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Section 1: Deciding to use focus group training
Section 2: Designing the study
Section 3: Selecting and training staff
Section 4: Selecting the study participants
Section 5: Developing the question line
Section 6: Managing the information you collect
Section 7: Analysis of the results
1.1 Introduction
Before you decide to use focus groups to obtain information on which to base your programme decisions, it is necessary to take a close look at the method and what it has to offer. This section describes focus groups and explains the types of information that they are best suited to collect. We will then outline the major advantages and disadvantages which should be considered when planning to use focus groups in a particular project.
1.2 What is a focus group?
A focus group is a group discussion that gathers together people from similar backgrounds or experiences to discuss a specific topic of interest to the researcher. The group of participants are guided by a moderator (or group facilitator), who introduces topics for discussion and helps the group to participate in a lively and natural discussion amongst themselves.
A focus group is not a group interview where a moderator asks the group questions and participants individually provide answers. The focus group relies on group discussion and is especially successful where the participants are able to talk to each other about the topic of interest. This is important as it allows the participants the opportunity to disagree or agree with each other. It can provide insight into how a group thinks about an issue, about the range of opinions and ideas, and the inconsistencies and variation that exist in a particular community in terms of beliefs and their experiences and practices.
The discussion is usually "focused" on a particular area of interest. It does not usually cover a large range of issues, but allows the researcher to explore one or two topics in greater detail.
Focus groups are also "focused" because the participants usually share a common characteristic. This may be age, sex, educational background, religion, or something directly related to the topic. This encourages a group to speak more freely about the subject without fear of being judged by others thought to be superior, more expert or more conservative. For example, young women may not be as forthcoming in their ideas and opinions in the presence of their mothers or mothers-in-law, as they might be if they participated in a group that excluded older women.
1.3 How is a focus group conducted?
There are different ways to conduct focus groups, but this mainly depends on whether you will be working in one common language, or if you need to use interpreters. Focus groups usually involve about eight participants. As already indicated, a person known as a moderator helps the group participate in a natural discussion. The moderator is aided by a pre-prepared question guide that is used to ask very general questions of the group. The question guide is only an outline of the major questions that will be asked of the group. It is flexible enough to allow the group to take the discussion in any way it chooses, while providing enough structure and direction to stop the discussion moving away from the original topic to be studied.
An observer or note-taker records key issues raised in the session, and other factors that may influence the interpretation of information. This involves noting down the responses from the group, and observing and documenting any non-verbal messages that could indicate how a group is feeling about the topic under discussion. The observer may also help the moderator if necessary. She or he may point out questions that are not well explored, questions missed, or suggest areas that could be investigated. The observer should not be especially obvious to the group, but needs to be able to communicate with the moderator if required.
1.4 Language
Sometimes, focus groups may be conducted in a language that is different from that of the researcher, or, that in which information will be analysed and reported. Usually a native speaker would be used to conduct the focus groups, but occasionally the researcher will still want to moderate the sessions, especially in more formal research projects, and so will need translation assistance. This can make the natural flow of discussion between the moderator and participants extremely difficult. Trying to run a focus group with a direct translation of each participant to the moderator reduces the flow of discussion, and often this means that the session becomes simply a group interview. You cannot stop the group after each response to translate, and expect a natural discussion to happen. However, if it is important that focus groups be conducted to meet project objectives, and translation cannot be avoided, we suggest that you follow the technique set out below, in Part II, Section 4.3.
1.5 What type of information do focus groups produce?
Focus groups are a method developed to explore people's beliefs, attitudes and opinions. They cannot tell you how general these opinions are in the community, although they may give you some indication for further investigation; neither can they be used to build up a detailed picture of specific beliefs. In addition, they do not allow you to document precise practices and behaviours: here, observation is an important and valuable method. However, focus groups indicate the range of a community's beliefs, ideas or opinions, and are especially valuable for gaining baseline information for a project. They are useful in designing question guides for individual interviews and questions for structured interview schedules.
1.6 How can focus groups be used in health programmes?
The method can be used in many different kinds of programmes relating to tropical diseases, primary health care, and other health issues. Focus groups are being used more and more often in new and exciting ways to develop research projects, to complement research information collected using other methods, and to help health planners design and maintain effective programmes. The following list will give you some ideas of ways to use this method in your own health research project or control programme.
Exploratory studies
Focus groups are a valuable method to explore a topic about which little is known, or little has been written in the past. For example, to set up health education programmes that will be effective in bringing about behavioural change, and take account of traditional health beliefs and practices, it will be necessary to have a good understanding of people's traditional health beliefs (Basch 1987). Focus groups can begin this process by providing the first in-depth descriptions of how the community sees the cause and treatment of certain illnesses.
If focus groups are conducted early in a research project, then the findings can be used to develop hypotheses that might then be tested using other methods. They are valuable in designing good questionnaires to test how strongly these beliefs, attitudes and opinions are held by the general community, and they can also be used to explain findings from a survey questionnaire. These surveys can describe what behaviours are occurring, but cannot explain why they have occurred. Focus groups can provide this greater depth of understanding.
Focus groups can also be used to discover local terms used for signs and symptoms of illness, types of illness, and other concepts relating to health. These can be of great use to health educators, and are important for both research projects and interventions. For example, focus groups relating to malaria in the Philippines indicated that people used a range of different words to describe "chills", which relates to their assessment of the severity of an illness episode and the appropriate treatment that was required.
Testing ideas about new programmes
In the planning phase of a new programme, it is possible to use focus groups to see what the community feels about the new plan. You can use the method to see what the community identifies to be major problems or difficulties in existing programmes, and build its needs into any changes. Focus groups can give you an understanding of how appropriate the new plan may be in terms of culture or technology.
Solving specific programme problems
Sometimes you have programmes that have been running for some time and do not appear to be working as well as expected. There may be services that are not used by the community, or health behaviours that have not changed despite health education or other interventions. The focus group can be used to explore some of these issues, and can be very successful in identifying problems that may be easily solved.
Evaluating programmes
You may wish to include focus groups as part of the routine evaluation procedure. They could be used in a simple form to provide extra information about a community's ideas about a programme's effectiveness.
Staffing/management problems
Focus groups can serve not only the community's needs, but can be very successful in solving staffing or personnel problems. They can provide a great deal of useful information about your staff and how they see their work. The method can be used to solve a whole range of problems, from poor motivation to assessing training needs.
Focus groups can be used to help a group think of new and creative ideas for a new programme, by getting the group to discuss the problem and its major issues, and then thinking about ways to solve that problem.
1.7 Advantages and limitations of focus groups
As the above discussion indicates, there are various advantages and disadvantages in using focus groups compared with other methods. In summary, these are:
Advantages
• They produce a lot of information far more quickly and at less cost than individual interviews.
• They are excellent for obtaining information from illiterate communities.
• If the focus group is used to explore relatively simple issues, it can be easily managed by people not trained in qualitative research methods.
• Because the questioning is so flexible, it means that you may discover attitudes and opinions that might not be revealed in a survey questionnaire.
• The researcher can be present at the session which allows follow-up of responses if required.
• They are usually well accepted by the community as they make use of the group discussion which is a form of communication found naturally in most communities.
• And, focus groups are good fun!
Limitations
• Results from focus groups cannot usually be used to make statements about the wider community, that is they can indicate a range of views and opinions, but not their distribution.
• Participants often agree with responses from fellow group members (for many different reasons) and so caution is required when interpreting the results.
• The moderator who is not well trained can easily force the participants into answering questions in a certain way.
• Focus groups have limited value in exploring complex beliefs of individuals, and as a result, in-depth interviews are a more appropriate method for this purpose.
• Focus groups can paint a picture of what is socially acceptable in a community rather than what is really occurring or believed, although this problem can be limited by careful participant selection and good moderating skills.
Once you have looked at all the
advantages and limitations of focus groups, considered the type of information you
require, and decided that focus groups are a suitable method for your project, the next
step is to develop the project plan.
2.1 Setting the project objectives
Introduction
Once the decision to use focus groups in the study has been made, you will need to go back and closely examine the problems you want to solve or the questions you want answered. This will take some time, but careful planning at this point will be very useful later on when you are designing questions and training the staff who will be involved. The entire project will be based on your objectives. These need to be well thought out to make sure the study design, the collection of data, and analysis and report writing, proceed smoothly.
Below, we set out a few questions that you can answer to help you start thinking about the research or programme problem with which you are concerned, and to help you to write good quality objectives to guide your study.
What is the exact problem?
Before you begin to define the problem that you will be working on, find out what information is already available. Others may have done some work, or at least thought about the issues.
Stating the problem will depend on the purpose of the focus groups. Suppose you wish to understand why the community usually chooses to see a traditional healer rather than go to the health service. It is wise to write down as clearly as possible all aspects of the problem that you think need to be investigated. Be specific. In this example, rather than simply state the problem as one of the community not using the health service, it would be better to divide your problem into as many parts as possible. For example: For what types of illnesses does the community choose the traditional healer? What are the consequences of choosing the traditional healer? What are the more common things that people do, like delay in contacting the health service or not contacting the service at all? You need to meet with others involved in the project to ensure you have examined the problem well. In this example, it would be useful to conduct a couple of in-depth interviews with traditional healers and with local health workers to enable you to define more clearly the research question.
When your list is complete, decide which issues or areas you are most interested in. These will be the basis of your objectives.
If you are preparing an intervention, for example, you need to ensure that you have stated exactly what issues are relevant to this. Suppose you have decided to introduce bed-nets into a community as a means of reducing malaria infection. You would need to check the community's acceptance of bed-nets, but to do this properly, you need to spell out all the relevant issues: whether people are already familiar with bed-nets; if so, whether they use them year-round or only seasonally; whether all people sleep indoors and in beds; who might be responsible for monitoring net use and re-impregnating them with insecticide; as well as people's understandings of the cause of malaria and its importance to their health. Focus groups cannot be used to answer a large range of different questions, so you need to decide on the most important information required to help you make good decisions.
Even if you are simply exploring a topic to have a better understanding of a particular issue-for example, people's beliefs regarding malaria, or how they believe schistosomiasis is transmitted-it is still important to state clearly the project objectives.
Who can provide the information we require?
After you have decided on the problem and the information you require, you need to think about which members of the community will best help you in providing that information. This will vary according to the type of research you are doing.
In our example of why a community does not use the health service but prefers the traditional system, you might want to include not only the caretakers of sick adults or children who are making the health care choices, but also the relatives and friends who influence them, the traditional healers, and the health workers in the system that is not being used. When deciding on the people you want to talk to, think as broadly as possible about your topic.
How will the information be used?
Is this the only method you will use to gather information, or will it be used with other information collected using other methods? For example, will it be used to supplement information collected from clinic records or survey data? Perhaps the information will be used to provide a good questionnaire for a later survey.
Will you want to explore an entirely new and unfamiliar area (for example traditional health beliefs), or are you aiming to see whether a plan for a new health programme will be accepted by the community (for example, setting up a community participation programme for the distribution, use and maintenance of impregnated bed-nets)?
Who are the results intended for? This will determine many aspects of the project, especially how you present your results. Is it for higher government officials, members of the community, or district level project planners, or is it part of a research project which has no immediate and direct application?
What is the desired outcome of the exercise?
Are you trying to solve a small problem in a programme? Will this information be the basis of major decisions? Is this information going to be used in a larger and more formal research project? How will the information be put to best use?
Looking at your resources
After you have decided what information you need, and who in the community may be able to provide that information, you need to examine what you have available in terms of money, staff and time to complete the task. Although this may seem obvious, often project planners do not spend enough time on this issue early in the project.
You need to think about the main points of your objectives and the logistics of the project as planned so far, and compare these with available resources. A more thorough and detailed examination of your requirements and resources will follow in later steps during the planning process, but for now, just think in general terms about how reasonable the project is. It may be necessary to change your objectives to meet your resources more appropriately. This could involve limiting the information you collect, the number of people in the study, or simplifying the focus group method to meet the skills of available staff.
Write your first set of objectives
This may well be the first of many attempts to set and then refine your objectives. If you have thought about the project carefully, it should minimise the number of times you change your objectives. But it is quite usual to alter them several times before they are satisfactory.
2.2 Making the project plan
Introduction
Planning the project well is very important, but it is outside the scope of this Manual to provide a detailed discussion on project planning. However, the important aspects of planning a project using focus groups will follow.
We are suggesting just one way of planning a project. If you are already using a good method for project planning, then you can apply this to focus groups.
Steps in planning the project
STEP 1: DECIDE HOW YOU WILL CARRY OUT THE PROJECT
Using the objectives that you have already set, you now need to decide how to carry out the project. To begin with you will only need to decide the major points. Depending on the size of your project and the amount of staff to be involved, other staff may be involved in the details of the project.
This first task includes answering these questions:
• What information do I need to meet the objectives (more specific than before)?
• How will the study participants be selected and contacted?
• How will the focus group sessions be conducted?
• What role will other staff have in the project?
• How will staff be selected and trained?
• How will the question-line be developed and by whom?
• Where and how will the focus group be pre-tested?
• How will the information be analysed?
• What form will the final report take?
STEP 2: PREDICT PROBLEM AREAS
Once you have made a plan on how to carry out your project, it is wise to spend some time trying to see where you may have problems later on. Sometimes problems (logistic or design problems) will only be clear after the pre-test. However, where you think there could be important problems that could affect the project, you should make alternative plans that you can put into action if necessary.
STEP 3: DECIDE WHAT YOU WILL NEED TO CARRY OUT THE PROJECT
Every project will be different depending on the size and complexity of the study, but a few suggestions for areas to look at include:
• Staff. How many? What skills will they need? Will a staff trainer be required/possible?
• Office, buildings and space. Where will the staff work? Where will the staff be trained? Where will the information be stored? Where will the focus groups be held?
• Equipment. What extra office equipment is necessary? How are we storing information? How are we analysing information, and what is required? What equipment is necessary for the focus group discussions, e.g., tape recorders, cameras, etc.?
• Transport. Is transport required? What type of vehicles? Drivers? Extra fuel?
• Incentives. Do we need to repay study participants in some way? If so, how?
STEP 4: MAKE A PROJECT TIMETABLE
After you have completed the above tasks, you will need to draw up a preliminary timetable. As well as demonstrating all the major tasks, you need to show who is responsible for each task and when it is due to be completed. This timetable will not only provide you with a constant check on progress, but will also show you if your original objectives or plans are possible in the time allocated.
STEP 5: DECIDE ON THE DETAILS OF THE PROJECT
The next step involves allocating responsibility to all your staff/team involved in the project. This will depend on the size of the project. Detailed planning can be done by those staff members responsible for a particular area. This does not mean that the team leader is unaware of these plans, but simply encourages the participation of all team members and frees the team leader for other activities. If the focus group discussions are part of a project to be undertaken by a control programme, this project may be a small part of the activities of the staff involved. You need to take account of this in your plans.
STEP 6: REVIEW THE PLAN
Once all the planning is complete,
all team members should receive a copy of the detailed plans to read, review, and to check
that it is reasonable and can be managed along with their other responsibilities. A team
meeting should then be held to discuss any problems, changes or new ideas.
3.1 Introduction
The selection and training of staff is an important area of the project. It is important to make the best of those staff who are available. Part II of this Manual is a detailed training guide for the other members of the team or staff that you select for the project. It is often presumed that you need specialised staff to do this type of work, usually people with post-graduate training in the social sciences. In most cases, however, such people are not available. We are convinced that this is not necessary for conducting these projects, and from experience, we are confident that with a far more basic criteria for staff selection, you can use these methods. This section looks at the decisions that need to be made concerning staff selection and training.
3.2 How much can we afford to spend on staff selection and training?
Depending on the size and purpose of the project, the budget for staff will vary. You will already have given this some thought in the early planning stage, but now you will need to be very clear about how much time and money you have available for the staff. The size of the budget will determine the complexity of staff selection and training.
One point worth stressing here is that by selecting staff carefully, and by offering good quality training, you can improve the quality of your project remarkably, and therefore be able to make more effective decisions about the problem you are trying to solve. Do not try and save time or money in this area as it really is the foundation of a successful project.
3.3 How many staff will we need?
This will depend on the size of the study, but there is a certain minimum requirement for the smallest project. "The smallest project" refers to solving a single research or programme problem; for example, "Do our health education messages concerning the prevention of malaria fit in with the community's beliefs about the causes and prevention of malaria or fever?"
The minimum requirement is two or three staff, assuming that they are responsible for other tasks in their usual work activities. It is possible that a single researcher could carry out most tasks associated with focus group research, but even so, she or he would need to have a collaborator to act as an observer/note-taker when the sessions are in progress. So you need at least a team leader/project co-ordinator who may or may not also act as a moderator, and an observer; you may also need someone else to be responsible for transcribing tape-recordings of the focus group discussions.
There are many functions that need to be performed within a focus group project, such as managing the information as it is produced, designing and redesigning the questions for the discussion sessions (see Part I, Section 5), analysing the data, making recommendations and writing the report. Do not be put off by this list as it can be incorporated into staff's normal workload if it is a small project. You may only be conducting a total of four focus groups, for example, in which case there is not too much information that needs to be analysed. You may not even need to analyse the information formally if, for example, health educators are involved in the collection of information and simply propose to discuss their findings with others before they proceed to develop an appropriate intervention. For projects that attempt to answer much larger questions, that try to look across more than one topic of interest, or that aim to use a wide range of methods, you may need to employ staff to work on the project full-time.
3.4 What will the selection criteria be for the staff?
As we have indicated, some projects may employ a number of staff specifically for the project, while others will be selecting staff who are already employed, for example, within a control programme or as local health workers. Regardless of the project size, we assume that staff with social science training are not available. However, we assume that all team members are literate, and if possible have completed high school.
Rather than make a long list of the skills required of each team member, it is recommended that you read the entire Manual before selecting staff. This will help you to have a better understanding of the method as well as what you will need to expect from each team member. Once you have decided how many staff you need, you will then need to write job descriptions for each position. This will help each team member know what his/her responsibilities will be in the project, as well as what the other team members will be doing. In addition, it will serve as a selection criteria for the staff.
3.5 Staff training
This is critical! Your whole project will depend on the commitment and skill of your team. Invest as much as possible in the training of the team. Once you have selected the staff, ensure that they are able to complete the training without distraction. Do not expect that it is reasonable to "fit it in" somewhere during the normal working day. Allow at least two full days for training on very small projects. If you have a larger project, or you intend to use the method regularly, then it is recommended that you allow five full days, not including field practice. The extra three days should be used for practical exercises and a more "hands-on" style of training. Larger projects will most certainly require a higher level of skill.
Part II of this Manual outlines the staff training component, and provides you with the main points necessary to understand and use focus groups. It is not designed to address the learning or training styles that may be necessary in your country.
Where will we conduct staff training?
You need to set aside a quiet area for staff training with quite a bit of room, especially if you want to practice the skills using artificial groups. If possible, try to conduct the training away from the office where staff can easily be distracted by normal work tasks.
Do we need a staff trainer?
This will depend on the size of the project and the resources available to you. For most projects you will not be able to have a special staff trainer, but you may be able to "borrow" a colleague who has experience in training. An experienced trainer is of great benefit, but is not essential. This Manual will provide you with all the information you need to pass on to the project team.