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The use of focus groups in developing prenatal health education materials

In Tijuana, Mexico

Rocio Abundis, Marian Abernathy, Annette Ghee, Laura Durazo, and Rosa A. Luna

Abstract

Focus groups were used to develop and pretest mass media prenatal-education materials in the final phase of a study of prenatal health behaviour in Tijuana. The project was designed to develop a mass-media campaign to give women sufficient information to enable them to initiate prenatal self-care and to seek professional care when needed. Following an ethnographic study of 40 pregnant, low-income women in Tijuana, 451 women from the same sampling frame were asked about beliefs, practices, and communication patterns regarding prenatal professional care and self-care.

This paper reports on the use of focus groups in the process of testing and refining draft materials created on the basis of information from the ethnographic study and survey. Focus-group discussions enabled the researchers to modify the draft materials for maximum appeal, comprehensibility, credibility, and relevance. For example, men were shown in supportive roles because many of the women reported a lack of support from their partners curing pregnancy.

Introduction

Low-income women in Tijuana, Mexico, have not attained an adequate level of prenatal health care to assess risk, prevent and treat infection, or obtain information that could help to empower them to make health-behaviour changes. A study of prenatal health behaviour in Tijuana was undertaken in order to design prenatal health-education materials based on the women's knowledge of, attitudes toward, and access to prenatal care and self-care during pregnancy. This paper discusses the final stage of the project, in which focus groups were used to pretest and revise mass communication materials drafted from ethnographic and survey data to ensure that they corresponded to the community's cultural and health needs.

The bi-national, interdisciplinary research project [1], which was co-ordinated by the University of California at Los Angeles (UCLA) and the Universidad Autónoma de Baja California in Tijuana, was completed in three phases. The first was an ethnographic phase to document knowledge, attitudes, and practices regarding prenatal health behaviour and to draft wording for the survey phase. Information from this phase was triangulated by a variety of anthropological methods. The second phase was a survey of 451 women to gather quantitative data on demographics, patterns of utilization of prenatal care services, formal and informal sources of information, pregnancy attitudes, beliefs, and behaviours, and communication patterns. The final phase of the project was the communications/focus-group phase discussed here.

Materials were designed to increase women's awareness of the importance of prenatal care, when to seek it, how to identify potential problems in their pregnancy (high-risk conditions), and how to maximize self-care and optimize nutrition during pregnancy. Implicit in the project was the concept that women from low-income areas of Tijuana would determine the content and medium for the prenatal-health campaign. Consideration of various media options was based on the target women's access to the medium, the likelihood of using the medium successfully, and its potential for being sustained over time. Focus groups tested the general themes and formats and the wording and graphics of the various materials selected on the basis of the survey and preliminary focus-group information.

The role of focus groups

Traditionally, focus grops have been used as a marketing technique for obtaining impressionson new products or concepts or to generate information for the development of new concepts [2]. More recently, health professionals have begun to use them as a rapid, efficient, and accurate research method applicable to many areas of public health. They have been used successfully to study such topics as prenatal eating behaviour, perceptions of risk, and other maternal-and-child-health and health-education topics, both domestically and internationally [3-5].

Focus groups can be used to gather new information, to confirm findings from previous research with similar populations, or as an educational tool in themselves. They performed all of these functions in this study.

Among the purposes served by focus groups in the health field, one is as a tool for formative research in the investigation of people's knowledge, attitudes, practices, problems, fears, and vocabulary relating to particular health issues [3-5]. Second, the groups use these data to develop programme goals and objectives consistent with the needs of the targeted community. Third, when a health project is implemented, group interviews can be used to evaluate its effectiveness within the community [2]. This community feedback can help to redirect the focus of the programme and consequently can save money and energy by avoiding implementation of misguided programmes. Fourth. focus groups provide the researcher with the means to pretest programme materials, such as health education pamphlets and posters, campaign messages, and the like. Responses from interviews will reveal the level of comprehensibility, relevance, cultural acceptability, and appeal of the proposed materials. Finally, focus groups allow the researcher to collect in-depth qualitative data on the community perception of health issues. The process yields information about the vocabulary, beliefs, attitudes, and knowledge expressed by focus-group participants that can be used to formulate a culturally acceptable and comprehensive quantitative survey [5]. It is evident that, in serving these varied purposes, focus groups can be a valuable asset in the collection of both quantitative and qualitative research data in the health field.

Guidelines for conducting focus groups are given in appendix A. This article describes how the thirteen focus groups used in the project in Tijuana were conducted and how the guidelines were adapted to suit the project's and the community's needs. It also examines how the focus groups fitted into the methodology used, their limitations, and possibilities for further research.

The setting of the research

All stages of the research were carried out in Tijuana' a sprawling border city of about one million inhabitants. It is reputed to be one of Mexico's most prosperous cities, but, in terms of per capita income, housing, and automobile ownership, it is an impoverished city with characteristics of a developing country [6].

In characteristic Latin pattern, the city is organized around its centre, where government offices, businesses, cultural centres, and tourist activities are located. The centre is only two miles from the busiest international border crossing in the world [6], and, although many people live in the centre and nearby rings, the majority of the low-income population live in the rapidly growing periphery areas.

Tijuana is the centre for medical services for all of the Baja California peninsula, and the local university trains doctors and dentists. There is a heavy concentration of medical services in the centre, but it diminishes dramatically in the neighbourhoods a mile and more from the city's centre. The study sites were in these outer areas.

Establishing the focus groups

The research team conducted 13 focus-group sessions-12 with members of the target population, currently pregnant women, and 1 with health professionals. The groups varied in size from 4 to 12 participants. (The ideal number would have been between 6 and 12 [5]; this size is both manageable and sufficient for active dialogue.)

The focus-group recruiters selected a convenient sample of participants from the community on the basis of the selection criteria (low-income pregnant women). The recruitment process was challenging, since many households did not have telephones. Furthermore, the location of several communities was problematic for recruiters, particularly when bad weather created adverse road conditions that did not allow safe access into or out of the community. These same limitations made it difficult to revisit or communicate with the invited respondents to ensure their participation.

The recruiters asked target-group women to participate in the focus groups and explained the general purpose of the research project. However, they avoided identifying the specific topic of discussion to prevent the participants from becoming sensitized to the subject matter. As an incentive, and to compensate them for their time, the target-group women who participated were given a small gift-a token amount of food, vitamins with iron, and/or diapers.

The participants typically did not know each other, which contributed to their ability to speak openly [4; 5]. ideally, they should have been categorized and interviewed by age and parity, since women with more experience were more likely to dominate the conversation, thus decreasing the participation of the younger women and those who had had fewer pregnancies.

To protect against contamination effects, the focus group facilitators did not answer specific questions relating to individual pregnancies during the sessions. Time was set aside at the end for the women to ask any questions relating to their pregnancies, and a member of the focus-group team, a local physician, responded to medical questions.

The discussions were held in various clinics, community centres (Desarrollo Integral de Familia), and participants' homes. Ideally, they should have been held in non-health-related settings because a neutral setting has fewer built-in biasing effects. However, alternative arrangements were not available. In some cases the team and women were forced to be very creative in site selection because the person with the keys to the planned site did not arrive. In one case, the discussion was held outdoors and the women were forced to sit on a concrete wall. Because unforeseen logistical problems can arise at any time, it is important to remain flexible and creative in finding alternative solutions.

An effort was made to make the settings conducive to informal discussion. Seating was arranged in a circular pattern to ensure equal participation and maximum comfort.

Decisions on the use of media

Decisions regarding the campaign were made in an interactive process among members of the research team, the focus-group team, and the graphic-design consultant. This process included ongoing examination of the ethnographic and survey data in combination with the focus-group activity described in this paper.

Preliminary data indicated that print media can be effective in reaching this population with health information. The research team had originally planned to develop several posters and a calendar. However, because focus-group women said that they preferred interpersonal education and pamphlets or booklets, it was decided to develop only one poster, a calendar, and an educational pamphlet.

The poster was designed to increase awareness of the seriousness of pregnancy and the importance of prenatal care.

The calendar, which was designed to provide cues to action and the reason for suggested actions and self-care, made it possible to include more information on each of four prenatal or self-care issues on which a lack of knowledge had been identified by the ethnographic study and the survey: use of services, high-risk conditions, nutrition and anaemia, and weight gain. And, not only could it be given to each woman so that she would have it as a useful, attractive personal learning tool throughout her pregnancy, but it had the further advantage that it would be displayed and visible to all household members.

Through the focus groups it became clear that an additional educational component was necessary to provide more information than the women would get from the poster, the calendar. or their physicians. They said that they liked and read pamphlets, and also that they put them away in a safe place and referred to them when they had questions or concerns. Pamphlets were reported to be a source of health information by 48% of the women in the survey (Susan Scrimshaw, personal communication), and have been shown to be an effective medium for educating Hispanic women [7]. Therefore, a pamphlet was designed to supplement the information on the four topic areas included on the poster and the calendar.

Although television was identified by the survey as an important source of health information for the target population (52%; Susan Scrimshaw, personal communication), it was decided not to use it because of the fleeting nature of TV messages and the high cost of TV production. The survey women spent an average of three hours a day listening to the radio, but radio spots were not developed because of their high cost and the lack of control over the time placement of public service announcements or their sustained use by local stations.

Draft versions of two songs about prenatal care were initiated, with a focus-group team member writing educational lyrics to existing popular Mexican tunes (see appendix B). One of the songs, a love ballad sung by a man to his pregnant wife, Cada vez que te veo ("Every time I see you"), was based on a concern that was raised in many of the focus groups. The words describe the paternal and protective feelings the husband has for his wife and the future child as he sees her growing belly. The husband's role during pregnancy is emphasized because many of the women reported a lack of support from their husbands or male partners and asked for materials to help educate them. The other song is a lighthearted tune in which a woman sings to her unborn child about all the things she would like to eat; but, knowing that they aren't good for the baby, she says that, for the baby's sake, she will eat "good" things and take care of herself. The words of both songs were pretested and approved by women in a focus group.

In summary, the decisions regarding the media to be used and the content of the materials were made on the basis of information from the ethnographic study, the survey, and health professionals in Tijuana. These decisions were reinforced by information generated in the focus groups. The major changes that came from the focus groups were the change in the media mix-the development of only one poster, and the inclusion of the educational pamphlet giving a greater level of detail on the four subject areas-the songs, and the inclusion of men in the images for the calendar. The images or pictures selected were based on the reactions and suggestions of the women participating in the focus groups.

Pretesting the materials

The focus groups were used to pretest the general consciousness-raising messages to be used; the images, texts, and layouts for the poster and the calendar; the text for the educational pamphlet; and the lyrics of the songs.

The techniques outlined in appendix A were utilized in this phase. For each session, an interview guide, the facilitator's outline of topics to be covered during the session, was developed from integrated results of the ethnographic and survey phases of the project.

Responses to the questions and discussion were used to analyse the credibility, acceptability, relevance, and clarity of draft materials for each of the media. Special attention was given to local vocabulary, which was integrated into the text as much as possible to increase cultural acceptance.

Consciousness-raising messages

The following five consciousness-raising messages were pretested, with the intent of selecting one or deriving a primary message to be chosen by the participants:

• Pregnancy is something serious (El embarazo es cosa seria);
• I want you [baby] to be healthy (Quiero que estés sang);
• Have a healthy baby (Tenga un bebé saludable);
• Every pregnancy is different (Cada embarazo es diferente); and
• Prevent complications (Prevenga las complicaciones).

The women selected the message "El embarazo es cosa seria" to be used as a campaign theme and suggested "Inform yourself, take care of yourself" (Informate y cuidate) for the poster.

The research team was also concerned with reinforcing awareness of the importance of initiating prenatal care during the early stages of pregnancy. Consequently, data from both the ethnographic study and the survey were used in developing a secondary message to serve as a call to action on the poster: "Seek medical care at least at the beginning, the middle, and the end of your pregnancy" (Busca atención médica por lo menos al principio, a mediados y al final de tu embarazo). The concepts of "beginning," "middle," and "end" was found to be more comprehensible than the concept of trimesters or even months [1].

The poster

Appropriate images/photos for each of the campaign elements were also selected during the focus-group discussions. For the poster six different images, some of them drawings and some photographs, were presented independently from the messages to elicit both verbal and non-verbal responses from participants. The moderator probed for reactions by asking: What does this picture say to you? What does it inspire you to do? What would you change about it? Which picture most reminds you of prenatal care? This partial list of questions served as a base and was modified depending on the level and variety of responses.

It became clear which images elicited immediate negative reactions or non-comprehension of the intended message, and, as a result, the selection became narrower. The 'finalists" were further pretested in different focus groups. The image finally selected by the women was a photograph of a young pregnant woman, dressed in "pretty'' clothes. touching her stomach. The woman was shown at a moderate stage of pregnancy since early prenatal care was one campaign goal.

Note that throughout the process of selecting both the verbal message and the image, the two were presented first separately and then together in order to test for consistency and comprehension of the intended prenatal-care message.

The calendar

The notion of creating an educational calendar was originally proposed because during the ethnographic study several researchers had noted the common use of calendars in Tijuana households. In the focus group discussions the women reinforced the idea, saying that they would display an "attractive" calendar in their homes if it were given to them. They pointed out that it could serve a dual educational purpose: to remind the woman of the appropriate behaviours during pregnancy, and also to educate the family and so create a more supportive environment. The calendar was designed to provide cues to action both in self-care and in seeking professional prenatal care.

Images for the calendar were pretested in the same way as for the poster. Drawings were preferred over photographs, which is consistent with research results on developing educational materials for audiences with low literacy [41. This preference could also have been due to differences in the clarity of the two media. The images pretested include photos of a woman with her male partner and a female doctor a display of nutritious and appropriate local food, a family gathered at a table for a balanced meal. and a woman weighing herself in her husband's presence. Male partners were included at the women's suggestion. The participants overwhelmingly wanted their husbands' participation in the prenatal care process, especially in regard to weight gain.

In regard to the text, the women asked for "few words that say a lot." The following are the calendar messages that resulted:

• Seek medical care at least at the beginning, the middle, and the end of pregnancy.
• Seek medical care if during your pregnancy you notice vaginal bleeding, strong abdominal pains, excessive thirst, excessive swelling of the hands and feet, or any other concerns that worry you.
• You can prevent anaemia by eating well and taking vitamins.
• It is important to gain 10 to 12 kilos during pregnancy. Discuss with your doctor what you ideal weight gain should be.

The pamphlet

Another component of the prenatal education campaign was the pamphlet, which was designed to expand on the four issues of the use of services, high risk conditions, nutrition and anaemia, and weight gain. The text was based on the already pretested, but much briefer, calendar text. Testing the text for the pamphlet in a group setting posed many challenges because of the length and content of the written information. Further pretesting of the pamphlet permitted modification and amplification of the calendar messages.

Observations

Verbal as well as non-verbal responses during the pretesting for the calendar and the pamphlet revealed a great deal about the participants' knowledge, attitudes, and practices pertaining to prenatal care. For example, many women identified excessive thirst as a symptom of pregnancy, but few understood the health implications involved. Differences in levels of knowledge among the women became evident during these discussions. It was clear that the proposed materials would need to provide a very basic level of prenatal education in order to satisfy the needs of low-income women in Tijuana.

The information derived from the focus groups corroborated data previously found in the ethnographic study and the survey [1] on lack of knowledge about risk factors, anaemia, weight gain, and minimum required visits for prenatal care. Focus-group women who were pregnant for the first time, like their counterparts from the survey and ethnographic study, were fearful of childbirth. Focus-group information, supporting survey data, suggested that many physicians do not inform the pregnant woman of her weight or of how much she should gain during pregnancy. The women almost uniformly believed that they should gain about three kilograms during pregnancy [1], which represents the weight of the baby; there was little understanding that it is necessary to gain weight in addition to that of the baby. We found a fairly high level of knowledge about other health issues relating to pregnancy, such as to whom to go for reliable information about pregnancy and what conditions (such as hypertension and diabetes) create risks for the pregnancy. Despite the knowledge of high-risk conditions, however, the women did not necessarily know the symptoms of these conditions. Women were fairly knowledgeable about what kinds of foods should be eaten; the level of knowledge was significantly correlated to the level of the woman's education (R = .143, df = 442, p < .001) and the length of her residence in Tijuana (R=.150, df=434, p<.001) [1].

As mentioned previously, an issue that often came up in the focus groups was the lack of support women felt from their partners. Several of the focus-group women indicated that their husbands did not like it when they gained weight. Some husbands were occasionally abusive during pregnancy. For this reason, the researchers decided to include images of men in supportive roles throughout the woman's pregnancy on the calendar. The calendar images include a man helping his pregnant wife during weighing, sitting by her while she is eating, and accompanying her during a doctor's visit.

Limitations

The focus-group team was not able to enter into the study communities as fully as would be considered ideal. Because of time and budgetary constraints, it was impossible for them to spend sufficient time in the study areas of Tijuana for the purposes of building trust. In a future project, this could be remedied by having the ethnographic team also conduct the focus groups. It is not known whether the foreign nature of the focus-group team may have improved local cooperation by encouraging women to speak candidly about personal experiences and perceptions or may have affected it adversely because of a lack of sufficient trust to discuss their knowledge and attitudes openly with strangers. This issue requires further research.

Conclusion

Throughout the implementation of this third and final phase of the Tijuana project, it was evident that focus groups can be utilized as a rapid and efficient research method in many areas of public health, such as maternal and child health and health education, both domestically and internationally. In the area of maternal and child health, this technique has been overlooked as a means of gathering new information. Focus groups can confirm findings from previous research on similar populations, pretest and design health messages and campaigns. and serve as an educational tool in themselves. Focus groups performed all of these functions in this study.

Focus groups served as an essential link toward the completion of comprehensible prenatal education materials. However, the many obstacles faced suggest that the technique must be modified to meet the needs both of projects (manpower, budget, etc. ) and of communities (participants, geographic obstacles, and socio-economic factors). While the Tijuana project successfully utilized an ethnographic study and survey, followed by the use of focus groups, it might have been more efficient to use focus groups more extensively during the initial study.

Focus-group women suggested that fathers should be included in future prenatal-education/research efforts. The father has traditionally been overlooked in the ' dyadic' relationship between the mother and child. Perhaps it would have been appropriate to conduct focus groups among future fathers to obtain their perceptions of pregnancy and of their roles during the prenatal and postpartum periods. This proposal would be a challenge both culturally and logistically within this population. This "triadic" relationship is an area of maternal and child health that deserves further attention, however.

In summary, focus groups serve as a complementary technique to surveys and provide qualitative data that may otherwise be overlooked in a structured interview. Although they provide an insider perspective on the topic being investigated, the technique is not without limitations. Focus groups can be adapted to research areas of public health both internationally and domestically. The Tijuana experience was valuable in demonstrating that such groups can generate important, in-depth concepts overlooked in quantitative research.

Acknowledgements

This study was a collaborative research effort between the University of California, Los Angeles, and the Universidad Autónoma de Baja California and was directed by Dr. Susan C. M. Scrimshaw. Funding was provided by the International Center for Research on Women through Cooperative Agreement DAN-1010A-00-7061-00. We gratefully acknowledge the International Studies Overseas Program at UCLA for sponsoring the draft production of the two educational songs. The authors wish to thank Dr. Scrimshaw for her advice and invaluable support in the preparation of this paper.

Appendix A. Steps in conducting focus groups

Successful focus groups require planning. The preparation process includes training a focus-group facilitator, an observer, and a recorder; selecting an appropriate location; recruiting participants; and designing the questionnaire guides. Analysis of the data is of utmost importance to the usefulness of the focus group methodology.

1. Training

The facilitator, observer, and recorder all must be trained in focus-group methodology and specific orientation to the project at hand. The training should include:

• knowledge of what the focus groups are testing for, how the information generated will be used, and what decisions will be made based on the information;
• group dynamics, subtle ways of getting nonparticipating members to speak up and reducing the participation of members who may dominate the discussion;
• awareness of one's own body language and intonations, and of one's own biases toward the subject of study;
• the roles and duties of both the facilitator and the observer (and the recorder, if one is used);
• how to operate all audio and/or visual equipment to be used;
• the importance of informed consent.

2. Selection of locale

• Neutrality of the focus-group location is essential. The site selected should be such that the participants answers are not influenced.
• The location should be conducive to flexible and comfortable seating.
• The site should be easily accessible to all participants, or transportation should be provided.
• A back-up site is essential in case something unforeseen occurs.

3. Recruitment of participants

• Select a very specific target population in accordance with the objectives of the study.
• The recruiter should be from or known to the community. Otherwise, enter the community with the permission/acceptance of community leaders.
• Invite representatives of the target population, informing them of their voluntary participation. They should be made aware of the nature of the meeting-but not of the topic for discussion to avoid sensitization to the subject.
• The ideal size for a focus group is 6 to 12 members. A few days ahead of time, remind the participants of the time and place of the meeting.

4. Designing the questionnaire guides

• Keep in mind the specific objective of the particular focus group and the overall goals of the project (know that information is needed, how it will be used, and what decisions it will form a basis for).
• Bear in mind the time it will take to complete the discussions, the difficulty of the subject matter, and the participants' available time.
• Be efficient. Have a reason for every question that is asked.
• Ask unbiased, open-ended questions.
• Ask questions that the respondents will be willing and able to answer in a group context.

5. Last-minute check-list

Make sure that the following are taken care of:

• keys to the site (if applicable),
• extra batteries and cassettes for recording the session,
• refreshments,
• questionnaire guides, materials to be discussed,
• notepaper, pens,
• compensation to be offered to the women to thank them for their participation.

6. Conducting the focus-group session

• Arrive early.
• Set up the meeting area into a circle or other comfortable formation so that everyone can see all participants.
• Test the functioning and placement of recording devices.
• Both the facilitator and the observer should greet the participants warmly as they arrive and begin getting to know their names and something about each participant.
• Serving refreshments at this time is helpful in creating an atmosphere conducive for informal discussion.
• When all have arrived, announce that the discussion is beginning.
• If recording equipment is being used, explain it, obtain the participants' consent, turn it on, and monitor it.
• Introduce the team and the project, and make sure that all participants have introduced themselves to each other. A name game is a good ice-breaker, and very useful for both the observer and the facilitator.
• The facilitator should begin by following the questionnaire guide. If it is well developed, discussion can flow through the questionnaire without having to ask all the questions.
• The facilitator should be flexible; extraneous discussion can lead to interesting findings that you may not have considered asking about, but be ready to get the discussion back on track and keep aware of time.
• Be aware of any biasing behaviour that the facilitator may engage in!
• The observer should make notes of the participants-reactions, expressions, and vocabulary.
• At the end of the discussion, thank the participants again for their time, and stay around to chat if they want.
• It is nice to thank the participants with a token gift to compensate for their time.

7. Field notes

Detailed field notes should be written by both the observer and the facilitator as soon as possible after the session. Amplified field notes should include:

• a copy of the questionnaire guide,
• where and when the meeting took place (time of starting and of finishing),
• who was there: participants, facilitator, and observer,
• what was said, and non-verbal reactions,
• a general summary of the outcome if there was a specific question or pretest.

Using a standardized format for the field notes from all focus groups will facilitate analysis of the contents.

Appendix B. Educational songs

Every time I see you

Every time I see you, I can imagine
How beautiful your womb must feel.
I feel such pride to share the flower
From this bud, a fruit from you and me
That we both created.

Chorus:

As the months pass,
I will care for you without fail,
Knowing that from your womb
Our child will be born.
With joy and tenderness
I want to caress,
So that this child will know
That in this life
There are two people
Who will give it love.

To achieve intimate nurturing is a woman's role,
But support and protection is the man's role.
Since part of my being is in your body,
I see your feel like being at your side
To care for him also.

Today I tell you, my dear, how beautiful you are to me.
As your body changes, I see our baby grow.
For now I can't have him with me;
Let me hold you, join our hearts,
And feel them beat together.

-Laura Durazo, David Silvan, 1989

I would like

I would like to eat a sugary cinnamon roll
And some cookies and fried food to calm my munchies.
I would like some fried potatoes, chocolates, and sodas;
I would like to drink a beer and smoke a cigarette.

Chorus:

But I know, beautiful baby,
That we have to give you good things
Like potatoes, carrots, and green leafy vegetables,
Fruit, cheese, and fresh meat.
Tortillas with beans, a meat and vegetable stew,
Rice, salad, and clean water all help you, baby.
For you, beautiful baby,
For you I will take care of myself;
You are part of my being and my body,
And I can better myself.

I would like to eat a loaf of bread with a lot of butter
And drink a cup of strong coffee to make it through the long day.
I would like to eat fried pork rinds with hot sauce;
I would like some fat sausage rolls; that would make me real happy.

-Laura Durazo, 1989

References

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