- Email: [email protected]
Focus Groups in Physiotherapy Evaluation and Research
189
SCHOLARLY PAPER
Focus Groups in Physiotherapy Evaluation and Research Julius S i m Jackie Snell Key Words Focus groups; research and evaluation; physiotherapy.
Summary The focus group is a form of group interview that is widely used in qualitative social science and market research. It has been applied in various areas of health care, especially health promotion and consumer satisfaction. Hitherto, little use seems to have made of this technique in physiotherapy. This paper explores the methodological characteristics of the focus group in relation to other methods of survey research, and examines some of its strengths and weaknesses. The nature and quality of focus group data are discussed, and the difficulty of obtaining individual, as opposed to collective, data is considered. It is emphasised that the group dynamics that occur within the focus group are crucial to the appropriateness or otherwise of this technique. An illustrative case study from physiotherapy is presented, concerning the construction of a patient-oriented outcome measurement tool. In conclusion, it is argued that the focus group technique, if used judiciously, offers considerable potential in physiotherapy evaluation and research.
Introduction A focus group can be defined as a group interview - centred on a specific topic (‘focus’)and facilitated and co-ordinated by a moderator or facilitator which seeks t o generate primarily qualitative data, by capitalising on the interaction that occurs within the group setting. The focus group is useful for exploring poorly understood areas, generating hypotheses, and studying the process of attitude formation and modification. The method is appropriate for exploratory and descriptive research questions, rather than for the formal testing of hypotheses.
colleagues in The Focused Interview (Merton et al, 1956). They described the group interview as a variant of this approach t o interviewing. Since then, the focus group has primarily been used in market research (Hague, 19931, but there has been a recent upsurge of interest in social science research, especially in evaluation research (Morgan and Krueger, 1993) and organisational research (Steyaert and Bouw,en, 1994). The focus group has attracted comparatively little attention in texts on professional health care research. However, the technique has been used in certain areas of health-related research. Focus groups are often advocated in relation to aspects of consumer satisfaction and quality assurance in health care (Peters, 1993; Rigge, 1994).They also have particular relevance to research within the sphere of health promotion (Basch, 19871, and a number of studies into health beliefs and illness behaviour have employed this technique. Thus, they have been used to investigate the attitudes, beliefs and self-reported behaviour of healthy factory foremen and their wives in Zaire (Irwin et al, 19911, and of black women at risk from HIV infection in the USA (Nyamathi and Shuler, 1990); t o explore beliefs about the risks and causes of heart attack (Morgan and Spanish, 1985); to examine risk-taking behaviour in relation t o drinking and driving (Basch et al, 1989); and t o study recruitment strategies for a programme of tobacco use cessation (Sussman et al, 1991).
While it has affinities with other group techniques such as ‘brainstorming’, problem-solving syndicate groups, quality circles, and the nominal group technique, the role of the focus group is distinct from these (Stewart and Shamdasani, 1990). The existence of a particular topic for discussion, the composition of the group, the specific role of the moderator, and the approach to data collection employed - each of which will be considered in more detail - are the hallmarks of the focus group, and distinguish it from other forms of group interview.
Relationship to Other Methods of Data Collection The most immediate comparison is with the conventional one-to-one interview. Two fundamental differences are apparent. The first of these is that in a one-to-one interview the main interaction is between the researcher and the respondent, whereas in a focus group it is among the group members. This provides an extra dimension to the data gathered, and may lead to a greater degree of spontaneity in the views expressed. Secondly, in a focus group the ‘agenda’ for discussion is inevitably predetermined t o a large degree; whereas the choice and nature of topic discussed in a one-to-one interview is often largely under the control of the respondent.
This approach t o research was first brought to prominence in the 1950s by Robert Merton and
Unlike questionnaire research, which generates predominantly quantitative data, the data
~~
Physiotherapy, March 1996, vol82, no 3
190
nature of the data (quantitative or qualitative) and their means of collection (structured or unstructured).
produced in focus groups are largely qualitative. The flexible structure of the focus group permits respondents t o express their views in terms of their own perceptions and definitions, whereas the traditional questionnaire study obliges informants t o respond in terms of the researcher’s own predetermined framework of concepts and meanings. The data obtained from a focus group usually possess greater depth than those yielded by questionnaires, but are less likely to be strictly representative of a particular population, owing t o the limited scope for probability sampling when setting up focus groups.
Applications In Physiotherapy There seems to be no previous literature relating t o the use of focus groups in physiotherapy. However, four main potential applications are identifiable: In general terms, focus groups are appropriate for exploring patients’ understanding and experience of, and attitudes towards, health and health care. The resulting insights are important for a patientcentred mode of practice, particularly in the context of health promotion.
Like the focus group, the Delphi technique makes use of a small collection of respondents (Reid, 1989; Reed, 1990). In this approach, however, the members of the panel of respondents never meet, and in this way interpersonal influences are deliberately excluded. The technique further differs from the focus group in having the specific purpose of identifying a consensus. In addition, the Delphi technique adopts a more structured approach t o the collection of data, based on postal questionnaires. The focus group may be used in an exploratory manner, prior t o survey research o r more formal hypothesis-testing studies. Fowler (1993) suggests t h a t focus groups should be a routine part of the early development of a survey research instrument. However, the focus group is not necessarily confined t o a n ancillary role, and Morgan argues that ‘there is no a priori reason to assume that focus groups, or any other qualitative techniques, require supplementation o r validation with quantitative techniques’ (Morgan, 1988, page 11).Indeed, there is no reason why focus groups should not be a means of developing and enriching the relatively superficial data that might emerge from prior quantitative research (Calder, 1977). Evidence can thereby be gained on the cognitive and social processes underlying individuals’ responses, and various quantitative patterns and relationships can be explored in more depth (Millward, 1995). The figure illustrates the relationship of the focus group to other methods, in terms of the
’
Audit, consumer satisfaction, and service needs analysis are recognised as important activities for physiotherapists (Merrall et al, 1991; CSP, 1994). The focus group has been identified as an appropriate method for conducting such evaluation of health care within a qualitative framework (Schroeder and Neil, 1992; Fizpatrick and Boulton, 1994). There is an increasing demand t o incorporate the consumer’s preferences in arrangements for the delivery of health care, rather than simply those of the professional providers themselves (Williamson, 1992; Rigge, 1994; Hopkins et al, 1994),and focus groups are a highly appropriate means of seeking the patient’s point of view on such matters. In studies of comparative treatment effectiveness, judgments as to the superiority of one treatment over another are commonly made on the basis of the quantitative measurement of ‘objective’variables. The use of techniques such as the focus group may complement these data by eliciting valuable information on the ‘subjective’ impact of different treatments on patients’ lives and their experience of illness or disability. Finally, the focus group has been advocated as a method of studying practitioners’ decision-making processes (DePoy and Gitlin, 1994);in the context of rehabilitation, this might involve exploring the ways in which therapists reach clinical decisions on diagnosis, goal-setting, or discharge. URstructured collection of primarily qualitative data
Structured collection of primarily quantitative data
,
Postal questionnaire
Structured interview or face-to-face questionnaire
Delphi technique
Focus group
Semi-structured or unstructured one-to-one interview
.I
Simplified illustration of relationship of focus group to other methods of gathering data on attitudes, beliefs and experiences. All but semi-structuredlunstructuredinterview can broadly be regarded as lying within the survey approach to research
Physiotherapy, March 1996, vol 82, no 3
191
The Focus Group Method Underlying the focus group method are a number of important considerations relating to the choice of respondents, the topic for discussion, and the role of the moderator. Generally speaking, respondents should have common experiences, interests and understanding; there should be a shared set of definitions within the group, relating t o the specific focus of the interview. Groups composed of very heterogeneous individuals are likely to be problematic (Stewart and Shamdasani, 19901, though a degree of diversity in the group may be beneficial in some cases. Equally, group members should be of roughly equal status, and be comparably articulate. It is helpful if they are previously unknown to each other, to minimise the effect of pre-existing personal relationships, and t o allow the exploration of potentially sensitive issues where appropriate. The topic should be one that lies within the experience o r expertise of participants, and which they will be happy t o discuss in a semi-public setting. Crucially, the topic should be one amenable t o exploration by qualitative means the focus is on people’s perceptions, attitudes, understandings, etc, not on their knowledge, or other factual data more amenable to quantitative modes of analysis. In order for the group to function effectively, the moderator should be skilled in the techniques of in-depth interviewing (Minichiello et a l , 1990), and adept at managing group dynamics. He or she should be passive, though not inert (Goldman, 1962). Indeed, insufficient participation on the part of the moderator may preclude a feeling of empathy and a n understanding of the group’s perspective (Calder, 1977).Hague (1993) suggests that the moderator’s input should be from onetwentieth to one-tenth of the resulting transcript. He or she should also be supportive and appreciative of all members and their contributions, and be seen to be impartial regarding the issues under discussion (Hague, 1993). In situations where a focus group is being run in order to assess the quality of a service, the moderator should not be identified with the service providers (Peters, 1993).
Running a Focus Group In outline, the usual stages in running a focus group are as follows: 1. Choice o f a suitable location. An informal, comfortable and private setting should be chosen, free from sources of visual o r auditory distraction (Basch, 1987; Krueger, 1994). The arrangement of seating should be such as not
to inhibit the participation of certain members of the group because of their position relative t o others. Each group member should be able to make eye-contact with any other participant, and with the moderator. In some instances, it may be useful t o run the group on ‘neutral’ territory; if the intention is t o evaluate the services offered by a physiotherapy department, participants may feel less constrained if the group is run elsewhere. 2. Preliminaries, such as ‘ice breaking’ activities, a general introduction by the moderator, distribution of stimulus materials (list of key topics, case studies, items for appraisal, etc), and time for individual collection of thoughts. Carey (1994) suggests that the provision of refreshments may fulfil a useful function at this stage. Depending on the nature of the topic, it may o r may not be useful for participants to identify themselves by name and brief biographical details. In the case of potentially sensitive topics, group members may find some degree of anonymity reassuring. 3. Explanation of the interview process. Specific reassurance should be given that contributions are sought from all members of the group, and that there are no ‘right’ or ‘wrong’answers to any questions posed by the moderator. The group should be assured that the data will not be published in a form that will threaten the anonymity of individual participants. When a tape-recorder is used, specific consent to this is generally sought (Carey and Smith, 1994; Peters, 1993; McDaniel and Bach, 1994). Participants should be encouraged to speak to one another, rather than to the moderator (Carey, 1994). 4. The group discussion itself, which normally lasts between one and two hours (Millward, 1995). The session should ideally be tape-recorded. However, some groups may find this threatening or inhibiting, in which case manual notes can be taken (Schroeder and Neil, 1992); this should usually be by someone other than the moderator. Questions should be open rather than closed, as the former will stimulate fuller and richer responses (Oppenheim, 1992; Millward, 1995). Krueger (1994) suggests that ‘why’ questions should be used with caution, and suggests that the reasons for individuals’ feelings or behaviour can be elicited by less direct means. He points out that: ‘The “why” question has a sharpness or pointedness to it that reminds one of interrogations. This sharpness sets off defensive barriers and the respondent tends to take a position on the socially acceptable side of controversial issues.’ (Krueger, 1994, page 59)
An appearance of relative naiveti2 or ‘incomplete understanding’ on the part of the moderator
Physiotherapy, March 1996, vol82, no 3
192
may help t o facilitate contributions from the group: ‘The moderator makes it clear that he or she is there t o learn from the participants’ (Millward, 1995, page 282).
of the group (Krueger, 1994).A ‘mini focus group’ of four to five members may be used, but this will limit the quantity and diversity of experience that can be drawn upon (Krueger, 1994).
5. Debriefing, which may usefully involve clarification of researcher’s impressions with the group. Members should be thanked for their contributions. Any notes taken should be checked for completeness and, if necessary, expanded as soon as possible after the event, when recall will be most accurate.
Methodological Strengths and Weaknesses of the Focus Group
6. Transcribing the proceedings. Basch (1987) suggests that this may take up to five hours for a one-hour group, and Millward (1995) estimates that a group lasting two hours will generate 40-50 pages of transcript. The transcript should be cross-referenced, where possible, with any notes made on the nature of the interaction that occurred during the group. 7. Coding and analysing the data. This typically involves the identification of significant ideas, concepts and supporting quotations within the transcript, allocating these to categories, and subsuming these categories under broader themes (Basch, 1987). Software packages are available to assist in this process (eg Ethnograph, NUD. IST).
How Many Groups and How Many Participants? A series of groups is usually conducted. This increases the total number of respondents, and allows homogeneous sub-categories of individuals within a wider population t o be studied. If the data from each group are analysed before conducting the next group, a ‘grounded theory’ approach may be incorporated, in which the analysis of one set of data influences the nature of the next phase of data collection (Strauss and Corbin, 1990). When subsequent groups appear to add little insight t o the findings of previous groups, a point of ‘saturation’ can be assumed to have been reached, and no further groups are necessary (Krueger, 1994). The size of the group can be crucial. ‘It should not be so large as t o be unwieldy o r t o preclude adequate participation by most members nor should it be so small that it fails t o provide substantially greater coverage than that of a n interview with one individual’ (Merton et al, 1956, page 137). The consensus in the literature seems to be that eight to twelve is a suitable number. Fewer participants may mean that one or two members become dominant, while a greater number of participants may be hard to manage and may inhibit some group members (Stewart and Shamdasani, 19901, or lead to fragmentation
Physiotherapy, March 1996, vol 82, no 3
The factors that constitute the strengths of the focus group can also be its weaknesses; much depends upon the identity of the group members, the skills of the moderator, and the nature of the topic.
‘Mix’of the Group Status differentials, dominant personalities, and various interpersonal sources of inhibition can undermine the process of expression and disclosure in a focus group. Merton et al (1956) found, in individual interviews conducted after a group interview, that lower status members would tend t o compare what more articulate members said with their own views, and consequently keep silent on many issues. This reflects early experimental work in social psychology, which demonstrated that, on matters of both factual and normative judgment, individuals who find themselves in a minority in a group situation are likely t o conform to the majority view (Asch, 1952; Deutsch and Gerard, 1955). Asch (1952) referred to this process as ‘yielding’, while Carey and Smith (1994) go further and talk of a phenomenon of ‘group mindlessness’. Merton et al (1956) also refer to a ‘leader effect’, whereby one or more participants may seek a dominant position in the group, and may vie with the moderator for control of the discussion. The sex mix of a group also influences the nature of the interaction (Aries, 1976). Sensitive issues may be readily aired in a homogeneous group, but repressed in a heterogeneous one, as participants may feel that people similar t o themselves may also have had such feelings or experiences. If a number of focus groups are conducted, the ‘mix’ of each can be varied somewhat, t o counteract the biasing effect of a particular group’s composition.
Group Context Respondents may be empowered t o a greater degree in a group setting than in one-to-one interviews. In social research, there is commonly an imbalance of power between interviewer and interviewee (Kelman, 1972). In a group situation, however, the presence of other participants of a similar background, and the simple fact that the moderator is ‘outnumbered’, may serve to redress this imbalance. One of the authors conducted a study of attitudes to organ donation among
193
members of the Asian community, in which a white female fieldworker was employed (Exley et al, 1996). A focus group was used t o counteract the cultural inhibitions that might have existed in a one-to-one interview. In the group situation, which took place on ‘home ground’ in a community setting, the respondents were interviewed among others of the same cultural background. This helped to minimise the effect of the researcher as an ‘outsider’.
The group also provides a sense of anonymity t o individual members (Heller et a l , 1990), which may further facilitate the expression of sensitive issues. Goldman (1962, page 63) points out: ‘The group provides support to its members in the expression of anxiety-provoking or socially unpopular ideas.’
At the point of analysis, however, the researcher should be aware that the data recorded may be more a record of the group dynamics of the interview situation than a specific account of the topic; it is important t o be clear which of these is the focus of interest. Indeed, the process of analysis may be quite problematic, for if transcripts alone are used, the dynamics of the group process are likely to be lost, and the data ‘decontextualised‘ (Carey and Smith, 1994). Along with recording the verbal interchange, it is advisable t o make field notes of some of the non-verbal interaction that took place.
Danger of a False Consensus So far as possible, the moderator should attempt t o pick up and facilitate divergent views. However, while some authors suggest that focus A focus group may be perceived as either a groups are a suitable means of establishing such natural or an artificial situation, depending on diversity of opinion among participants (eg the normal experiences of group members. The Schatzman and Strauss, 1973; Heller et al, 19901, context of a group discussion on a topic of common it is not at all clear that they are well poised t o interest may be more familiar t o a collection of do so. It is easy for the moderator, consciously or health professionals than to a group of patients. subconsciously, t o lead the group t o endorse a Much depends upon whether the moderator can preconceived hypothesis, and in the process t o conduct the session in a natural, unobtrusive suppress disagreement that may have existed manner. Indeed, the correct degree of control within the group. Moreover, the group dynamics exercised by the moderator is crucial - too that take place may cause a process of ‘censoring’ much and discussion is constrained o r biased, t o occur, whereby less dominant participants too little and the notion of ‘focus’ is lost. The are inhibited from expressing opinions that moderator has t o be able t o control the more are contrary t o the prevailing view (Carey and loquacious members of the group, encourage Smith, 1994). If a divergence of views does those who are less forthcoming, and keep emerge from the data, this will doubtless reflect the discussion on track, without in the process a corresponding underlying difference of undermining the natural, spontaneous nature opinion. However, the absence of such diversity of the proceedings. should not be taken as evidence of an underlying consensus. A feeling of conformity in The interaction that occurs in a focus group allows the data may merely be a n artefact of the respondents to develop and refine their views in group dynamics, and say little about the true the light of the views of others, in a ‘synergistic’ of opinion: spread manner (Stewart and Shamdasani, 1990, page 16). There may be a lively interchange and chal‘The shared understanding that comes from a group lenging of views among participants. This makes interaction may sometimes be important, but may it possible to study the way in which attitudes miss the subtle individual variations that can be and opinions are created and modulated vital to understanding a particular health concern.‘ (Crabtreeeta/, 1993, page 143). (Morgan, 19881, in contrast t o the rather static cross-sectional portrayal of attitudes that a I t has been suggested that getting participants questionnaire typically achieves (Ackroyd and t o complete a questionnaire before the group Hughes, 1992). To facilitate this process, the meets (Sussman et al, 1991), o r asking particimoderator should encourage group members t o pants t o write their views down before saying respond t o one another, not to the leader (Carey, them (Albrecht et a l , 19931, may help t o coun1994). If this fails to occur, and the moderator teract such conformity bias. becomes the channel for virtually all communication, what results is not so much a group A further problem is that a consensus view that discussion as ‘multiple o r serial interviewing’ already lies in one direction o r other on the atti(Goldman, 1962, page 61). It is important t o tude continuum may be exaggerated through remember that the interaction within a focus what is known as a group polarisation effect group is itself a valuable source of data, and (Turner, 1991). There may be not only a convershould not be regarded as ‘noise’ obscuring the gence but also an amplification of the prevalent group norm, together with a suppression of underlying attitudes or perceptions.
Physiotherapy,March 1996, vol 82, no 3
194
contrary viewpoints. A study by Sussman et ul (1991) confirmed this tendency, and suggested t h a t the role of the focus group may lie not so much in the generation of new ideas, but in allowing group members t o be exposed t o each other’s views. Fern (1982) found that focus groups tend to produce fewer ideas than nominal groups (ie where members of the group are interviewed individually). I t should be noted, however, that the quantitative approach taken in this particular study reveals little about the comparative nature or quality of the ideas generated by way of the two techniques. Indeed, the focus group seems to be in something of a quandary here. As previously noted, in order to provide productive and uninhibited discussion, a relatively homogeneous group should be chosen. However, this very homogeneity is likely to encourage a polarisation effect.
External Validity Even when several focus groups are conducted, the total number of participants is likely t o be relatively small. The selection of group members is usually on the basis of purposive sampling (Basch, 1987), and there is likely to be a further process of self-selection (certain individuals are more likely than others to agree to take part). These factors may all threaten the external validity of the findings obtained from focus groups. However, the technique is often used in studies of a n exploratory nature, where generalisability is not necessarily the primary concern. Indeed, Calder (1977, page 361) argues t h a t it is ‘misleading even t o speak about the generalisability of exploratory focus groups’. If it is important for a particular study to produce strictly representative findings, a larger scale survey, using some form of probability sampling, should be employed instead of, or in addition to, the use of focus groups. A less obvious threat to external validity stems from the dynamics of focus group methodology. An important consideration in qualitative research is that respondents’ accounts are ‘situated’, ie they are inescapably influenced, and thus specific to, the situation in which they are produced. Accordingly, there is a tendency to get ‘public’ accounts in a focus group (ie those subject t o a social acceptability bias), t o a greater degree than in a one-to-one interview. The data arising from focus groups are therefore firmly contextualised, and this may limit their generalisability. Because a group ‘has a chemistry and a dynamic that are greater than the sum of the members’ (Carey, 1994, page 233), we can
Physiotherapy, March 1996, vol82, no 3
never know whether the perceptions or interaction expressed in the group mirror those which would be found a t the level of the individual (Morgan, 1988). Moreover, Carey (1994) argues that the impact of the psychosocial factors that operate at the level of the group cannot be separated out from the resulting data. Hence, it may not be possible to interpolate from group t o individual. This has important implications for the analysis of focus group data.
Quality of Focus Group Data In addition to the notion of a false consensus and the question of external validity, there are a number of other issues that affect the quality of the findings derived from focus groups. First, the dynamics of the group setting may cause an artificial sense of veracity t o be attached to the data from a focus group. Stewart and Shamdasani (1990, page 17) comment: ‘The “live” and immediate nature of the interaction may lead a researcher o r decisionmaker t o place greater faith in the findings than is actually warranted.’ Secondly, the moderator may become too immersed in the group process to collect data efficiently or objectively. Having a moderator who is not also the researcher can help (Carey, 1994; McDaniel and Bach, 1994). Alternatively, in line with Denzin’s notion of ‘investigator triangulation’ (Denzin, 1989), the unobtrusive presence of a second researcher can serve to check the principal researcher’s interpretations during the subsequent analysis phase. Finally, although the focus group is often referred to a form of ‘depth interviewing’ (eg Goldman, 1962), there is a limit to the depth and richness of data that may be achieved. Indeed, Oppenheim (1992, page 79) suggests that focus groups are likely to be appropriate when the topic under consideration is ‘relatively straightforward’. By the very nature of the group situation, the time available for any individual to develop his or her views will be limited. Also, as noted above, there should be a relatively common frame of reference among the group. This limits the potential for exploring complex individual accounts in the way that can occur in one-to-one depth interviews conducted within a n ethnographic approach. Furthermore, the probing and detailed clarification that might occur in a one-to-one interview may be inappropriate in a group situation. While a breadth of views may be obtained, a more in-depth analysis may be difficult. In fact, for all its apparent flexibility, the focus group can probably achieve neither the exploratory depth nor, a t the other extreme, the control, of the individual interview.
195 ~~
Practical Experience of Using the Focus Group Interview The following case will illustrate one way in which focus groups have been used in physiotherapy. The group members were patients from an outpatient physiotherapy department, who had in common that they were currently attending for physiotherapy. However, a deliberate attempt was made to include a cross-section of diagnoses in each group as the moderator did not wish the focus of the interview t o centre on a particular diagnosis or its related problems o r treatment. The intention is not t o provide a detailed methodological description of the groups, nor a comprehensive account of the substantive findings. Rather, a summary of the groups will be given t o illustrate their overall operation and function.
Validating the Inclusion of Various Health Domains in a Patient-oriented Outcome Measurement Audit Tool As noted earlier, there is a strong move in the National Health Service towards obtaining and responding to patients’ own perceptions and opinions of all aspects of the service, from delivery through to outcome (Ahorny and Strasser, 1993). In line with this trend is the belief that the development of satisfaction surveys and instruments designed to measure outcome should be patientled (Rigge, 1994). The success of treatment has traditionally been assessed by recording one o r more objective clinical variables, but patients attach considerable importance to aspects of their health other than those measurable by simple objective measurements (Thomas and Little, 1980). They are concerned with the impact that health and illness have on their life, eg in respect of their ability to work, or to continue their leisure pursuits, or to fulfil their role as carers or parents. Self-completion health status questionnaires are often used to access this outcome information by allowing patients t o rate themselves in terms of pre-determined health domains. However, this assumes that the developer of the questionnaire knows which health domains are relevant and appropriate to the patient population. Patients can only agree or disagree, t o a greater or lesser extent, with the ideas proposed by the developer, and have little opportunity to express their own points of view, which are likely to be of more significance and importance for them. This example describes the development of a patient-oriented outcome measurement tool, to be used for audit purposes. A set of health domains had previously been arrived at using a consensus group approach with a group of experienced outpatient physiotherapists. As recommended in the
literature (UK Clearing House, 1993), these health domains reflected the clinical objectives of the out-patient service as a whole. To validate the inclusion of these health domains in this measurement tool, and to demonstrate that it was truly patient-oriented, focus group interviews were conducted with a group of patients. The patients were selected from a group attending the out-patient physiotherapy department at a certain time on a certain day, and represented various diagnoses and a mix of ages and sexes. The outcome measurement tool being validated was designed to be applicable across the whole of the musculoskeletal out-patient department and was not intended to be condition-specific. Therefore the moderator sought to maintain discussion at a generic level. The focus groups were assembled informally around a table in a quiet meeting room, away from the physiotherapy department, and refreshments were supplied. With each group, the moderator outlined the objectives of the interview, described how and for what purpose the outcome measurement tool would be used, and explained the way in which the information gained from these interviews would be used in its development. Anonymity was assured, and no record was made of the patients’ names or hospital numbers. Although a tape recorder would have been preferable as a means of data collection, this facility was not available, and manual notes were made of the proceedings. Each group lasted between one and 11/2hours, although no time constraints were applied. At the close of the interview, the notes taken were read back to the group, seeking confirmation that they were a n accurate and complete representation of the proceedings. In total five groups were conducted. At this point no new themes or categories were being generated, and saturation was deemed to have occurred. The data from the groups were given to four outpatient physiotherapists, who were requested to allocate the statements into themes. No guidance was given as t o the appropriate number of themes. The participating physiotherapists had not been involved with the drawing up of the health domains in the measurement tool, and were therefore unaware of the domains against which the patients’ responses were being validated. This method of analysis had the inevitable drawback of decontextualising the data from the interaction that occurred within the groups. However, it would have been inappropriate for the moderator, who had been privy to the initial selection of health domains for the outcome questionnaire, t o be involved in the analysis. Had this occurred, subconscious bias on the
Physiotherapy, March 1996, vol82, no 3
196
Themes identified by individual therapists during analysis of the focus group data Physiotherapist 1
Physiotherapist 2
Physiotherapist 3
Physiotherapist 4
Activities of daily living (including categories of driving, housework, and personal care)
Activities of daily living (including categories of driving, housework, personal care, and sleep)
Activities of daily living (including categories of driving, housework,and personal care)
Activities of daily living (including categories of driving, housework, and personal care)
Leisure (including categories of sport, and non-active pastimes)
Leisure (including categories of sport, and non-active pastimes)
Leisure
Leisure
Occupation
Occupation
Occupation
Sleep
Occupation (including categories of driving, and working)
Sleep
Independence (including categories of pain, specific activities, and self-reliance)
Psychological (including categories of independence, motivation, education, and confidence)
~
Pain and analgesia Education (including categories of knowledge of diagnosis, and knowledge of self-management techniques)
Education and motivation
part of the moderator might have caused the preconceived list of health domains t o be endorsed in the analysis of the data. The physiotherapists were encouraged not t o regard the frequency of the responses as relating t o any sort of priority, and were instructed not t o arrange the responses in any order as they classified them. The themes that emerged from the data analysis are shown in the table above. The four physiotherapists showed a remarkable consistency in the themes within which they placed the patients’ statements. Of particular interest was the association with the health domains previously nominated by the other group of expert physiotherapists. Overall, there was good correlation between these domains and the themes identified by the four therapists who coded the patients’ statements. There were two main areas of discrepancy. The first of these concerned the categorisation of pain. In the therapist-derived health domains, pain was considered as a concept in its own right, whereas in the patient-derived health domains, pain was usually described in terms of its functional impact, eg ‘it stops me from doing things’. In the analysis of the patient responses, only one physiotherapist classified pain as an independent theme. The second discrepancy had t o do with the ‘non-physical’ components of physiotherapy, eg motivation, confidence and education. Typical comments from the focus groups included: ‘I want t o know how t o stop it happening again.’ ‘She really gave me the confidence to try something I would never have dared t o if I hadn’t come here.’ ‘They keep you going, they keep moving the goal posts so you have t o
Physiotherapy, March 1996, vol 82, no 3
~~
Sleep Education and other (including categories of motivation, and confidence)
keep trying.’ The physiotherapist-derived health domains had not even considered the inclusion of a topic such as these, yet in each patientderived domain it appears as a theme, even though it may be labelled differently. This information is now being incorporated into the out-patient outcome measurement tool. Methods for evaluating the effect of therapy on motivation and confidence are being considered.
Conclusion The focus group is a relatively neglected method of qualitative research in physiotherapy. It offers considerable potential in the evaluation of physiotherapy services, and in gaining insight into patients’ experiences and perceptions of health and illness. It may also be used in the context of treatment effectiveness research, and to elucidate professional decision-making procedures. The technique should not, however, be used indiscriminately. If there is a requirement for largescale representative data of a primarily quantitative nature, conventional questionnaire studies are generally preferable as the primary means of data collection. Conversely, if the intention is to gain an in-depth understanding of feelings and experiences at the level of the individual, a one-toone interview is likely to be more appropriate. In many instances, however, the focus group can usefully be employed in combination with other techniques, either as a preliminary means of developing more structured data collection instruments, or as a method of expanding and enriching quantitative data gathered earlier. If used judiciously, with due attention t o its methodological strengths and weaknesses, the focus group offers considerable potential in physiotherapy evaluation and research.
197
Authors Julius Sim BA MSc MCSP is principal lecturer in research methods, School of Health and Social Sciences, Coventry University. Jackie Snell MCSP is a research physiotherapist in the departments of physiotherapy and occupational therapy, Coventry and Warwickshire Hospital. This article was received on May 12, 1995, and accepted on December 13, 1995.
Fern, E F (1982). ‘The use of focus groups for idea generation: The effects of group size, acquaintanceship, and moderator on response quantity and quality’, Journal of Marketing Research, 19, 1-13. Fizpatrick, R and Boulton, M (1994). ‘Qualitative methods for assessing health care’, Quality in Health Care, 3, 107-113. Fowler, F J (1993). Survey Research Methods (2nd edn) Sage Publications, Newbury Park. Goldman, A E (1962). ‘The group depth interview’, Journal of Marketing, 26, 61-68. Hague, P (1993). Interviewing, Kogan Page, London.
Address for Correspondence Mr J Sim, School of Health and Social Sciences, Coventry University, Priory Street, Coventry CV1 5FB.
References Ackroyd, S and Hughes, J (1992). Data Collection in Context, (2nd edn) Longman, London. Ahorny, L and Strasser, S (1993). ‘Patient satisfaction: What we know and what we still need to explore’, Medical Care Review, 50, 49-79. Albrecht, T L, Johnson, G M and Walther, J B (1993). ‘Understanding communication processes in focus groups’ in: Morgan, D L (ed) Successful Focus Groups: Advancing the state of the art, Sage Publications, Newbury Park. Aries, E (1976). ‘Interaction patterns and themes of male, female, and mixed groups’, Small Group Behavior, 7 , 7-18. Asch, S E (1952). ‘Effects of group pressure on the modification and distortion of judgments’ in: Swanson, G E, Newcomb, T M and Hartley, E L (eds) Readings in Social Psychology (revised edn) Holt, Rinehart and Winston, New York.
Heller, K E, Crockett, S J, Merkel, J M and Peterson, J M (1990). ‘Focus group interviews with seniors’, Journal of Nutrition for the .Elderly, 9, 89-100. Hopkins, A, Gabbay, J and Neuberger, J (1994). ‘Role of users of health care in achieving a quality service’, Quality in Health Care, 3, 203-209. Irwin, K, Bertrand, J, Mibandumba, K, Nzilambi, N, Bosenge, N, Ryder, R, Peterson, H, Lee, N C, Wingo, P, O’Reilly, K and Rufo, K (1991). ‘Knowledge, attitudes and beliefs about HIV infection and AIDS among healthy factory workers and their wives, Kinshasa, Zaire’, Social Science and Medicine, 32, 917-930. Kelman, H C (1972). ‘The rights of the subject in social research: An analysis in terms of relative power and legitimacy’, American Psychologist, 27, 989-1016. Krueger, R A (1994). Focus Groups: A practicalguide for applied research (2nd edn) Sage Publications, Thousand Oaks. McDaniel, R W and Bach, C A (1994). ‘Focus groups: A datagathering strategy for nursing research’, Nursing Science Quarterly, 7 , 4-5. Merrall, A, Patel, R and Taylor, J (1991). Audit for the Therapy Professions, Mercia Publications, Keele.
Basch, C E (1987). ‘Focus group interview: An underutilized research technique for improving theory and practice in health education’, Health Education Quarterly, 14, 41 1-448.
Merton, R K, Fiske, M and Kendall, P L (1956). The Focused Interview: A manual of problems and procedures, Free Press, Glencoe.
Basch, C E, DeCicco, I M and Malfetti, J L (1989). ‘A focus group study on decision processes of young drivers: Reasons that may support a decision to drink and drive’, Health Education Quarterly, 16, 389-396.
Millward, L J (1995). ‘Focus groups’ in: Breakwell, G M, Hammond, S and Fife-Schaw, C (eds) Research Methods in Psychology, Sage Publications, London.
Calder, B J (1977). ‘Focus groups and the nature of qualitative marketing research’, Journal of Marketing Research, 14, 353-364.
Minichiello, V, Aroni, R, Timewell, E and Alexander, L (1990). In-depth lnterviewing: Researching people, Longman Cheshire, Melbourne. Morgan, D L (1988). Focus Groups as Qualitative Research, Sage Publications, Newbury Park.
Carey, M A (1994). ‘The group effect in focus groups: Planning, implementing, and interpreting focus group research’ in: Morse, J M (ed) Critical Issues in Qualitative Research Methods, Sage Publications, Thousand Oaks.
Morgan, D L and Krueger R A (1993). ‘When to use focus groups and why’ in: Morgan, D L (ed) Successful Focus Groups: Advancing the state of the art, Sage Publications, Newbury Park.
Carey, M A and Smith M W (1994). ‘Capturing the group effect in focus groups: A special concern in analysis’, Qualitative Health Research, 4, 123-127.
Morgan, D L and Spanish, M T (1985). ‘Social interaction and the cognitive organisation of health-relevant knowledge’, Sociology of Health and Illness, 7 , 401 -422.
Chattered Society of Physiotherapy (1994). Information on Standard Setting, Audit and Outcome Measurement for Chartered Physiotherapists, CSP, London.
Nyamathi, A and Shuler, P (1990). ‘Focus group interview: A research technique for informed nursing practice’, Journal of Advanced Nursing, 15, 1281-88.
Crabtree, B F, Yanoshik, M K, Miller W L and O’Connor, P J (1993). ‘Selecting individual or group interviews’ in: Morgan, D L (ed) Successful Focus Groups: Advancing the state of the art, Sage Publications, Newbury Park.
Oppenheim, A N (1992). Questionnaire Design, lnterviewing and Attitude Measurement (new edn) Pinter Publishers, London. Peters, D A (1993). ‘Improving quality requires consumer input: using focus groups. Journal of Nursing Care Quality, 7, 34-41.
Denzin, N K (1989). The Research Act: A theoretical introduction to sociological methods (3rd edn) Prentice Hall, Englewood Cliffs.
Reed, A (1990). ‘An investigation into the problems involved in teaching electrotherapy and their possible solutions using the Delphi technique’, Physiotherapy Theory and Practice, 6, 9-16. Reid, N G (1989). ‘The Delphi technique: Its contribution to the evaluation of professional practice’ in: Ellis, R (ed) Professional Competence and Quality Assurance in the Caring Professions, Chapman and Hall, London. Rigge, M (1994). ‘Involving patients in clinical audit’, Quality in Health Care, 3(suppl), S2-S5. Schatzman, L and Strauss, A L (1973). Field Research: Strategies for a natural sociology, Prentice-Hall, Englewood Cliffs.
DePoy, E and Gitlin, L N (1994). lntroduction to Research: Multiple strategies for health and human services, Mosby, St Louis. Deutsch, M and Gerard, H B (1955). ‘A study of normative and informational social influences upon individual judgment’, Journal of Abnormal and Social Psychology, 51, 629-636. Exley, C, Sim, J, Reid, N G, Jackson, S and West, N (1996). ‘Attitudes and beliefs within the Sikh community regarding organ donation: A pilot study’, Social Science and Medicine (in press).
Physiotherapy, March 1996, vol82, no 3
198
Schroeder, C and Neil, R M (1992). 'Focus groups: A humanistic means of evaluating an HIV/AIDS programme based on caring theory', Journal of Clinical Nursing, 1, 265-274.
Thomas, M R and Little D (1980). 'Patient expectation about success of treatment and reported relief from low back pain', Journal of Psychosomatic Research, 24, 297-301.
Stewart, D W and Shamdasani, P N (1990). Focus Groups: Theory and practice, Sage Publications, Newbury Park.
Turner, J C (1991). Social Influence, Open University Press, Milton Keynes.
Steyaert, C and Bouwen, R (1994). 'Group methods of organizational analysis' in: Cassell, C and Symon, G (eds) Qualitative Methods in Organizational Research: A practical guide, Sage Publications, London.
UK Clearing House for Information on the Assessment of Health Outcomes (1 993). 'Issues in outcome measurement', Outcomes Briefing, Nuffield Institute for Health, University of Leeds, Leeds, 2, 16-22.
Strauss, A and Corbin, J (1990). Basics of Qualitative Research: Grounded theory procedures and techniques,Sage Publications, Newbury Park.
Williamson, C (1 992). Whose Standards? Consumer andprofessional standards in health care, Open University Press, Buckingham.
Sussman, S, Burton, D, Dent, C W, Stacy, A W and Flay, B R (1991). 'Use of focus groups in developing an adolescent tobacco use cessation program: Collective norm effects', Journal of Applied Social Psychology, 21, 1772-1782.
MEDICAL DEVICES AGENCY ADVERSE INCIDENT CENTRE
Safety Notices These notices are distributed to Regional general managers, chief executives of District Health Authorities and Health Commissions, chief executives of NHS trusts, general managers of directly managed units, managers of indpendent/private health care units and Family Health Services Authorities for GP practices. They should be available for consultation by employees. Summaries of relevant notices are given here. The full versions include action notes, background information and contact names. 9522: September
9525: October
Bayreuth standing frame - Failure of adjustment locks
Howmedica International Inc: Fracture and fragmentation of the large posterior cruciate retaining tibial component (6 mm) of the KinematiPtotal knee replacement
Adjustment locks on Bayreuth standing frames may become loose as a consequence of damage to their screw threads. Users should check the screw threads of the locks for signs of wear or damage. 9523: October
Wheelchairs - Removal and replacement of circlips Incidents have been reported to the Medical Devices Agency where wheels have come off wheelchairs while they have been in use. In one case injury was sustained by the user. In each case it was found on investigation that a deformed circlip or the wrong type of circlip has been used. Those carrying out repairs or maintenance on wheelchairs must ensure that circlips being fitted are to the specification and of the type recommended by the manufacturer. Deformed circlips must not be re-used. 9524: October
Wheelchair battery charger The Medical Devices Agency has been informed of a number of incidents where the front panel of Heayberd wheelchair battery chargers have been pushed inwards causing risk of a short circuit. Haeyberd wheelchair battery charges are obsolete and should be replaced at the earliest opportunity.
Physiotherapy, March 1996, vol 82, no 3
The Medical Devices Agency has received four reports of the fracture and fragmentation of the 6 mm Howmedica Kinematic large metal tibial component (Cat No 64715-406) necessitating revision. These failures occurred between six and nine years after implementation. Regular radiological examination of patients with these implants should be considered.
1996: 9601: January
Reporting adverse incidents relating to medical devices Action taken as a result of reporting adverse incidents to the Medical Devices Agency (MDA) contributes to the safety of patients, users and others, and the MDA analyses all reports received concerning medical devices. Where the results of investigations have implications for other patients or users, MDA issues a Hazard or other warning advising of hazardous products or unsafe procedures. Chief executives and other senior managers are responsible for ensuring adverse incidents relating to medical devices are promptly reported to the Medical Devices Agency's Adverse Incident Centre: this leaflet contains details of how to make such reports. Chief executives and other senior managers are also responsible for ensuring prompt action is taken on receipt of Hazard or other warning notification. 9605: January
9528: October
Medix two-pin universal mains leads: Risk of electric shock The Medical Devices Agency has received a report of a nurse receiving an electric shock from a Medix two-pin universal mains lead. The lead was supplied with a Medix nebuliser, but was being used with another piece of medical equipment. Medix Limited is recalling the affected two-pin universal mains leads supplied with its nebulisers. Users are advised to identify and return the leads to Medix for free replacements. 9529: November
Radcliffe Rehabilitation Services: Failure of Mk / I Shadow wheelbase Seat tubes have failed in service. A modification kit should be fitted to all affected Shadow Mk II wheelbases.
Powered wheelchairs fitted with Fracmo motors: Possible brake defects Investigation of reported incidents have revealed a number of defects that may affect powered wheelchairs fitted with Fracmo motors. These are: 1 . The brake drive hub had been omitted from the motor at the assembly stage. 2. The grub screw intended to retain the brake hub in position had been insufficiently tightened. 3. Some motors where the rating plate indicated that 12 volt brakes should have been fitted, had been fitted with 24 volt brakes. Powered wheelchairs should be examined and rectified as necessary as part of normal servicing procedures.
SCHOLARLY PAPER
Focus Groups in Physiotherapy Evaluation and Research Julius S i m Jackie Snell Key Words Focus groups; research and evaluation; physiotherapy.
Summary The focus group is a form of group interview that is widely used in qualitative social science and market research. It has been applied in various areas of health care, especially health promotion and consumer satisfaction. Hitherto, little use seems to have made of this technique in physiotherapy. This paper explores the methodological characteristics of the focus group in relation to other methods of survey research, and examines some of its strengths and weaknesses. The nature and quality of focus group data are discussed, and the difficulty of obtaining individual, as opposed to collective, data is considered. It is emphasised that the group dynamics that occur within the focus group are crucial to the appropriateness or otherwise of this technique. An illustrative case study from physiotherapy is presented, concerning the construction of a patient-oriented outcome measurement tool. In conclusion, it is argued that the focus group technique, if used judiciously, offers considerable potential in physiotherapy evaluation and research.
Introduction A focus group can be defined as a group interview - centred on a specific topic (‘focus’)and facilitated and co-ordinated by a moderator or facilitator which seeks t o generate primarily qualitative data, by capitalising on the interaction that occurs within the group setting. The focus group is useful for exploring poorly understood areas, generating hypotheses, and studying the process of attitude formation and modification. The method is appropriate for exploratory and descriptive research questions, rather than for the formal testing of hypotheses.
colleagues in The Focused Interview (Merton et al, 1956). They described the group interview as a variant of this approach t o interviewing. Since then, the focus group has primarily been used in market research (Hague, 19931, but there has been a recent upsurge of interest in social science research, especially in evaluation research (Morgan and Krueger, 1993) and organisational research (Steyaert and Bouw,en, 1994). The focus group has attracted comparatively little attention in texts on professional health care research. However, the technique has been used in certain areas of health-related research. Focus groups are often advocated in relation to aspects of consumer satisfaction and quality assurance in health care (Peters, 1993; Rigge, 1994).They also have particular relevance to research within the sphere of health promotion (Basch, 19871, and a number of studies into health beliefs and illness behaviour have employed this technique. Thus, they have been used to investigate the attitudes, beliefs and self-reported behaviour of healthy factory foremen and their wives in Zaire (Irwin et al, 19911, and of black women at risk from HIV infection in the USA (Nyamathi and Shuler, 1990); t o explore beliefs about the risks and causes of heart attack (Morgan and Spanish, 1985); to examine risk-taking behaviour in relation t o drinking and driving (Basch et al, 1989); and t o study recruitment strategies for a programme of tobacco use cessation (Sussman et al, 1991).
While it has affinities with other group techniques such as ‘brainstorming’, problem-solving syndicate groups, quality circles, and the nominal group technique, the role of the focus group is distinct from these (Stewart and Shamdasani, 1990). The existence of a particular topic for discussion, the composition of the group, the specific role of the moderator, and the approach to data collection employed - each of which will be considered in more detail - are the hallmarks of the focus group, and distinguish it from other forms of group interview.
Relationship to Other Methods of Data Collection The most immediate comparison is with the conventional one-to-one interview. Two fundamental differences are apparent. The first of these is that in a one-to-one interview the main interaction is between the researcher and the respondent, whereas in a focus group it is among the group members. This provides an extra dimension to the data gathered, and may lead to a greater degree of spontaneity in the views expressed. Secondly, in a focus group the ‘agenda’ for discussion is inevitably predetermined t o a large degree; whereas the choice and nature of topic discussed in a one-to-one interview is often largely under the control of the respondent.
This approach t o research was first brought to prominence in the 1950s by Robert Merton and
Unlike questionnaire research, which generates predominantly quantitative data, the data
~~
Physiotherapy, March 1996, vol82, no 3
190
nature of the data (quantitative or qualitative) and their means of collection (structured or unstructured).
produced in focus groups are largely qualitative. The flexible structure of the focus group permits respondents t o express their views in terms of their own perceptions and definitions, whereas the traditional questionnaire study obliges informants t o respond in terms of the researcher’s own predetermined framework of concepts and meanings. The data obtained from a focus group usually possess greater depth than those yielded by questionnaires, but are less likely to be strictly representative of a particular population, owing t o the limited scope for probability sampling when setting up focus groups.
Applications In Physiotherapy There seems to be no previous literature relating t o the use of focus groups in physiotherapy. However, four main potential applications are identifiable: In general terms, focus groups are appropriate for exploring patients’ understanding and experience of, and attitudes towards, health and health care. The resulting insights are important for a patientcentred mode of practice, particularly in the context of health promotion.
Like the focus group, the Delphi technique makes use of a small collection of respondents (Reid, 1989; Reed, 1990). In this approach, however, the members of the panel of respondents never meet, and in this way interpersonal influences are deliberately excluded. The technique further differs from the focus group in having the specific purpose of identifying a consensus. In addition, the Delphi technique adopts a more structured approach t o the collection of data, based on postal questionnaires. The focus group may be used in an exploratory manner, prior t o survey research o r more formal hypothesis-testing studies. Fowler (1993) suggests t h a t focus groups should be a routine part of the early development of a survey research instrument. However, the focus group is not necessarily confined t o a n ancillary role, and Morgan argues that ‘there is no a priori reason to assume that focus groups, or any other qualitative techniques, require supplementation o r validation with quantitative techniques’ (Morgan, 1988, page 11).Indeed, there is no reason why focus groups should not be a means of developing and enriching the relatively superficial data that might emerge from prior quantitative research (Calder, 1977). Evidence can thereby be gained on the cognitive and social processes underlying individuals’ responses, and various quantitative patterns and relationships can be explored in more depth (Millward, 1995). The figure illustrates the relationship of the focus group to other methods, in terms of the
’
Audit, consumer satisfaction, and service needs analysis are recognised as important activities for physiotherapists (Merrall et al, 1991; CSP, 1994). The focus group has been identified as an appropriate method for conducting such evaluation of health care within a qualitative framework (Schroeder and Neil, 1992; Fizpatrick and Boulton, 1994). There is an increasing demand t o incorporate the consumer’s preferences in arrangements for the delivery of health care, rather than simply those of the professional providers themselves (Williamson, 1992; Rigge, 1994; Hopkins et al, 1994),and focus groups are a highly appropriate means of seeking the patient’s point of view on such matters. In studies of comparative treatment effectiveness, judgments as to the superiority of one treatment over another are commonly made on the basis of the quantitative measurement of ‘objective’variables. The use of techniques such as the focus group may complement these data by eliciting valuable information on the ‘subjective’ impact of different treatments on patients’ lives and their experience of illness or disability. Finally, the focus group has been advocated as a method of studying practitioners’ decision-making processes (DePoy and Gitlin, 1994);in the context of rehabilitation, this might involve exploring the ways in which therapists reach clinical decisions on diagnosis, goal-setting, or discharge. URstructured collection of primarily qualitative data
Structured collection of primarily quantitative data
,
Postal questionnaire
Structured interview or face-to-face questionnaire
Delphi technique
Focus group
Semi-structured or unstructured one-to-one interview
.I
Simplified illustration of relationship of focus group to other methods of gathering data on attitudes, beliefs and experiences. All but semi-structuredlunstructuredinterview can broadly be regarded as lying within the survey approach to research
Physiotherapy, March 1996, vol 82, no 3
191
The Focus Group Method Underlying the focus group method are a number of important considerations relating to the choice of respondents, the topic for discussion, and the role of the moderator. Generally speaking, respondents should have common experiences, interests and understanding; there should be a shared set of definitions within the group, relating t o the specific focus of the interview. Groups composed of very heterogeneous individuals are likely to be problematic (Stewart and Shamdasani, 19901, though a degree of diversity in the group may be beneficial in some cases. Equally, group members should be of roughly equal status, and be comparably articulate. It is helpful if they are previously unknown to each other, to minimise the effect of pre-existing personal relationships, and t o allow the exploration of potentially sensitive issues where appropriate. The topic should be one that lies within the experience o r expertise of participants, and which they will be happy t o discuss in a semi-public setting. Crucially, the topic should be one amenable t o exploration by qualitative means the focus is on people’s perceptions, attitudes, understandings, etc, not on their knowledge, or other factual data more amenable to quantitative modes of analysis. In order for the group to function effectively, the moderator should be skilled in the techniques of in-depth interviewing (Minichiello et a l , 1990), and adept at managing group dynamics. He or she should be passive, though not inert (Goldman, 1962). Indeed, insufficient participation on the part of the moderator may preclude a feeling of empathy and a n understanding of the group’s perspective (Calder, 1977).Hague (1993) suggests that the moderator’s input should be from onetwentieth to one-tenth of the resulting transcript. He or she should also be supportive and appreciative of all members and their contributions, and be seen to be impartial regarding the issues under discussion (Hague, 1993). In situations where a focus group is being run in order to assess the quality of a service, the moderator should not be identified with the service providers (Peters, 1993).
Running a Focus Group In outline, the usual stages in running a focus group are as follows: 1. Choice o f a suitable location. An informal, comfortable and private setting should be chosen, free from sources of visual o r auditory distraction (Basch, 1987; Krueger, 1994). The arrangement of seating should be such as not
to inhibit the participation of certain members of the group because of their position relative t o others. Each group member should be able to make eye-contact with any other participant, and with the moderator. In some instances, it may be useful t o run the group on ‘neutral’ territory; if the intention is t o evaluate the services offered by a physiotherapy department, participants may feel less constrained if the group is run elsewhere. 2. Preliminaries, such as ‘ice breaking’ activities, a general introduction by the moderator, distribution of stimulus materials (list of key topics, case studies, items for appraisal, etc), and time for individual collection of thoughts. Carey (1994) suggests that the provision of refreshments may fulfil a useful function at this stage. Depending on the nature of the topic, it may o r may not be useful for participants to identify themselves by name and brief biographical details. In the case of potentially sensitive topics, group members may find some degree of anonymity reassuring. 3. Explanation of the interview process. Specific reassurance should be given that contributions are sought from all members of the group, and that there are no ‘right’ or ‘wrong’answers to any questions posed by the moderator. The group should be assured that the data will not be published in a form that will threaten the anonymity of individual participants. When a tape-recorder is used, specific consent to this is generally sought (Carey and Smith, 1994; Peters, 1993; McDaniel and Bach, 1994). Participants should be encouraged to speak to one another, rather than to the moderator (Carey, 1994). 4. The group discussion itself, which normally lasts between one and two hours (Millward, 1995). The session should ideally be tape-recorded. However, some groups may find this threatening or inhibiting, in which case manual notes can be taken (Schroeder and Neil, 1992); this should usually be by someone other than the moderator. Questions should be open rather than closed, as the former will stimulate fuller and richer responses (Oppenheim, 1992; Millward, 1995). Krueger (1994) suggests that ‘why’ questions should be used with caution, and suggests that the reasons for individuals’ feelings or behaviour can be elicited by less direct means. He points out that: ‘The “why” question has a sharpness or pointedness to it that reminds one of interrogations. This sharpness sets off defensive barriers and the respondent tends to take a position on the socially acceptable side of controversial issues.’ (Krueger, 1994, page 59)
An appearance of relative naiveti2 or ‘incomplete understanding’ on the part of the moderator
Physiotherapy, March 1996, vol82, no 3
192
may help t o facilitate contributions from the group: ‘The moderator makes it clear that he or she is there t o learn from the participants’ (Millward, 1995, page 282).
of the group (Krueger, 1994).A ‘mini focus group’ of four to five members may be used, but this will limit the quantity and diversity of experience that can be drawn upon (Krueger, 1994).
5. Debriefing, which may usefully involve clarification of researcher’s impressions with the group. Members should be thanked for their contributions. Any notes taken should be checked for completeness and, if necessary, expanded as soon as possible after the event, when recall will be most accurate.
Methodological Strengths and Weaknesses of the Focus Group
6. Transcribing the proceedings. Basch (1987) suggests that this may take up to five hours for a one-hour group, and Millward (1995) estimates that a group lasting two hours will generate 40-50 pages of transcript. The transcript should be cross-referenced, where possible, with any notes made on the nature of the interaction that occurred during the group. 7. Coding and analysing the data. This typically involves the identification of significant ideas, concepts and supporting quotations within the transcript, allocating these to categories, and subsuming these categories under broader themes (Basch, 1987). Software packages are available to assist in this process (eg Ethnograph, NUD. IST).
How Many Groups and How Many Participants? A series of groups is usually conducted. This increases the total number of respondents, and allows homogeneous sub-categories of individuals within a wider population t o be studied. If the data from each group are analysed before conducting the next group, a ‘grounded theory’ approach may be incorporated, in which the analysis of one set of data influences the nature of the next phase of data collection (Strauss and Corbin, 1990). When subsequent groups appear to add little insight t o the findings of previous groups, a point of ‘saturation’ can be assumed to have been reached, and no further groups are necessary (Krueger, 1994). The size of the group can be crucial. ‘It should not be so large as t o be unwieldy o r t o preclude adequate participation by most members nor should it be so small that it fails t o provide substantially greater coverage than that of a n interview with one individual’ (Merton et al, 1956, page 137). The consensus in the literature seems to be that eight to twelve is a suitable number. Fewer participants may mean that one or two members become dominant, while a greater number of participants may be hard to manage and may inhibit some group members (Stewart and Shamdasani, 19901, or lead to fragmentation
Physiotherapy, March 1996, vol 82, no 3
The factors that constitute the strengths of the focus group can also be its weaknesses; much depends upon the identity of the group members, the skills of the moderator, and the nature of the topic.
‘Mix’of the Group Status differentials, dominant personalities, and various interpersonal sources of inhibition can undermine the process of expression and disclosure in a focus group. Merton et al (1956) found, in individual interviews conducted after a group interview, that lower status members would tend t o compare what more articulate members said with their own views, and consequently keep silent on many issues. This reflects early experimental work in social psychology, which demonstrated that, on matters of both factual and normative judgment, individuals who find themselves in a minority in a group situation are likely t o conform to the majority view (Asch, 1952; Deutsch and Gerard, 1955). Asch (1952) referred to this process as ‘yielding’, while Carey and Smith (1994) go further and talk of a phenomenon of ‘group mindlessness’. Merton et al (1956) also refer to a ‘leader effect’, whereby one or more participants may seek a dominant position in the group, and may vie with the moderator for control of the discussion. The sex mix of a group also influences the nature of the interaction (Aries, 1976). Sensitive issues may be readily aired in a homogeneous group, but repressed in a heterogeneous one, as participants may feel that people similar t o themselves may also have had such feelings or experiences. If a number of focus groups are conducted, the ‘mix’ of each can be varied somewhat, t o counteract the biasing effect of a particular group’s composition.
Group Context Respondents may be empowered t o a greater degree in a group setting than in one-to-one interviews. In social research, there is commonly an imbalance of power between interviewer and interviewee (Kelman, 1972). In a group situation, however, the presence of other participants of a similar background, and the simple fact that the moderator is ‘outnumbered’, may serve to redress this imbalance. One of the authors conducted a study of attitudes to organ donation among
193
members of the Asian community, in which a white female fieldworker was employed (Exley et al, 1996). A focus group was used t o counteract the cultural inhibitions that might have existed in a one-to-one interview. In the group situation, which took place on ‘home ground’ in a community setting, the respondents were interviewed among others of the same cultural background. This helped to minimise the effect of the researcher as an ‘outsider’.
The group also provides a sense of anonymity t o individual members (Heller et a l , 1990), which may further facilitate the expression of sensitive issues. Goldman (1962, page 63) points out: ‘The group provides support to its members in the expression of anxiety-provoking or socially unpopular ideas.’
At the point of analysis, however, the researcher should be aware that the data recorded may be more a record of the group dynamics of the interview situation than a specific account of the topic; it is important t o be clear which of these is the focus of interest. Indeed, the process of analysis may be quite problematic, for if transcripts alone are used, the dynamics of the group process are likely to be lost, and the data ‘decontextualised‘ (Carey and Smith, 1994). Along with recording the verbal interchange, it is advisable t o make field notes of some of the non-verbal interaction that took place.
Danger of a False Consensus So far as possible, the moderator should attempt t o pick up and facilitate divergent views. However, while some authors suggest that focus A focus group may be perceived as either a groups are a suitable means of establishing such natural or an artificial situation, depending on diversity of opinion among participants (eg the normal experiences of group members. The Schatzman and Strauss, 1973; Heller et al, 19901, context of a group discussion on a topic of common it is not at all clear that they are well poised t o interest may be more familiar t o a collection of do so. It is easy for the moderator, consciously or health professionals than to a group of patients. subconsciously, t o lead the group t o endorse a Much depends upon whether the moderator can preconceived hypothesis, and in the process t o conduct the session in a natural, unobtrusive suppress disagreement that may have existed manner. Indeed, the correct degree of control within the group. Moreover, the group dynamics exercised by the moderator is crucial - too that take place may cause a process of ‘censoring’ much and discussion is constrained o r biased, t o occur, whereby less dominant participants too little and the notion of ‘focus’ is lost. The are inhibited from expressing opinions that moderator has t o be able t o control the more are contrary t o the prevailing view (Carey and loquacious members of the group, encourage Smith, 1994). If a divergence of views does those who are less forthcoming, and keep emerge from the data, this will doubtless reflect the discussion on track, without in the process a corresponding underlying difference of undermining the natural, spontaneous nature opinion. However, the absence of such diversity of the proceedings. should not be taken as evidence of an underlying consensus. A feeling of conformity in The interaction that occurs in a focus group allows the data may merely be a n artefact of the respondents to develop and refine their views in group dynamics, and say little about the true the light of the views of others, in a ‘synergistic’ of opinion: spread manner (Stewart and Shamdasani, 1990, page 16). There may be a lively interchange and chal‘The shared understanding that comes from a group lenging of views among participants. This makes interaction may sometimes be important, but may it possible to study the way in which attitudes miss the subtle individual variations that can be and opinions are created and modulated vital to understanding a particular health concern.‘ (Crabtreeeta/, 1993, page 143). (Morgan, 19881, in contrast t o the rather static cross-sectional portrayal of attitudes that a I t has been suggested that getting participants questionnaire typically achieves (Ackroyd and t o complete a questionnaire before the group Hughes, 1992). To facilitate this process, the meets (Sussman et al, 1991), o r asking particimoderator should encourage group members t o pants t o write their views down before saying respond t o one another, not to the leader (Carey, them (Albrecht et a l , 19931, may help t o coun1994). If this fails to occur, and the moderator teract such conformity bias. becomes the channel for virtually all communication, what results is not so much a group A further problem is that a consensus view that discussion as ‘multiple o r serial interviewing’ already lies in one direction o r other on the atti(Goldman, 1962, page 61). It is important t o tude continuum may be exaggerated through remember that the interaction within a focus what is known as a group polarisation effect group is itself a valuable source of data, and (Turner, 1991). There may be not only a convershould not be regarded as ‘noise’ obscuring the gence but also an amplification of the prevalent group norm, together with a suppression of underlying attitudes or perceptions.
Physiotherapy,March 1996, vol 82, no 3
194
contrary viewpoints. A study by Sussman et ul (1991) confirmed this tendency, and suggested t h a t the role of the focus group may lie not so much in the generation of new ideas, but in allowing group members t o be exposed t o each other’s views. Fern (1982) found that focus groups tend to produce fewer ideas than nominal groups (ie where members of the group are interviewed individually). I t should be noted, however, that the quantitative approach taken in this particular study reveals little about the comparative nature or quality of the ideas generated by way of the two techniques. Indeed, the focus group seems to be in something of a quandary here. As previously noted, in order to provide productive and uninhibited discussion, a relatively homogeneous group should be chosen. However, this very homogeneity is likely to encourage a polarisation effect.
External Validity Even when several focus groups are conducted, the total number of participants is likely t o be relatively small. The selection of group members is usually on the basis of purposive sampling (Basch, 1987), and there is likely to be a further process of self-selection (certain individuals are more likely than others to agree to take part). These factors may all threaten the external validity of the findings obtained from focus groups. However, the technique is often used in studies of a n exploratory nature, where generalisability is not necessarily the primary concern. Indeed, Calder (1977, page 361) argues t h a t it is ‘misleading even t o speak about the generalisability of exploratory focus groups’. If it is important for a particular study to produce strictly representative findings, a larger scale survey, using some form of probability sampling, should be employed instead of, or in addition to, the use of focus groups. A less obvious threat to external validity stems from the dynamics of focus group methodology. An important consideration in qualitative research is that respondents’ accounts are ‘situated’, ie they are inescapably influenced, and thus specific to, the situation in which they are produced. Accordingly, there is a tendency to get ‘public’ accounts in a focus group (ie those subject t o a social acceptability bias), t o a greater degree than in a one-to-one interview. The data arising from focus groups are therefore firmly contextualised, and this may limit their generalisability. Because a group ‘has a chemistry and a dynamic that are greater than the sum of the members’ (Carey, 1994, page 233), we can
Physiotherapy, March 1996, vol82, no 3
never know whether the perceptions or interaction expressed in the group mirror those which would be found a t the level of the individual (Morgan, 1988). Moreover, Carey (1994) argues that the impact of the psychosocial factors that operate at the level of the group cannot be separated out from the resulting data. Hence, it may not be possible to interpolate from group t o individual. This has important implications for the analysis of focus group data.
Quality of Focus Group Data In addition to the notion of a false consensus and the question of external validity, there are a number of other issues that affect the quality of the findings derived from focus groups. First, the dynamics of the group setting may cause an artificial sense of veracity t o be attached to the data from a focus group. Stewart and Shamdasani (1990, page 17) comment: ‘The “live” and immediate nature of the interaction may lead a researcher o r decisionmaker t o place greater faith in the findings than is actually warranted.’ Secondly, the moderator may become too immersed in the group process to collect data efficiently or objectively. Having a moderator who is not also the researcher can help (Carey, 1994; McDaniel and Bach, 1994). Alternatively, in line with Denzin’s notion of ‘investigator triangulation’ (Denzin, 1989), the unobtrusive presence of a second researcher can serve to check the principal researcher’s interpretations during the subsequent analysis phase. Finally, although the focus group is often referred to a form of ‘depth interviewing’ (eg Goldman, 1962), there is a limit to the depth and richness of data that may be achieved. Indeed, Oppenheim (1992, page 79) suggests that focus groups are likely to be appropriate when the topic under consideration is ‘relatively straightforward’. By the very nature of the group situation, the time available for any individual to develop his or her views will be limited. Also, as noted above, there should be a relatively common frame of reference among the group. This limits the potential for exploring complex individual accounts in the way that can occur in one-to-one depth interviews conducted within a n ethnographic approach. Furthermore, the probing and detailed clarification that might occur in a one-to-one interview may be inappropriate in a group situation. While a breadth of views may be obtained, a more in-depth analysis may be difficult. In fact, for all its apparent flexibility, the focus group can probably achieve neither the exploratory depth nor, a t the other extreme, the control, of the individual interview.
195 ~~
Practical Experience of Using the Focus Group Interview The following case will illustrate one way in which focus groups have been used in physiotherapy. The group members were patients from an outpatient physiotherapy department, who had in common that they were currently attending for physiotherapy. However, a deliberate attempt was made to include a cross-section of diagnoses in each group as the moderator did not wish the focus of the interview t o centre on a particular diagnosis or its related problems o r treatment. The intention is not t o provide a detailed methodological description of the groups, nor a comprehensive account of the substantive findings. Rather, a summary of the groups will be given t o illustrate their overall operation and function.
Validating the Inclusion of Various Health Domains in a Patient-oriented Outcome Measurement Audit Tool As noted earlier, there is a strong move in the National Health Service towards obtaining and responding to patients’ own perceptions and opinions of all aspects of the service, from delivery through to outcome (Ahorny and Strasser, 1993). In line with this trend is the belief that the development of satisfaction surveys and instruments designed to measure outcome should be patientled (Rigge, 1994). The success of treatment has traditionally been assessed by recording one o r more objective clinical variables, but patients attach considerable importance to aspects of their health other than those measurable by simple objective measurements (Thomas and Little, 1980). They are concerned with the impact that health and illness have on their life, eg in respect of their ability to work, or to continue their leisure pursuits, or to fulfil their role as carers or parents. Self-completion health status questionnaires are often used to access this outcome information by allowing patients t o rate themselves in terms of pre-determined health domains. However, this assumes that the developer of the questionnaire knows which health domains are relevant and appropriate to the patient population. Patients can only agree or disagree, t o a greater or lesser extent, with the ideas proposed by the developer, and have little opportunity to express their own points of view, which are likely to be of more significance and importance for them. This example describes the development of a patient-oriented outcome measurement tool, to be used for audit purposes. A set of health domains had previously been arrived at using a consensus group approach with a group of experienced outpatient physiotherapists. As recommended in the
literature (UK Clearing House, 1993), these health domains reflected the clinical objectives of the out-patient service as a whole. To validate the inclusion of these health domains in this measurement tool, and to demonstrate that it was truly patient-oriented, focus group interviews were conducted with a group of patients. The patients were selected from a group attending the out-patient physiotherapy department at a certain time on a certain day, and represented various diagnoses and a mix of ages and sexes. The outcome measurement tool being validated was designed to be applicable across the whole of the musculoskeletal out-patient department and was not intended to be condition-specific. Therefore the moderator sought to maintain discussion at a generic level. The focus groups were assembled informally around a table in a quiet meeting room, away from the physiotherapy department, and refreshments were supplied. With each group, the moderator outlined the objectives of the interview, described how and for what purpose the outcome measurement tool would be used, and explained the way in which the information gained from these interviews would be used in its development. Anonymity was assured, and no record was made of the patients’ names or hospital numbers. Although a tape recorder would have been preferable as a means of data collection, this facility was not available, and manual notes were made of the proceedings. Each group lasted between one and 11/2hours, although no time constraints were applied. At the close of the interview, the notes taken were read back to the group, seeking confirmation that they were a n accurate and complete representation of the proceedings. In total five groups were conducted. At this point no new themes or categories were being generated, and saturation was deemed to have occurred. The data from the groups were given to four outpatient physiotherapists, who were requested to allocate the statements into themes. No guidance was given as t o the appropriate number of themes. The participating physiotherapists had not been involved with the drawing up of the health domains in the measurement tool, and were therefore unaware of the domains against which the patients’ responses were being validated. This method of analysis had the inevitable drawback of decontextualising the data from the interaction that occurred within the groups. However, it would have been inappropriate for the moderator, who had been privy to the initial selection of health domains for the outcome questionnaire, t o be involved in the analysis. Had this occurred, subconscious bias on the
Physiotherapy, March 1996, vol82, no 3
196
Themes identified by individual therapists during analysis of the focus group data Physiotherapist 1
Physiotherapist 2
Physiotherapist 3
Physiotherapist 4
Activities of daily living (including categories of driving, housework, and personal care)
Activities of daily living (including categories of driving, housework, personal care, and sleep)
Activities of daily living (including categories of driving, housework,and personal care)
Activities of daily living (including categories of driving, housework, and personal care)
Leisure (including categories of sport, and non-active pastimes)
Leisure (including categories of sport, and non-active pastimes)
Leisure
Leisure
Occupation
Occupation
Occupation
Sleep
Occupation (including categories of driving, and working)
Sleep
Independence (including categories of pain, specific activities, and self-reliance)
Psychological (including categories of independence, motivation, education, and confidence)
~
Pain and analgesia Education (including categories of knowledge of diagnosis, and knowledge of self-management techniques)
Education and motivation
part of the moderator might have caused the preconceived list of health domains t o be endorsed in the analysis of the data. The physiotherapists were encouraged not t o regard the frequency of the responses as relating t o any sort of priority, and were instructed not t o arrange the responses in any order as they classified them. The themes that emerged from the data analysis are shown in the table above. The four physiotherapists showed a remarkable consistency in the themes within which they placed the patients’ statements. Of particular interest was the association with the health domains previously nominated by the other group of expert physiotherapists. Overall, there was good correlation between these domains and the themes identified by the four therapists who coded the patients’ statements. There were two main areas of discrepancy. The first of these concerned the categorisation of pain. In the therapist-derived health domains, pain was considered as a concept in its own right, whereas in the patient-derived health domains, pain was usually described in terms of its functional impact, eg ‘it stops me from doing things’. In the analysis of the patient responses, only one physiotherapist classified pain as an independent theme. The second discrepancy had t o do with the ‘non-physical’ components of physiotherapy, eg motivation, confidence and education. Typical comments from the focus groups included: ‘I want t o know how t o stop it happening again.’ ‘She really gave me the confidence to try something I would never have dared t o if I hadn’t come here.’ ‘They keep you going, they keep moving the goal posts so you have t o
Physiotherapy, March 1996, vol 82, no 3
~~
Sleep Education and other (including categories of motivation, and confidence)
keep trying.’ The physiotherapist-derived health domains had not even considered the inclusion of a topic such as these, yet in each patientderived domain it appears as a theme, even though it may be labelled differently. This information is now being incorporated into the out-patient outcome measurement tool. Methods for evaluating the effect of therapy on motivation and confidence are being considered.
Conclusion The focus group is a relatively neglected method of qualitative research in physiotherapy. It offers considerable potential in the evaluation of physiotherapy services, and in gaining insight into patients’ experiences and perceptions of health and illness. It may also be used in the context of treatment effectiveness research, and to elucidate professional decision-making procedures. The technique should not, however, be used indiscriminately. If there is a requirement for largescale representative data of a primarily quantitative nature, conventional questionnaire studies are generally preferable as the primary means of data collection. Conversely, if the intention is to gain an in-depth understanding of feelings and experiences at the level of the individual, a one-toone interview is likely to be more appropriate. In many instances, however, the focus group can usefully be employed in combination with other techniques, either as a preliminary means of developing more structured data collection instruments, or as a method of expanding and enriching quantitative data gathered earlier. If used judiciously, with due attention t o its methodological strengths and weaknesses, the focus group offers considerable potential in physiotherapy evaluation and research.
197
Authors Julius Sim BA MSc MCSP is principal lecturer in research methods, School of Health and Social Sciences, Coventry University. Jackie Snell MCSP is a research physiotherapist in the departments of physiotherapy and occupational therapy, Coventry and Warwickshire Hospital. This article was received on May 12, 1995, and accepted on December 13, 1995.
Fern, E F (1982). ‘The use of focus groups for idea generation: The effects of group size, acquaintanceship, and moderator on response quantity and quality’, Journal of Marketing Research, 19, 1-13. Fizpatrick, R and Boulton, M (1994). ‘Qualitative methods for assessing health care’, Quality in Health Care, 3, 107-113. Fowler, F J (1993). Survey Research Methods (2nd edn) Sage Publications, Newbury Park. Goldman, A E (1962). ‘The group depth interview’, Journal of Marketing, 26, 61-68. Hague, P (1993). Interviewing, Kogan Page, London.
Address for Correspondence Mr J Sim, School of Health and Social Sciences, Coventry University, Priory Street, Coventry CV1 5FB.
References Ackroyd, S and Hughes, J (1992). Data Collection in Context, (2nd edn) Longman, London. Ahorny, L and Strasser, S (1993). ‘Patient satisfaction: What we know and what we still need to explore’, Medical Care Review, 50, 49-79. Albrecht, T L, Johnson, G M and Walther, J B (1993). ‘Understanding communication processes in focus groups’ in: Morgan, D L (ed) Successful Focus Groups: Advancing the state of the art, Sage Publications, Newbury Park. Aries, E (1976). ‘Interaction patterns and themes of male, female, and mixed groups’, Small Group Behavior, 7 , 7-18. Asch, S E (1952). ‘Effects of group pressure on the modification and distortion of judgments’ in: Swanson, G E, Newcomb, T M and Hartley, E L (eds) Readings in Social Psychology (revised edn) Holt, Rinehart and Winston, New York.
Heller, K E, Crockett, S J, Merkel, J M and Peterson, J M (1990). ‘Focus group interviews with seniors’, Journal of Nutrition for the .Elderly, 9, 89-100. Hopkins, A, Gabbay, J and Neuberger, J (1994). ‘Role of users of health care in achieving a quality service’, Quality in Health Care, 3, 203-209. Irwin, K, Bertrand, J, Mibandumba, K, Nzilambi, N, Bosenge, N, Ryder, R, Peterson, H, Lee, N C, Wingo, P, O’Reilly, K and Rufo, K (1991). ‘Knowledge, attitudes and beliefs about HIV infection and AIDS among healthy factory workers and their wives, Kinshasa, Zaire’, Social Science and Medicine, 32, 917-930. Kelman, H C (1972). ‘The rights of the subject in social research: An analysis in terms of relative power and legitimacy’, American Psychologist, 27, 989-1016. Krueger, R A (1994). Focus Groups: A practicalguide for applied research (2nd edn) Sage Publications, Thousand Oaks. McDaniel, R W and Bach, C A (1994). ‘Focus groups: A datagathering strategy for nursing research’, Nursing Science Quarterly, 7 , 4-5. Merrall, A, Patel, R and Taylor, J (1991). Audit for the Therapy Professions, Mercia Publications, Keele.
Basch, C E (1987). ‘Focus group interview: An underutilized research technique for improving theory and practice in health education’, Health Education Quarterly, 14, 41 1-448.
Merton, R K, Fiske, M and Kendall, P L (1956). The Focused Interview: A manual of problems and procedures, Free Press, Glencoe.
Basch, C E, DeCicco, I M and Malfetti, J L (1989). ‘A focus group study on decision processes of young drivers: Reasons that may support a decision to drink and drive’, Health Education Quarterly, 16, 389-396.
Millward, L J (1995). ‘Focus groups’ in: Breakwell, G M, Hammond, S and Fife-Schaw, C (eds) Research Methods in Psychology, Sage Publications, London.
Calder, B J (1977). ‘Focus groups and the nature of qualitative marketing research’, Journal of Marketing Research, 14, 353-364.
Minichiello, V, Aroni, R, Timewell, E and Alexander, L (1990). In-depth lnterviewing: Researching people, Longman Cheshire, Melbourne. Morgan, D L (1988). Focus Groups as Qualitative Research, Sage Publications, Newbury Park.
Carey, M A (1994). ‘The group effect in focus groups: Planning, implementing, and interpreting focus group research’ in: Morse, J M (ed) Critical Issues in Qualitative Research Methods, Sage Publications, Thousand Oaks.
Morgan, D L and Krueger R A (1993). ‘When to use focus groups and why’ in: Morgan, D L (ed) Successful Focus Groups: Advancing the state of the art, Sage Publications, Newbury Park.
Carey, M A and Smith M W (1994). ‘Capturing the group effect in focus groups: A special concern in analysis’, Qualitative Health Research, 4, 123-127.
Morgan, D L and Spanish, M T (1985). ‘Social interaction and the cognitive organisation of health-relevant knowledge’, Sociology of Health and Illness, 7 , 401 -422.
Chattered Society of Physiotherapy (1994). Information on Standard Setting, Audit and Outcome Measurement for Chartered Physiotherapists, CSP, London.
Nyamathi, A and Shuler, P (1990). ‘Focus group interview: A research technique for informed nursing practice’, Journal of Advanced Nursing, 15, 1281-88.
Crabtree, B F, Yanoshik, M K, Miller W L and O’Connor, P J (1993). ‘Selecting individual or group interviews’ in: Morgan, D L (ed) Successful Focus Groups: Advancing the state of the art, Sage Publications, Newbury Park.
Oppenheim, A N (1992). Questionnaire Design, lnterviewing and Attitude Measurement (new edn) Pinter Publishers, London. Peters, D A (1993). ‘Improving quality requires consumer input: using focus groups. Journal of Nursing Care Quality, 7, 34-41.
Denzin, N K (1989). The Research Act: A theoretical introduction to sociological methods (3rd edn) Prentice Hall, Englewood Cliffs.
Reed, A (1990). ‘An investigation into the problems involved in teaching electrotherapy and their possible solutions using the Delphi technique’, Physiotherapy Theory and Practice, 6, 9-16. Reid, N G (1989). ‘The Delphi technique: Its contribution to the evaluation of professional practice’ in: Ellis, R (ed) Professional Competence and Quality Assurance in the Caring Professions, Chapman and Hall, London. Rigge, M (1994). ‘Involving patients in clinical audit’, Quality in Health Care, 3(suppl), S2-S5. Schatzman, L and Strauss, A L (1973). Field Research: Strategies for a natural sociology, Prentice-Hall, Englewood Cliffs.
DePoy, E and Gitlin, L N (1994). lntroduction to Research: Multiple strategies for health and human services, Mosby, St Louis. Deutsch, M and Gerard, H B (1955). ‘A study of normative and informational social influences upon individual judgment’, Journal of Abnormal and Social Psychology, 51, 629-636. Exley, C, Sim, J, Reid, N G, Jackson, S and West, N (1996). ‘Attitudes and beliefs within the Sikh community regarding organ donation: A pilot study’, Social Science and Medicine (in press).
Physiotherapy, March 1996, vol82, no 3
198
Schroeder, C and Neil, R M (1992). 'Focus groups: A humanistic means of evaluating an HIV/AIDS programme based on caring theory', Journal of Clinical Nursing, 1, 265-274.
Thomas, M R and Little D (1980). 'Patient expectation about success of treatment and reported relief from low back pain', Journal of Psychosomatic Research, 24, 297-301.
Stewart, D W and Shamdasani, P N (1990). Focus Groups: Theory and practice, Sage Publications, Newbury Park.
Turner, J C (1991). Social Influence, Open University Press, Milton Keynes.
Steyaert, C and Bouwen, R (1994). 'Group methods of organizational analysis' in: Cassell, C and Symon, G (eds) Qualitative Methods in Organizational Research: A practical guide, Sage Publications, London.
UK Clearing House for Information on the Assessment of Health Outcomes (1 993). 'Issues in outcome measurement', Outcomes Briefing, Nuffield Institute for Health, University of Leeds, Leeds, 2, 16-22.
Strauss, A and Corbin, J (1990). Basics of Qualitative Research: Grounded theory procedures and techniques,Sage Publications, Newbury Park.
Williamson, C (1 992). Whose Standards? Consumer andprofessional standards in health care, Open University Press, Buckingham.
Sussman, S, Burton, D, Dent, C W, Stacy, A W and Flay, B R (1991). 'Use of focus groups in developing an adolescent tobacco use cessation program: Collective norm effects', Journal of Applied Social Psychology, 21, 1772-1782.
MEDICAL DEVICES AGENCY ADVERSE INCIDENT CENTRE
Safety Notices These notices are distributed to Regional general managers, chief executives of District Health Authorities and Health Commissions, chief executives of NHS trusts, general managers of directly managed units, managers of indpendent/private health care units and Family Health Services Authorities for GP practices. They should be available for consultation by employees. Summaries of relevant notices are given here. The full versions include action notes, background information and contact names. 9522: September
9525: October
Bayreuth standing frame - Failure of adjustment locks
Howmedica International Inc: Fracture and fragmentation of the large posterior cruciate retaining tibial component (6 mm) of the KinematiPtotal knee replacement
Adjustment locks on Bayreuth standing frames may become loose as a consequence of damage to their screw threads. Users should check the screw threads of the locks for signs of wear or damage. 9523: October
Wheelchairs - Removal and replacement of circlips Incidents have been reported to the Medical Devices Agency where wheels have come off wheelchairs while they have been in use. In one case injury was sustained by the user. In each case it was found on investigation that a deformed circlip or the wrong type of circlip has been used. Those carrying out repairs or maintenance on wheelchairs must ensure that circlips being fitted are to the specification and of the type recommended by the manufacturer. Deformed circlips must not be re-used. 9524: October
Wheelchair battery charger The Medical Devices Agency has been informed of a number of incidents where the front panel of Heayberd wheelchair battery chargers have been pushed inwards causing risk of a short circuit. Haeyberd wheelchair battery charges are obsolete and should be replaced at the earliest opportunity.
Physiotherapy, March 1996, vol 82, no 3
The Medical Devices Agency has received four reports of the fracture and fragmentation of the 6 mm Howmedica Kinematic large metal tibial component (Cat No 64715-406) necessitating revision. These failures occurred between six and nine years after implementation. Regular radiological examination of patients with these implants should be considered.
1996: 9601: January
Reporting adverse incidents relating to medical devices Action taken as a result of reporting adverse incidents to the Medical Devices Agency (MDA) contributes to the safety of patients, users and others, and the MDA analyses all reports received concerning medical devices. Where the results of investigations have implications for other patients or users, MDA issues a Hazard or other warning advising of hazardous products or unsafe procedures. Chief executives and other senior managers are responsible for ensuring adverse incidents relating to medical devices are promptly reported to the Medical Devices Agency's Adverse Incident Centre: this leaflet contains details of how to make such reports. Chief executives and other senior managers are also responsible for ensuring prompt action is taken on receipt of Hazard or other warning notification. 9605: January
9528: October
Medix two-pin universal mains leads: Risk of electric shock The Medical Devices Agency has received a report of a nurse receiving an electric shock from a Medix two-pin universal mains lead. The lead was supplied with a Medix nebuliser, but was being used with another piece of medical equipment. Medix Limited is recalling the affected two-pin universal mains leads supplied with its nebulisers. Users are advised to identify and return the leads to Medix for free replacements. 9529: November
Radcliffe Rehabilitation Services: Failure of Mk / I Shadow wheelbase Seat tubes have failed in service. A modification kit should be fitted to all affected Shadow Mk II wheelbases.
Powered wheelchairs fitted with Fracmo motors: Possible brake defects Investigation of reported incidents have revealed a number of defects that may affect powered wheelchairs fitted with Fracmo motors. These are: 1 . The brake drive hub had been omitted from the motor at the assembly stage. 2. The grub screw intended to retain the brake hub in position had been insufficiently tightened. 3. Some motors where the rating plate indicated that 12 volt brakes should have been fitted, had been fitted with 24 volt brakes. Powered wheelchairs should be examined and rectified as necessary as part of normal servicing procedures.