Journal of Nutrition For the Elderly
ISSN: 0163-9366 (Print) 1540-8566 (Online) Journal homepage: http://www.tandfonline.com/loi/wjne20
Focus Group Interviews with Seniors Karen E. Heller PhD, LRD , Susan J. Crockett PhD, LRD , Joyce M. Merkel MS, LRD & Jane M. Peterson MS To cite this article: Karen E. Heller PhD, LRD , Susan J. Crockett PhD, LRD , Joyce M. Merkel MS, LRD & Jane M. Peterson MS (1990) Focus Group Interviews with Seniors, Journal of Nutrition For the Elderly, 9:4, 89-100, DOI: 10.1300/J052v09n04_07 To link to this article: http://dx.doi.org/10.1300/J052v09n04_07
Published online: 18 Oct 2008.
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Focus Group Interviews with Seniors Karen E. Heller, PhD, LRD Susan J. C r o c k e t t , PhD, LRD Joyce M. Merkel, MS, LRD J a n e M. Peterson, MS
ABSTRACT. The focus group interview technique provides indepth information on a specific topic in a group discussion setting and can be effectively used with older adults. Successful focus group interviews include careful question preparation and participant recruitment as well as securing a capable moderator and comfortable setting. The technique is used as a preliminary research step to elicit feelings, attitudes and perceptions about a topic. However, Karen E. Heller is Food & Nutrition Specialist and Assistant Professor, NDSU Extension Service, FLC/Home Economics/4-H 219, North Dakota State University, Fargo, ND 58105. Susan J. Crockett is Chair and Associate Professor, Department of Food and Nutrition, Room 351B Home Economics, North Dakota State University, Fargo, ND 58105. Joyce M. Merkel is an English language teacher, 121 Kyuoshokuin Jutaku, Otake Cho 4622, Nobeokashi 882, Miyazaki Ken, Japan. Jane M. Peterson is Clinical Dietitian, Veterans Administration Medical Center, Fargo, ND 58102. Scnd correspondence to Karen E. Heller at the address given above. Support foi this work was provided by United States Depart~entof Agriculture Extension Service, Section 1440 Program Funding under the "Rural Crisis Recovery Program Act of 1987." Journal of Nutrition for the Elderly, Yo). 9(4) 1990 O 1990 by The Haworth Press, Inc. All rights reserved.
89
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results should not be generalized without further quantitative research.
Downloaded by [University of Birmingham] at 09:54 06 November 2015
INTRODUCTION The focus group interview technique is a qualitative research approach that provides in-depth information on a specific topic in a discussion group format. The focus group technique, historically widely-used in marketing research to obtain informal information from consumers (Bellenger et al., 1976), is becoming popular in social marketing fields such as health and nutrition education (Basch, 1987). The focus group interview technique has not been widely used with senior citizens in social marketing, however. Telephone surveys, written questionnaires, or one-on-one interviews have more often been used with seniors (Breitung, 1980; Fanelli et al., 1987; Goodwin, 1987; Timmreck, 1977). A few published reports describe effective use of focus groups with seniors including perceptions about food (Betts, 1985), beliefs and needs of senior citizens (Keller et al., 1987) and problems of the elderly that influence food choices (Madeira and Goldman, 1988). We have reported results of focus group interviews which were used as a preliminaly step in developing a nutrition education intervention for rural seniors (Crockett et al., in press). While the technique has not been widely used with seniors, at least outside of marketing settings, the approach has promise for use with this age group. Senior citizens are an important target audience for health promotion because of their increasing numbers and their need to improve nutrition and other health habits (Bausell, 1986; Teague, 1987). Seniors have been shown to be receptive to health behavior change and nutrition education programs (Barbaro & Noyes, 1984; Betts, 1985). It is generally agreed that health promotion programs for the elderly do enhance quality of life (Bender & Hart, 1987). In planning nutrition education strategies for seniors, knowledge about the target audience is necessaly in order to plan appropriate interventions (Fanelli, 1988). Nutrition educators can no longer plan programs according to their own interests and priorities, assuming target groups will share their views (Parks & Moody,
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1986). There is increasing recognition that older Americans are frequently stereotyped as a homogeneous group assuming that all people over 60 years of age have the same needs, interests, health status and lifestyle (Atchley, 1983). This stereotyping can lead educators to develop programs that have little appeal and can even be offensive to older Americans. The focus group interview is a research technique that can be used to gain insight into variables related to the health promotion needs and interests of seniors. This approach can also help identify appropriate innovative approaches and strategies for delivering programs, thereby helping to make health and nutrition education programs for seniors more effective and successful. Our purpose in this article is to increase awareness and interest in the focus group interview technique as a useful qualitative research method with seniors. We will present an overview of the focus group technique, discuss advantages and limitations and describe a general process for structuring and conducting focus groups with older adults. DEFINITION OF FOCUS GROUPS A focus group interview is a discussion, under the guidance of a moderator, in which people provide qualitative data on a specific topic (Folch-Lyon & Trost, 1981; Krueger, 1988). The technique is based on the assumption that an individual may be more willing to share opinions in the security of a group of peers who share common characteristics. In contrast to a rigid, structured question-andanswer methodology, the focus group procedure encourages a discussion of feelings, attitudes, and perceptions about a topic while allowing insight into the behavior and thinking of individual group members. In contrast to normal group functioning, emphasis in a focus group interview is not on achieving consensus but rather on eliciting a variety of opinions. Focus group interviews can be used to gain insight into the dynamic relationships of attitudes, opinions, motivations, concerns, and problems related to current and projected actions. The interviews can help understand questions of how, and in particular, why people behave as they do (Folch-Lyon & Trost, 1981). Focus group
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discussions can help assess a target population in order to effectively develop and evaluate program needs (Keown, 1983) and can elicit reactions to ideas and directional information for use in subsequent quantitative studies (Hannah, 1978).
Downloaded by [University of Birmingham] at 09:54 06 November 2015
ADVANTAGES OF FOCUS GROUPS
When used properly, focus group interviews offer advantages over structured questionnaires and individual interviews: (1) they are relatively easy to use for learning about the target group's ideas and opinions; (2) groups can be gathered according to preplanned stratification schemes and a permanent record of responses and group dynamics can be obtained by tape recording and verbatim transcripts; (3) synergism allows for a combined group effort producing a wider range of information, insights and ideas that may not have been considered in an individual interview; (4) a comfortable atmosphere of peers can allow participants to express their feelings and emotions on the topic being discussed (Basch, 1987; Bellenger et al., 1976; Folch-Lyon & Trost, 1981; Wells, 1974). The group situation facilitates a greater feeling of anonymity than an individual interview and this feeling may encourage participants to disclose behaviors and attitudes they might not reveal individually (Axelrod, 1975). Each person feels less pressure to respond to every question, item and issue and the group setting may create an atmosphere where sensitive topics can be discussed openly (Basch, 1987). Flexibility is an advantage of the focus group interview technique. In contrast to a structured questionnaire which may be very rigid, the moderator of a focus group can provide structure to the interview but make adjustments as the group discussion progresses (Basch, 1987; Wells, 1974). A good moderator works from a list of topics, carefully listening, thinking, probing throughout the discussion in an attempt to gain an intuitive understanding of what is being revealed by participants (Krueger, 1988; Wells, 1974). The turnaround time for group interviews may be shorter and the cost, depending on the nature and scope of the project, less than for individual interviews (Basch, 1987; Bellenger et al., 1976; Wells, 1974). Because the number of focus group interviews is usually
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small and the time consumed short, it is an added advantage that the researcher can participate in the interviews and observe participants first hand (Bellenger et al., 1976; Morgan & Spanish, 1984; Wells, 19741. In comparison to quantitative research techniques, the focus group, as a qualitative method, has some advantages in program evaluation research and program planning. A qualitative technique may provide more insight about the reasons and mechanisms involved in behavior change, may provide more complete information on variables that fall between pre- and post-measurements, and may yield reports of effects that are not anticipated by program planners (Achterberg, 1988). LIMITATIONS OF FOCUS GROUPS
Potential disadvantages and limitations of the focus group technique must also be considered. Focus groups are generally not appropriate for drawing inferences about larger populations or for statistical testing and interval estimation which require quantitative data (Bellenger et a]., 1976). Since a small number of people are interviewed (usually eight to twelve persons per group), the results from a focus group may serve as a preliminary step to survey research but interview findings should not be generalized without further quantitative data (Gage, 1980; Hannah, 1978). Group settings and group norms may inhibii sharing and individual articulation in some instances (Basch, 1987) and may also encourage exaggeration by those participants who are caught up in a responsive audience (Stycos, 1981). The technique may also suffer from a biased atmosphere if the moderator is intimately involved with the research project (Bellenger et al., 1976; Gage, 1980). This involvement may bias the interpretation and analysis of focus group's results. The careful planning and organization necessary for effective focus groups does demand considerable time and moderating the groups requires a great deal of skill (Bellenger et al., 1976). Analysis of focus group results may be difficult due to the diversity and volume of information obtained. Also, recruiting participants may be difficult due to the nature of the topic or if the location of the
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focus group interview is inconvenient or uncomfortable (Krueger, 1988).
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STRUCTURING FOCUS GROUPS Proper preparation for focus group interviews with seniors is important in order to achieve meaningful results. Definition of the research problem and clear objectives are necessary in order to appropriately direct the focus group discussion (Keown, 1983). The target sample of seniors from which potential focus group participants are recruited should be carefully defined in terms of the objectives and goals of the study. When recruiting seniors for focus groups, researchers should decide which common characteristics are desired including age, residence, marital status, socioeconomic status, education level, activity level, and health status. Research does suggest that the more homogeneous the group, the more productive its results (Festervand, 1985); there must be sufficient variation among the participants to allow for diversity of opinions, however. Researchers should be aware of subtle differences that may affect the group discussion. For example, in groups of mixed gender, ethnic or socioeconomic composition, it may be extremely difficult to achieve a high level of interaction: One approach to r&edy this is to conduct several focus groups so each group is homogeneous but represents a different segment of the senior population. Participants are not randomly selected for focus groups because the objective is to understand and to determine the entire range of responses and not to generalize about the entire population (Krueger, 1988). After the objectives and the target group are defined, a list of questions is developed. Careful preparation of these questions is necessary to ensure that the researchers have thought about what they really want to know and to ensure agreement on specific objectives before the study begins (Payne, 1976; Wells, 1974). The choice of language in the discussion questions is important and must be appropriate to the audience. Questions should be tactful, clear, and simple, with a minimum of technical language and appropriate for the target audience. Focus group discussions should begin with general questions and proceed to specific questions
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(Basch, 1987; Payne, 1976) and open-ended questions are preferred to dichotomous ones since they allow group participants some control in the scope of the answer. For example, asking "Is your doctor a major source of health information?" requires a yes or no answer. In contrast, asking "What are your major sources of health information?" can elicit a variety of responses. Identification and recruitment of senior participants is governed by the characteristics desired by the researchers. The recruitment process can use an existing list such as driver's license holders, organization membership rosters, referrals, and random telephone screening (Krueger, 1988). For each of the five focus group sessions, we identified prospective participants by contacting county extension home economists, senior citizen clubs, area and county councils on aging, and congregate feeding site staff members (Crockett et al., in press). Focus groups should have eight to twelve members (Bellenger et al., 1976) because groups of larger size tend to have groups fragment and whisper among each other. Groups of fewer than eight members do encourage more participation but produce a smaller pool of ideas on a topic (Krueger, 1988). Generally with focus groups, two to four extra participants should be recruited to allow for no-shows. However, our experience with rural seniors was that they wanted to participate and were eager to bring their spouse or a friend (Crockett et al., in press). Participants should be told that only they will be included in the interview. Inclusion of spouses and friends may interfere with optimal focus group functioning. Either telephone or mail may be used to recruit participants. Initial personal contact by telephone may be more successful than using a letter because questions can be answered, fear dispensed and in-depth explanations given. A follow-up letter helps to remind participants about the details of the group interview. We used these steps as well as a reminder telephone call a day or two before the interview. The call served to remind senior participants of the session, state that their participation is valued and assure maximum attendance. Incentives for participation must also be considered for successful recruitment. The opportunity to gather socially for refreshments and conversation with peers may be sufficient incentive to motivate
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retired or more social seniors to participate, while monetary or other material incentives may be needed to attract the senior who is still working or who is less social. We paid participants $10 or $15 depending on travel distance; we offered to send the money to a favorite charity in their name if they preferred. During recruitment, the general topic of discussion is usually revealed to satisfy curiosity (Folch-Lyon & Trost, 1981) but details about the topic are withheld. This avoids the possibility that participants may become too familiar with the topic prior to the interview. We did have a couple of senior participants express interest in studying to prepare for the focus group interview which we discouraged. The number of focus groups needed can be determined by a rule of thumb which suggests that researchers conduct interviews until little new information is obtained (Krueger, 1988). Generally, planning four groups, with evaluation after the third, and an addition of a fifth if necessary, is an acceptable procedure. We conducted five interviews and found that little new information was added after the fourth .grour, .. . interview. It is possible to conduct focus groups in a variety of locations. Choosing a location that is easy to find, accessible to seniors, including handicapped access, and free from distractions, is important. A neutral location is preferable. For some target groups, a Senior Citizen meeting room or center may be appropriate. However, a location identified with senior populations may not be optimal when seeking to include participants who either do not consider themselves to be senior citizens or do not participate in Senior Citizen center programs. A comfortable room arrangement, usually around a table, and the availability of refreshments will help make group participants feel more at ease and willing to talk. Permission should be obtained from participants and provisions made for audio-taping the session. The moderator's role is of prime importance to the success of focus group interviews (Bellenger et al., 1976). This person must be a good listener, interested in people, and able to establish rapport and gain the confidence of the participants so that they feel relaxed and anxious to talk. The moderator must also be comfortable and familiar with group process, able to draw comments from quiet
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group members and direct attention from dominant group members (Krueger, 1988). The moderator must also be able to keep the discussion on track when irrelevant topics surface and have a sense of timing, knowing when to conclude discussion on one topic and move on to the next issue (Axelrod, 1975; Krueger, 1988). In the course of leading the discussion and questioning, the moderator acts to reflect the responses of the participants and should not contribute personal opinions or bias. Sometimes the researcher is too involved in the project to remain unbiased. The moderator should prepare for the interview by gaining a thorough understanding of the research problem and of participant characteristics (Payne, 1976). Focus group interviews usually last one and a half to two hours, which gives the moderator enough time to develop a good rapport with participants and to solicit honest and complete answers (Bellenger et al., 1976). Participants should be told how long the session will last. If the researcher is not the moderator, the group discussion process can be observed by the researcher. The researcher is then able to judge the intensity of the group's feelings and to assess the ability of the moderator, as well as to monitor whether the discussion meets the stated objectives. This allows redirection, if necessary, of subsequent focus group interviews to explore new questions or topics (Keown, 1983). It is important to have someone observe and take notes during the session noting body language or other details not recorded by the audiotape. Immediately after each session the researcher, moderator and observer should schedule a de-briefing to compare impressions of the interview while they are still fresh on their minds. Relying on memory of group sessions is not effective; after several focus group discussions of the same topic, important details may be lost. After all focus group interviews have been conducted, the researcher analyzes and interprets the results of the sessions (Festervand, 1985; Keown, 1983). A tape recording of the discussion, comments to highlight major points, and a summary report of the general findings are the basis of analysis (Keown, 1983). The amount of data is likely to be overwhelming; the researcher needs to remember that the original problem or goal drives the analysis. The researcher's role is to decide what factors are more important. Con-
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sideration is given to actual words used, tone, context and notes made about nonverbal responses. It is important to note the internal consistency of the group, whether group members were swayed by the discussion to change their original point of view. Major or salient ideas must be noted. Each comment must be thought of as unique and individual. One individual's comment may be representative of several hundred or may be simply a personal trait of that one participant. For this reason, content analysis of focus group discussions purposely neglects numbers and reports comments by category (Keown, 1983). Themes and patterns are identified and then summary statements are prepared. With the inclusion of pertineht participant quotations, the summaries serve to transform the raw data into an accessible and compact form from which conclusions can be drawn (Krueger, 1988).
SUMMARY
The focus group interview technique has potential for use with seniors as a means of identifying concerns and opinions about nutrition, health, and nutrition education. To be successful, careful preparation and structuring of focus group interviews is necessary and consideration must be given to carefully choosing participants, preparing questions, selecting a capable moderator, choosing an appropriate setting, and providing participation incentives. Reminder phone calls and telephone recruitment work best with a senior target group. The focus group interview technique provides qualitative, not quantitative data, and subsequent follow-up surveys may be necessary. As a preliminary planning tool, the technique can be a useful and successful component for targeting health interventions to diverse groups of seniors. REFERENCES Achterberg, A. (1988). Qualitative methods in nutrition education evaluation research. Journal of Nutrition Education, 20, 244-250. Atchley, R.C. (1983). Aging: Continuity and Change. Belmont, CA: Wadsworth, Inc.
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Axelrod, M.D. (1975, March 14). Ten essentials for good qualitative research. Marketing News, 14, 10-11. Barbara, E.L., & Noyes, L.E. (1984). A wellness program for a life care community. The Cerontologrst, 24, 568-571. Basch, C.E. (1987). Focus group interview: An underutilized research technique for improving theory and practice in health education. Health Education Quorterly, 14, 411-448. Bausell, R.B. (1986). Health seeking behavior among the elderly. The Gerontologist, 26, 556-59. Bellenger, D.N., Bcrnhardt, K.L., & Goldstucker, J.L. (1976). Qualitative research techniques: Focus group interviews. In Qualitative Research in Marketing. Chicago: American Marketing Association. Bender, C. and Hart, J.P. (1987). A model for health promotion for the rural elderly. The Gerontologist, 27, 139-142. Betts, N.M. (1985). A method to measure perceptions of food among the elderly. Journal of Nutrition for the Elderly, 4 (4), 15-21. Breitung, J. (1980, November/December). A nutrition survey of the well older adult. Perspectives on Aging, 9 , 19-21. Crockett, S.J., Heller K.E., Merkel, J. and Peterson J.' (In press). Assessing beliefs of older rural Americans about nutrition education: Use of the focus group approach. Journal of the American Dietetic Association. Fanelli, M.T. (1988). Effective nutrition education for older adults. Topics in Clinical Nutrition, 3, (4), 65-71. Fanelli, M.T., Kannon, G.A., & McDuffie, J.R. (1987). An assessment of the nutrition education needs of congregate meal program participants. Journal of Nutrition Education, 19, 131-137. Festervand, T.A. (1985). An introduction and application of focus group research to the health industry. Health Marketing Quarterly, 2, 199-209. Folch-Lyon, E., & Trost, J.F. (1981). Conducting focus group sessions. Srudies in Family Planning, 12, 443-449. Gage, T.J. (1980, February 4). Theories differ on use of focus groups. Advertising Age, 51, S19-S22. Goodwin, J. (1987). Nutrition education interests of older adults in North Dakota. Unpublished manuscript. Grand Forks, ND: University of North Dakota. Hannah, M. (1978, July). A perspective in focus groups. Viewpoints, 18, 4-8. Keller, K.L., Sliepcevish, E.M., Vitello, E.M.,Lacey, E.P., & Wright, R.W. (1987). Assessing beliefs about and needs of senior citizens using the focus group interview: A qualitative approach. Health Education, 18 (I), 44-49. Keown, C. (1983). Focus group research: Tool for the retailer. Journal of Small Business Management, 21, 59-65. Krueger, R.A. (1988). Focus groups: A practical guide for applied research. Newbury Park, CA: Sage Publications. Madeira, K. & Goldrnan, A. (1988). Some aspects of sensory properties of food that relate to food habits and associated problems of elderly consumers. Journal of Nulrition for the Elderly, 8 (2), 3-24.
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Morgan, P.L., & Spanish, M.T. (1984). Focus groups: A new tool for qualitative research. Qualirative Sociology, 7, 253-270. Parks, S.C. and Moody, D.L. (1986). Marketing: A survival tool for dietetic professionals in the 1990's. Journal of the American Dietetic Association, 86, 33-36. Payne, M.S. (1976). Preparing for group interviews. Advances i n Consumer Research, 4, 434-436. Slycos, J.M. (1981). A critique of focus group and survey research: The Machismo case. Studies i n Family Planning, 12, 450-456. Teague, M. (1987). Health promotion: Achieving high-level wellness in the later years. Indianapolis: Benchmark Press. Timmreck. T.C. (1977). Nutrition oroblems: A survev of the rural elderlv. Geriatrics, 32 (10); 1371140. Wells, W.D.(1974). . . Group interviewing. I n R. Ferber, ed., Handbook of Marketing Research. New 'iork: ~c~rac- ill.
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ISSN: 0163-9366 (Print) 1540-8566 (Online) Journal homepage: http://www.tandfonline.com/loi/wjne20
Focus Group Interviews with Seniors Karen E. Heller PhD, LRD , Susan J. Crockett PhD, LRD , Joyce M. Merkel MS, LRD & Jane M. Peterson MS To cite this article: Karen E. Heller PhD, LRD , Susan J. Crockett PhD, LRD , Joyce M. Merkel MS, LRD & Jane M. Peterson MS (1990) Focus Group Interviews with Seniors, Journal of Nutrition For the Elderly, 9:4, 89-100, DOI: 10.1300/J052v09n04_07 To link to this article: http://dx.doi.org/10.1300/J052v09n04_07
Published online: 18 Oct 2008.
Submit your article to this journal
Article views: 19
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wjne20 Download by: [University of Birmingham]
Date: 06 November 2015, At: 09:54
Downloaded by [University of Birmingham] at 09:54 06 November 2015
CURRENT PRACTICE
Focus Group Interviews with Seniors Karen E. Heller, PhD, LRD Susan J. C r o c k e t t , PhD, LRD Joyce M. Merkel, MS, LRD J a n e M. Peterson, MS
ABSTRACT. The focus group interview technique provides indepth information on a specific topic in a group discussion setting and can be effectively used with older adults. Successful focus group interviews include careful question preparation and participant recruitment as well as securing a capable moderator and comfortable setting. The technique is used as a preliminary research step to elicit feelings, attitudes and perceptions about a topic. However, Karen E. Heller is Food & Nutrition Specialist and Assistant Professor, NDSU Extension Service, FLC/Home Economics/4-H 219, North Dakota State University, Fargo, ND 58105. Susan J. Crockett is Chair and Associate Professor, Department of Food and Nutrition, Room 351B Home Economics, North Dakota State University, Fargo, ND 58105. Joyce M. Merkel is an English language teacher, 121 Kyuoshokuin Jutaku, Otake Cho 4622, Nobeokashi 882, Miyazaki Ken, Japan. Jane M. Peterson is Clinical Dietitian, Veterans Administration Medical Center, Fargo, ND 58102. Scnd correspondence to Karen E. Heller at the address given above. Support foi this work was provided by United States Depart~entof Agriculture Extension Service, Section 1440 Program Funding under the "Rural Crisis Recovery Program Act of 1987." Journal of Nutrition for the Elderly, Yo). 9(4) 1990 O 1990 by The Haworth Press, Inc. All rights reserved.
89
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JOURNAL OF NUTRITION FOR THE ELDERLY
results should not be generalized without further quantitative research.
Downloaded by [University of Birmingham] at 09:54 06 November 2015
INTRODUCTION The focus group interview technique is a qualitative research approach that provides in-depth information on a specific topic in a discussion group format. The focus group technique, historically widely-used in marketing research to obtain informal information from consumers (Bellenger et al., 1976), is becoming popular in social marketing fields such as health and nutrition education (Basch, 1987). The focus group interview technique has not been widely used with senior citizens in social marketing, however. Telephone surveys, written questionnaires, or one-on-one interviews have more often been used with seniors (Breitung, 1980; Fanelli et al., 1987; Goodwin, 1987; Timmreck, 1977). A few published reports describe effective use of focus groups with seniors including perceptions about food (Betts, 1985), beliefs and needs of senior citizens (Keller et al., 1987) and problems of the elderly that influence food choices (Madeira and Goldman, 1988). We have reported results of focus group interviews which were used as a preliminaly step in developing a nutrition education intervention for rural seniors (Crockett et al., in press). While the technique has not been widely used with seniors, at least outside of marketing settings, the approach has promise for use with this age group. Senior citizens are an important target audience for health promotion because of their increasing numbers and their need to improve nutrition and other health habits (Bausell, 1986; Teague, 1987). Seniors have been shown to be receptive to health behavior change and nutrition education programs (Barbaro & Noyes, 1984; Betts, 1985). It is generally agreed that health promotion programs for the elderly do enhance quality of life (Bender & Hart, 1987). In planning nutrition education strategies for seniors, knowledge about the target audience is necessaly in order to plan appropriate interventions (Fanelli, 1988). Nutrition educators can no longer plan programs according to their own interests and priorities, assuming target groups will share their views (Parks & Moody,
Downloaded by [University of Birmingham] at 09:54 06 November 2015
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1986). There is increasing recognition that older Americans are frequently stereotyped as a homogeneous group assuming that all people over 60 years of age have the same needs, interests, health status and lifestyle (Atchley, 1983). This stereotyping can lead educators to develop programs that have little appeal and can even be offensive to older Americans. The focus group interview is a research technique that can be used to gain insight into variables related to the health promotion needs and interests of seniors. This approach can also help identify appropriate innovative approaches and strategies for delivering programs, thereby helping to make health and nutrition education programs for seniors more effective and successful. Our purpose in this article is to increase awareness and interest in the focus group interview technique as a useful qualitative research method with seniors. We will present an overview of the focus group technique, discuss advantages and limitations and describe a general process for structuring and conducting focus groups with older adults. DEFINITION OF FOCUS GROUPS A focus group interview is a discussion, under the guidance of a moderator, in which people provide qualitative data on a specific topic (Folch-Lyon & Trost, 1981; Krueger, 1988). The technique is based on the assumption that an individual may be more willing to share opinions in the security of a group of peers who share common characteristics. In contrast to a rigid, structured question-andanswer methodology, the focus group procedure encourages a discussion of feelings, attitudes, and perceptions about a topic while allowing insight into the behavior and thinking of individual group members. In contrast to normal group functioning, emphasis in a focus group interview is not on achieving consensus but rather on eliciting a variety of opinions. Focus group interviews can be used to gain insight into the dynamic relationships of attitudes, opinions, motivations, concerns, and problems related to current and projected actions. The interviews can help understand questions of how, and in particular, why people behave as they do (Folch-Lyon & Trost, 1981). Focus group
92
JOURNAL OF NUTRITION FOR THE ELDERLY
discussions can help assess a target population in order to effectively develop and evaluate program needs (Keown, 1983) and can elicit reactions to ideas and directional information for use in subsequent quantitative studies (Hannah, 1978).
Downloaded by [University of Birmingham] at 09:54 06 November 2015
ADVANTAGES OF FOCUS GROUPS
When used properly, focus group interviews offer advantages over structured questionnaires and individual interviews: (1) they are relatively easy to use for learning about the target group's ideas and opinions; (2) groups can be gathered according to preplanned stratification schemes and a permanent record of responses and group dynamics can be obtained by tape recording and verbatim transcripts; (3) synergism allows for a combined group effort producing a wider range of information, insights and ideas that may not have been considered in an individual interview; (4) a comfortable atmosphere of peers can allow participants to express their feelings and emotions on the topic being discussed (Basch, 1987; Bellenger et al., 1976; Folch-Lyon & Trost, 1981; Wells, 1974). The group situation facilitates a greater feeling of anonymity than an individual interview and this feeling may encourage participants to disclose behaviors and attitudes they might not reveal individually (Axelrod, 1975). Each person feels less pressure to respond to every question, item and issue and the group setting may create an atmosphere where sensitive topics can be discussed openly (Basch, 1987). Flexibility is an advantage of the focus group interview technique. In contrast to a structured questionnaire which may be very rigid, the moderator of a focus group can provide structure to the interview but make adjustments as the group discussion progresses (Basch, 1987; Wells, 1974). A good moderator works from a list of topics, carefully listening, thinking, probing throughout the discussion in an attempt to gain an intuitive understanding of what is being revealed by participants (Krueger, 1988; Wells, 1974). The turnaround time for group interviews may be shorter and the cost, depending on the nature and scope of the project, less than for individual interviews (Basch, 1987; Bellenger et al., 1976; Wells, 1974). Because the number of focus group interviews is usually
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small and the time consumed short, it is an added advantage that the researcher can participate in the interviews and observe participants first hand (Bellenger et al., 1976; Morgan & Spanish, 1984; Wells, 19741. In comparison to quantitative research techniques, the focus group, as a qualitative method, has some advantages in program evaluation research and program planning. A qualitative technique may provide more insight about the reasons and mechanisms involved in behavior change, may provide more complete information on variables that fall between pre- and post-measurements, and may yield reports of effects that are not anticipated by program planners (Achterberg, 1988). LIMITATIONS OF FOCUS GROUPS
Potential disadvantages and limitations of the focus group technique must also be considered. Focus groups are generally not appropriate for drawing inferences about larger populations or for statistical testing and interval estimation which require quantitative data (Bellenger et a]., 1976). Since a small number of people are interviewed (usually eight to twelve persons per group), the results from a focus group may serve as a preliminary step to survey research but interview findings should not be generalized without further quantitative data (Gage, 1980; Hannah, 1978). Group settings and group norms may inhibii sharing and individual articulation in some instances (Basch, 1987) and may also encourage exaggeration by those participants who are caught up in a responsive audience (Stycos, 1981). The technique may also suffer from a biased atmosphere if the moderator is intimately involved with the research project (Bellenger et al., 1976; Gage, 1980). This involvement may bias the interpretation and analysis of focus group's results. The careful planning and organization necessary for effective focus groups does demand considerable time and moderating the groups requires a great deal of skill (Bellenger et al., 1976). Analysis of focus group results may be difficult due to the diversity and volume of information obtained. Also, recruiting participants may be difficult due to the nature of the topic or if the location of the
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focus group interview is inconvenient or uncomfortable (Krueger, 1988).
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STRUCTURING FOCUS GROUPS Proper preparation for focus group interviews with seniors is important in order to achieve meaningful results. Definition of the research problem and clear objectives are necessary in order to appropriately direct the focus group discussion (Keown, 1983). The target sample of seniors from which potential focus group participants are recruited should be carefully defined in terms of the objectives and goals of the study. When recruiting seniors for focus groups, researchers should decide which common characteristics are desired including age, residence, marital status, socioeconomic status, education level, activity level, and health status. Research does suggest that the more homogeneous the group, the more productive its results (Festervand, 1985); there must be sufficient variation among the participants to allow for diversity of opinions, however. Researchers should be aware of subtle differences that may affect the group discussion. For example, in groups of mixed gender, ethnic or socioeconomic composition, it may be extremely difficult to achieve a high level of interaction: One approach to r&edy this is to conduct several focus groups so each group is homogeneous but represents a different segment of the senior population. Participants are not randomly selected for focus groups because the objective is to understand and to determine the entire range of responses and not to generalize about the entire population (Krueger, 1988). After the objectives and the target group are defined, a list of questions is developed. Careful preparation of these questions is necessary to ensure that the researchers have thought about what they really want to know and to ensure agreement on specific objectives before the study begins (Payne, 1976; Wells, 1974). The choice of language in the discussion questions is important and must be appropriate to the audience. Questions should be tactful, clear, and simple, with a minimum of technical language and appropriate for the target audience. Focus group discussions should begin with general questions and proceed to specific questions
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(Basch, 1987; Payne, 1976) and open-ended questions are preferred to dichotomous ones since they allow group participants some control in the scope of the answer. For example, asking "Is your doctor a major source of health information?" requires a yes or no answer. In contrast, asking "What are your major sources of health information?" can elicit a variety of responses. Identification and recruitment of senior participants is governed by the characteristics desired by the researchers. The recruitment process can use an existing list such as driver's license holders, organization membership rosters, referrals, and random telephone screening (Krueger, 1988). For each of the five focus group sessions, we identified prospective participants by contacting county extension home economists, senior citizen clubs, area and county councils on aging, and congregate feeding site staff members (Crockett et al., in press). Focus groups should have eight to twelve members (Bellenger et al., 1976) because groups of larger size tend to have groups fragment and whisper among each other. Groups of fewer than eight members do encourage more participation but produce a smaller pool of ideas on a topic (Krueger, 1988). Generally with focus groups, two to four extra participants should be recruited to allow for no-shows. However, our experience with rural seniors was that they wanted to participate and were eager to bring their spouse or a friend (Crockett et al., in press). Participants should be told that only they will be included in the interview. Inclusion of spouses and friends may interfere with optimal focus group functioning. Either telephone or mail may be used to recruit participants. Initial personal contact by telephone may be more successful than using a letter because questions can be answered, fear dispensed and in-depth explanations given. A follow-up letter helps to remind participants about the details of the group interview. We used these steps as well as a reminder telephone call a day or two before the interview. The call served to remind senior participants of the session, state that their participation is valued and assure maximum attendance. Incentives for participation must also be considered for successful recruitment. The opportunity to gather socially for refreshments and conversation with peers may be sufficient incentive to motivate
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retired or more social seniors to participate, while monetary or other material incentives may be needed to attract the senior who is still working or who is less social. We paid participants $10 or $15 depending on travel distance; we offered to send the money to a favorite charity in their name if they preferred. During recruitment, the general topic of discussion is usually revealed to satisfy curiosity (Folch-Lyon & Trost, 1981) but details about the topic are withheld. This avoids the possibility that participants may become too familiar with the topic prior to the interview. We did have a couple of senior participants express interest in studying to prepare for the focus group interview which we discouraged. The number of focus groups needed can be determined by a rule of thumb which suggests that researchers conduct interviews until little new information is obtained (Krueger, 1988). Generally, planning four groups, with evaluation after the third, and an addition of a fifth if necessary, is an acceptable procedure. We conducted five interviews and found that little new information was added after the fourth .grour, .. . interview. It is possible to conduct focus groups in a variety of locations. Choosing a location that is easy to find, accessible to seniors, including handicapped access, and free from distractions, is important. A neutral location is preferable. For some target groups, a Senior Citizen meeting room or center may be appropriate. However, a location identified with senior populations may not be optimal when seeking to include participants who either do not consider themselves to be senior citizens or do not participate in Senior Citizen center programs. A comfortable room arrangement, usually around a table, and the availability of refreshments will help make group participants feel more at ease and willing to talk. Permission should be obtained from participants and provisions made for audio-taping the session. The moderator's role is of prime importance to the success of focus group interviews (Bellenger et al., 1976). This person must be a good listener, interested in people, and able to establish rapport and gain the confidence of the participants so that they feel relaxed and anxious to talk. The moderator must also be comfortable and familiar with group process, able to draw comments from quiet
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group members and direct attention from dominant group members (Krueger, 1988). The moderator must also be able to keep the discussion on track when irrelevant topics surface and have a sense of timing, knowing when to conclude discussion on one topic and move on to the next issue (Axelrod, 1975; Krueger, 1988). In the course of leading the discussion and questioning, the moderator acts to reflect the responses of the participants and should not contribute personal opinions or bias. Sometimes the researcher is too involved in the project to remain unbiased. The moderator should prepare for the interview by gaining a thorough understanding of the research problem and of participant characteristics (Payne, 1976). Focus group interviews usually last one and a half to two hours, which gives the moderator enough time to develop a good rapport with participants and to solicit honest and complete answers (Bellenger et al., 1976). Participants should be told how long the session will last. If the researcher is not the moderator, the group discussion process can be observed by the researcher. The researcher is then able to judge the intensity of the group's feelings and to assess the ability of the moderator, as well as to monitor whether the discussion meets the stated objectives. This allows redirection, if necessary, of subsequent focus group interviews to explore new questions or topics (Keown, 1983). It is important to have someone observe and take notes during the session noting body language or other details not recorded by the audiotape. Immediately after each session the researcher, moderator and observer should schedule a de-briefing to compare impressions of the interview while they are still fresh on their minds. Relying on memory of group sessions is not effective; after several focus group discussions of the same topic, important details may be lost. After all focus group interviews have been conducted, the researcher analyzes and interprets the results of the sessions (Festervand, 1985; Keown, 1983). A tape recording of the discussion, comments to highlight major points, and a summary report of the general findings are the basis of analysis (Keown, 1983). The amount of data is likely to be overwhelming; the researcher needs to remember that the original problem or goal drives the analysis. The researcher's role is to decide what factors are more important. Con-
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sideration is given to actual words used, tone, context and notes made about nonverbal responses. It is important to note the internal consistency of the group, whether group members were swayed by the discussion to change their original point of view. Major or salient ideas must be noted. Each comment must be thought of as unique and individual. One individual's comment may be representative of several hundred or may be simply a personal trait of that one participant. For this reason, content analysis of focus group discussions purposely neglects numbers and reports comments by category (Keown, 1983). Themes and patterns are identified and then summary statements are prepared. With the inclusion of pertineht participant quotations, the summaries serve to transform the raw data into an accessible and compact form from which conclusions can be drawn (Krueger, 1988).
SUMMARY
The focus group interview technique has potential for use with seniors as a means of identifying concerns and opinions about nutrition, health, and nutrition education. To be successful, careful preparation and structuring of focus group interviews is necessary and consideration must be given to carefully choosing participants, preparing questions, selecting a capable moderator, choosing an appropriate setting, and providing participation incentives. Reminder phone calls and telephone recruitment work best with a senior target group. The focus group interview technique provides qualitative, not quantitative data, and subsequent follow-up surveys may be necessary. As a preliminary planning tool, the technique can be a useful and successful component for targeting health interventions to diverse groups of seniors. REFERENCES Achterberg, A. (1988). Qualitative methods in nutrition education evaluation research. Journal of Nutrition Education, 20, 244-250. Atchley, R.C. (1983). Aging: Continuity and Change. Belmont, CA: Wadsworth, Inc.
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Axelrod, M.D. (1975, March 14). Ten essentials for good qualitative research. Marketing News, 14, 10-11. Barbara, E.L., & Noyes, L.E. (1984). A wellness program for a life care community. The Cerontologrst, 24, 568-571. Basch, C.E. (1987). Focus group interview: An underutilized research technique for improving theory and practice in health education. Health Education Quorterly, 14, 411-448. Bausell, R.B. (1986). Health seeking behavior among the elderly. The Gerontologist, 26, 556-59. Bellenger, D.N., Bcrnhardt, K.L., & Goldstucker, J.L. (1976). Qualitative research techniques: Focus group interviews. In Qualitative Research in Marketing. Chicago: American Marketing Association. Bender, C. and Hart, J.P. (1987). A model for health promotion for the rural elderly. The Gerontologist, 27, 139-142. Betts, N.M. (1985). A method to measure perceptions of food among the elderly. Journal of Nutrition for the Elderly, 4 (4), 15-21. Breitung, J. (1980, November/December). A nutrition survey of the well older adult. Perspectives on Aging, 9 , 19-21. Crockett, S.J., Heller K.E., Merkel, J. and Peterson J.' (In press). Assessing beliefs of older rural Americans about nutrition education: Use of the focus group approach. Journal of the American Dietetic Association. Fanelli, M.T. (1988). Effective nutrition education for older adults. Topics in Clinical Nutrition, 3, (4), 65-71. Fanelli, M.T., Kannon, G.A., & McDuffie, J.R. (1987). An assessment of the nutrition education needs of congregate meal program participants. Journal of Nutrition Education, 19, 131-137. Festervand, T.A. (1985). An introduction and application of focus group research to the health industry. Health Marketing Quarterly, 2, 199-209. Folch-Lyon, E., & Trost, J.F. (1981). Conducting focus group sessions. Srudies in Family Planning, 12, 443-449. Gage, T.J. (1980, February 4). Theories differ on use of focus groups. Advertising Age, 51, S19-S22. Goodwin, J. (1987). Nutrition education interests of older adults in North Dakota. Unpublished manuscript. Grand Forks, ND: University of North Dakota. Hannah, M. (1978, July). A perspective in focus groups. Viewpoints, 18, 4-8. Keller, K.L., Sliepcevish, E.M., Vitello, E.M.,Lacey, E.P., & Wright, R.W. (1987). Assessing beliefs about and needs of senior citizens using the focus group interview: A qualitative approach. Health Education, 18 (I), 44-49. Keown, C. (1983). Focus group research: Tool for the retailer. Journal of Small Business Management, 21, 59-65. Krueger, R.A. (1988). Focus groups: A practical guide for applied research. Newbury Park, CA: Sage Publications. Madeira, K. & Goldrnan, A. (1988). Some aspects of sensory properties of food that relate to food habits and associated problems of elderly consumers. Journal of Nulrition for the Elderly, 8 (2), 3-24.
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Morgan, P.L., & Spanish, M.T. (1984). Focus groups: A new tool for qualitative research. Qualirative Sociology, 7, 253-270. Parks, S.C. and Moody, D.L. (1986). Marketing: A survival tool for dietetic professionals in the 1990's. Journal of the American Dietetic Association, 86, 33-36. Payne, M.S. (1976). Preparing for group interviews. Advances i n Consumer Research, 4, 434-436. Slycos, J.M. (1981). A critique of focus group and survey research: The Machismo case. Studies i n Family Planning, 12, 450-456. Teague, M. (1987). Health promotion: Achieving high-level wellness in the later years. Indianapolis: Benchmark Press. Timmreck. T.C. (1977). Nutrition oroblems: A survev of the rural elderlv. Geriatrics, 32 (10); 1371140. Wells, W.D.(1974). . . Group interviewing. I n R. Ferber, ed., Handbook of Marketing Research. New 'iork: ~c~rac- ill.
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