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Hisp Health Care Int. Author manuscript; available in PMC 2015 July 27. Published in final edited form as: Hisp Health Care Int. 2003 ; 2(3): 129–134.

From Practice to Research: Training Health Care Providers to Conduct Culturally Relevant Community Focus Groups Gwenyth R. Wallen and Migdalia V. Rivera-Goba National Institutes of Health, Bethesda, MD

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Qualitative data from focus groups can provide an “insiders’ view” of the culture of those being studied. Such data can help health care providers and program planners understand how people perceive themselves, and therefore guide providers and planners in developing culturally appropriate outcome measures that can strengthen the planning, implementation, and evaluation of future programs. This article discusses the process used to train Latino and African American health care providers to moderate focus groups that will be conducted as one phase of a research study looking at health beliefs and health practices in an urban arthritis health center. After taking part in two lecture and discussion training sessions, members of the training class were asked to participate in a pilot focus group. The ½ to 2 hour focus group included nine individuals who fulfilled the roles of moderator, facilitator, or respondent. Community health center practitioners provided valuable insight into the design and feasibility of the focus groups during their training sessions.

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Qualitative data from focus groups can provide an insider’s view and a means with which to define and understand the culture of the respondents being studied (Krueger & Casey, 2000). Providing an “insider’s” view can assist health care providers and program planners in understanding how people perceive themselves and guide them in developing culturally appropriate outcome measures to strengthen the planning, implementation, and evaluation of future programs. The selection of moderators with similar cultural and linguistic backgrounds to the proposed participants is essential to facilitate communication and identify cultural nuances. Focus groups are a valuable qualitative method for generating hypotheses and theory development in newly emerging areas of research and practice, however, the cost of conducting these groups is often prohibitive. It is particularly difficult to find bilingual moderators and facilitators trained to conduct focus groups in Spanish. Because of limited funding and limited numbers of trained bilingual focus group moderators and facilitators, training health care providers to conduct focus group research can be both a practical and cost-effective solution.

Background Rheumatic diseases are among the most common health problems in the United States. They are a diverse group of disorders, with several shared characteristics (Lawrence et al., 1998).

Offprints. Requests for offprints should be directed to Gwenyth Wallen, PhD, RN, Clinical Nurse Scientist, Warren Magnuson Clinical Center, Bldg. 10 12S-235B, National Institutes of Health, Bethesda, MD 20892. [email protected].

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Marked differences in the incidence, prevalence, severity, processes of care, and outcomes in a number of rheumatic conditions exist among racial and ethnic groups as compared to White Americans (Jordan et al., 2002; Kington & Smith, 1997). Furthermore, access to health care and treatment also differs in the minority community as compared with the majority community (Cooper & Roter, 2003).

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A three-phased, descriptive, exploratory study has been designed to examine the diverse health beliefs and behaviors among the minority patients who are enrolled in a National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) natural history study of rheumatic diseases in minority communities. Phase I of the study includes face-to-face, in-depth, cognitive interviews to pilot test potential instruments. Phase II consists of focus groups to further develop methodologies for program evaluation. Phase III will include faceto-face baseline and 6-month follow-up quantitative assessments designed using results from Phases I and II. The two formative phases of this study will involve qualitative methods because relying too heavily on quantitative methods and structured surveys can often obscure the multiple perspectives and diversity among respondents (Nichols-Casebolt & Spakes, 1995).

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The purpose of this paper is to describe the techniques used to train an interdisciplinary team of National Institutes of Health health care providers to conduct culturally relevant community focus groups for Phase II of the “Creencias Sobre la Salud y Prácticas de Comportamiento en las Minorías con Enfermedades Reumáticas” (Health Beliefs and Health Behavior Practices Among Minorities With Rheumatic Diseases) study. We will identify strategies for designing and implementing culturally relevant focus groups conducted by health care providers in a community health center and describe the utility of role playing sessions in developing and pilot testing a focus group moderator’s guide.

Design and Methods

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During Phase II of the study, eight focus groups will be conducted to assess the psychosocial and cultural correlates of rheumatic diseases in previously enrolled patients followed at the NIAMS Community Health Center (CHC) located in the District of Columbia in the Upper Cardozo Health Center. In addition to the six patient focus groups, two focus groups will be conducted with community leaders and members of a community health partnership who have convened periodically to provide feedback related to the human subjects research being conducted within their community (see Table 1). The sample size estimate of eight focus groups is based on a review of the literature and supported by feedback from the community health partnership. A recent study of older adults with arthritis successfully examined barriers to managing chronic pain (n = 57) through the use of eight focus groups (Davis, Hiemenz, & White, 2002). These researchers were able to use focus groups to explore the pain management experience, identify common themes and their properties by conceptually grouping these barriers, and generate a theoretical model of the relationships among the themes. We have proposed a total of eight focus groups, since the goal is to reach saturation, a point at which the groups are no longer generating new themes capable of enhancing study design, development, and implementation. It is also possible that we will find that eight

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groups are either too few or too many; in that instance, we will adjust the sample size accordingly. The focus group questions have been designed to identify:

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1.

Potential barriers to conducting community health research in this population.

2.

Strategies to facilitate a study that explores these issues.

3.

Best methods for assessing the health beliefs and behaviors in minority patients with rheumatic diseases (i.e., face-to-face interviews, telephone interviews, or selfadministered instruments).

4.

The level of comfort and ease patients have with current English and Spanish versions of quantitative instruments.

5.

Complementary and alternative medicine (CAM) practices, foods, food groups, and spices used to treat rheumatic diseases or their symptoms.

6.

Foods, food groups, or spices that are avoided in an effort to prevent rheumatic diseases or their symptoms.

7.

Dietary practices, such as fasting and weight control measures, used to control or treat rheumatic disease.

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Like the traditional focus groups used in market research, community health focus groups permit qualitative data to be gathered from 6 to 10 individuals during a 1 to 2 hour taperecorded session. The purpose of the focus groups is to promote interactive self-disclosure among individuals with specific characteristics in common (Kitzinger, 1994, 1995; Krueger, 1998b; Krueger & Casey, 2000). Each group will be led by one moderator and at least one facilitator. The moderator leads the discussion with a Moderator’s Guide that includes preselected questions and probes. The questions are grouped in categories recommended by Krueger (1998a): opening, introductory, transition, key, and closing. The facilitator takes notes, makes observations, and manages the equipment (name tags, tape recorder, microphones, etc.). Moderators with ethnic/racial, cultural, and linguistic backgrounds similar to the participants were selected and trained to conduct the focus groups. In order for the participants to communicate with the moderators in the language most comfortable to them, the Moderator’s Guide has been translated into Spanish.

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Following two lecture and discussion training sessions, members of the training class were asked to participate in a pilot/mock focus group (see Table 2 for more detailed goals and objectives). Each member of the training class met individually with an outside consultant to assess their previous experiences with group facilitation, and received written materials to review before the first training session (Krueger, 1998a, 1998b, 1998c; Krueger & Casey, 2000). These previously published materials included general background information about the purpose of focus groups and the roles of both the moderator and facilitator during such groups. In addition to these materials, a draft copy of the Moderator’s Guide was also included for members of the training class to review. The first of two 1 ½-hour training sessions included a review of the training manuals; expectations for moderators; and time to discuss members’ past experiences with group facilitation. The second training session

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featured discussions about moderators’ responsibilities; pitfalls to avoid during focus group implementation; group process dynamics; and tips on maintaining objectivity. Five health professionals (one African American and four Hispanics) directly involved with the NIAMS Community Health Center fulfilled the roles of moderator, facilitator, or respondent during the 1 ½- to 2-hour mock focus group. In addition to the five community health professionals, one Hispanic nutrition intern and three volunteers with behavioral health and group therapy backgrounds were coached in advance to fulfill the roles of focus group participants. In order to make the mock focus group as realistic as possible, the behavioral health participants were asked to play the roles of particularly challenging participants: the group “monopolizer” or grandstander; the reserved, shy participant; the expert; and the rambler.

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Results Throughout the three training sessions participants were encouraged to make suggestions and voice any concerns regarding the feasibility and implementation of the focus groups. Ongoing discussions were held about the ways the presence of this research in the community would be culturally relevant, ethically acceptable, and ideologically appropriate (Sixsmith, Boneham, & Goldring, 2003). McKague and Verhoef (2003) found that gaining perspectives from both clients and their providers enriched their understanding of the health determinants affecting the clients in an inner-city community health center.

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The Moderator’s Guide was revised during the training sessions based on feedback provided by the practitioners. For example, introductions of the group members were felt to come too late in the introductory phase of the focus group and were rewritten to coincide with the introduction of the moderator and facilitators to improve the initial dialogue flow (see Figure 1). The training participants also suggested that in addition to the initial consent process, a clear definition and explanation of confidentiality should be reemphasized during the “ground rules” section of the guide. In addition, the original ice-breaker activity, which involved asking focus group participants to draw a picture of themselves or someone they knew with rheumatic disease, was revised because training participants felt it was culturally inappropriate and not feasible för the target population to complete. The group devised a more relevant activity that did not require the same level of fine motor skills to complete, but would still elucidate initial discussions among the participants. The revised ice-breaker activity is as follows:

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Before we begin with specific questions about your health beliefs and health practices we’d like to do a “warm-up” exercise (sometimes also referred to as an “ice-breaker”) that we hope will be an informal way for us to get to know each other a little better. You’ve just been handed a collection of cut-out pictures. In the next 5 minutes, we’d like each of you to select a picture or two that reminds you of someone in your community with arthritis or a musculoskeletal disease (try to depict their age, ethnicity, physical and emotional status, mobility, etc.) As you select your picture(s) please go to the front of the room where _____ (facilitator’s name) will assist you in adding to a group collage (a collection of pictures). At the

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end of 5 minutes you will each have the opportunity to briefly describe your addition to the collage. You may also want to comment on your feelings about the group’s collage as a whole.

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Following the training sessions and the mock focus group, questions related to trust and health-seeking behaviors were reorganized with the most sensitive questions being asked near the end of the discussion. By asking the least sensitive questions near the beginning of the discussion the moderator was able to promote an environment of open communication and a rapport with the focus group participants. Without this rapport and a sense of confidence and trust between the moderator and the participants, the questions may not be effective (Krueger, 1998a). The health care practitioners also suggested that specific cues be imbedded in the Moderator’s Guide to assist them in acknowledging participant introductions, providing consent, and checking logistics such as tape recorders and sound systems (see Figure 1). Suggestions regarding the potential locations and room configurations for conducting the focus groups were also discussed at each of the training sessions. We were initially planning to conduct the focus groups in a meeting room at the clinic, however, community members have suggested the possibility of less traditional, more convenient locations, such as neighborhood churches or recreation centers.

Discussion and Implications for Practice

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Community health center practitioners can provide valuable insight into the design and feasibility of focus groups during the training process. The varied background of these health care professionals promoted a rich exchange of ideas that enhanced our understanding of the community we seek to explore (Sixsmith et al., 2003). The challenges encountered in developing a moderator’s guide for conducting community focus groups to support the methodology for the quantitative third phase of the study are similar to the challenges described by other qualitative researchers (Barr & Schumacher, 2003; Owen, 2001). Designing research by conducting it, in contrast to conducting studies solely by a priori designs, forces the researcher to anticipate how the study might proceed (Sandelowski & Barroso, 2003).

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Sandelowski and Barroso (2003) have eloquently described these aspects of qualitative research proposals as “exercises in imaginative rehearsal” (p. 781). By engaging minority health professionals who specialize in rheumatic and musculoskeletal and skin diseases in training and focus group rehearsal, we were able to gain insight into the strengths and weaknesses of our proposed methodology including the moderator’s guide. The ability and willingness of the health care providers and community members to share their knowledge regarding rheumatic diseases and cultural nuances during the development of the moderator’s guide will likely contribute to our efforts in providing a permissive, culturally relevant environment where our focus group participants feel free to share individual perceptions regarding their health beliefs and health behaviors.

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Acknowledgments This paper was presented at the 28th Annual Conference of the National Association of Hispanic Nurses. The authors would like to acknowledge the interdisciplinary collaboration and support of the entire research team: Barbara Mittleman, MD, Gregory Dennis, MD, Margarita Velarde, CRNP, Kelli Carrington, MA CHES, Reva C. Lawrence, MPH, Janet Austin, PhD, Blakely Denkinger, RD, Madeline Michael, MS, RD, Robert MirandaAcevedo, BA, Nicole Schuett, BS, and Deloris E. Koziol, PhD. We would also like to thank Andrew Sparber, RN, MS, for his role in assembling the mock focus group.

References

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Barr J, Schumacher G. Using focus groups to determine what constitutes quality of life in clients receiving medical nutrition therapy: First steps in the development of a nutrition quality-of-life survey. Journal of the American Dietetic Association. 2003; 103(7):844–851. [PubMed: 12830022] Cooper, LA.; Roter, DL. Patient-provider communication: The effect of race and ethnicity on process and outcomes of health care. In: Smedley, BD.; Stith, AY.; Nelson, AR., editors. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: Institute of Medicine of the National Academies Press; 2003. p. 552-593. Davis GC, Hiemenz ML, White TL. Barriers to managing chronic pain of older adults with arthritis. Journal of Nursing Scholarship. 2002; 34(2):121–126. [PubMed: 12078535] Jordan JM, Lawrence RC, Kington R, Fraser P, Karlson E, Lorig K, et al. Ethnic health disparities in arthritis and musculoskeletal diseases: Report of a scientific conference. Arthritis and Rheumatism. 2002; 46(9):2280–2286. [PubMed: 12355474] Kington RS, Smith JP. Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health. 1997; 87:805–810. [PubMed: 9184510] Kitzinger J. The methodology of focus groups: The importance of interaction between research participants. Sociology of Health & Illness. 1994; 16(1):103–121. Kitzinger J. Qualitative research: Introducing focus groups. British Medical Journal. 1995; 311:299– 302. [PubMed: 7633241] Krueger, RA. Developing questions for focus groups. Thousand Oaks, CA: Sage; 1998a. Krueger, RA. Moderating focus groups. Thousand Oaks, CA: Sage; 1998b. Krueger, RA. Analyzing & reporting focus groups. Thousand Oaks, CA: Sage; 1998c. Krueger, RA.; Casey, MA. Focus groups: A practical guide for applied research. Thousand Oaks, CA: Sage; 2000. Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the U.S. Arthritis and Rheumatism. 1998; 41:778–799. [PubMed: 9588729] McKague M, Verhoef M. Understanding of health and its determinants among clients and providers at an urban community health center. Qualitative Health Research. 2003; 13(5):703–717. [PubMed: 12756689] Nichols-Casebolt A, Spakes P. Policy research and the voices of women. Social Work Research. 1995; 19(1):49–55. [PubMed: 10140999] Owen S. The practical methodological and ethical dilemmas of conducting focus groups with vulnerable clients. Journal of Advanced Nursing. 2001; 36(5):652–658. [PubMed: 11737497] Sandelowski M, Barcoso J. Writing the proposal for a qualitative research methodology project. Qualitative Health Research. 2003; 13(6):781–820. [PubMed: 12891715] Sixsmith J, Boneham M, Goldring JE. Accessing the community: Gaining insider perspectives from the outside. Qualitative Health Research. 2003; 13(4):578–589. [PubMed: 12703418]

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Figure 1.

Sample Moderator Guide cues.

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TABLE 1

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Planned Focus Groups Group 1

Community leaders and/or members of the health partnership

Group 2

Spanish-speaking, Hispanic patients previously seen in the NIAMS Community Health Center with a diagnosis of systemic lupus erythematosus (SLE)

Group 3

English-speaking, African American patients previously seen in the NIAMS Community Health Center with a diagnosis of SLE

Group 4

Spanish-speaking, Hispanic patients previously seen in the NIAMS Community Health Center with a diagnosis of rheumatoid arthritis

Group 5

English-speaking, African American patients previously seen in the NIAMS Community Health Center with a diagnosis of rheumatoid arthritis

Group 6

Spanish-speaking, Hispanic patients previously seen in the NIAMS Community Health Center with varying rheumatic diseases including osteoarthritis

Group 7

English-speaking, African American patients previously seen in the NIAMS Community Health Center with varying rheumatic diseases including osteoarthritis

Group 8

Community leaders and/or members of the health partnership

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TABLE 2

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Focus Group Training Goals and Objectives Individual Meetings with Outside Consultant: (45 minute 1:1) 1

To establish rapport with the health care providers.

2

To discuss the role of the focus group trainers.

3

To assess the health care providers’ past experience with groups.

4

To assess the health care providers’ understanding of focus groups.

5

To introduce the training program.

Group meeting #1: Introduction (2 hours) Health care providers will:

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1

Review focus group training materials.

2

Share past focus group experience with the group.

3

Understand the expectations of focus group moderators and facilitators.

4

Discuss their understanding of complementary and alternative medicine (CAM).

5

Health care providers/trainees will review the proposed Focus Group Moderator’s Guide and make suggestions for revisions as needed.

Group meeting #2: Groups (2 hours) Focus Group trainer will: 1

Discuss concepts of focus groups.

2

Discuss the responsibilities of moderators.

3

Describe barriers and pitfalls to avoid.

4

Describe focus group process.

5

Discuss strategies for maintaining moderator/facilitator objectivity.

Group meeting # 3: Mock Focus Group: Role Playing (2 ½ hours)

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Health care providers will participate in a mock focus group through role playing using the revised Focus Group Moderator’s Guide.

2

Health care providers will receive feedback provided by the trainers and other mock focus group participants at the conclusion of the focus group.

3

At the conclusion of the mock focus group, each focus group trainee will be able to process the learning experience through group discussion.

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From Practice to Research: Training Health Care Providers to Conduct Culturally Relevant Community Focus Groups.

Qualitative data from focus groups can provide an "insiders' view" of the culture of those being studied. Such data can help health care providers and...
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