. For example, participants mentioned that the option to buy a gift card for a diagnostic test package did not align with a website designed for health. In addition, regarding the high prices for diagnostic test packages and the website’s general appearance, they said the following:

The website said: buy this. But I want to know why this test? [Participant 4]

I found it a very commercial website; this lowers my enthusiasm. [Participant 8]

Participants did not notice that health care professionals were involved in the service and partly developed the service, while this could increase the credibility of the website.

Second, the availability of reviews was frequently mentioned as a facilitator for reliability and credibility but as a barrier in some cases. Good reviews could be considered as a facilitator, and bad reviews could be considered as a barrier to experiencing the website as reliable and trustworthy. The following was said about this view:

Yes, [...] I found it important if I go to a new website to sell or buy something to see that others used the site and what they bought. [Participant 13]

Third, 37% (7/19) of the participants mentioned the facilitator’s “privacy.” For the participants, it was important to know where the data were stored and for how long. However, this information was difficult to find on the website:

And then it is the question of how long data is stored and how that is important to know. [Participant 8]

I want to know, what happens to the data and how long is it stored? [Participant 16]

Participant 7 pointed out that a clear and transparent privacy statement could be a unique selling point of the service.

Finally, the most mentioned barrier in the innovation source was the presence of stock pictures on Directlab Online:

[...] those stock pictures on the website; they gave an image of unreliability. [Participant 3]

Participants mentioned that pictures of real people or famous people who used the tests could be a facilitator and positively influence the reliability and use of the service. Furthermore, they mentioned that a short video with education and instructions about diagnostic test packages could improve the triage’s clarity and the diagnostic packages’ content.

Innovation Relative Advantage

Participants mentioned several factors regarding why they would use this innovative service. These factors were mostly related to the accessibility of the service compared to other services or normal practice. For example, the easiness of ordering a test on the web without going to the general practitioner was a relative advantage of the service, as mentioned by a participant:

Yes, I would rather order online because going to the general practitioner [...] it takes time. [Participant 7]

Furthermore, another participant mentioned the benefit of ordering a test on the web without going to the general practitioner:

Hmm yes, I thought of a few things when I first saw the website... of the vitamin tests, STI tests, and COVID tests, I thought yes, you do not want to go to the general practitioner for that. Especially for STI testing, the threshold is high. In this way, you still test and see if you are healthy. [Participant 1]

However, the relative advantage was negatively influenced by the high costs of the tests. One participant stated:

The costs will stop people from buying anything. [Participant 17]

Innovation Complexity

Several facilitators and barriers that influenced the complexity of the service were mentioned by the participants.

First, the number of test packages and parameters available was confusing. It became clear from the focus groups that offering the “right” number of diagnostic tests was important; participants were not enthusiastic about a test package with many separate parameters. Participants mentioned that they were optimistic about the possibility of ordering STI testing, COVID-19 testing, and some prevention tests. However, they mentioned that after the triage, they received advice to select many different test packages. Recommending many diagnostic test packages to the participants was a barrier because they were confused about which test package was important for them. Furthermore, the high amount of information provided about these test packages was experienced as challenging by approximately half (11/19, 58%) of the participants:

When I open the website, a lot of information is present. Too many tests are available. Of course, this website wants to sell tests, but... I do not know. I found the home page too complicated, too unclear. [Participant 13]

Second, the language used on the website was a factor that influenced the use of the service. The language on the home page was experienced as straightforward and was therefore a facilitator. However, when completing the triage and choosing the diagnostic package, the information was more challenging to understand. Notably, medical and incomprehensible terms were used:

I think you have a very broad target group of people who would like to use this, and I think it is written for the somewhat well-educated, reasonably well-informed citizen, shall we say [...] Offer more comfort to people by using less difficult vocabulary. [Participant 8]

Third, the participants mentioned elements of the website that influenced user-friendliness. Participants were happy with the filters in the search bar to find a particular test, as well as the search function and the website’s colors:

Personally, I found the website easy to use, and what I experienced as very positive were the filters [...]. [Participant 14]

However, approximately one-third (6/19, 32%) of the participants found the website unclear—among others, due to too much text—and complicated (eg, where to find what they were looking for), and they found the home page too busy.

Facilitators and Barriers in the Outer Setting Domain

Partnerships and connections.

The service was linked to academic institutions, which increased its reliability. Mentioning partners would increase the uptake according to the participants:

Yes, mentioning partners would be nice. And famous names always attract attention. [Participant 13]

Societal Pressure

Participants mentioned that reviews and blogs could help in increasing the use of the service and its reliability:

You want to read reviews and experiences of others. [Participant 5]

Facilitators and Barriers in the Individuals Domain

The individual’s skills and knowledge regarding services such as Directlab Online influenced their willingness to use the service and their perception of potentially using it. The younger participants (aged 20 to 30 years) mentioned that they had experience with this type of website, which reassured them to use this service. However, some older participants (aged ≥39 years) had less experience with digital services in general and mentioned some anxiety and tension when they needed to order a test. Some (4/19, 21%) preferred to go to the general practitioner for diagnostic tests. However, participants of all age groups mentioned the benefit of ordering STI tests on the web without visiting the general practitioner.

Future Needs

Different needs were identified regarding services such as Directlab Online. First, the service’s purpose must be more explicit for the participants. For them, it was unclear whether the service could help them self-manage their health:

And this is what I miss on the website; what is in it for me and my health as a patient or consumer? [Participant 19]

Second, there was a need to understand the advantages of ordering diagnostic tests on the web (eg, more accessible than going to the general practitioner for tests). Participants wanted this information to be more evident on the website. Third, after receiving their results, the participants explained that they preferred to have more information regarding how they could remain healthy or what they could do to become healthier. It could help, according to the participants, to let them know more specifically that general practitioners make the diagnostic test packages designed for the service. All participants saw the benefit of ordering STI diagnostic test packages on the web and undergoing them at home. The current offer of diagnostic test packages does not meet the wishes of all participants. There was a need for additional tests, such as tests for food allergies, testosterone levels, fertility, or urinary infections. A participant mentioned as follows:

I want a urine tract infection test; those are relatively cheap, I think [...]. [Participant 1]

Principal Findings

This qualitative study aimed to evaluate the facilitators of and barriers to web-based direct access to diagnostic test services from the perspective of potential users. In addition, the study tried to identify the need to use such services. The study showed that a tailored amount of information could benefit the service. Participants need to use a service such as Directlab Online to ensure that the website is available for their health. The participants needed to see the benefit of a diagnostic test package. Identified barriers and facilitators were categorized using the CFIR. The study showed that a lack of privacy, information overload, and a commercial appearance were important barriers. Facilitators included providing the right amount of information on the service and involving a health care professional in developing the service. In addition, the study showed that a tailored amount of information could benefit the use of the service. In short, we noticed that several facilitators and barriers were influencing the reliability or accessibility of the service. For example, the commercial appearance and lack of privacy information contributed to a less reliable service for the potential users, and ordering a test on the web without a health care professional influenced the accessibility.

Directlab Online is a service for users to support themselves in self-managing their health. An important quality-enhancing element for Directlab Online was that health care professionals were actively involved in developing this service. Health care professionals significantly influenced the content and information shown on the website. However, the focus groups with potential users identified needs and wishes that did not completely align with the ideas of the general practitioner. To illustrate, health care professionals preferred other types of diagnostic test packages on the web than those that the participants preferred to use. Furthermore, the general practitioners preferred detailed information on the website, whereas this information overload was not always beneficial for the participants. A study by Talboom-Kamp et al [ 34 ] regarding a web-based results portal discussed the complex balance between the general practitioner’s necessities and participants’ needs for the right amount of understandable information. Presenting information requires a balance between an overload of medical information and the information users need to understand test packages and results. A potential way to solve overwhelming participants with information is to not present all the information directly in one view to the participant but by offering clickable links or short videos [ 34 ].

This study used the CFIR to identify and categorize the facilitators and barriers. In another study, Versluis et al [ 33 ] performed an inventory to determine the obstacles that must be overcome and how to optimize eHealth in primary care using this framework. They found similar results to our study; costs and privacy issues were identified as important barriers. In addition, in line with other studies, the following facilitators were identified as having “experience with eHealth” and “easiness of use” [ 33 , 35 ]. In comparison with other studies using the CFIR to classify facilitators and barriers, similar factors were predominantly identified. A notable factor highlighted in the study by Verweij et al [ 36 ] involving patients with cancer using a digital self-monitoring system was the necessity to elucidate the service’s added value, alongside concerns regarding privacy issues. However, other factors were also mentioned, such as the connection with health care professionals, which were not identified in our study. The target population (patients with cancer) could be an important explanation for this difference. The comparison with other literature revealed that, irrespective of the type of digital service or the user population, the facilitators and barriers remained quite consistent. This study’s inventory could help determine what obstacles need to be overcome and how we might optimize an application such as Directlab Online.

Depending on the participants, mainly influenced by age, some would use a web-based website to organize their health. In contrast, other participants, mainly older participants, were more at ease with visiting the general practitioner and organizing their health directly via the general practitioner [ 37 ]. In this study, the older participants preferred to visit the general practitioner, which could lead to the cautious conclusion that web-based direct access to diagnostic services is not attractive to everyone [ 37 ]. In addition, this study showed that using a service such as Directlab Online is not only related to age but also related to the user’s health problem and that the type of test package was important. Participants’ needs were to feel the relevance of ordering a diagnostic test package on the web instead of visiting the general practitioner. The relevance was clear for the STI test packages but unclear for other diagnostic test packages. The study results showed that it remains important to involve all end users in the service to ensure that the service supports the needs of the target population [ 38 ]. Directlab Online was developed with general practitioners, and the elements that they found important were integrated into the service. While this study provided insight into the facilitators and barriers of potential users, it appeared that these things were not the same. It is important for a reliable and proper service that both perspectives of all stakeholders should be included in (further) development of such services. Finally, the facilitators and barriers to using a service such as Directlab Online found in this study could be used to optimize this service and other comparable services.

Strengths and Limitations

There is a lot of direct access to diagnostic testing services available, mainly when it entails STI diagnostic test packages. However, not many of them have a scientific basis or are developed by medical professionals. This is the first study that examined the facilitators of and barriers to a service that provides more diagnostic test packages than only STI tests and which is developed in cocreation with health care professionals. Another strength of the study was that the CFIR was used to analyze the facilitators and barriers mentioned in the focus groups. Embedding the facilitators and barriers in this framework made the comparison with other research easier. In addition, the domains identified by the CFIR can help to find the right implementation strategy [ 33 , 39 ].

This study focused on potential users because we were interested in their first impression of the service. The rationale was that, in the real world, such a service could be visited by many new users [ 40 ]. Previous experiences have not biased the impression of potential users. However, this could also be a limitation because participants who did use Directlab Online before could have another opinion regarding the service. This made the results less generalizable. Another limitation is that the mean age of participants was relatively low, making it more difficult to generalize the results to the general Dutch population. However, all participants, independent of age, mentioned the benefit of ordering STI tests on the web. The service showed benefits for participants who were ashamed to visit a general practitioner for a diagnostic package and for participants who wished to order tests in an accessible, nonbinding manner.

Future Research

Directlab Online is a service developed for a wide range of users. However, this study showed that it is important to include end users to ensure that the service aligns with the population’s needs. Cocreation with end users and medical professionals could be a solution to solve disbalances in wishes and needs between them and to improve an eHealth application [ 38 ]. For future research, organizing cocreation sessions and analyzing their results could be beneficial to improve the service. Finally, in future research, information about the influence of the diagnostic test’s result on the user’s lifestyle could be analyzed. Namely, this could result in a preventive role for a service such as Directlab Online to improve the health of a population.

Conclusions

According to participants, information provision, comprehension, and the overall appearance of the website were the most important elements that influenced the use and uptake of a direct-to-consumer website for diagnostic test packages. Barriers, such as the commercial appearance and lack of privacy information, negatively influenced reliability and accessibility. The study showed that it is important to include relevant stakeholders in creating an eHealth intervention because there was a disbalance between the users’ needs and what the involved general practitioners considered necessary. Future research could take a quantitative approach to further identify the needs regarding test packages and to identify the demographics of users and the influence of test results on the behavior of users. Directlab Online offers opportunities for more web-based self-management of health.

Acknowledgments

The authors would like to thank all participants for their input and contributions during the focus groups. Funding for this research was provided by Unilabs.

Conflicts of Interest

During the research, KS and EPWATK were employees at Unilabs.

Diagnostic test packages overview of Directlab Online.

Semistructured interview protocol.

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Abbreviations

Edited by A Kushniruk; submitted 30.01.23; peer-reviewed by S Choemprayong, Y Chu, CE Moe; comments to author 19.12.23; revised version received 02.01.24; accepted 20.03.24; published 10.05.24.

©Kyma Schnoor, Esther P W A Talboom-Kamp, Muamer Hajtić, Niels H Chavannes, Anke Versluis. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 10.05.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Human Factors, is properly cited. The complete bibliographic information, a link to the original publication on https://humanfactors.jmir.org, as well as this copyright and license information must be included.

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What Is a Focus Group? | Step-by-Step Guide & Examples

What Is a Focus Group? | Step-by-Step Guide & Examples

Published on 4 May 2022 by Tegan George . Revised on 6 February 2023.

What is a focus group, step 1: choose your topic of interest, step 2: define your research scope and hypotheses, step 3: determine your focus group questions, step 4: select a moderator or co-moderator, step 5: recruit your participants, step 6: set up your focus group, step 7: host your focus group, step 8: analyse your data and report your results, advantages and disadvantages of focus groups, frequently asked questions about focus groups.

Focus groups are a type of qualitative research . Observations of the group’s dynamic, their answers to focus group questions, and even their body language can guide future research on consumer decisions, products and services, or controversial topics.

Focus groups are often used in marketing, library science, social science, and user research disciplines. They can provide more nuanced and natural feedback than individual interviews and are easier to organise than experiments or large-scale surveys .

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Focus groups are primarily considered a confirmatory research technique . In other words, their discussion-heavy setting is most useful for confirming or refuting preexisting beliefs. For this reason, they are great for conducting explanatory research , where you explore why something occurs when limited information is available.

A focus group may be a good choice for you if:

You’re interested in real-time, unfiltered responses on a given topic or in the dynamics of a discussion between participants
Your questions are rooted in feelings or perceptions , and cannot easily be answered with ‘yes’ or ‘no’
You’re confident that a relatively small number of responses will answer your question
You’re seeking directional information that will help you uncover new questions or future research ideas
Structured interviews : The questions are predetermined in both topic and order.
Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.
Unstructured interviews : None of the questions are predetermined.

Differences between types of interviews

Make sure to choose the type of interview that suits your research best. This table shows the most important differences between the four types.

Topics favorable to focus groups

As a rule of thumb, research topics related to thoughts, beliefs, and feelings work well in focus groups. If you are seeking direction, explanation, or in-depth dialogue, a focus group could be a good fit.

However, if your questions are dichotomous or if you need to reach a large audience quickly, a survey may be a better option. If your question hinges upon behaviour but you are worried about influencing responses, consider an observational study .

If you want to determine whether the student body would regularly consume vegan food, a survey would be a great way to gauge student preferences.

However, food is much more than just consumption and nourishment and can have emotional, cultural, and other implications on individuals.

If you’re interested in something less concrete, such as students’ perceptions of vegan food or the interplay between their choices at the dining hall and their feelings of homesickness or loneliness, perhaps a focus group would be best.

Once you have determined that a focus group is the right choice for your topic, you can start thinking about what you expect the group discussion to yield.

Perhaps literature already exists on your subject or a sufficiently similar topic that you can use as a starting point. If the topic isn’t well studied, use your instincts to determine what you think is most worthy of study.

Setting your scope will help you formulate intriguing hypotheses , set clear questions, and recruit the right participants.

Are you interested in a particular sector of the population, such as vegans or non-vegans?
Are you interested in including vegetarians in your analysis?
Perhaps not all students eat at the dining hall. Will your study exclude those who don’t?
Are you only interested in students who have strong opinions on the subject?

A benefit of focus groups is that your hypotheses can be open-ended. You can be open to a wide variety of opinions, which can lead to unexpected conclusions.

The questions that you ask your focus group are crucially important to your analysis. Take your time formulating them, paying special attention to phrasing. Be careful to avoid leading questions , which can affect your responses.

Overall, your focus group questions should be:

Open-ended and flexible
Impossible to answer with ‘yes’ or ‘no’ (questions that start with ‘why’ or ‘how’ are often best)
Unambiguous, getting straight to the point while still stimulating discussion
Unbiased and neutral

If you are discussing a controversial topic, be careful that your questions do not cause social desirability bias . Here, your respondents may lie about their true beliefs to mask any socially unacceptable or unpopular opinions. This and other demand characteristics can hurt your analysis and bias your results.

Engagement questions make your participants feel comfortable and at ease: ‘What is your favourite food at the dining hall?’
Exploration questions drill down to the focus of your analysis: ‘What pros and cons of offering vegan options do you see?’
Exit questions pick up on anything you may have previously missed in your discussion: ‘Is there anything you’d like to mention about vegan options in the dining hall that we haven’t discussed?’

It is important to have more than one moderator in the room. If you would like to take the lead asking questions, select a co-moderator who can coordinate the technology, take notes, and observe the behaviour of the participants.

If your hypotheses have behavioural aspects, consider asking someone else to be lead moderator so that you are free to take a more observational role.

Depending on your topic, there are a few types of moderator roles that you can choose from.

The most common is the dual-moderator , introduced above.
Another common option is the dueling-moderator style . Here, you and your co-moderator take opposing sides on an issue to allow participants to see different perspectives and respond accordingly.

Depending on your research topic, there are a few sampling methods you can choose from to help you recruit and select participants.

Voluntary response sampling , such as posting a flyer on campus and finding participants based on responses
Convenience sampling of those who are most readily accessible to you, such as fellow students at your university
Stratified sampling of a particular age, race, ethnicity, gender identity, or other characteristic of interest to you
Judgement sampling of a specific set of participants that you already know you want to include

Beware of sampling bias , which can occur when some members of the population are more likely to be included than others.

Number of participants

In most cases, one focus group will not be sufficient to answer your research question. It is likely that you will need to schedule three to four groups. A good rule of thumb is to stop when you’ve reached a saturation point (i.e., when you aren’t receiving new responses to your questions).

Most focus groups have 6–10 participants. It’s a good idea to over-recruit just in case someone doesn’t show up. As a rule of thumb, you shouldn’t have fewer than 6 or more than 12 participants, in order to get the most reliable results.

Lastly, it’s preferable for your participants not to know you or each other, as this can bias your results.

A focus group is not just a group of people coming together to discuss their opinions. While well-run focus groups have an enjoyable and relaxed atmosphere, they are backed up by rigorous methods to provide robust observations.

Confirm a time and date

Be sure to confirm a time and date with your participants well in advance. Focus groups usually meet for 45–90 minutes, but some can last longer. However, beware of the possibility of wandering attention spans. If you really think your session needs to last longer than 90 minutes, schedule a few breaks.

Confirm whether it will take place in person or online

You will also need to decide whether the group will meet in person or online. If you are hosting it in person, be sure to pick an appropriate location.

An uncomfortable or awkward location may affect the mood or level of participation of your group members.
Online sessions are convenient, as participants can join from home, but they can also lessen the connection between participants.

As a general rule, make sure you are in a noise-free environment that minimises distractions and interruptions to your participants.

Consent and ethical considerations

It’s important to take into account ethical considerations and informed consent when conducting your research. Informed consent means that participants possess all the information they need to decide whether they want to participate in the research before it starts. This includes information about benefits, risks, funding, and institutional approval.

Participants should also sign a release form that states that they are comfortable with being audio- or video-recorded. While verbal consent may be sufficient, it is best to ask participants to sign a form.

A disadvantage of focus groups is that they are too small to provide true anonymity to participants. Make sure that your participants know this prior to participating.

There are a few things you can do to commit to keeping information private. You can secure confidentiality by removing all identifying information from your report or offer to pseudonymise the data later. Data pseudonymisation entails replacing any identifying information about participants with pseudonymous or false identifiers.

Preparation prior to participation

If there is something you would like participants to read, study, or prepare beforehand, be sure to let them know well in advance. It’s also a good idea to call them the day before to ensure they will still be participating.

Consider conducting a tech check prior to the arrival of your participants, and note any environmental or external factors that could affect the mood of the group that day. Be sure that you are organised and ready, as a stressful atmosphere can be distracting and counterproductive.

Starting the focus group

Welcome individuals to the focus group by introducing the topic, yourself, and your co-moderator, and go over any ground rules or suggestions for a successful discussion. It’s important to make your participants feel at ease and forthcoming with their responses.

Consider starting out with an icebreaker, which will allow participants to relax and settle into the space a bit. Your icebreaker can be related to your study topic or not; it’s just an exercise to get participants talking.

Leading the discussion

Once you start asking your questions, try to keep response times equal between participants. Take note of the most and least talkative members of the group, as well as any participants with particularly strong or dominant personalities.

You can ask less talkative members questions directly to encourage them to participate or ask participants questions by name to even the playing field. Feel free to ask participants to elaborate on their answers or to give an example.

As a moderator, strive to remain neutral. Refrain from reacting to responses, and be aware of your body language (e.g., nodding, raising eyebrows). Active listening skills, such as parroting back answers or asking for clarification, are good methods to encourage participation and signal that you’re listening.

Many focus groups offer a monetary incentive for participants. Depending on your research budget, this is a nice way to show appreciation for their time and commitment. To keep everyone feeling fresh, consider offering snacks or drinks as well.

After concluding your focus group, you and your co-moderator should debrief, recording initial impressions of the discussion as well as any highlights, issues, or immediate conclusions you’ve drawn.

The next step is to transcribe and clean your data . Assign each participant a number or pseudonym for organisational purposes. Transcribe the recordings and conduct content analysis to look for themes or categories of responses. The categories you choose can then form the basis for reporting your results.

Just like other research methods, focus groups come with advantages and disadvantages.

They are fairly straightforward to organise and results have strong face validity .
They are usually inexpensive, even if you compensate participant.
A focus group is much less time-consuming than a survey or experiment , and you get immediate results.
Focus group results are often more comprehensible and intuitive than raw data.

Disadvantages

It can be difficult to assemble a truly representative sample. Focus groups are generally not considered externally valid due to their small sample sizes.
Due to the small sample size, you cannot ensure the anonymity of respondents, which may influence their desire to speak freely.
Depth of analysis can be a concern, as it can be challenging to get honest opinions on controversial topics.
There is a lot of room for error in the data analysis and high potential for observer dependency in drawing conclusions. You have to be careful not to cherry-pick responses to fit a prior conclusion.

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest. It is one of four types of interviews .

As a rule of thumb, questions related to thoughts, beliefs, and feelings work well in focus groups . Take your time formulating strong questions, paying special attention to phrasing. Be careful to avoid leading questions , which can bias your responses.

The four most common types of interviews are:

Focus group interviews : The questions are presented to a group instead of one individual.

Social desirability bias is the tendency for interview participants to give responses that will be viewed favourably by the interviewer or other participants. It occurs in all types of interviews and surveys , but is most common in semi-structured interviews , unstructured interviews , and focus groups .

Social desirability bias can be mitigated by ensuring participants feel at ease and comfortable sharing their views. Make sure to pay attention to your own body language and any physical or verbal cues, such as nodding or widening your eyes.

This type of bias in research can also occur in observations if the participants know they’re being observed. They might alter their behaviour accordingly.

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Intergenerational Ambivalence, Self-differentiation and Ethnic Identity: A Mixed-methods Study on Family Ethnic Socialization

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Published: 08 May 2024

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Hong Yao 1 ,
Yajie Hou 2 ,
Carolina Hausmann-Stabile 3 &
Angel Hor Yan Lai 4

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Ethnic identity, profoundly influenced by familial factors, embodies multifaceted layers; yet, the intricate process of family ethnic socialization warrants deeper exploration. This study focuses on exploring the complexities of ethnic identity formation, specifically within the context of Yi adolescents. Employing a mixed-methods approach, it delves into family ethnic socialization dynamics among Yi adolescents. The research engaged 606 surveyed participants and conducted interviews with 188 individuals in focused group settings in Liangshan Yi Autonomous Prefecture, Sichuan Province, China. Quantitative analysis revealed correlations between caregiver-adolescent relationships (CAR) and ethnic identity. Adolescents experiencing ambivalent, positive, or neutral CAR exhibited higher ethnic identity levels than those with negative CAR. Qualitative analysis highlighted two key themes. Firstly, families tended to acculturate love through traditional cultural expectations and socialization, demonstrated through unconscious integration of Yi culture and a focus on individual modernity within family values. Secondly, ethnic identity attainment was observed through self-differentiation, including reflexive awareness of Yi ethnicity, enrichment of Yi identity through peer interactions, and the connection of self-actualization with Yi prosperity. The findings emphasize the need for culturally sensitive support, particularly for social workers, to facilitate reflexive self-differentiation among ethnic minority adolescents during family ethnic socialization.

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In China’s diverse ethnic landscape, home to 56 distinct ethnic groups, the Yi community stands as a culturally rich and significant minority group. Known for their unique traits, including a distinct language, intricate customs, and traditional practices, the Yi represent a unique segment of China’s vast ethnic mosaic. These characteristics, deeply embedded in their daily lives and social structures, are critical in shaping the Yi’s socialization processes within their families, influencing everything from daily interactions to broader communal engagements (Tao et al. 2020 ). This rich cultural backdrop provides a fertile ground for examining ethnic identity and socialization, key elements in understanding how minority groups like the Yi navigate their cultural and individual identities within a broader societal context.

The exploration of ethnic identity within the Yi community is compelling due to their distinct cultural heritage. Ethnic identity development, involving a dynamic process from unexamined identity to active exploration and achievement as proposed by Phinney ( 1993 ), is particularly salient for the Yi. Their rich cultural practices, languages, and traditions significantly contribute to the development of a cohesive ethnic identity. Understanding this process is crucial, as it forms a core component of an individual’s self-concept and well-being, especially within minority groups (Ong et al. 2010 ). The ethnic identity formation in minority communities like the Yi is influenced by a multitude of factors, including cultural preservation, intergenerational transmission of values, and adaptation to broader societal contexts (Umaña-Taylor et al. 2014 ).

The exploration of ethnic identity within the Yi community revolves around the pivotal concept of family ethnic socialization, encapsulating the diverse ways families impart values, traditions, and customs associated with their ethnic-racial group (Umaña-Taylor, and Hill, 2020 ). Contemporary research in ethnic-racial socialization underscores the profound influence of parent-child relationships on the efficacy of these practices (Hu et al. 2015 ; Parke, and Buriel, 2006 ). Children, nurtured within warm and supportive relationships, are more likely to internalize cultural messages and values, fostering the development of a robust and positive ethnic identity (Hughes et al. 2006 ). This insight holds particular relevance for the Yi, where familial bonds and intergenerational relationships intricately intertwine with cultural traditions and practices. Consequently, examining the dynamics of parent-child interactions within Yi families becomes instrumental in comprehending ethnic socialization’s impact on the formation of ethnic identity among Yi youth.

The intricate interplay of parent-child relationships within Yi families finds its grounding in theories of parent-adolescent communication, relational trust, and intergenerational transmission of values. These frameworks provide invaluable perspectives for understanding how familial interactions, characterized by varying degrees of warmth, trust, and communication quality, shape the development of ethnic identity among Yi youth (King, 2015 ; McLoyd et al. 2000 ). In the context of the Yi community, where traditional values intersect with modern influences, created intricate and multilayered experiences, like other (multi)ethnic-racial families (Roy and Rollins, 2022 ). This study adopts a mixed-methods approach to comprehensively explore both the processes and outcomes of family ethnic socialization among the Yi. By combining qualitative and quantitative methods, the research endeavors to capture the multifaceted nature of parent-child dynamics and their profound influence on the development of ethnic identity among Yi youth.

This study used sequential mixed methods explanatory design consisting of a quantitative and a qualitative strand. Quantitative data ( n = 631 adolescents, grades 7–9) were obtained in Oct 2018, followed by qualitative focus group interviews conducted in May 2021. The research was conducted with the support of local community organizations serving Yi students in Liangshan. Ethical approval was obtained at institutions involved in the project (Reference no: HASC/17-18/0540). Informed consent was obtained from Yi adolescents and their legal guardians prior to the research.

Quantitative Participants

After data cleaning, the quantitative analysis included data from 606 students from grades 7 through 9, from five rural boarding schools in Liangshan Yi Autonomous Prefecture and Sichuan Province. These five schools are affiliated with the partner organization, which has been serving Yi students in rural educational settings since 2006. Approximately 72% of participants were women, and 93% were Yi. The ages of participants ranged from 9 to 19. Details are found in Table 1 .

Qualitative Participants

For the qualitative study, one classroom of students from these five schools was selected to participate, yielding a pool of 15 classrooms. However, because one of the selected classrooms was not available during the time of the study, only 14 classrooms were recruited. Among these students, 92.5% were Yi, 7% were Han, and 0.5% were from other ethnic groups. For the purposes of the study, only Yi students were selected to participate in the qualitative interviews. All of the selected students agreed to join the focus group interviews. The focus group process ceased when the data were saturated. Students who were not selected were invited to participate in cultural activities led by our research team members. As a result, a total of 188 Yi youths (aged 12 to 18), with a mean age of 14.77 (SD = 1.35) participated in 30 focus group interviews, with each group consisting of five to seven participants. The majority of the participants were females (females = 73.4%; males = 26.6%).

Quantitative Measures

To achieve the research goals, four measures were included in quantitative analysis. Demographic information also included age, gender (0 = male; 1 = female), ethnicity (0 = Yi; 1 = Others), and caregiver (1 = parent as caregiver; 0 = family relatives as caregivers, such as grandparents, aunts, uncles, etc).

Caregiver-Adolescent Relationship (CAR)

In this study, the Emotional Quality Subscale of The Self-Reported Relatedness Questionnaire (Lynch and Cicchetti, 1997 ) had been adapted to evaluate the concept of Caregiver-Adolescent Relatedness (CAR) among Yi adolescents. This subscale measured the intensity of specific positive and negative emotions experienced in the presence of primary caregivers. Participants rated their feelings on a 4-point scale with items such as “When I’m with [primary caregiver], I feel happy” to capture positive emotions, and “When I’m with [primary caregiver], I feel ignored” for negative emotions. Cronbach’s alpha values for negative subscale and positive subscale were 0.72 and 0.74 in this study.

Based on these responses, CAR was categorized into four distinct types using the medians of scores of positive emotions and negative emotions. Ambivalent CAR was identified by both high positive (positive emotions scores > 21) and high negative scores (negative emotions scores> 7), reflecting a complex, multifaceted relationship with caregivers. The amicable type was characterized by high positive (positive emotions scores > 21) and low negative scores (negative emotions scores ≤ 7), indicating predominantly positive relationships. The negative CAR type was defined by low positive (positive emotions scores ≤ 21) and high negative scores (negative emotions scores > 7), suggesting relationships dominated by negative feelings. Lastly, the neutral type, marked by low scores in both positive (positive emotions scores ≤ 21) and negative (negative emotions scores ≤ 7) dimensions, implied a relationship lacking strong emotional ties. This nuanced categorization provided a deeper understanding of the varied emotional dynamics in caregiver-adolescent relationships.

Ethnic Identity

Ethnic identity was measured with the revised 12-item Multigroup Ethnic Identity Measure–Revised, consisting of two subscales: Exploration and Commitment (Lai et al. 2019 ). There were five items measuring exploration (e.g., “I participate in cultural practices of my own group”) and seven items measuring commitment (e.g., “I have a lot of pride in my ethnic group”). Cronbach’s alpha value was 0.8 in this study. Participants responded on a scale ranging from 1 (strongly disagree) to 4 (strongly agree), with higher scores indicating stronger EI.

Peer Support

Peer support was measured by a 4-item Chinese version of the Classmate Support Scale (Torsheim et al. 2016 ). A total score was generated by summarizing responses to four items. Participants responded on a scale of 1 (strongly disagree) to 5 (strongly agree) to items such as “My classmates accept me.” Higher scores indicated a higher level of peer support perceived by individuals. The Cronbach’s alpha for the current study was 0.71.

Data Collection

In the parent study, a multistage sampling approach, with a convenience sampling strategy in stage one and random sampling strategy in stage two, was used to collect the quantitative data. In stage one, we selected five out of the eight schools recommended by local community organizations within their school serving network. The local organization selected these schools as they have a relatively representable population of Yi students and also they have a deeper working relationships with the school management there. The team then contacted the schools via the partnering organization to invite them to join the study. All selected schools agreed to participate in the research.

In stage two, we randomly selected one class of students (grade 7 to 9) from each secondary level of each participating school. All students from the selected class were invited to complete a survey that included demographic information, parental relatedness, ethnic identity, peer support, trauma experience, and more. Prior to the administration of the survey, consent from the students’ guardian were also obtained. During survey administration, the team first explained the purposes of the research and the potential benefits and risks of filling out the survey to the teacher in charge and students in the classroom. All participation was voluntary and students were informed that they could withdraw from filling out the survey any time. All selected students accepted the invitation to fill out the survey. Informed consent was then obtained from all participants before the study. After the survey was administered, a small incentive was given to each student for their participation.

Focus groups were conducted to collect qualitative data. A non-random purposive sampling strategy was used to select the participants based on the students’ attachment to their Yi ethnic group membership. Students who scored in the top 25% (i.e., 1st Quartile) and bottom 20% (i.e., 4th Quartile) in their self-reported ethnic identity scores relative to their classmate in each classroom were selected to join the focus group interviews. This selection strategy allows the team to obtain richer information with a variety of participants based on their connection to their ethnic community. After the participants selection process, the research team then contact the school to invite the selected students to join the interview. Again, the students were reminded of their rights to decline participation or to withdraw anytime without any consequences. All invited students joined the study.

The participating schools assigned the research team to a private indoor or outdoor area, depending on space availability, in which to conduct the interviews. All focus groups were audiotaped after obtaining informed consent from the participants. Each focus group lasted approximately 45 to 60 min. All focus group interviews were conducted by at least two members of the research team, with one person moderating the interview while the other observed. Notes were taken during the interviews to facilitate subsequent analyses, and the interviewers’ observations were triangulated for cross-validation.

The guidelines for the focus group interviews included questions regarding family ethnic socialization (i.e., “What does your family think of being Yi?” and “What did your parents/family teach you about Yi?”), attitudes about Yi ethnicity (i.e., “What do you like/dislike about Yi ethnicity?” and “How do you feel about being Yi?”), and school ethnic socialization (i.e., “What do you think of the Han majority?” and “What is the difference between Yi and Han?”). To ensure that all students in the focus group interviews had a chance to express themselves, the moderator encouraged each participant to share his or her opinions throughout the data collection. If participants indicated that they had nothing to share, the moderator proposed topics from the interview guidelines.

Data Analysis

Quantitative analysis adopted linear regressions to investigate the relationships between CAR and ethnic identity. In comparison to negative CAR, ambivalent CAR(H1), positive CAR(H2), and neutral(H3). CAR were positively associated with ethnic identity. Age, gender, ethnicity, caregiver (caregiver as parents or as relatives) and peer support were controlled as covariates. All qualitative data were analysed by the first and second authors independently. After data collection, two researchers first read the transcripts multiple times to become familiar with the data, then coded the transcripts independently and generated meaning initial codes line by line. Then, we highlighted codes and quotes that were relevant to our research questions, thereby generating an initial list of codes that were illustrated with specific segments of texts. Those codes were used to develop a preliminary analytic framework upon which subsequent transcriptions were then coded. With the text segments, we created data matrices in an Excel spreadsheet (Ose, 2016 ). Next, we categorized the codes into emergent themes. In the final stage, we refined, named, and analysed the themes. When discrepancies were found, we revisited the themes and deliberated with the research team until we reached a consensus.

Quantitative analysis investigated the associations between perceived caregiver relatedness and ethnic identity. Moreover, qualitative analysis further elaborated on the family process of ethnic socialization among young Yi.

Quantitative Analysis: The Impacts of CAR on EI

We used regression analysis to examine the relations between caregiver-adolescent relationship (CAR) and the outcome variables of (i) ethnic exploration (EE) (ii) ethnic commitment (EC) and (iii) ethnic identity (EI), controlling for age, ethnicity, having parent as caregiver, and level of peer support. With EE as outcome variable, we found that ambivalent, positive, and neutral CAR are significant positive contributors, F (1, 606) = 8.79, p < 0.01, ∆R2 = 0.105. Approximately 10% of the variance of EE was accounted for by ambivalent, positive, and neutral CAR while controlling covariates. Compared to negative CAR, students with the other three CAR were more likely to achieve ethnic identity. Second, with EC as outcome variable, ambivalent, positive, and neutral CAR were significantly and positive associated with ethnic commitment, F (1, 606) = 15.53, p < 0.01, ∆R2 = 0.17. Third, a significant relation between ambivalent, positive, and neutral CAR and the outcome variable of EI was found, with negative CAR as a reference, F (1, 606) = 15.56, p < 0.01, ∆R2 = 0.17. Peer support tended to have significant and positive correlations with EE, EC, and total EI. However, the interaction between peer support and CAR was insignificant (Table 2 ).

Qualitative Analysis: Family Process of Ethnic Socialization

Based on qualitative data analysis, two themes emerged, namely “acculturating love through traditional cultural expectations and socialization” and “ethnic identity achievement through self-differentiation”. Exemplar quotations were provided for each theme. Each quotation was identified with the participant ID.

Acculturating Love Through Traditional Cultural Expectations and Socialization

During the ethnic socialization process, family tended to socialize the youth with their ethnic values, beliefs, norms, and behaviors through their daily child-rearing practices, rather than through conscious teachings. However, parental or familial affection and love was conveyed through expecting the best for the adolescents’ future. Viewing education as a life-changing path, parents or caregivers were always aware of their roles in urging their children to take initiatives in study, which might have benefitted their adjustment into civilized social lives outside of their hometown. The tension between unaware family process of practicing Yi and reinforcement the importance of education shaped a complex and even conflicting family ethnic socialization, out of which a youth’s ambivalence towards parents or family might grow.

Unaware Family Process of Practising Yi

Based on data analysis, interviewees enacted a sense of ethnicity through unconscious normative family practices, such as celebrations of Yi festivals, caregivers’ accounts of Yi cultural stories, and daily behaviors. Family practices of transmitting Yi values and behaviors included exposing children to culturally relevant folktales, teaching music and dance, celebrating traditions and holidays, eating ethnic foods, wearing Yi accessories and clothes, and communicating with the family’s native language.

I learned rituals of Torch festivals Footnote 1 from my grandparents. We walked around our house, holding a torch and murmuring prayer words in Yi language, which is supposed to chase the ghosts away and keep us safe. (FS17)

My parents told me the history of Yi, as well as the ghost stories. (FS113)

Moreover, family ethnic socialization practices were embedded in the localized community, where the situational context of Yi might vary slightly.

The story of our ancestor was a story of a boy moving from place to place. Some versions of the story indicate that the boy was born out of a peach. Other versions tell that a couple had two peaches. The wife grew a peach into a boy, while the husband ate half of another peach, and the second half turned into a girl, eventually. We (family members) talk about ancestor stories whenever we have time. (GMAG)

Family ethnic socialization practices were also reflected in the rules and rituals of daily activities taught by parents and senior family members. They taught the young Yi to respect the elderly, internalize a sense of family obligations, supervise younger siblings, provide help when demanded by others, and handle illness through Yi rituals. These rules and rituals were intimately attached to the spirit of Yi, particularly highlighting the cohesive integration of self, Yi ethnicity, nature, and existential humanity.

If someone gets sick, we (family) practice bimbo to pray for his recovery. Otherwise, we (family) do it annually. (FS190)

Yi people are somewhat refined in our rough ways. We are taught to respect the elderly and care for children. We are not allowed to bully the weak. (EI7)

Family Values on Individual Modernity

Families of interviewees, like many of the Yi ethnic minority, might have feelings of inferiority and being un-modernized compared to the Han majority (Postiglione, 2017 ). Therefore, families were expected to have a modern and even “civilized” lifestyle for the future of their children who do not need to repeat their lifestyles of labor-intensive, low-income jobs and less education. Although these caregivers are traditionally and authentically committed to Yi, they still expected that their children might move away from their ethnic communities and adjusting to modern lives in developed areas of China, which is reflected their unconditional love and affection for their children. Furthermore, even when young Yi finally return, family members assume that the interviewees will be able to find stable and well-paid occupations (i.e., civil servants or teachers) in local communities after years of educational experiences in developed cities.

Many young Yi mentioned that they grew up as part of a family where academic achievement and educational productivity were highly valued and that parents often emphasized the importance of higher education and decent jobs. If financially possible, Yi families were likely to list their children’s academic achievements as a priority and hoped for a better life for their children through education. For the young Yi, parents and families served as a continuous and stable resource for their autonomous motivation in education.

My grandma is my favorite. She told me to study hard. When she was a child, her family could not afford education. Although my mom and aunt were excellent in terms of academic performance, they had to work early for a living. Now, I have the chance for education, and my grandmother constantly to encourages me to seize the opportunity to change my life. (FS165)

Education can change my life. Though it is not the only pathway, I was told by my parents that it was the best pathway. (CC16)

Both intrinsic and extrinsic motivations were found among the young Yi in the focus group. Many students mentioned their improved self-satisfaction and self-efficacy through academic growth, while others indicated extrinsic motivations derived from parental appraisals, teachers’ encouragements, and peer support. In particular, the young Yi repeatedly mentioned that their families value education as a life-changing opportunity for their and their family’s social economic status.

Ethnic Identity Achievement through Self-differentiation

As mentioned before, the young Yi’s perceptions, interpretations, and practices of being Yi was mainly influenced by their parents and families, while their self-differentiation included their cognitive efforts in clarifying, bargaining, and recognizing that inherited information about being Yi. During this process, the young Yi actively achieve a reflexive awareness of Yi ethnicity, enrich their understandings of being Yi through peer interactions, and internalize a notion of self-actualization for Yi development.

Reflexive Awareness of Yi Ethnicity

In the current study, reflexivity refers to an action that comes after an individual has become aware of and reflected on their own ethnicity (Chatterton and McKay, 2015 ). Years of family ethnic socialization helped to enact a cultural system within young Yi, manifesting a collection of patterns of meaning through time. With this intrapersonal cultural system, interviewees were more capable of absorbing cultural norms and behaviors that they approbated, simultaneously abandoning those they disconfirmed.

As Yi, we are proud of our Torch festivals, Yi New Year, and our own faith. However, I am also frustrated by some traditions, such as Wawa Qin (child betrothals). (EI33)

Since I am Yi, I love Yi ethnicity 100%. However, I know we have shortcomings, such as low quality of our people. They are less educated and not receptive to new knowledge and science. In poor families with many children, parents might discourage us from going to school if they cannot afford fees for all kids. We (children) have to insist on receiving education as one in multi-child families; otherwise, you might drop out if siblings went to school. Putting myself into parents’ shoes, I could do nothing but wanted to change their thoughts. All I can do is be excellent in every aspect and help my family. (EI1)

Many interviewees experienced distress due to negative comments or social stigma assigned to Yi people, such as being unhygienic, lazy, and crude. However, a resilient aspect of reflexive awareness was triggered by the youth’s forgiveness of being judged or discriminated against from external environments. In discussions of social stigma about Yi ethnicity, interviewees reflected a sense of ethnic confidence and psychological resilience:

As Yi, we should have confidence in own ethnicity; of course, we need to change some negative habits too. (EBAF6113)

We, Yi people, might have had less education, but we kept our integrity as human beings, which matters most. Thus, I love my Yi identity. (EI9)

Enriching Yi through Peer Interactions

Prior to attending their current school, most of the interviewees had completed their early education in local villages, immersed in environments predominantly inhabited by their family members and a specific subset of the Yi people. Upon transitioning to their current school, which hosts a mix of Yi and Han students, these interviewees found themselves in a linguistically and culturally varied setting, shaping their ethnic identity in new ways. The ethnic identity perceptions of Yi youth often showed a marked difference from the views held by their families. Yet, these individual perspectives were deeply intertwined with their personal aspirations, mirroring their unique sense of self amidst a complex web of relationships, encompassing both their ethnic community and broader societal interactions. Consequently, the construction of their ethnic identity emerged as a dynamic process, influenced by a confluence of personal factors, contextual surroundings, language use, and interactions, particularly with peers.

I had no idea of black or white Yi Footnote 2 before coming to this school. I’ve made friends arriving here, later finding out that my new friend is black Yi. I went to my mom and asked her about it, and she explained the differences to me then. (FS44)

They speak a Yi dialect that different from my Yi dialect. I cannot understand what they say. (EMAB 3125)

For young Yi, equality was a concept applied to both in-group and out-group interactions, rather than limited to the relationships between Yi and Han. Social interactions among same-ethnicity peers were conducive to increasing ethnic identity because such interactions offered opportunities to experience and express their ethnicity. For interviewees, even among Yi students, differences in Yi language proficiency, mastery of different Yi dialects, family cultural orientations, and exposure to cultural knowledge could affect what ethnicity meant to them and, ultimately, their self-identity formation.

We should treat people as the same. I felt that it was wrong to treat white and black Yi differently; after all, we are both Yi. (EI10)

Sometimes, the Yi ethnicity is given negative labels. Maybe there are some Yi people who behave badly, but it could not be applied to the whole Yi ethnicity. Han people just applied it to all Yi. (EI35)

Connecting Self-actualization to Yi Prosperity

It was important to understand the meanings assigned by the youth to the connection between self-actualization and Yi prosperity. For interviewees, belonging to a native place is essential to their ethnic and personal identity, creating a sense of native-place identity, such as bendiren , butuo -ness, and laojia Footnote 3 . This native-place belonging, through interacting with ethnic identity and witnessing the under-developmental native places, nurtured a seed of social changes at the bottom of youths’ hearts.

Knowledge was helpful in changing the conservative thought of older generations. I am going to be a teacher in our village and convey knowledge to the next generation in case they remained conservative, like our grandparents.

I would like to be a doctor; because Yi people are quite feudal, most of them are superstitious. When they get sick, they do not go to see a doctor. As a result, treatment time is delayed, and many might lose their lives. When I got sick, my educated father would take me to the hospital… but mother and my grandfather stopped him on the road and insisted on superstitious things. I was not fully conscious at that time and do not remember how my father convinced them. In our village, there are a lot of sick young. children or middle-aged people who get superstitious therapies and die in the end. (GHAH)

In fact, the living conditions of the Yi people have gradually improved since China initiated its nationwide poverty eradication policy in 2012. However, many interviewees’ ideal occupations were teacher and doctor, as they believed that education and medical care need to be further enhanced. They believed that their individualistic self-actualization, becoming educators and medical professionals, could not only address practical demands, but also contribute to the prosperity of the Yi community through changing indigenous stereotypes of illness and education.

One day, when I am capable, I will go outside to learn to bring the new knowledge and experiences back to the Yi community. I will come back to develop our Yi ethnicity. (EBAF)

When I grow up, my dream and goal is to develop our Yi ethnicity through educating children and enhancing their virtues and thoughts. As individuals, motivated children will complete education; as a group, they may contribute to the development of Yi ethnicity. (EMAA)

The triangulation of quantitative and qualitative data in the current study provided several conclusions regarding family ethnic socialization. The study findings indicated that young Yi who had ambivalent relationships with caregivers reported higher levels of ethnic exploration in comparison to counterparts with negative or neutral child-caregiver relationships. With parents or caregivers as significant figures who symbolically represented or practically conveyed Yi culture, these adolescents might have struggled with the tensions between socialization by caregivers and agency in defining Yi ethnic identity, leading to ambivalence. Such mixed emotions were widely found among offspring who had to accept parental expectations on their own attainments of social roles, such as being married, employed, or dependent (Beaton et al. 2003 ; Birditt et al. 2010 ; Bucx et al. 2010 ). Some qualitative excerpts further confirmed that reflexive self-differentiation was meaningful in navigating the process of ethnic exploration and resolution, especially with the presence of intergenerational ambivalence. Self-differentiation appeared to be a bargaining between autonomy and relatedness, though autonomy has often been viewed as conflicting with relatedness (Chung and Gale, 2006 ). With reflexive self-differentiation, the construction of ethnic identity was then associated with an integrated sense of self and might have even served as a strong predictor of mental health among young Yi.

Intergenerational ambivalence might essentially reflect the crux of family ethnic socialization as a dynamic context for the ethnic identity formation of young Yi. Born and raised in Liangshan, parents and grandparents practiced their ethnic identity through ethnic rituals, such as the Torch Festival and Yi New Year, and daily routines and norms. With fewer opportunities to step out of the local community, they might be authentically committed to Yi cultural beliefs and norms that they inherited from their original families and unable to reflect on what Yi stood for by comparing it with other ethnic groups. Without an active ethnic exploration process, their ethnic commitment might not contribute to resolution in self-identity. In recent decades, China’s government implemented a series of poverty elimination and national revival movements. Especially in Southwest provinces where Liangshan is located, efforts had been made to ensure the provision of high-quality education for Yi children and adolescents. With increasing knowledge and experiences in schooling, young Yi are more likely to gain a comprehensive and critical understanding about Yi and their ethnic identities through constantly comparing Yi with other ethnicities (Sladek et al. 2021 ). Thus, their reflective awareness of ethnicity itself might differ from or contradict what the previous generation practiced, resulting in an adjustment in identification.

Although a cultural system was mentally established through family ethnic socialization, the majority of interviewees in focus groups showed high self-differentiation from family interpretations about practicing Yi. Familism, a significant feature of Chinese culture, tended to influence the concept of self for interviewed Yi students. Empirical evidence showed that youth played an active role in their own ethnic identity formation, rather than being a container for family ethnic socialization (Umana-Taylor et al. 2013 ). Self-differentiation, mainly referring to the level of differentiating the self from their family-of-origin, was associated with their psychological and social development. For interviewees, their self-differentiation from family ethnic socialization was achieved by their reflexivity of accepting, interpreting, and contributing to Yi ethnicity, which eventually brought a cohesive sense of self. As young Yi, ethnic identity appeared to be a reflexive self-relation as a unity of self, necessarily connected to a negotiation between native culture and mainstream culture. A mature ethnic identity was an important developmental competence contributing to sense of self, academic adjustment, and psychosocial wellbeing (Lai et al. 2019 ; Lai et al. 2017 ).

Together with family, exposure to school and community might collectively contribute to the youths’ construction of ethnic identity (Eng and Tram, 2021 ). Although family are the primary transmitters of ethnic-racial socialization, transmitters within the school context are also important in the development of youth from ethnic minorities (Saleem and Byrd, 2021 ). Furthermore, family ethnic socialization served as a developmental asset for school-based ethnic-racial identity programs aiming at nurturing a mature ethnic-racial identity (Sladek et al. 2021 ). In this way, family and schools should be cooperative in building a healthy climate for youth from ethnic minorities to explore their ethnicity. A recent meta-analysis indicated that social dominance orientation, intergroup anxiety, identification with the national ingroup, and parental prejudice contributed to increasing later levels of adolescents’ prejudice; however, intergroup friendship contributed to lessening it (Crocetti et al. 2021 ). Yi ethnic minority have often expressed feeling inferior and un-modernized compared to the Han majority (Harrell, 2012 ). However, ingroup and outgroup interactions in school might provide the youth with chances to examine their perceptions regarding their own and other ethnicities then come to forgive the prejudices and stigma assigned to Yi (Degener et al. 2021 ). Given that Yi is often downwardly compared, it makes sense that they may be academically motivated to devote themselves to the economic and social development of the local community and Yi ethnicity.

This study carries some limitations. Firstly, we focus on a single case of ethnicity in China, thus, findings in current study should be carefully used for generalizability. Future research should consider diverse samples from various regions and ethnic groups both within and outside China to enhance representativeness. Additionally, our study acknowledges the limitation of lacking detailed familial data, which restricts our capacity to deeply analyze how aspects like parental education, occupation, and socioeconomic status affect the aspirations of Yi youths and their connection with different CAR types. Future study should design to provide a clearer understanding of the interplay between familial backgrounds and the development of ethnic identity and aspirations among minority youth.

Practical Implications

Firstly, the findings indicate the crucial role of reflexive self-differentiation in ethnic identity achievement. As a facet of self-identity, the construction of Yi youths’ ethnic identity may be shaped by exposure to mainstream culture; thus, ethnic minority young people have to navigate and handle the duality of native and mainstream cultures (Umana-Taylor et al. 2014 ). Social works should be equipped with cultural sensitivity and competence in order to provide high-quality services when ethnic minority young people are struggling with ambivalent feelings towards family ethnic socialization. Particularly, future social work interventions should endeavor to mobilize the unique family resources of youth from ethnic minorities in China to build their ethnic identity, despite ambivalence.

Secondly, dissimilarity in values and beliefs in parent-child relationships could result in estrangement between children and parents, ultimately affecting the mental health of both generations (Coleman et al. 2006 ). Although youths’ differing perceptions of ethnicity as compared to the previous generation might create opportunities for their own ethnic identity exploration and resolution, it could also cause intergenerational tensions for the family and psychosocial maladjustment for the youth. Family social workers might facilitate ethnic minority families to clarify the fact that ethnic identity as Yi is not only collective, but also personal. Acceptance and an embrace of incongruence in terms of ethnic identity might lead to ethnic resolution for both generations.

Lastly, the mixed results highlight dynamics between family and systems beyond family (i.e., school) during the process of ethnic socialization, emphasizing the importance of school, community, and family collaboration on the positive development of ethnic minority young people (Eng and Tram, 2021 ; Torres et al. 2019 ). Psychosocial interventions should be collectively designed and implemented by an alliance of multiple stake takers (i.e., parents and caregivers, peers, teachers, social workers, and policy makers) to enhance the reflexive self-differentiation of youth from ethnic minorities and more effectively prepare them to navigate multi-ethnic social contexts (Laird, 2011 ).

Findings suggested that family ethnic socialization, as a primary context, interplayed with interactions in schools and communities, ultimately contributing to ethnic identity formation among Yi adolescents. Moreover, reflexive self-differentiation was crucial in achieving ethnic identity resolution, providing motivations for youth from ethnic minorities in academic and life goals.

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Yao, H., Hou, Y., Hausmann-Stabile, C. et al. Intergenerational Ambivalence, Self-differentiation and Ethnic Identity: A Mixed-methods Study on Family Ethnic Socialization. J Child Fam Stud (2024). https://doi.org/10.1007/s10826-024-02819-w

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Focus groups

Focus group considerations

Focus group management

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