focus group literature review

Literature review: considerations in undertaking focus group research with culturally and linguistically diverse groups

Affiliation.

• 1 Centre for Applied Nursing Research, University of Western Sydney and Sydney South West Area Health Service, Liverpool, NSW, Australia.
• PMID: 17518876
• DOI: 10.1111/j.1365-2702.2006.01760.x

Aims: This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups.

Background: The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions.

Methods: The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors.

Results: Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified.

Conclusions: Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants.

Relevance to clinical practice: Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

Publication types

• Attitude to Health / ethnology
• Clinical Competence
• Communication Barriers
• Cultural Diversity*
• Data Collection
• Data Interpretation, Statistical
• Focus Groups / methods*
• Focus Groups / standards
• Group Processes
• Health Knowledge, Attitudes, Practice
• Health Services Needs and Demand
• Health Services Research / methods
• Interviews as Topic / methods
• Nursing Methodology Research / methods*
• Nursing Methodology Research / standards
• Patient Selection
• Qualitative Research
• Reproducibility of Results
• Research Design* / standards
• Research Personnel / organization & administration
• Research Personnel / psychology
• Sample Size
• Time Factors
• Transcultural Nursing

Literature review: Considerations in undertaking focus group research with culturally and linguistically diverse groups

Research output : Contribution to journal › Review article › peer-review

Aims. This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups. Background. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions. Methods. The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors. Results. Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified. Conclusions. Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants. Relevance to clinical practice. Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

• Focus groups
• Multicultural populations
• Qualitative research
• Research methods

ASJC Scopus subject areas

• General Nursing

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• 10.1111/j.1365-2702.2006.01760.x

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• Focus Groups Medicine & Life Sciences 100%
• Transcultural Nursing Medicine & Life Sciences 13%
• Population Medicine & Life Sciences 11%
• Cultural Diversity Medicine & Life Sciences 10%
• Cultural Competency Medicine & Life Sciences 10%
• Search Engine Medicine & Life Sciences 9%
• Health Services Research Medicine & Life Sciences 8%
• Nursing Care Medicine & Life Sciences 7%

T1 - Literature review

T2 - Considerations in undertaking focus group research with culturally and linguistically diverse groups

AU - Halcomb, Elizabeth J.

AU - Gholizadeh, Leila

AU - DiGiacomo, Michelle

AU - Phillips, Jane

AU - Davidson, Patricia M.

PY - 2007/6

Y1 - 2007/6

N2 - Aims. This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups. Background. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions. Methods. The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors. Results. Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified. Conclusions. Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants. Relevance to clinical practice. Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

AB - Aims. This integrated literature review seeks to identify the key considerations in conducting focus groups and discusses the specific considerations for focus group research with culturally and linguistically diverse groups. Background. The focus group method is a technique of group interview that generates data through the opinions expressed by participants. Focus groups have become an increasingly popular method of data collection in health care research. Although focus groups have been used extensively with Western populations, they are a particularly useful tool for engaging culturally and linguistically diverse populations. The success of focus groups in this context is dependent upon the cultural competence of the research team and the research questions. Methods. The electronic databases Medline, CINAHL, Embase, Psychlit and the Internet using the Google Scholar search engine were explored using the search terms 'focus group', 'cultural sensitivity', 'transcultural nursing', 'transcultural care', 'cultural diversity' and 'ethnic groups'. Hand searching of reference lists and relevant journals was also undertaken. English language articles were selected for the review if they discussed the following issues: (i) methodological implications of the focus group method; (ii) strengths and limitations of the focus group method; (iii) recommendations for researchers and (iv) use of the focus group in culturally and linguistically diverse groups. Conclusions were drawn from each of the articles and consensus regarding a summary of recommendations was derived from a minimum of two authors. Results. Findings from this review revealed several key issues involving focus group implementation including recruitment, sample size, data collection, data analysis and use within multicultural populations. Strengths and limitations of the focus group method were also identified. Conclusions. Focus groups are a useful tool to expand existing knowledge about service provision and identify consumer needs that will assist in the development of future intervention programmes, particularly within multicultural populations. Careful planning related to methodological and pragmatic issues are critical in deriving effective data and protecting participants. Relevance to clinical practice. Focus groups can facilitate increased understanding of perspectives of culturally and linguistically diverse groups and thereby shape clinical practice to better meet the needs of these groups.

KW - Focus groups

KW - Multicultural populations

KW - Nurses

KW - Nursing

KW - Qualitative research

KW - Research methods

UR - http://www.scopus.com/inward/record.url?scp=34249021069&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=34249021069&partnerID=8YFLogxK

U2 - 10.1111/j.1365-2702.2006.01760.x

DO - 10.1111/j.1365-2702.2006.01760.x

M3 - Review article

C2 - 17518876

AN - SCOPUS:34249021069

SN - 0962-1067

JO - Journal of clinical nursing

JF - Journal of clinical nursing

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Methodological Aspects of Focus Groups in Health Research

Anja p. tausch.

1 GESIS–Leibniz Institute for the Social Sciences, Mannheim, Germany

Natalja Menold

Although focus groups are commonly used in health research to explore the perspectives of patients or health care professionals, few studies consider methodological aspects in this specific context. For this reason, we interviewed nine researchers who had conducted focus groups in the context of a project devoted to the development of an electronic personal health record. We performed qualitative content analysis on the interview data relating to recruitment, communication between the focus group participants, and appraisal of the focus group method. The interview data revealed aspects of the focus group method that are particularly relevant for health research and that should be considered in that context. They include, for example, the preferability of face-to-face recruitment, the necessity to allow participants in patient groups sufficient time to introduce themselves, and the use of methods such as participant-generated cards and prioritization.

Focus groups have been widely used in health research in recent years to explore the perspectives of patients and other groups in the health care system (e.g., Carr et al., 2003 ; Côté-Arsenault & Morrison-Beedy, 2005 ; Kitzinger, 2006 ). They are often included in mixed-methods studies to gain more information on how to construct questionnaires or interpret results ( Creswell & Plano Clark, 2007 ; Kroll, Neri, & Miller, 2005 ).

The fact that the group process helps people to identify and clarify their views is considered to be an important advantage of focus groups compared with individual interviews ( Kitzinger, 1995 ). The group functions as a promoter of synergy and spontaneity by encouraging the participants to comment, explain, disagree, and share their views. Thus, experiences are shared and opinions voiced that might not surface during individual interviews ( Carey, 1994 ; Stewart, Shamdasani, & Rook, 2007 ). Although focus groups allow participants to respond in their own words and to choose discussion topics themselves, they are not completely unstructured. Questions relating to the research topic are designed by the researchers and are used to guide the discussion ( Stewart et al., 2007 ). The degree of structure of the focus group depends on the openness of the research question(s). Hence, although it takes more time and effort to organize focus groups, and they cause greater logistical problems than individual interviews do, they might generate more ideas about, and yield deeper insights into, the problem under investigation ( Coenen, Stamm, Stucki, & Cieza, 2012 ; Kingry, Tiedje, & Friedman, 1990 ; Morgan, 2009 ).

Historically, focus groups were used mainly for market research before the method was adopted for application in qualitative research in the social sciences ( Morgan, 1996 ). The use of focus groups in health care research is even more recent. For this reason, methodological recommendations on using focus groups in the health care context are quite rare, and researchers rely mainly on general advice from the social sciences (e.g., Krueger, 1988 ; Morgan, 1993 ; Morgan & Krueger, 1998 ; Stewart et al., 2007 ). Even though focus groups have been used in a great variety of health research fields, such as patients’ treatments and perceptions in the context of specific illnesses (rheumatoid arthritis: for example, Feldthusen, Björk, Forsblad-d’Elia, & Mannerkorpi, 2013 ; cancer: for example, Gerber, Hamann, Rasco, Woodruff, & Lee, 2012 ; diabetes: for example, Nafees, Lloyd, Kennedy-Martin, & Hynd, 2006 ; heart failure: for example, Rasmusson et al., 2014 ), community health research (e.g., Daley et al., 2010 ; Rhodes, Hergenrather, Wilkin, Alegría-Ortega, & Montaño, 2006 ), or invention of new diagnostic or therapeutic methods (e.g., Vincent, Clark, Marquez Zimmer, & Sanchez, 2006 ), the method and its particular use in health research is rarely reflected. Methodological articles about the focus group method in health care journals mainly summarize general advice from the social sciences (e.g., Kingry et al., 1990 ; Kitzinger, 1995 , 2006 ), while field-specific aspects of the target groups (patients, doctors, other medical staff) and the research questions (not only sociological but often also medical or technical) are seldom addressed. Reports on participant recruitment and methods of conducting the focus groups are primarily episodic in nature (e.g., Coenen et al., 2012 ; Côté-Arsenault & Morrison-Beedy, 2005 ) and often focus on very specific aspects of the method (communication: for example, Lehoux, Poland, & Daudelin, 2006 ; activating methods: for example, Colucci, 2007 ) or aim at a comparison between face-to-face focus groups and other methods (individual interviews: for example, Coenen et al., 2012 ; telephone groups: for example, Frazier et al., 2010 ; Internet groups: for example, Nicholas et al., 2010 ). Thus, systematic reviews of factors influencing the results of focus groups as well as advantages, disadvantages, and pitfalls are missing. One consequence is that researchers might find it difficult to recruit enough participants or might be surprised by the communication styles of the target groups. Furthermore, in the tradition of classical clinical research, the group discussions might result in a question-and-answer situation or “resemble individual interviews done in group settings” ( Colucci, 2007 , p. 1,424), thereby missing out on the opportunity to use the group setting to activate all participants and to encourage a deeper elaboration of their ideas. Colucci, for example, proposed the use of exercises (e.g., activity-oriented questions) to focus the attention of the group on the core topic and to facilitate subsequent analyses.

Recommendations from the social sciences on using the focus group method can be subsumed under the following headings: subjects (target groups, composition of groups, recruitment), communication in the groups (discussion guide, moderator, moderating techniques), and analysis of focus groups (e.g., Morgan, 1993 ; Morgan & Krueger, 1998 ; Stewart et al., 2007 ). Specific requirements for health research can be identified in all three thematic fields: Recruitment might be facilitated by using registers of quality circles to recruit physicians or pharmacists, or by recruiting patients in outpatients departments. It might be hampered by heavy burdens on target groups—be they time burdens (e.g., clinical schedules, time-consuming therapy) or health constraints (e.g., physical fitness). With regard to communication in focus groups, finding suitable locations, identifying optimal group sizes, planning a good time line, as well as selecting suitable moderators (e.g., persons who are capable of translating medical terms into everyday language) might pose a challenge. The analysis of focus groups in health care research might also require special procedures because the focus group method is used to answer not only sociological research questions (e.g., related to the reconstruction of the perspectives of target groups) but also more specific research questions, such as user requirements with regard to written information or technical innovations.

The aim of our study was to gather more systematic methodological information for conducting focus groups in the context of health research in general and in the more specific context of the implementation of a technical innovation. To this end, we conducted interviews with focus group moderators about their experiences when planning and moderating focus groups. The groups in question were part of a research program aimed at developing and evaluating an electronic personal health record. We chose this program for several reasons: First, because it consisted of several subprojects devoted to different research topics related to the development of a personal electronic health record, it offered a variety of research content (cf. next section). Second, the focus groups were conducted to answer research questions of varying breadth, which can be regarded as typical of research in health care. Third, the focus groups comprised a variety of target groups—not only patients but also different types of health care professionals (general practitioners, independent specialists with different areas of specialization, hospital doctors, pharmacists, medical assistants, nursing staff).

In this article, we report the findings of these interviews in relation to the following questions: (a) What challenges associated with the characteristics of the target groups of health research (patients, physicians, other health care professionals) might be considered during the recruitment process? How should the specific research question relating to a technical innovation be taken into account during the recruitment process? (b) Should specific aspects of the communication styles of target groups be taken into account when planning and moderating focus groups in health care? Can additional challenges be identified in relation to the technical research question? and (c) How was the method appraised by the interviewees in their own research context?

Research Program and Description of Focus Groups

The “Information Technology for Patient-Centered Health Care” (INFOPAT) research program ( www.infopat.eu ) addresses the fact that, because patients with chronic conditions (e.g., colorectal cancer, type 2 diabetes) have complex health care needs, many personal health data are collected in different health care settings. The aim of the program is to develop and evaluate an electronic personal health record aimed at improving regional health care for chronically ill people and strengthening patients’ participation in their health care process. Subprojects are devoted, for example, to developing the personal electronic health record (Project Cluster 1), a medication platform (Project Cluster 2), and a case management system for chronically ill patients (Project Cluster 3). In the first, qualitative, phase, the researchers explored patients’ and health care professionals’ experiences with cross-sectoral health care and patient self-management, and their expectations regarding the advantages and disadvantages of a personal electronic health record. The information gathered in this phase of the program served as a basis for constructing a personal electronic health record prototype. This prototype was implemented as an intervention in a second, quantitative, phase dedicated to investigating the impact of such a record on a range of health care variables (e.g., self-management, health status, patient–doctor relationship, compliance). The University Hospital Heidelberg Ethics Committee approved the studies of the INFOPAT research program. All participants gave their written informed consent, and the participants’ anonymity and confidentiality were ensured throughout the studies according to the ethical standards of German Sociological Association. 1

Twenty-one focus groups were conducted during the qualitative phase of the program. Three groups consisted of colorectal cancer patients, four comprised type 2 diabetes patients, four were made up of physicians, three comprised physicians and pharmacists, four consisted of physicians and other health care professionals, and three consisted of other health care professionals (for more detailed information, see Tausch & Menold, 2015 ). Participants were recruited from urban and rural districts of the Rhine-Neckar region in Germany. Patients were approached in clinics, by their local general practitioners, or in self-help groups. Health care professionals were recruited in clinics, cooperating medical practices, and professional networks.

The focus groups took place at several locations at the National Center of Tumor Diseases (NCT) in Heidelberg, Germany, and the University of Heidelberg. The groups consisted of between four and seven participants and lasted between 1.5 and 2 hours. All focus groups were conducted by two researchers—a moderator and a co-moderator; a third researcher took notes. Semistructured discussion guides were used, and the groups were video- and audio recorded (cf., for example, Baudendistel et al., 2015 ; Kamradt et al., 2015 ). The researchers performed content analysis on the transcripts; the schema of categories was oriented toward the research questions. The focus groups addressed research questions of varying breadth, including, for example, individual health care experiences (comparatively broad), the expected impact of the record on the patient–doctor relationship (medium breadth), and technical requirements for such a personal health record (comparatively narrow). The variety of the research questions was important for our study because it proved to be of relevance for the interviewees’ appraisal of the usefulness of the focus group method.

Interviews With the Focus Group Moderators

We conducted qualitative interviews with nine of the 10 focus group moderators in the INFOPAT program (one moderator moved to a different department shortly after the completion of data collection and was not available for interview). The interviewees were aged between 30 and 54 years ( M age = 36 years; SD = 8.3 years). Their professions were health scientist, pharmacist, general practitioner, or medical ethicist. Their professional experience ranged from one to 23 years ( M = 7.1 years, SD = 7.7 years), and they had little or no previous experience of organizing and conducting focus groups. The moderators were interviewed in groups of one to three persons according to their project assignment (cf. Table 1 ).

Overview of Interviews and Interviewees.

The interviews lasted approximately 1 hour, and the interview questions were guided by the chronological order in which a focus group is organized and conducted (recruitment, preparation, moderation, methods) and by the utilization and usefulness of the results. We tape recorded the interviews, transcribed them verbatim, and performed qualitative content analysis on the transcripts ( Elo & Kyngäs, 2008 ; Mayring, 2015 ) with the help of the program MAXQDA 10.0.

The final system of categories 2 ( Tausch & Menold, 2015 ) consisted of two types of codes: All relevant text passages were coded with respect to the content of the statement. In addition, a second type of code was required if the statement related to a specific group of participants (e.g., patients, hospital doctors, men, women).

On the basis of the research questions, the contents of interview statements were classified into the three superordinate thematic categories: recruitment, communication in the focus groups, and appraisal of the focus group method. Consequently, the reporting of the results is structured according to three main topics.

Recruitment

Statements relating to the recruitment of the participants were sorted into the main categories “factors promoting participation”, “factors preventing participation”, and “general appraisal of the recruitment process”. Figure 1 shows the subcategories that were identified under these main categories. Because many of the statements referred only to patients or only to health care professionals (physicians, other health care professionals), the subcodes shown in Figure 1 are sorted by these two types of participants.

Factors relating to the recruitment process.

Factors relevant for all target groups

As the following interviewee statement shows, addressing potential participants face-to-face (rather than in writing) proved crucial for the success of recruitment in all target groups:

Well, a really good tip when recruiting patients is . . . to address the people yourself. Not to get someone else to do it who . . . has nothing to do with [the project], because ultimately you really do have to explain a lot of things, also directly to the patient. And then it’s always good if the person [who does the recruiting] is actually involved in the project. 3

In the case of the clinicians, being addressed by a superior was even more effective for their willingness to participate: “And then top down. If the nursing director asks me, then it’s not so easy to say no.”

Furthermore, a positive response was more often achieved if the groups were scheduled at convenient times for the addressees, and they only had to choose between several alternatives. Patients welcomed times contiguous with their therapies: “And many [of the patients] said: ‘Yes, maybe we can do it after my chemotherapy, on that day when I’m in the clinic anyway?’” Whereas medical assistants were given the opportunity to take part in the groups during working hours, general practitioners preferred evening appointments on less busy weekdays (e.g., Wednesdays and Fridays):

Well, what I found quite good was to suggest a day and a time. And we concentrated on the fact that practices are often closed on Wednesday afternoons. So that’s a relatively convenient day. And then evenings for the pharmacists from seven-thirty onwards.

Interest in the topic of the discussion, or at least in research in general, was an important variable for participation. Together with lack of time, it turned out to be the main reason why sampling plans could not be realized. Among patients, men were much more interested in discussing a technical innovation such as an electronic personal health record, while women—besides their lesser interest—often declined because of family responsibilities: “Well, I’d say a higher proportion of women said: ‘I have a lot to do at home, housework and with the children, therefore I can’t do it.’”

Family physicians, physicians from cooperating medical practices, and hospital doctors showed more interest in discussing an electronic personal health record than did medical specialists in private practice, who often saw no personal gain in such an innovation. For example, one interviewee stated,

Family physicians generally have a greater willingness [to engage with] this [health] record topic. They see . . . also a personal benefit for themselves. . . . or they simply think it might be of relevance to them or they are interested in the topic for other reasons. Some of them even approached us themselves and said, “Oh, that interests me and I’d like to take part.”

In addition, because of heavy workload, private practitioners were difficult to reach (e.g., by telephone). This also lowered the participation of this target group on the focus groups.

Factors relevant only for patients

Two other variables that influenced patients’ willingness to participate were mentioned in the interviews. First, because this target group consisted of cancer patients and diabetes patients with multimorbidity, poor physical fitness also prevented several addressees from participating in the groups. The inability to climb stairs, or the general inability to leave the house, made it impossible for them to reach the location where the groups took place: “[They] immediately replied: ‘Well, no, . . . that’s really too much for me,’ and unfortunately they could not, therefore, be included in the groups.” Furthermore, unstable physical fitness often led to high drop-out rates. The moderators of the focus groups therefore proposed that up to twice as many participants as required should be recruited: “And depending on the severity of the illness, you have to expect a drop-out rate of up to fifty percent. So, if you want to have four people, you should invite eight.”

Second, moderators reported that patients’ liking for, or dislike of, talking and discussing influenced their tendency to join the groups. Participating patients were generally described as talkative. For example: “And with patients, all in all, I had the feeling that those who agreed [to participate] were all people who liked talking, because those who did not like talking refused out of hand.” Patients who refused to participate often argued that they felt uncomfortable speaking in front of a group: “And the men, when they declined they often said: ‘No, group discussion is not for me! I don’t like talking in front of a group.’”

The researchers eventually succeeded in recruiting sufficient participants. However, they were not able to realize the sampling plans according to a certain proportion of male and female patients or types of physicians. “Well, we finally managed to fill up our groups, but only as many [participants] as necessary.” Comparing the different target groups, recruiting patients was described as easier than recruiting physicians: “And that was much easier insofar as you just had to go to the clinic and each day there were five or six patients whom you could address.” However, only 10% of the patients who were addressed agreed to participate. In the health care professional group, the recruitment rates ranged between 0% and 30%, depending on the subgroup. This can be demonstrated by the following interviewee utterance:

And in the private practitioner sector it was rather . . . . Well, we tried to recruit specialists in private practice, in other words internists, gastroenterologists, and oncologists. The success [rate proved to be] extremely poor. . . . Well, on the whole, the willingness to take part, the interest, is not there. Or, well they don’t give the reasons, but they say they don’t want to take part. So that was difficult and, yes, it didn’t go too well.

Communication in the Focus Groups

With regard to the communication in the focus groups, the moderators identified factors that influenced communication in a positive or negative way. In addition, we discussed a number of factors with them that are often described in the social science literature as problematic when conducting focus groups. However, the interviewees considered that some of these factors had not influenced communication in the focus groups conducted within the framework of the INFOPAT program. In our system of categories, we also coded whether the factors in question were related to (a) the setting or (b) the moderation of the focus groups (cf. Figure 2 ).

Influences on and characteristics of the focus group discussion.

Factors relating to the setting

As Figure 2 shows, communication was reported to be positively influenced by small group size, location, provision of food and beverages, and conducting the focus group without a break. In contrast to general recommendations on focus groups in the context of sociological research, the moderators in the INFOPAT program considered a smaller group size of between four and six participants to be ideal. With regard to location, the interviewees reported that, depending on the target group, different places were perceived as positive. Patients preferred locations inside the clinic because they were easy to reach and caused no additional effort. Furthermore, because these locations were familiar to them, they facilitated an atmosphere of security and ease, which was seen as an important prerequisite for an open and honest discussion. This is clear from the following quotation:

Well, the patient focus groups were all located at the clinic. We chose this location on purpose to make it easier for them, because they come to the clinic anyway for their therapy. And they know the place and they feel comfortable and in good hands.

By contrast, the clinician groups benefited from being located outside the clinic. In contrast to other common addressees of focus groups, these professionals were not only accustomed to participating in groups outside their familiar surroundings but also this location helped them to distance themselves from their professional duties and to engage more deeply in the discussion, as shown by the following quotation:

Yes, one was located at the O-Center. We chose this location on purpose so that the clinicians had to leave the hospital. It’s not too far, only a few yards away. But we wanted them to leave the clinic, and not to run back to the ward when they were called. And, well, I liked this location.

Food and beverages were welcome in all the groups and also helped to create a positive and trusting atmosphere. And finally, the interviewees found that it was better to omit the break, thereby avoiding the interruption of the ongoing discussion. This is reasonable considering the comparatively short duration of the focus group session (between 1.5 and 2 hours). Statements relating to a break might have been different in the case of longer focus group durations.

The interviewees reported that the size and temperature of the room and time pressure on the participants or the moderator had a negative impact on communication. Some of the focus groups in the project took place in midsummer and had to be held in rooms without blinds or air conditioning. The moderators of these groups had to work hard to maintain the participants’ (and their own) attention and concentration. Time pressure on the participants (e.g., the clinicians) led to an unwillingness to engage in active discussion and created a question-and-answer situation, as shown by the following statement:

And in one group of physicians . . . we never reached the point where they joined in fully. During the whole discussion they never completely arrived. And they had already cut the time short in advance. They were under so much time pressure that they were not able to discuss in an open manner.

Moderators reported that they, too, had experienced time pressure—namely, in situations where they did not have enough time to prepare the room and the recording devices. This had caused them to be nervous and stressed at the beginning of the discussion, which had negatively affected the mood of the participants, thereby rendering an honest and open discussion particularly difficult.

Factors relating to the moderation

Many of the positive factors reported by the interviewees have already been described for focus groups in general—for example, using open questions, directly addressing quiet participants, and handling the discussion guide in a flexible way. Furthermore, by showing interest in every statement, and by generating a feeling of security in every participant, moderators fostered a fruitful discussion:

I believe that another important point is that you are calm yourself. That you give the people the feeling “you can feel safe with me, you don’t have to worry that I will make fun of you . . . or that I won’t take you seriously.”

Interviewees also considered that building a bridge between the technical innovation under discussion (a web-based electronic personal health record) and everyday life (e.g., online banking) was an important factor in getting all participants to contribute to the discussion. As one interviewee noted,

We tried to anchor it in their everyday lives. And . . . the example that always worked was when we said: “Think of it as if it were a kind of online banking.” Everyone understands what online banking is. It’s about important data on the internet; they’re safe there somehow. I have my password. And people understood that. Well, it’s important to anchor it in their reality . . . because otherwise the topic is simply far too abstract.

In this context, the fact that the groups were moderated by the researchers themselves proved very helpful because they were able to answer all questions relating to the research topic. As the following quote shows, this was an important prerequisite for opinion formation on the part of participants:

Well, I think that a really important quality criterion . . . is that you have completely penetrated [the topic]. If you only know the process from the outside . . . and you then conduct the focus group about it. . . . Somewhere, at some stage, [one discussion] narrowly missed the point. . . . You simply have to be totally immersed in the topic, well, I believe that [someone who is totally immersed in the topic] is the ideal person for the job. And in our case the thinking was, okay, so I’m a doctor, but on balance it’s more important that both [moderators] are absolutely well informed because it’s a complex topic.

The more specific the research question was, the more useful the moderating strategy of inviting one participant after the other to express their opinion appeared to be. By using this strategy, the moderators ensured that every participant contributed to the discussion.

A point that was strongly emphasized by the interviewees was the duration of the round of introductions at the beginning of the focus group session. In the patient groups, introductions took much more time than the researchers had expected. Patients had a high need to express themselves and to tell the others about their illness and their experiences with the health system. Although this left less time to work through the topics in the discussion guide, the researchers came to realize that there were several good reasons not to limit these contributions: First, the introductions round proved important for helping the participants to “arrive” at the focus group, for creating a basis of trust, and for building up a sense of community among the participants. Second, the interviewees reported that, because many topics in the discussion guide (e.g., participants’ experiences with coordinating visits to different medical specialists) had already been brought up in the round of introductions, they did not have to be discussed further at a later stage:

And that is the crux of this general exchange of experiences at the beginning. Sure, it costs you a lot of time, but I almost think that if you don’t give them that time, you won’t get what you want from them, in the sense that you say: “I want to hear your frank opinion or attitude.” You don’t want them to simply answer you because they think that’s what you want to hear. You have to create an atmosphere in which they really forget where they are. I’m relatively convinced that you wouldn’t achieve that without such [a round of introductions].

The moderators’ experience in the physician groups was different. These groups benefited from having a rather short round of introductions. Giving participants too much time to introduce themselves meant that they presented their expertise rather than reporting their experiences. In contrast to the patient groups, this did not substantially contribute to the discussion of the research topics.

Depending on the context, status differences between the moderators and the participants, or among the participants, were appraised differently by interviewees. In one group comprising physicians and medical assistants, the moderators observed that status differences had a negative influence on communication. Very young female medical assistants, in particular, did not feel free to express their opinions in the presence of their superiors. By contrast, presumed differences in status between family doctors, hospital doctors, and medical specialists in private practice did not have any negative impact on communication. Nor did different forms of address (some participants in these groups were addressed by their first name and some by their last name, depending on the relationship between the moderator and the participants). Status differences between moderators (if medical doctors) and participants (patients) had an impact on communication when patients regarded doctors as an important source of information (e.g., about the meaning of their blood values) or as representatives of the health care system to whom complaints about the system should be addressed. The latter case was the subject of the following interview statement by a moderator who is a physician by profession:

And a lot [was said about] the kind of experiences they had had here at the NCT. And of course, when the patients have been treated here for many years—or even for not so many [years], but they have had many experiences—they sometimes reported at length. And I had the feeling that this had a bit of a feedback function, quite generally, for the NCT. Also the somehow frustrating experiences they had had, or a lot of things that had not gone that well in conversational exchanges [with the staff]. There was a relatively large amount of feedback that didn’t have a lot to do with the topic because I was, of course, involved as a senior physician and I am not an external researcher, but rather someone who is also seen as being jointly responsible, or at least as someone who can channel criticism.

Finally, because most of the moderators were not medical professionals, they did not experience the translation of medical or technical terms into everyday language as problematic. Rather, they automatically used terms that were also familiar to the participants.

Characteristics of the discussion

The factors described above resulted in focus group discussions that might be interpreted as characteristic of health research. The patient focus groups were characterized by a strong need to talk and a high need for information. In the health care professional focus groups, researchers experienced a greater variety of communication styles. Because of a lack of time, or because they falsely expected a question-and-answer situation, some groups demonstrated a low degree of willingness to engage in discussion:

Although, I believe that was partly due . . . well there was one [woman] who was very demanding; she wanted to know straight away: “Yes, what’s the issue here? What do I have to say to you?” Well, the three who came from the one practice, I think they really had the feeling that we would ask them questions and they would bravely answer them and then they could go home again. So, for them this principle that they were supposed to engage in a discussion, for them that was somehow a bit, I don’t know . . . disconcerting. . . . They really thought: “Okay, well we want to know now what this is all about. And they’ll ask us the questions and then we’ll say yes, no, don’t know, maybe. And then we’ll go home again.” Well, at least that was my impression.

Other groups, especially those consisting of different types of health care professionals (e.g., physicians with different areas of specialization, or physicians and pharmacists), were characterized by lively discussion and a great variety of opinions.

Appraisal of the Focus Group Method

We classified moderators’ statements relating to the appraisal of the focus group method into four main categories: “advantages of the method”, “disadvantages of the method”, “recommendations for other researchers in related research areas”, and “statements on how they used the results” (cf. Figure 3 ).

Appraisal of the focus group method.

The researchers reported that the focus group method yielded a rich blend of perspectives and opinions, brought forth, in particular, by the interaction between the participants:

But for this question and the topic, and for our lack of knowledge, that was . . . a lot of new information . . . and very many good ideas and critical remarks that you naturally read in the literature from time to time. But, let’s say, because of the complexity of the participants’ reactions and the weight they attached to things, it’s different than reading in a literature review that [this or that] could be taken into account.

The results of the focus groups further enriched the researchers’ work by relating it to everyday life: “Well, what was nice was that the topic was related to the participants’ lives. That people said: ‘Now the topic is important for me.’” Furthermore, the method yielded information about which aspects were most important and how the variety of opinions should be prioritized. This was achieved, in particular, by using participant-generated cards:

And with regard to prioritization, we incorporated it using participant-generated cards. We said: “Look: If you could develop this record now, what would be the three most important things that must absolutely be taken into consideration, from your point of view, no matter what they relate to.” And they wrote them down on the cards. And after that they were asked to carry out their own prioritization—that is, what was most important to them personally. One person wrote “data protection” first, while another [wrote] “sharing with my wife.” . . . That was good. . . . That helped a lot because it was simply clear once again what things were important to them.

In cases where concrete questions had to be answered or decisions had to be made, the interviewees also welcomed the opportunity to use structuring methods such as presentations, flip-charts, and participant-generated cards to obtain the relevant information:

. . . Well, the aim was that at the end we [would] have a set of requirements for the engineering [people]. And the engineering [people] don’t so much want to know about experiences and desires and barriers, but rather they want to know should the button be green or red and can you click on it. And that’s why I thought at the beginning it will be difficult with a focus group and an open discussion. Now, if you say that one can also interpret a focus group the way we did, partly with very specific questions and these participant-generated cards, then I think it is indeed possible to answer such questions as well.

Disadvantages

The main disadvantages of the focus group method were seen in the considerable organizational effort and expenditure of time involved. A question raised by some of the interviewees was whether comparable results could have been achieved using less time-consuming and organizationally demanding methods.

It’s true to say that you lose time. Well, you could implement [the innovation] straight away and see whether it’s better. Maybe, in this case you’re wrong and you just think it’s better or in any case not worse than before. You basically lose a year on this whole focus groups thing.

Moreover, in some cases, the discussion went in an unwanted direction and the moderators never fully succeeded in bringing the group back to the intended topics.

Furthermore, like many other medical research projects, INFOPAT included quite specific research questions. In this connection, the moderators emphasized that open focus group discussions would not have succeeded in answering those questions. Only by using methods such as participant-generated cards and prioritization was it possible to answer at least some of them. Nonetheless, some interviewees did not consider the focus group method to be really suitable for this type of research questions:

Of course we also have our engineers as counterparts who . . . need very specific requirements at some point. The question is whether such a focus group . . . . [It] can’t answer that in detail in this first stage. It’s simply not practicable.

Recommendations

As described under the “Communication in the Focus Groups” section above, the round of introductions in the patient groups lasted much longer than planned, thereby shortening the time available for other topics in the discussion guide. As a result, the moderators decided to choose a different thematic focus in each group so that every topic was discussed more deeply in at least one group.

What we usually did was to consider what hadn’t been addressed that much in the previous focus group. That [topic] was given more room in the next focus group because the guide, well it was quite a lot. You could have easily gone on discussing for another hour or two.

Using the results

On the whole, the researchers were satisfied with the number of groups that were conducted and the results that they yielded. They did not agree that more groups would have led to better, or different, results—with one possible exception, namely, in the case of specific target groups (e.g., migrants). Only one group had been composed of patients with a migrant background, and, as one interviewee stated, “I just thought, the patients with a migrant background . . . now that was [only] one group, it by no means covers the whole range.”

In cases where the results of the focus groups were perceived as not being concrete enough to proceed to the next research step (e.g., formulating a specification sheet for the construction of the electronic personal health record), the researchers planned to bring experts together in a roundtable format to make decisions on the basis of the priorities, agreements, and disagreements that had emerged from the focus groups. Following the construction of a prototype, they intended to conduct further focus groups to validate or adapt the usability of the electronic personal health record system.

Our analysis of interviews with focus group moderators yielded considerable insights into methodological aspects of conducting focus groups in health research. Our first research question related to characteristics of the target groups that should be considered during the recruitment process. We identified face-to-face contact as an important factor promoting focus group participation. The interviewees considered this type of contact to be better suited to answering target persons’ questions and explaining the method and aims of the focus groups. Moreover, they felt that addressees might find it more difficult to decline a face-to-face invitation than a written one. With regard to health care professionals, an invitation issued by a hierarchically higher person was most effective, even though ethical aspects should be considered in this case, and voluntary participation should nevertheless be ensured. Otherwise, the order to participate might prevent an atmosphere of open communication and might lead to a lower quantity or to more negative statements.

Furthermore, whereas physicians are usually accustomed to discussing topics with others, an important characteristic that influenced willingness to participate on the part of members of other target groups (other health care professionals, patients) was a liking for, or a dislike of, talking. Researchers might take account of this fact by explaining the method in more detail, by developing arguments to overcome fears, or, as suggested, for example, by Colucci (2007) , by convincing the addressees with other activities implemented in the focus groups. Other relevant personal characteristics—be they related to the research topic (e.g., technical interest in the case of an electronic innovation) or to the specific target group (e.g., physical fitness on the part of patients or lack of time on the part of health care professionals)—should be anticipated when planning recruitment. These characteristics might be taken into account by preparing arguments, providing incentives, giving thought to favorable dates and times, and choosing easily accessible locations. An interesting finding was that, depending on the target group, different locations were considered to have a positive influence on the discussion. Whereas locations inside the clinic were preferred in the case of the patient focus groups because of familiarity and easy accessibility, hospital doctors were more engaged in the discussion when the focus group site was located at least some yards away from their workplace.

Finally, the experience of our researchers that up to 50% of the patients had to cancel at short notice because of health problems does not appear to be uncommon in this research context. That overrecruitment is an effective strategy—particularly in health care research—has been reported by other authors (e.g., Coenen et al., 2012 ).

With our second research question, we focused on aspects of communication in the focus groups. The interviews revealed several factors specific to research topics and addressees of health care studies that influenced the discussions. Consequently, in addition to considering general recommendations regarding the organization and moderation of focus groups (e.g., choosing adequate rooms with a pleasant atmosphere, serving food and beverages, using open questions, showing interest in all contributions, and directly addressing quiet participants), these health care specific aspects should be taken into account. Relevant factors that should be addressed when moderating focus groups in this context are (a) the strong need to talk and the high need for information in the patient groups, (b) status differences between the participants or between the moderators and the participants, (c) the size of the focus group, and (d) the specificity of the topic of discussion. The interview data revealed that these factors influenced the discussions and thus the results achieved with the groups. In addition, the following four possibilities of addressing these factors were identified:

First, the moderators had to devote more time to the round of introductions in the patient groups, which served as a warm-up, created an atmosphere of fellowship and openness, and accommodated this target group’s strong need to talk. Second, with respect to status differences between the moderator and the participants, no definite recommendations can be derived from the interviews. The interviewees found that it was less favorable when the moderator was perceived not only in that role but also in other roles (e.g., physician), because this might hamper a goal-oriented discussion. However, they considered deep insight into the research topic on the part of the moderators to be beneficial, at least for certain research topics. Thus, one should carefully weigh up whether it is more advantageous or more disadvantageous when the group moderator is a physician. Interviewees considered status differences between participants to be disadvantageous only in one case, where—because of organizational constraints—medical assistants and their superiors joined the same focus group, which gave rise to some reticence on the part of the young assistants. Similar problems have been reported by other authors, for example, Côté-Arsenault and Morrison-Beedy (2005 ; see also Hollander, 2004 ). However, interviewees did not experience as problematic status differences between physicians with different areas of specialization.

Third, with respect to group size, interviewees found comparatively small focus groups appropriate to give all participants enough time to tell their stories. In contrast to social science research, where groups of between eight and 20 participants are recommended, our interviewees considered groups of between four and six persons to be optimal. This is in line with Côté-Arsenault and Morrison-Beedy (2005) , who recommended small groups for health research, especially when sensitive topics are discussed. Our interview data revealed that this recommendation might also be useful for other health research topics.

Fourth, with regard to the topic of the discussion, interviewees found it helpful to structure different phases of the discussion in different ways, depending on the specificity of the research questions. In contrast to social science research, certain types of research questions in health research require comparatively specific answers. Some of the focus groups in our study were aimed at collecting participants’ expectations regarding an electronic personal health record or—even more specifically—at developing a product specifications document. Conducting focus groups during the development of a technical innovation is a method that is being increasingly used in health care research. Hence, the experiences of the interviewees with regard to these aspects of their research might be relevant for many other research programs. For this type of research questions, it proved useful to include more structured parts in the discussion, for example, having certain questions answered by each participant in turn, or using methods such as participant-generated cards and prioritization. This made it easier to obtain the opinion of each participant and to cover as many concerns and expectations as possible. This finding is in line with recommendations by Colucci (2007) , who proposed the use of activity-oriented questions for health research topics as an enrichment of data collection and a means of making it easier to talk about sensitive and complex topics.

All the moderators found that their discussion guides contained too many questions and too many topics. This might have been due, at least partly, to a desire to determine all relevant aspects in advance—a tendency that might be typical of health research. However, Morgan (1995) also addressed this phenomenon in relation to social research in general: “A common error in focus group question guidelines is too much emphasis on what is of interest to the researcher and not enough emphasis on what is of interest to the participants” (p. 520).

With our third research question, we addressed the appraisal of the focus group method in the interviewees’ research context. Our results show that one should think carefully before using focus groups in the field of health research. The impression that they are quick and easy to conduct might be a misconception, especially in this research context. In fact, the appraisal of the method by the moderators revealed both advantages and disadvantages. The main advantages were the rich blend of perspectives and opinions obtained and the opportunity to have them prioritized by the target groups. For their research topics, the interviewees saw a further important advantage in the fact that they were able to relate their scientific research to everyday life, a point that might be of general importance for a number of research questions in health research, especially those that refer to new medical diagnostics or technical innovations.

The interviewees considered that the main disadvantages of focus groups were the substantial organizational effort and expenditure of time they required. They raised the question whether comparable results could have been achieved using less costly methods. Fortunately, we conducted our interviews with researchers from a research program aimed at answering research questions of different degrees of specificity. As a result, the moderators were able to compare the usefulness of focus groups for different types of research questions. Their statements revealed that they were satisfied with the results relating to more open research questions such as experiences with cross-sectoral health care. For more specific research questions, the interviewees valued the possibility of organizing the discussions in a more structured way and using methods that activated all participants (e.g., participant-generated cards, prioritizations). Nonetheless, they considered meetings of experts to be a necessary intermediate step, for example, on the way to a product specifications document. We recommend that, depending on the specificity of the results that are projected, consideration should be given to including such intermediate steps in the planning stage.

Limitations of the Study

Our analysis of the interviews with the focus group moderators revealed a number of methodological problems that typically occur when focus groups are used in a health research context and yielded recommendations on using such groups in this context. However, some limitations of the present study should also be discussed: First, we conducted our research with focus group moderators, all of whom worked in the same research program. Even though the INFOPAT program consists of several subprojects, they all deal to a greater or lesser extent with the advantages and disadvantages of an electronic support system (electronic personal health record). Furthermore, the moderators were mainly health scientists and had little or no experience with conducting focus groups. This might also have been specific for the research program in which our study was conducted. In other health care programs, focus groups might be moderated mainly by physicists or lay persons (e.g., in participatory health research). Consequently, had we also conducted interviews with focus group moderators from other research areas or included moderators with other professions or more focus group experience, this might have led to different results. However, our research project is rather typical for applied qualitative research in medical science when developing new technologies. Here, focus groups are used by the researchers to find out the potential requirements for the new technology. The researchers are often experts in a specific scientific topic and have no or only limited experience in conducting qualitative research in terms of focus groups. Therefore, our findings are of a particular importance for the researchers with little experiences in conducting focus groups, which can apply to every research, conducted first time. In addition, the little experience of our focus group moderators was a special advantage and strength of the study. More experienced moderators would have prevented some of the problems our moderators—as other unexperienced moderators—faced. As a result, the moderators would not have named these potential problems in the interviews and given no advice for preventing them.

Second, the study was conducted in Germany and thus represents problems and challenges of the German health care system. In other countries, physicians might have different work-shifts or there might be different possibilities in the health care system to reach the target groups. Therefore, more research on the methodology of focus groups in the context of the development of new technologies in health care in other countries and cultures with a consideration of additional relevant groups is needed.

Third, in our interviews, we focused mainly on the organization and conducting of focus groups. For two reasons, we did not address the aspect of data analysis: First, we conducted the interviews shortly after the focus groups had been completed, at a time when data analysis was still in progress. Second, analysis of qualitative data can be carried out in many different ways, depending on research questions and preferences of researchers, and some of the recommended methods are very complex. Had we discussed them in detail, it would have been too time-consuming in the interviews.

Concluding Remarks

Our results revealed a number of methodological challenges that might be typical of conducting focus groups in health research. We hope that our findings will be of use to researchers in similar research fields. Furthermore, we encourage other researchers who are interested in health research topics to gather more information about methodological aspects specific to this research field. Our results were achieved in the context of the development of a technical innovation. It might be interesting to endeavor to replicate them in other health care research projects dealing with technical innovations. Moreover, we would encourage researchers of other topics in health research to interview focus group moderators about their experiences in their specific research context. We hope that our results will serve as a useful basis for comparing results in different areas of health research.

Acknowledgments

We thank the focus group moderators in the INFOPAT program for their great willingness to share their experiences and for their openness during the interviews.

Author Biographies

Anja P. Tausch , PhD, is senior researcher at GESIS–Leibniz Institute for the Social Sciences, Mannheim, Germany.

Natalja Menold , PhD, is senior researcher and head of the Survey Instruments Unit at GESIS–Leibniz Institute for the Social Sciences, Mannheim, Germany.

1. http://www.soziologie.de/en/gsa/ethik-kommission/code-of-ethics.html , retrieved on 05/10/2015.

2. The language of the research project, focus groups, and interviews was German. The scheme was developed in German on the basis of the German text material from the transcribed interviews. The scheme and the citations were translated for the purpose of international publication by an experienced, qualified, and fully bilingual translator, whose mother tongue is English and who also has an MA in sociology from a German university. A German version of the full categorial system can be found in Tausch and Menold (2015) .

3. All citations included in this publication were translated from German.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the German Federal Ministry of Education and Research (BMBF; FKZ 01KQ1003D).

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The use of focus groups in cultural ecosystem services research: a systematic review

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Focus groups are an increasingly popular method for eliciting non-material values and cultural ecosystem services (CES) in the context of studying human–nature relationships. We conducted a systematic review of the literature with the aim of exploring where and how focus groups were used in the research into CES. Furthermore, we aimed to highlight good practices and potential caveats of the use of the focus groups method with respect to recommendations in methodological literature. We employed an inclusive CES classification framework and observed that focus groups were mostly used to research Recreation, Aesthetics, and Education categories. The review also discovered insufficient reporting and methodological inconsistencies in some of the studies. We provide suggestions for more robust and trustworthy applications of the focus group method, which can advance both research in this field and the implementation of the ecosystem services concept in the future.

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Introduction.

Nature and its ecosystems provide a plethora of benefits to people and society, which can be conceptualized in various ways. The ecosystem services (ES) framework provides one such lens to look at human–nature relationships which can highlight the importance of nature for human well-being (Millennium Ecosystem Assessment, 2005 ). Traditionally, ES are distinguished into three to four main categories—regulating, provisioning, cultural, and (in some cases) supporting (Costanza et al., 2017 ). The latest ‘evolution’ of the ES framework into nature’s contributions to people (NCP) framework by Díaz et al. ( 2018 ) brought up many conceptual discussions (e.g., Peterson et al., 2018 ; Maes et al., 2018 ), some of them focusing on the role of social science in ES research (Kadykalo et al., 2019 ). Especially in the case of cultural ES (CES), scholars were calling attention to insufficient research coverage in other than ecological and economic disciplines (Daniel et al., 2012 ). The involvement of social science researchers and methods in ES research seems to be growing (Kadykalo et al., 2019 ). Thus, we assume that the social perspectives on ES are better reflected in this growing body of research (Scholte et al., 2015 ). Generally, the ES framework can be applied as a transdisciplinary and multidisciplinary approach that has the potential to work as a boundary object across disciplines (Milcu et al., 2013 ; Steger et al., 2018 ).

Most CES are intangible and therefore need different approaches to elicit them compared to other ES categories which can be relatively ‘straightforwardly’ measured in biophysical or economic terms (Raymond et al., 2013 ). Thus, the specific nature of CES calls for appropriate methods for an empirical assessment (Dickinson and Hobbs, 2017 ). On the one hand, CES can be measured or assessed with biophysical or economic indicators (e.g., diversity of potential for nature experiences, the density of monuments and cultural historical facilities, and number of tourists per year) (Jakubínský et al., 2021 ). Such approaches are more suitable to address the potential of a certain landscape or ecosystem to provide specific ES. They can also provide information on the actual use of CES but with a significantly limited depth compared to other, e.g., social science methods. On the other hand, the actual use of CES calls for its empirical measurement with the actual beneficiary of the service, which is a cornerstone of socio-cultural valuation methods (Scholte et al., 2015 ). The importance of involving the human element in the study of CES is highlighted by the fact that CES is inextricably linked to e.g., the physical and mental health of humans, their emotions and perceptions, meanings of nature and landscape, identities or sense of belonging to a place: in other words, they are co-constructed by humans (Fischer and Eastwood, 2016 ). Given the increasing number of CES publications (Milcu et al., 2013 ; Gould et al., 2019 ), we suggest there is a need to reflect on and discuss the use of specific methodological tools. Such integration and synthesis of research can enrich scientific discourse and progress in the ES field. We also acknowledge the need to be clearer and reflexive within the CES research to overcome existing confusions and contradictions (Gould et al., 2020a ).

The social science arena has a range of methods from both qualitative and quantitative domains which can be used to address and systematically assess CES, or non-material NCP, that people obtain from nature, landscape, and ecosystems (Daniel et al., 2012 ). The need to elicit in-depth information or meaning of phenomena favors qualitative and participatory methods such as interviews, focus groups, or ethnography methods (Bryman, 2016 ). In this paper, we will look more closely at the focus groups method, which is an established interpretative approach suitable for researching a range of intangible benefits stemming from the human–nature relationship (O’Brien, 2003 ) and as such can presumably be successfully used also to study CES. However, it has been argued that it could have often been adopted as a fashionable research technique that is considered to be easy to organize and inexpensive and used “without any prior consideration of whether it really is the most suitable research technique for achieving the cognitive goals of the research” (Acocella, 2012 , p. 1126). Further potential concerns can be drawn out from reflections on the use of focus groups (or other typologically similar methods such as interviews) in other related areas, such as biodiversity and conservation research (Young et al., 2018 ; Nyumba et al., 2018 ).

In this paper, we aim to provide an overview of the current state of research and critically reflect on the use of the focus group method to study CES. Furthermore, we highlight good practices and limitations of the method in addressing CES. For these purposes, we use a systematic literature review and apply recommendations from methodological literature. Our review consists of both quantitative and qualitative components (Palmatier et al., 2018 ). In order to achieve our aims, we first develop our methodological approach. To assess the use of the focus groups method in the studies, we produce a synthesis of recommendations found in methodological literature. Then we develop a CES conceptual framework based on a synthesis of various established classifications. This framework will be used to analyze the reviewed studies. The section “Methodology” concludes with an elaboration on the systematic review method we used. For the review itself, we then defined four objectives. First, to provide an overview of how the focus groups method was used to elicit CES, including the temporal trends, the geographical distribution of case studies, and specific characteristics of the use of the focus groups method. Second, to provide descriptive characteristics of CES conceptual frameworks used and categories addressed in the studies. Here we apply the CES classification developed in our framework. Third, to critically assess the reported use of the focus groups method with respect to general recommendations in methodological literature. Moreover, fourth, to provide critical reflection on selected aspects of the use of the focus groups method— suitability, limitations, and its use in combination with other methods. For the latter two objectives, we utilize the methodological synthesis from the focus group’s literature. The results are presented in the “Results” section according to the four objectives. In the “Discussion” section, we discuss the most important issues encountered in the review and compare the findings with similar reviews, especially the use of focus groups and interviews in conservation research (Young et al., 2018 ; Nyumba et al., 2018 ) and examine the most problematic issues discovered. Finally, we provide suggestions for more robust and trustworthy use of it in future research and discuss the general question of the suitability of the focus groups method for the research into CES.

Methodology

Focus groups in the methodological literature.

First, we summarize key characteristics and recommendations in methodological literature in order to provide an analytical framework to critically reflect the use of focus groups in our sample of case studies.

Uses and dis/advantages

The focus group methodology is a qualitative method based on group discussions aimed at eliciting the perspectives and experiences of their participants on a particular topic, especially when the intersubjective dimension is important. Similarly to in-depth interviews, focus groups are used to not only discover what the participants think but also why. Focus groups stem from a premise that these perspectives, experiences, and thoughts are not static, but dynamic, i.e. can be modified through interaction with others; focus groups can, and are, particularly suited for capturing this process (Morgan, 2019 ). Similarly, they are useful for studying group norms, meanings and processes and can be well used as a method of public participation (Bloor et al., 2001 ). In terms of participants, they are especially good for “accessing the hard-to-reach” persons due to their informal character (Barbour, 2018 , p. 17). Furthermore, they can allow the researchers to reach vulnerable groups—also thanks to their informality as well as allowing the participants to meet with others with a similar experience. Content-wise this means that sensitive topics might be more easily discussed in a focus group than in an interview (Barbour, 2018 ).

If one needs to find out as much as possible about individuals, interviews are a better choice, as in a focus group, there is comparably less time for each participant and much of the time is spent discussing, not elaborating one’s own views. However, if one is interested in diversity, consensus, group meanings, and processes, focus groups are better (Morgan, 2019 ). It might even be said that these aims are better and economically more efficient than other ethnographic methods in general (Blor et al., 2001 ). Though, if only idea generation is required, several interviews are proven to be more effective than a focus group with the same number of participants, basically because of a “process loss” with the discussion between participants in a focus group (Morgan, 2019 ). On the other hand, focus groups are not very good for studying group behavior or group attitudes, “since intra-group variations will be under-reported” (Bloor et al., 2001 , p. 17). Interviews or questionnaires are better for this goal.

There are also disadvantages and issues to pay attention to. Focus groups are generally rather difficult to organize—e.g. to find a common time and to get the right number of participants, since often they may not even turn up if they signed up for the discussion (Bloor et al., 2001 ). Therefore, it might be desirable to over-recruit a bit (but not too much). There are also challenges arising from group dynamics. Some people tend to be more dominant in discussions, while others are rather submissive or not assertive enough to express their true views (Morgan, 2019 ). Dominant participants may not only steer the discussion towards issues they consider important, but also intimidate other people. Good facilitation is crucial to tackling these possible problems. Attention should also be given to how the participants may feel within the group and also with the facilitator. It is important that precautions are taken to allow them to feel as comfortable as possible (Morgan, 2019 ).

Combining with other methods

Focus groups might be and indeed often are employed together with other methods, both qualitative and quantitative. Within qualitative research, focus groups and interviews are complementary (Morgan, 2019 ), though not equivalent methods, as they produce different kinds of data (Barbour, 2018 ). Interviews may be used e.g., to inform the discussion guide for focus groups or to select participants. Conversely, focus groups might be utilized to select participants for more in-depth interviews. Combination with quantitative methods is also common. They might serve as input, e.g., to help create or validate a questionnaire, or as a follow-up method to expand findings with deeper insights or to improve the interpretation of results (Bloor et al., 2001 ; Barbour, 2018 ; Morgan, 2019 ). They can also be used to communicate the findings to the research subjects or to get feedback on these findings (Bloor et al., 2001 ). In such multi-method research, combining focus groups with other methods should not be understood as a way to validate the results, but rather as expanding or complementing them for a better understanding of the phenomenon (Bloor et al., 2001 ; Barbour, 2018 ). Richardson ( 1994 ; in Barbour, 2018 ) calls this crystallization, as it is different from triangulation (see also textbox Quality in qualitative research).

Doing focus groups—crucial aspects

In the following table, we compiled the recommendations and best practices from selected methodological literature concerning design, conducting of the discussions, and data analysis. We selected the literature based on three criteria: first, the recency of the title. Methodologies evolve and we wanted to capture the current standard. Second, we included authors that are heavily cited in social sciences (Morgan, Barbour). Third, we aimed for a diversity of approaches in terms of the aspects in Table 1 .

Drawbacks and limits

One set of drawbacks is logistical. Focus groups are harder to organize than individual interviews. While for some people and in some cases, group discussion might be more comfortable, it is usually harder to get more people to attend at the same time (Morgan, 2019 ). In terms of data, focus groups are not able to yield narrative data and they are not very well suited to elicit attitudes (in a manner relevant to social science research; marketing applications aside) (Barbour, 2018 ). The disadvantages in comparison to other methods, especially interviews, were already discussed (see the section “Uses and dis/advantages”).

Conceptual framework of cultural ecosystem services

Here, we define our analytical framework of CES, including specific categories which we applied to each case study in order to provide descriptive characteristics of CES across the publications reviewed.

The intangible nature of CES and their difficult operationalization in the context of other ES categories motivated us to use an inclusive CES framework which could accommodate a broad and detailed range of benefits derived by qualitative methods such as focus groups or interviews (see also Daněk et al., 2023 ). Since we found that some CES categories would fit into one classification but not into another, we conducted a “concept matching” exercise (Czúcz et al., 2018 ) by linking correspondent categories of CES or non-material NCP from the following frameworks: MA—Millennium Ecosystem Assessment, TEEB—The Economics of Ecosystems and Biodiversity, CICES—Common International Classification of Ecosystem Services, and NCP—Nature’s Contributions to People (Millennium Ecosystem Assessment, 2005 ; TEEB, 2010 ; Haines-Young and Potschin, 2018 ; Díaz et al., 2018 ). This allowed us to find both similarities and variations across the classifications and in this way to arrive at a classification that tries to be as granular as possible while keeping a reasonable degree of abstraction. We complemented this desk research exercise with empirical findings from the “CultES” project focused on socio-cultural valuation and participatory mapping of CES in the landscape. It was an iterative dialectic process of categories clarification between established CES definitions and qualitative findings from the field. In the end, we established 15 CES categories that were used in the analysis presented in this paper (Fig. 1 ).

CES categories used in this paper (including their description) and their accordance tonon-material nature’s contributions to people (for the description of NCP categories see Díaz et al., 2018 ).

In general, we do not distinguish between ecosystem “services” and “benefits” as would be the case, e.g. when employing the ES cascade model (Potschin and Haines-Young, 2011 ). Rather, we conceptualize CES as the benefits stemming from interactions between the cultural practices of people and the environment or landscape (Fish et al., 2016 ). This provides a rationale for the co-constructed nature of CES (Fischer and Eastwood, 2016 ). We agree with Gould et al. ( 2020a ) and use CES in a broader way that is similar to the approach established by the NCP framework (Díaz et al., 2018 ). From the conceptual perspective, it is important that both frameworks (Fish et al., 2016 ; Díaz et al., 2018 ) consider the constituting role of the human element in CES or its equivalent non-material NCP. The involvement of human individuals or the collective is in line with the notion of relational values, which can be understood as a complementary concept to CES (and has some overlapping aspects such as Social cohesion or Cultural identity) (Chan et al., 2016 , 2018 ). While there are only four non-material categories in the NCP framework they actually cover all 15 CES categories in our framework. For a better understanding, we provide the corresponding non-material NCP category for each CES listed in Fig. 1 .

Material and methods

Systematic review.

We used a s ystematic review of the literature to create our sample and to collect, assess and synthesize data in a structured, reliable, and replicable way. The preparatory phase of systematic review consists of establishing eligibility criteria and methodological protocol to ensure “consistent conduct by the review team, accountability, research integrity and transparency of the eventual completed review” (PRISMA Group guidelines in Moher et al., 2015 ). Systematic review is a popular methodology across many disciplines, such as medical or environmental science, and with recent applications also in ecosystem services science (Czúcz et al., 2018 ; Vačkář et al., 2018 ).

We established an input—process—output protocol that clearly defined each step of the systematic review (Fig. 2 ). Our systematic review process was guided by the following question—How and to what methodological detail was the focus group method used in research addressing CES? In 2021, we searched the following keywords in the academic journal database Scopus: “focus group” and “cultural ecosystem service” which yielded 15 results. The year of publication was limited to include all results until the end of 2020. As this first search brought only a small number of potentially relevant studies, we added a second search string: “focus group” and “ecosystem service” which resulted in 230 publications. Consequently, all 245 search results were analyzed in the systematic review process following the established protocol.

This conceptual diagram shows the protocol of systematic review process (P = process; I = input; O = output).

The systematic review process had four stages to ensure the selection of only relevant studies for further analysis (see Fig. 2 for more information on the content of each step). After the first round of title and abstract screening, we ended up with 100 potentially relevant studies. These were checked with a full-text screening based on inclusion and exclusion criteria resulting in a selection of 49 relevant studies (for a list of publications reviewed, see Supplementary material). During the last stage, we created a template spreadsheet to collect and organize data extracted from relevant studies. To provide a general context on the use of the focus groups method, we established the following categories: case study country, year of publication, type of study area (ecosystem or landscape type), number of focus groups per case study, type and number of participants, use of other methods. We also extracted the following CES-related characteristics: CES classification used, other ES groups addressed, number and categories of CES researched.

We found no review papers but two methodological or conceptual studies which deal specifically with the use of the focus groups method to identify, assess or map CES (Kaplowitz and Hoehn, 2001 ; Orenstein et al., 2015 ).

During the last stage (P4) of the systematic review analysis, we assessed two aspects of the focus group method use. Firstly, we focused on the level of comprehensiveness of the reporting on the use of the focus groups method and distinguished three categories: high (detailed description including all main steps—initial focus group design, data collection, data analysis); medium (average description but some key steps missing); low (insufficient description with many or most key steps missing). Second, we tracked any significant inconsistencies from the main characteristics of the focus groups method as described in the methodological literature (e.g., extreme number of participants or joint data analysis from different methods). Additionally, we provide a reflection on selected aspects of the use of the focus groups method in order to demonstrate good practices but also highlight potentially problematic applications. We guided this reflection with the following questions—why were focus groups chosen as a suitable method? Do studies include a critical reflection on the use of focus groups? What is the rationale for using focus groups in combination with other methods?

Each subsection in this section is focused on describing results according to objectives one to four. First, we describe the systematic review results from the 49 relevant publications about the general context and design of focus groups. In the second subsection, we report on CES-related characteristics. In the third subsection, we present results regarding the use of the focus groups method. In the last subsection, we provide a reflection on selected aspects of the use of the focus groups method—suitability, limitations, and use in combination with other methods. Where applicable, we also contextualize selected results with recommendations from methodological literature.

Context and design of focus groups

Geographical distribution of case studies is uneven across the globe and across continents (Fig. 3 ). We found no case study in South America and Australia, while most case studies were conducted in Africa ( n  = 16) and Europe ( n  = 15), followed by Asia ( n  = 12). and North America ( n  = 6). The only country with four case studies was the United Kingdom, followed by several countries with three studies (Italy, Ethiopia, Tanzania, USA, Vietnam).

Geographical distribution of case studies using focus groups in CES research.

There is an increasing trend in the number of studies (Fig. 4 a) with most being published in the years 2016–2020. The majority of studies were focused on a specific ecosystem or landscape, most frequently on forest ( n  = 11) and wetland ( n  = 8) ecosystems and mountain landscapes ( n  = 9) (Fig. 4 b). However, some characterized their study area as a national park ( n  = 5), watershed ( n  = 2) or district/region ( n  = 2). The number of focus group discussions per study greatly varied with the minimum being one focus group ( n  = 5) and a maximum of 42 focus groups ( n  = 1), with a median of 5 (Fig. 4 c). Usually there was more than one focus group per study, most often three. Two studies did not report the number of focus groups.

a Number of case studies using focus groups in CES research published in academic literature. b Wordcloud presenting various types of study areas (mixture of ecosystems, landscapes, and governance status of study areas based on available data). c Number of focus groups per case study. d Wordcloud presenting various types of participants in focus groups (coded into similar groups as reported in case studies).

The types of participants most targeted in the studies reviewed were community members ( n  = 12) followed by farmers ( n  = 11) and local inhabitants ( n  = 8) (Fig. 4 d), with some studies creating homogeneous groups while others mixed the types of participants. The number of participants per focus group per case study also varied significantly, with the minimum being 3–4 to the maximum being 41–58. The majority of studies ( n  = 28) reported such intervals for the number of participants per focus group, but some also reported exact numbers (from 5 to 12 participants). Due to these variations in reporting on the number of participants, these different types of variables are not simply comparable by computing a mean number of participants. Two studies reported an average number of participants (5 and 10, respectively) and twelve studies did not mention any specification on the size of their focus groups. Total sample sizes (number of participants) ranged from 7 to 160 with a median size of 46. Several studies did not report a total sample size ( n  = 12).

Regarding gender, only a part of the studies ( n  = 19) reported the exact ratio of men and women among the participants. Several studies ( n  = 15) indicated both men and women participating or verbally specified a majority of one gender (“mostly males”). The same number of studies ( n  = 15) did not specify the gender composition (or it was reported jointly with another method, esp. individual interviews). In some studies, the cultural context was mentioned as the reason for including only one gender (e.g., Cuni-Sanchez et al., 2019 ; Gupta et al., 2021 ) or having gender-homogenous groups in each focus group (Kaplowitz and Hoehn, 2001 ; Chaigneau et al., 2019 ; Ngwenya et al., 2019 ; Kpienbaareh et al., 2020 ).

Cultural ecosystem services addressed

Generally, the majority of studies did not aim at researching only CES categories but targeted more ES groups (provisioning, regulating, supporting). Most of the studies were based on the MA classification ( n  = 22) of CES while a few studies used the TEEB classification ( n  = 5) (Fig. 5 a). One study was based on the UK National Ecosystem Assessment approach (Church et al., 2011 ) and one study was based on the framework proposed by de Groot et al. ( 2002 ). Some studies ( n  = 11) used their own, inductively built classification of CES without adhering to any established framework. In one of these cases, researchers aligned their approach with an established conceptual model of “final” ecosystem goods and services but used their own, inductively built categories (Weber and Ringold, 2019 ). Thus, the majority of studies employed a deductive approach with predefined categories of CES. Unfortunately, some studies did not describe or mention which classification of CES was used ( n  = 11). Regarding the range of CES researched, most studies selected or ended up (depending on the chosen approach—deductive or inductive) with one to five, or ten CES categories (Fig. 5 b). Only six studies researched solely CES while most other studies also addressed other ES categories such as provisioning, regulating or supporting services.

a Proportion of case studies distinguished by the type of CES classification used. b Number of CES categories researched per study.

Recreation (including tourism) was the most researched CES category ( n  = 39) followed by Aesthetics ( n  = 28) and Education ( n  = 24) (Fig. 6 ). Nearly half of the studies also focused on Spirituality ( n  = 21) and Identity ( n  = 20) CES categories. Only two studies researched Symbol or Bequest CES. Reflecting the qualitative character of focus group inquiries, many CES researched do not fit into established categories. Therefore, we present them in a list to provide an overview of what other CES or CES-reported categories appeared in relevant studies (list sorted alphabetically): a place of solitude; animal welfare; archive of plant history; archive of society and civilization history; built features; commerce; festivals; general cultural value; hunting; innovation; landscape variety (colors); management; open space (and sense of), sense of fresh air; opportunities to contact nature; topography; traditional architecture; traditional boats; traditional products and handcraft; transportation.

Categories are based on MA, TEEB, CICES, and NCP frameworks but were elaborated into our own CES classification.

Use of the focus groups method

The extent of reporting on the use of the focus groups method varied greatly across the studies. The biggest group of studies was classified as having insufficient description (low level) of the use of the focus groups method, with many key steps missing ( n  = 20). These were followed by studies with an average description (medium level) of the use of the focus groups method but some key steps were missing ( n  = 18). Lastly, the smallest group of studies had a detailed description (high level) of the use of the focus groups method, including all steps ( n  = 11). Regarding methodological inconsistencies, only ~25% of studies ( n  = 12) were classified as having some aspect of the focus groups method that lies outside the recommendations and common practice in focus groups literature (see Table 1 : Main characteristics of the focus groups method). Most studies ( n  = 30) did not report any aspect that would not be aligned with the methodological recommendations. However, some studies ( n  = 7) did not provide enough information about the use of the focus groups method, so we could not classify them. We distinguished two main aspects regarding methodological inconsistencies. First, there was an extreme number of participants ranging from 25 to 49 participants per focus group in some studies (e.g., Rai et al., 2020 ; Dou et al., 2020 ; Gupta et al., 2021 ). Second, some studies analyzed data from focus groups together with data from other methods such as interviews (e.g., Adhikari et al., 2018 ), or it was not clear whether the data from the focus groups were analyzed separately or not (e.g., Ward et al., 2018 ; Tran and Brown, 2019 ).

The focus group method was often used in conjunction with other methods. In our final review sample, several studies ( n  = 12) used (or reported) the focus group method as the only method for data collection. Mostly, the other methods used were questionnaires or surveys ( n  = 22), closely followed by interviews ( n  = 19). Several studies also used participatory mapping (but in 4 out of 6 cases it was part of the focus group) or field observation ( n  = 4). Other methods include, e.g., workshop, expert panel, scenario building, spatial analysis, modeling, biophysical assessment, stakeholder analysis, remote sensing, transect walk, participant observation, literature review, Q-methodology, Delphi, and secondary data collection.

Reflection on selected aspects of the use of the focus groups method

In many cases, the focus group method was selected due to its suitability to attain a rich or in-depth understanding of people’s perceptions and experiences. Specific reasons why focus groups were particularly suitable included the aim of studying group meanings, values, or processes, or inciting a deeper examination through discussion (Asah et al., 2012 ; McDonough et al., 2014 ; O’Brien et al., 2014 ; Stålhammar and Pedersen, 2017 ; Chan et al., 2019 ).

A critical reflection on the limitations of the approach was scarce even in the studies that reported the use of the focus groups method quite comprehensively. For example, Weber and Ringold ( 2019 ) were an exception in their discussion of limitations, e.g., people were reluctant to speak about controversial topics and repeatedly slipped into the discussion of other, well-known and general topics that were not the focus of the study. A few other studies discussed the challenges and limitations related to sampling.

Other methods can be either a part of the actual focus group or used alongside focus groups as complementary methods. In the case of using other methods within focus groups, participatory mapping was used to catalyze the discussion using visual and tactile stimuli (Chan et al., 2019 ), or a socio-cultural valuation was done through a scoring exercise (Jeanloz et al., 2016 ). When using focus groups as one of the methods for collecting data, it is important to acknowledge data differences between various methods. Some studies did not do this and used interviews alongside focus groups to presumably get the same type of data that was then processed in a similar way (Moore and Tully, 2018 ). An example of a better approach is analyzing the data from focus groups and interviews separately and then combining only the results (Chan et al., 2019 ). Another study used an approach employing interviews as a sort of validation for checking the results from focus groups (Weber and Ringold, 2019 ). This adheres to recommendations in the methodological literature (see the section “Doing focus groups—crucial aspects”) and serves to improve the trustworthiness of the results (see the box “Quality of qualitative research”). Moore and Tully ( 2018 ) also used additional methods to accompany the focus groups and interviews, namely perception mapping and questionnaires.

An exemplary use of focus groups in combination with other methods can be seen in O’Brien et al. ( 2014 ), where the focus group was used as a direct follow-up after an in-situ walk in woodlands, during which the technique of photo-elicitation was also used. Such a procedure can create a very good setting for the group discussion, which is stimulated by both the previous walk and the photographs, and which can easily connect to the recent experience of the participants. Also, the group has more time to get to know each other during the walk, which might also enhance the quality of the follow-up discussion.

Our review confirms that the focus groups method has been increasingly employed in CES research, although most of the studies focused on more ES groups and categories. Most of the studies utilizing focus groups were done in Africa and Europe, while in many parts of the world, we found no evidence of the use of this method in relation to CES research. Such geographical bias could be partly explained by our systematic review approach, which excluded studies in languages other than English and gray literature. The focus groups method was used for eliciting (C)ES in a range of environments, from forests and mountains, through wetlands, to urban parks, and with different groups of people, from community members and farmers, through local authorities to hunters and pastoralists. Regarding specific CES categories, focus groups were employed to elicit a broad range of CES, either deductively (most often based on the MA classification) or inductively. Recreational and aesthetic services were then the most frequently addressed in the studies examined. This finding is consistent with Milcu et al. ( 2013 ), who report them as the most frequently studied categories of CES in general. There were also many CES-reported categories that do not fit into established classifications. While there can be new categories emerging based on empirical findings (cf. Gould and Lincoln, 2017 ), in some cases, it is questionable whether categories such as built features, traditional architecture, or transportation really fit into the conceptual framework of CES.

If we compare our results with that of Nyumba et al. ( 2018 ), who assessed the use of the focus groups method in the context of conservation research, we can see both similarities and differences. Regarding the number of focus groups per the study, they reported a median of 7, while in our sample, it was 5. The size of the groups in our case varied much more, with a few studies having more than 20 participants per focus group, while Nyumba et al. ( 2018 ) observed a maximum of 21, with a median of 10. We were not able to calculate the median value because many studies reported only a range across all focus groups conducted. However, in our sample, only 24% of studies did not report the size of groups, whereas, in conservation research, it was 55%. This suggests somewhat better reporting about the usage of the method in our sample, but there were also important issues in this regard (see the section “Reflection on selected aspects of the use of the focus groups method”).

Focus groups were often used as a part of multi-method research. In such cases, proper integration of complementary methods might prove very useful to better explore the complex nature of CES. As one typical use, other methods (such as participatory mapping, walk with photo elicitation, or scoring exercise) might be used to improve or catalyze the focus group itself and help participants with grasping the eluding characteristics of CES (O’Brien et al., 2014 ; Jeanloz et al., 2016 ; Chan et al., 2019 ). Another option is to use focus groups as one of several complementary methods (e.g., with individual interviews, questionnaires, etc.) to look at the research question from different angles (O’Brien et al., 2014 ; Moore and Tully, 2018 ; Weber and Ringold, 2019 ). However, it is crucial to acknowledge the different nature of data from different methods. For example, the similarity with individual interviews in terms of the nature of data and methods of their analysis might mislead some researchers into the unreasonable simplification of data analysis. In one case, the researchers tried to get as similar data as possible from focus groups as from interviews in terms of the type of data and did so by more strict methodological constraints placed on the focus groups (Jeanloz et al., 2016 ). That caused the focus groups being effectively reduced to group interviews. Other studies neglected even the question of the type of data generated by the two methods and simply mixed them together in the same stage of the research—part of the data obtained through interviews, part through focus groups, but treated as one homogeneous data set analyzed in the same way they would analyze interviews (Moore and Tully, 2018 ). Such studies did not use any of the advantages of focus groups regarding group processes and attitudes and instead presumably obtained much less data from each of the focus group participants than from their interviewees, making the former underrepresented in the overall data set. Such an approach prompts the question of the suitability of focus groups for their purposes, as it seems that using just interviews would have provided more consistent and possibly richer data. Differences in the type of data obtained through interviews and focus groups should also be considered when choosing approaches to analysis (Barbour, 2018 ).

One of the aspects we studied proved similarly ambivalent—the number of participants per focus group. Although there is a quite strong recommendation as to the maximum number of participants in one discussion, this still leaves space to do small groups of a few people, going deep into the topic, or larger groups of up to 12–13 people, and various sizes were also seen in the review. In most cases, the studies were complying well with methodological recommendations, with the number of participants between 3 and 13. However, there were also a few unusual cases with sizes of groups ranging from 25 to as much as 58. One of these (Ngwenya et al., 2019 ) divided the group into smaller subgroups, which is similar to conducting several smaller focus groups. Others, however, seemed not to do any kind of division (Gupta et al., 2021 ; Rai et al., 2020 ). In such big groups, it is questionable whether even the basic processes in focus group discussions can be achieved (e.g., suitable facilitation or that every participant can be given enough space). Good facilitation of a group discussion with tens of people is nearly impossible, and it raises questions about the available time for each participant, or the possibility of meaningful interaction. Regarding gender composition of groups, it is in general only relevant in focus group design when it has an important bearing on the participant’s background or experience in relation to the studied topic. However, the comfort of the group is an important factor as well, which corresponds with conducting gender-homogenous groups in certain cultural contexts, such as traditional societies (Bloor et al., 2001 ; Morgan, 2019 ).

A general insight from this review is that many studies suffer from improper or inadequate reporting on the use of the focus groups method. This is in line with results from other fields such as conservation regarding the use of qualitative methods such as focus groups and interviews (Young et al., 2018 ; Nyumba et al., 2018 ). What we found particularly lacking was providing a rationale for the suitability of the method (including its role in the research framework), reporting key aspects of its application (separately from the description of other methods), or acknowledging the different nature of data from different methods. These three practices were also among the basic recommendations for best practices in focus groups in a similar review of the use of focus groups in the context of conservation (Nyumba et al., 2018 ). Also, a discussion of limits and critical reflection on the methodological approach applied were often missing. In many cases, we were thus not able to do a more detailed assessment of their use. This lack of key information supports the argument that focus groups can be in some cases chosen due to their perceived simplicity and cost-effectiveness (Acocella, 2012 ).

Insufficient reporting and methodological issues might jeopardize the quality of the research in question. And although the quality of qualitative research might be perceived as tricky or unattainable due to the non-exact nature of such research, there are various established approaches that improve it significantly (see the following box, Quality of qualitative research).

Box 1 Quality of qualitative research

There has been an overall move away from trying to establish generally accepted universal criteria of quality akin to those applied in quantitative research. This reflects both the fact that qualitative research does not and cannot adhere to the positivist requirements, and that there is actually no one universal research paradigm for qualitative research but rather a plurality of paradigms. Thus, the established notions from quantitative research, such as validity and reliability, cannot be easily adapted and applied in qualitative research, although there are also approaches that try to do this (e.g., Silverman, 2017 ). Nevertheless, there are various approaches developed that can be used to reflect on and ensure the quality of research. In one of the quite well-established schemes, Lincoln and Guba ( 1985 ) state that the overall goal of ensuring the quality of any research is its trustworthiness. However, as Seale ( 1999a :468) notes, “trustworthiness is always negotiable and open-ended, not being a matter of final proof whereby readers are compelled to accept an account.” Lincoln and Guba ( 1985 ) proposed five criteria of trustworthy qualitative research: credibility, transferability, dependability, confirmability and authenticity (expanded from four, see Guba and Lincoln, 1989 , 1994 ). Silverman ( 2017 ) also offers his proposal for evaluating qualitative research through quality criteria. Seale ( 1999b ), on the other hand, is more skeptical about general criteria and proposes rather that a variety of procedures might be used to improve the quality of research regardless of the research paradigm applied, such as triangulation, member checking, accounting for contradiction, or grounding of theory. In general, it can be said that while qualitative research does not and cannot aim at objectivity, validity or reliability in the positivist sense, the quality of such research should not be neglected. Critical self-reflection of the research, application of established techniques of improving quality, and transparency and rigor in reporting are key to ensuring the trustworthiness of qualitative research, including studies using focus groups.

Suitability of the focus groups method for CES research

The observed methodological inaccuracy might be the flipside or a misunderstanding of the possible flexibility in the application of the method. However, this flexibility, in our view, makes the method particularly suitable for the research of CES, which are complex, elusive and context-dependent in character (Chan et al., 2012 ; Fish et al., 2016 ). Furthermore, due to its possibility to capture meanings stemming from interpersonal interactions, it can be a suitable approach to provide insights into the intricate socially constructed, or co-produced nature of CES (Fischer and Eastwood, 2016 ).

The suitability of focus groups for studying CES may be shown by the use of this method in some of the reviewed studies. These examples may also be considered good practices within the current state of the field. First, the co-production of CES may be well accessed through studying group views, attitudes, or values. For this purpose, focus groups are especially suitable (Morgan, 2019 ) and were successfully employed to this end, for instance, by Asah et al. ( 2012 ) and Stålhammar and Pedersen ( 2017 ). If one aims to reach a more definitive group view or valuation of CES, focus groups may well be utilized to facilitate a deliberative process or to reach a consensus, as in McDonough et al. ( 2014 ) or Shipley et al. ( 2020 ). And finally, as a qualitative method that is particularly suitable for exploring diversity in a certain topic, focus groups may provide means of discovering a wide range of CES, including ones that do not fit into established categories (if using an inductive approach to analysis). Such a diversity of CES was found in e.g. Asah et al. ( 2012 ) and Byg et al. ( 2017 ). Therefore, we suggest that focus groups are a potentially unique and insight-generating methodology in CES research.

On the other hand, the elusive nature of CES together with unsettled classification based on various conceptualizations can be a double-edged sword in such research (Blicharska et al., 2017 ). Drawing on our results, the unclassified CES-reported categories may be the result of unsettled terminology and poor understanding of CES conceptual foundations (Gould et al., 2020a ). However, these ‘other’ categories may also be just a legitimate result of an inductive approach which is often applied in qualitative methods such as focus groups or interviews. Some of these ‘other’ CES could fit into the conceptualization of cultural practices (e.g., hunting), environmental spaces (e.g., a place of solitude; built features), or cultural goods (e.g., traditional products and handcraft; traditional boats) in the CES framework by Fish et al. ( 2016 ). Furthermore, this ‘extension’ of what CES can encompass supports the trend of broadening conceptualizations of CES (Gould et al., 2020b ). Nonetheless, we would need enough justification for CES to be placed in a certain established category and this information was not always reported in the publications reviewed. Another flaw in reporting is that every fifth study did neither describe which CES classification was used nor that they did not use any classification intentionally. Furthermore, a potential limitation of our systematic review design is that we were not able to systematically explore the rationale behind the CES categories addressed as such information was not provided in most of the studies, e.g., due to their broader focus on more ES groups. Therefore, our suggestions are rather based on the general characteristics of CES in relation to possible applications of the focus groups method.

The aforementioned flexibility of the focus group method combined with the elusiveness of CES might also lead to untrustworthy results. This can be mitigated by a more rigorous application of the method that can be achieved by following a plethora of recommendations from the literature (some included in our review) and applying processes for ensuring the quality of research (see above). For instance, an appropriate combination with other methods acknowledging various pathways between different types of data and their analysis might also help address this potential pitfall.

Conclusions

In this article, we have provided a systematic review describing the use of the focus groups method in CES research, including its variations in both quantitative and qualitative terms. They suggest that opportunities for how and in what context the focus groups method might be successfully utilized are ample. The potential to uncover the co-constructed nature of CES, coupled with the ability to capture nuances in perception, valuation, etc., of non-material benefits in our view makes the focus groups method an effective tool in the CES research toolbox. But such flexibility and potential also require the researchers to be very conscious of when, why, and in particular how they apply the method and to report on these methodological aspects (Young et al., 2018 ; Nyumba et al., 2018 ). Nevertheless, we suggest that focus groups are a highly suitable method for researching CES. It provides a way to access both personal and group perceptions, meanings, and values, that are particularly relevant when studying CES. In the reviewed sample, focus groups have been used to elicit a broad range of CES both deductively and inductively. Furthermore, the increasing use of the method in recent years may also suggest that more researchers find this method suitable. At the same time, we have seen significant variations in the contextual but also practical methodological approach. Therefore, the research community can benefit from summarizing the most frequent applications as well as a synthesis of benefits and drawbacks learnt from the past use of the focus groups method.

A common issue we discovered is inadequate reporting on how the method was employed within a research design and how it was conducted. Also, a critical assessment of its use is often lacking. Still, to the extent that the level of reporting allowed us to assess the methodological rigor, most of the studies seemed to adhere to general methodological recommendations as we summarized them in the section “Doing focus groups—crucial aspects”. Among those we identified as methodologically problematic, two issues were the most prominent. The first is the relatively common practice of analyzing data from focus groups and individual interviews together as if they were equivalent. That shows either methodological negligence or a misunderstanding of the data that a focus group produces, which are specific due to the interactions in the group. The second issue that we observed has to do with the size of the groups, which in some cases exceeded 14, and in a few cases reached tens of participants. This also indicates a misunderstanding of the method and its goals.

We conclude that the good suitability of focus groups for research of CES might sometimes be hindered by methodological and reporting inadequacies. To strengthen the use of focus groups in future research, we would thus recommend the following. First of all, we would propose to use the method only after careful consideration of its suitability and refrain from opting for it merely because of its presumed simplicity or inexpensiveness. Second, a good design of the place of the method within a frame of larger research is a crucial first step both to avoid methodological issues and to fully utilize the potential of the method. In particular, the differences in the data produced, especially in the context of other qualitative methods, need to be considered. Proper reporting on the design is a general imperative to complement this. The reporting should cover all crucial design choices (integration of the method within research, number and size of groups, their composition) and methodological steps (design of the discussion guide, facilitation, additional techniques used, analysis of data) and a reflection on the limits and the quality of research. In designing and executing the focus groups themselves, we would obviously suggest adhering to generally accepted methodological recommendations, particularly with regard to the number of participants and the crucial role of facilitation. To this end, our summary (see the section “Doing focus groups—crucial aspects”) might be utilized. Overall, these recommendations all relate to the question of the quality of qualitative research, which needs to be considered and ensured by the researchers to improve the trustworthiness of their results.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

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Acknowledgements

This research was supported by the Technology Agency of the Czech Republic, grant no. TL02000520 – Landscape cultural ecosystem services assessment and mapping. We thank Franciene Oost for help with data analysis and English corrections. We also thank Julia Leventon and Jiří Pánek for comments and edits on the draft manuscript.

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Ľuboš Slovák, Jan Daněk & Tomáš Daněk

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Ľuboš Slovák

Faculty of Humanities, Charles University, Prague, Czech Republic

Department of Development and Environmental Studies, Faculty of Science, Palacký University, Olomouc, Czech Republic

Tomáš Daněk

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Slovák, Ľ., Daněk, J. & Daněk, T. The use of focus groups in cultural ecosystem services research: a systematic review. Humanit Soc Sci Commun 10 , 45 (2023). https://doi.org/10.1057/s41599-023-01530-3

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Scoping literature review and focus groups with healthcare professionals on psychosocial and lifestyle assessments for childhood obesity care

• L. W. Koetsier 1 ,
• E. van den Eynde 1 , 2 ,
• E. G. A. H. van Mil 3 , 4 ,
• M. van der Velde 5 ,
• R. de Vries 6 ,
• C. A. Baan 7 ,
• J. C. Seidell 1 &
• J. Halberstadt 1  

BMC Health Services Research volume  23 , Article number:  125 ( 2023 ) Cite this article

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Childhood obesity is a complex disease resulting from the interaction of multiple factors. The effective management of childhood obesity requires assessing the psychosocial and lifestyle factors that may play a role in the development and maintenance of obesity. This study centers on available scientific literature on psychosocial and lifestyle assessments for childhood obesity, and experiences and views of healthcare professionals with regard to assessing psychosocial and lifestyle factors within Dutch integrated care.

Two methods were used. First, a scoping review (in PubMed, Embase, PsycInfo, IBSS, Scopus and Web of Science) was performed by systematically searching for scientific literature on psychosocial and lifestyle assessments for childhood obesity. Data were analysed by extracting data in Microsoft Excel. Second, focus group discussions were held with healthcare professionals from a variety of disciplines and domains to explore their experiences and views about assessing psychosocial and lifestyle factors within Dutch integrated care. Data were analysed using template analysis, complemented with open coding in MAXQDA.

The results provide an overview of relevant psychosocial and lifestyle factors that should be assessed and were classified as child, family, parental and lifestyle (e.g. nutrition, physical activity and sleep factors) and structured into psychological and social aspects. Insights into how to assess psychosocial and lifestyle factors were identified as well, including talking about psychosocial factors, lifestyle and weight; the professional-patient relationship; and attitudes of healthcare professionals.

Conclusions

This study provides an overview of psychosocial and lifestyle factors that should be identified within the context of childhood obesity care, as they may contribute to the development and maintenance of obesity. The results highlight the importance of both what is assessed and how it is assessed. The results of this study can be used to develop practical tools for facilitating healthcare professionals in conducting a psychosocial and lifestyle assessment.

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Introduction

Urgency and complexity of childhood obesity.

In the Netherlands, in 2020, 12.2% of the children aged 4–17 years had overweight and 2.5% had obesity [ 1 ]. Childhood obesity is associated with a range of short-term and long-term physical health problems and psychosocial problems [ 2 , 3 ]. Moreover, childhood obesity is regarded as a chronic disease that tracks into adulthood [ 4 ]. It is a complex disease resulting from the interaction of multiple underlying factors, including personal characteristics (e.g. genetic, hormonal, physical and psychological) and environmental factors (e.g. socio-economic, cultural and physical environments) that can influence lifestyle behaviour and lead to the development or maintenance of childhood obesity [ 5 , 6 , 7 ]. Adequate management of childhood obesity calls for taking into account biomedical factors (e.g. genetic factors, comorbidities, extent of overweight or obesity), psychological factors (e.g. self-image, mood, well-being) and social factors (at various levels, including contact with peers, school or authorities) [ 8 , 9 ].

Context of the Dutch healthcare system

The importance of conducting an assessment of potentially interacting biomedical, psychosocial and lifestyle factors has been internationally recognised in clinical guidelines [ 10 , 11 , 12 , 13 ]. The Dutch ‘National model integrated care for childhood overweight and obesity’ describes the assessment of psychosocial and lifestyle factors, which is an essential step as part of the integrated care process. The psychosocial and lifestyle assessment is conducted by a coordinating professional (CP) [ 14 , 15 , 16 ]. The CP role can be fulfilled by various professionals from different disciplines and domains (e.g. healthcare domain, social domain). In many cases, it is fulfilled by a professional in the local youth healthcare (YHC) system [ 15 , 16 ]. The YHC system is based on a municipal or regional infrastructure in which all children 0–19 years of age receive frequent medical check-ups and referrals [ 17 ].

Assessment of psychosocial and lifestyle factors

In a previous study, we examined a supporting assessment tool that CPs can use as a guide for obtaining information about factors that may contribute to the development and maintenance of obesity and obtaining a broad view of children and their family circumstances [ 18 , 19 ]. In that study, we also identified several potential improvements to be made in the further development of the tool, including the addition of in-depth questions for assessing psychosocial factors, the inclusion of an instructional guide explaining how to use the assessment tool and the adaptation of the tool to make it more age-specific [ 19 ]. In addition, the CPs who were interviewed for that study expressed a need for more knowledge about the complexity of obesity and the development of age-appropriate visual materials for conducting psychosocial and lifestyle assessments [ 19 ]. Because the study was conducted amongst only fourteen CPs, broader insight is needed with regard to the experiences and views of healthcare professionals (HCPs) from a variety of disciplines and domains with assessing psychosocial and lifestyle factors within the integrated care. Such insights could help to optimise the tool and to assist HCPs in the provision of personalised childhood obesity care.

Aim of the study

The combination of the designated CP role, the conduction of the psychosocial and lifestyle assessment, mentioned required improvements based on an earlier study and a need from practice for more knowledge and materials makes this study necessary as broader insight is needed [ 19 ].

Therefore, the aim of this study is to investigate available literature on psychosocial and lifestyle assessments for childhood obesity and experiences and views of HCPs with regard to assessing psychosocial and lifestyle factors within Dutch integrated care for childhood overweight and obesity.

In order to address the aim, this study centers on two research questions:

What national and international scientific literature is available on psychosocial and lifestyle assessments for childhood obesity, and which factors do these assessments address?

What are experiences and views of HCPs with regard to assessing psychosocial and lifestyle factors within Dutch integrated care for childhood overweight and obesity?

The research process was iterative. To explore the first research question, a scoping review was performed by systematically searching databases for available national and international scientific literature on psychosocial and lifestyle assessments for childhood obesity and describing the factors that are addressed in these studies by doing a deductive analysis. For the second research question, online focus groups were organised with Dutch HCPs from a variety of disciplines and domains in order to explore their experiences and views with regard to assessing psychosocial and lifestyle factors within the Dutch integrated care by doing an inductive analysis.

Search strategy

A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement ( www.prisma-statement.org ) [ 20 ].

To identify all relevant publications, we conducted systematic searches in the bibliographic databases PubMed, Embase.com, APA PsycInfo (EBSCO), IBSS (ProQuest), Scopus and Web of Science from inception to 21 January 2022, in collaboration with a medical information specialist (RdV). The following terms were used (including synonyms and closely related words) as index terms or free-text words:

“Overweight”, “Obesity”, “Children”, “Patient history”, “Anamnesis”, “Psychosocial aspects”, “Lifestyle”.

Duplicate articles were excluded. All languages were accepted. The full search strategies for all databases are provided in the supplementary material.

Selection of articles

Studies were included if they met the following criteria: children with obesity aged 0–19 years and a description of an assessment of psychosocial and/or lifestyle factors, or systematic review of nutrition and/or physical activity assessments. We excluded studies if they: (i) were limited to only one dimension (e.g. nutrition, physical activity or medical assessment); (ii) concerned assessments related to patients who were screened for eligibility for bariatric surgery; (iii) were aimed exclusively at assessing motivation; (iv) were editorials, letters, legal cases or interviews. When full-text versions were not available, we contacted authors in an attempt to obtain complete information. Abstracts in languages other than English were translated.

Studies were screened in two stages using the Rayyan systematic review software. First, all relevant titles and abstracts were screened for eligibility (LK) using the inclusion and exclusion criteria, with the first 1000 titles and abstracts independently screened by one of the authors (EvdE). Differences in judgment were resolved through a consensus procedure. The two authors noticed complete agreement, therefore only one author (LK) screened all articles. If relevant, the full-text article was checked for the eligibility criteria. Second, the full-text articles were evaluated independently by two authors (LK and EvdE) for further review. A Microsoft Excel database for data management was created based on an iterative process. LK and EvdE discussed the eligibility, and differences were discussed until consensus was reached.

Data synthesis and analyses

For each article, the following data of the full-text articles were extracted in Microsoft Excel by spreadsheet: (i) year of publication; (ii) title; (iii) summary; (iv) target group; (v) study design; (vi) setting in which the assessment was conducted; (vii) how often and by whom the assessment was conducted; (viii) the format of the assessment; (ix) how the assessment was conducted by the HCPs; and (x) the content of the assessment.

The data synthesis was done by LK and EvdE and consisted of searching for consistency of patterns across the extracted data in Microsoft Excel and making comparisons between the extracted data of the studies with similar methodologies. Similarities were observed as a pattern and supplemented with any important distinguishing information. For example, nine articles focused on parent and family factors as part of the assessment which was seen as a similarity, whereas two articles only focused on child factors which was seen as a difference. Differences in how the data was analysed by screening the extracted data were discussed within the research team (LK, EvdE, CB, JS and JH) until consensus was reached.

Focus groups

Participants.

Professionals were recruited through the researchers’ professional national network and approached based on varieties in their professional background (healthcare practice, science and policy). The inclusion criterion for participation were knowledge of the supporting assessment tool and, preferably, the Dutch integrated care. Professionals were approached by telephone or by email and asked if they would be willing to participate in the study. Participants received a €10 webshop voucher.

Each participant received an information letter stating the reasons for conducting the research, and all provided recorded informed consent within the Zoom session to participate in this study. The study protocol was approved by the Medical Ethical Committee of the Amsterdam University Medical Center (METC number 2019.511).

Data collection

The focus group sessions were held between November 2020 and February 2021. Due to COVID-19 restrictions the sessions were conducted online using Zoom and lasted one and a half hour to 2 h. Each group consisted of four to nine participants. The sessions were conducted by two researchers with prior training in carrying out qualitative research. One of the researchers (LK) moderated the sessions, and another (EvdE) was an observer during the sessions. The focus group topic guide for each session was developed by LK and EvdE in consultation with the research team [see Additional file  1 ). The focus group topic guides were provided with input on the format of the assessments and the content of the assessment from national and international scientific literature (evidence based) and supplemented with themes from practice (practice based) based on gaps and needs as a result of an earlier performed study [ 19 ]. Professionals were asked to provide their availability and the interviews were scheduled based on when most professionals were available. Five focus group sessions were scheduled, with the order of the first four sessions based on the availability of the participants, the final focus group consisted of presenting the interim results and asking for additional input based on the first four focus groups. The focus groups (FG) were intended to generate insight into:

General experiences and views of CPs with the assessment (FG1)

Embedding of the assessment within the Dutch integrated care model (FG2)

Experiences with and views on other assessments (FG3)

Experiences with and views on the assessment of professionals other than CPs (FG4)

Embedding of the assessment within the practice of the Dutch integrated care by presenting the interim results and asking for additional input (FG5)

The sessions included interactive methods using the Mentimeter interactive presentation software to generate useful data and to receive input from each participant [available in Dutch on request]. The content of the discussion was audio-recorded and transcribed verbatim. Transcripts were summarised and sent to all participants, who were allowed time to complete or refine their statements as a member check.

Data analysis

Template analysis was used to thematically organise and analyse the data of the focus groups (inductive analysis) [ 21 , 22 , 23 ]. First, the researchers became familiar with the data by reading the transcripts, summaries, Mentimeter data, additions mentioned in the Zoom chat and field notes. Subsequently, for the initial template, LK performed the preliminary coding of the data, with a subset coded independently by EvdE (open coding). Emerging themes were organised into meaningful clusters (axial coding), and hierarchical relationships were defined (selective coding). LK and EvdE discussed discrepancies until consensus was reached with additional input from the research team (LK, EvdE, CB, JS and JH) and the initial version of the coding template based a subset of the data was defined. The coding template was applied to the remaining data. After necessary modifications and revisions, the template was finalised and applied to the full data set. The data were analysed using MAXQDA 2020 software. The Consolidated Criteria for Reporting Qualitative research (COREQ) were used to guide the reporting of the qualitative findings and has been included as supplementary information (see Additional file 5 ) [ 24 ].

Selection and description of included articles

The literature search generated a total of 8842 references: 1,755 in PubMed, 3478 in Embase.com , 532 in PsycInfo, 70 in IBSS, 1755 in Scopus and 1252 in Web of Science [see Additional file  2 ]. After removing duplicate references, 5376 references remained. The flow chart for the search and selection procedure is presented in Fig.  1 .

Flowchart for the search and selection procedure for articles

The 11 included articles are listed in Table  1 . Two articles focused only on child factors [ 27 , 30 ], whereas the others also focused on parent and family factors as part of the assessment [ 25 , 26 , 28 , 29 , 31 , 32 , 33 , 34 , 35 ]. Seven articles incorporated the broader healthcare process, including the assessment and the referral and treatment or weight management [ 26 , 27 , 28 , 29 , 32 , 33 , 34 ].

What to include in a psychosocial and lifestyle assessment

Factors that could potentially contribute to the development and maintenance of childhood obesity are presented in Table 2 . Assessment factors have been classified as child, family, parental and lifestyle factors and structured into psychological and social aspects. An extensive table with the original description of the factors has been included as supplementary information [see Additional file  3 ]. Although all articles described biomedical factors (e.g. anthropometric methods) as part of the assessment, these factors were not included in the present study [ 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. In general, the articles devoted greater attention to biomedical factors than to psychosocial factors.

Psychosocial assessment

The extent to which psychosocial factors were described in the articles varied from elaborate descriptions, including assessment techniques and examples of questions for both children and parents [ 35 ], to a table containing brief descriptions of psychosocial problems [ 30 ].

Child factors

Psychological factors of the child included weight-related depression and anxiety, eating disorders, self-esteem and body image, which are specific to the assessment of childhood obesity, as opposed to more generic assessments [ 25 , 26 , 27 , 28 , 29 , 30 , 33 , 34 , 35 ]. Additionally, three articles included the identification of adverse events, such as major family events and a history of abuse or neglect [ 30 , 31 , 35 ].

In nine articles, social concerns (e.g. bullying, loneliness or problems with social interaction) were identified as social factors of the child [ 25 , 26 , 28 , 29 , 30 , 31 , 33 , 34 , 35 ]. Five articles noted to the importance of considering education (e.g. school avoidance and school performance) [ 28 , 30 , 33 , 34 , 35 ].

Family factors

One major aspect of social factors of the family identified in most assessments is the importance of determining family functioning in terms of environment, structure, composition or other aspects [ 25 , 26 , 28 , 31 , 32 , 33 , 34 , 35 ]. Four assessments included ethnicity and cultural factors, albeit to varying extents [ 25 , 26 , 28 , 29 ]. For example, one assessment in the form of a clinical guideline was specifically intended for minority populations (i.e. Maori, Pacific and South Asian populations) [ 29 ].

Parental factors

Four articles reported psychological factors of the parents that related to mental well-being. These articles differed in the extent to which the factors were described in relation to childhood obesity. Factors reported included adverse events, mental health concerns and eating disorders [ 26 , 31 , 34 , 35 ]. The social factor of the parents that was most prominently identified as being important to take into account was financial situation [ 25 , 26 , 31 , 32 , 33 ]. Six articles did not consider social parental factors [ 27 , 28 , 29 , 30 , 34 , 35 ].

Lifestyle assessment

Ten articles included the assessment of nutrition and physical activity as part of the lifestyle assessment [ 25 , 26 , 27 , 28 , 29 , 30 , 32 , 33 , 34 , 35 ]. The majority of the lifestyle assessments focused on the current lifestyle behaviour, and one article also focused on the adoption of desired healthy lifestyle behaviours by the entire family (nutrition education and physical activity) in addition to current lifestyle behaviour [ 30 ].

The specificity and extent of nutritional and physical activity assessment varied, as did the extent of resources provided to professionals. For example, one nutritional assessment offered a structured assessment to ensure the inclusion of relevant information concerning details of eating habits, including intake of sugar-sweetened beverages, milk and juices, fruits and vegetables, snacks and fast food, as well as appetite and portion size [ 28 ]. Physical activity assessments included details on time spent in a variety of activities or organised sports, transportation to and from school, time spent in sedentary behaviour and screen time per day.

The focus on the psychological and social aspects of nutrition and physical activity varied, and these aspects were not considered in a literature review and a clinical guideline for the examination and treatment of children and adolescents with obesity [ 27 , 28 ]. Psychological aspects of nutrition and physical activity were mentioned in six assessments and in relation to readiness to change and the level of confidence in the ability to make changes (self-efficacy) [ 25 , 29 , 30 , 31 , 33 , 35 ].

The majority of the assessments mentioned sleep behaviour as potentially contributing to excessive weight gain during childhood [ 25 , 26 , 27 , 28 , 29 , 30 , 32 , 35 ]. Most of the articles did not describe sleep patterns as part of lifestyle factors, but often as part of the biomedical assessment. For example, some assessments included the identification of various sleep-related problems, including disordered sleep, obstructive sleep apnoea syndrome and disruptive snoring [ 25 , 26 , 27 , 28 , 29 , 30 ].

How to conduct a psychosocial and lifestyle assessment

The included articles focused on what to include in a psychosocial and lifestyle assessment. Eight of these articles also paid attention to how to conduct the assessment of psychosocial and lifestyle factors [ 25 , 26 , 29 , 30 , 31 , 34 , 35 ]. These findings were divided into the three most prominent themes: (a) talking about psychosocial factors, lifestyle and weight; (b) the professional-patient relationship; and (c) attitudes of healthcare professionals.

Talking about psychosocial factors, lifestyle and weight

As noted by Barlow et al. and Varkula et al., it is important to communicate sensitively and introduce the topic carefully (e.g. by asking whether a patient or parent has any concern about the child’s weight) [ 25 , 35 ], as children and parents might feel ashamed and defensive about obesity [ 25 ]. They further advised HCPs to use the terms preferred by parents [ 25 , 35 ]. According to Jull, HCPs should avoid jargon and explain any health terms clearly, in addition to reflecting on their own communication preferences (e.g. the words and tone used; body language) [ 29 ].

Four articles paid explicit attention to behaviour change techniques (e.g. goal setting, stimulus control and self-monitoring) and conversational techniques (e.g. motivational interviewing) that should be applied [ 26 , 30 , 31 , 34 ]. According to Johansen et al., open-ended questions and reflective listening techniques could help direct communication towards changes in behaviour [ 26 ].

The professional-patient relationship

The importance of the professional-patient relationship was explicitly mentioned in articles by Jull et al. and Varkula et al. [ 29 , 35 ]. According to these two articles, early rapport building and a non-judgmental demeanour are of the utmost importance to the ideal assessment and management of childhood obesity. The authors stressed the vital importance of involving the family and engaging with children and families, building enhancing and collaborative relationships, and showing genuine respect [ 29 , 35 ].

Attitudes of healthcare professionals

As noted in studies by Barlow et al., Baur et al. and Jull et al., ideal assessment and management calls for HCPs to adopt an emphatic, supportive, non-judgmental and collaborative attitude [ 25 , 26 , 29 ].

Study characteristics

An overview of the self-reported general characteristics of the focus-group participants is presented as supplementary information [see Additional file  4 ]. In all, 28 professionals participated in the study, one of who participated in two focus groups. Four other professionals cancelled their participation due to personal circumstances. The mean age of the participants was approximately 45 years, and 25 (89%) of the participants were female.

The participants represented a total of 35 functions, as several participants combined multiple functions. The focus groups included professionals working 15 different positions at a variety of levels in the healthcare system, ranging from community care to secondary care: integrated (or general) care advisors ( n  = 8; 27.6%), YHC nurses ( n  = 6; 17.1%), CPs ( n  = 5; 14.3%), YHC doctor ( n  = 3; 8.6%), paediatricians ( n  = 2; 5,7%), project leaders of the local integrated care ( n  = 2; 5.7%), managers of the local integrated care ( n  = 2; 5.7%), specialised YHC nurses ( n  = 2; 5.7%), professor of nutrition and health ( n  = 1; 2.9%), social worker ( n  = 1; 2.9%), dietician ( n  = 1; 2.9%), researcher ( n  = 1; 2.9%) and trainer and developer of national education for CPs ( n  = 1; 2.9%). An overview of the distribution of positions is provided as supplementary information [see Additional file 4 ].

The participants represented a total of 29 different organisations, most within the municipal health services ( n  = 12; 41.4%). Other organisations included a municipality ( n  = 3; 10.3%), ‘Youth on a Healthier Weight’ (JOGG) ( n  = 3; 10.3%), a hospital ( n  = 2; 6.9%), the Netherlands Youth Institute ( n  = 2; 6.9%), the Dutch Centre for Youth Healthcare ( n  = 2; 6.9%), a dietician practice ( n  = 1; 3.5%), a university ( n  = 1; 3.5%), a primary school ( n  = 1; 3.5%) and a professional association ( n  = 1; 3.5%). One participant (3.5%) was self-employed. An overview of the organisations represented is provided as supplementary information [see Additional file 4 ].

Relevant factors that should be taken into account as part of the assessment have been classified as child, family, parental and lifestyle factors and structured into psychological and social aspects. According to the HCPs, there is no need to assess all these factors in detail at once, the CP makes the decision what is assessed and when it is assessed depending on the situation of the child and family.

Factors that participants identified as important to consider focused largely on the well-being of the child, stress and relaxation. The participants also emphasised the importance of discussing the strengths and capabilities of the child and family. Depending on the child’s age (predominantly with children aged 12 years and older), factors such as peer pressure, gaming behaviour and gaming in combination with sleeping were regarded as relevant.

When children go to secondary school, they often have money and go along with the group. Those who can’t afford to buy snacks between meals are in an awkward position, because the rest of the group is going, and they like these things as well. (Focus group 2, R5).

Participants emphasised the need to consider various aspects of family functioning, including the family situation and composition (e.g. separated parents and blended families) and mutual relationships between family members. They also mentioned the importance of assessing parenting skills, including the following topics: parental trust, setting clear boundaries, parental attitudes and beliefs with regard to upbringing, parental agreements on parenthood, and the experiences of parents with their own upbringing. According to the participants, co-caregivers (e.g. grandparents, daycare workers) who play a role in childcare and who bear some responsibility for upbringing should also be taken into account, given the critical importance of agreements on upbringing and lifestyle behaviour between caregivers.

Grandparents play an important role in families, and their views often conflict with those of the parents. Many parents are glad when grandparents are willing to take on a caregiving role. When grandparents want to reward children with fast food, sweets or salty snacks that the parents don’t approve of, however, this places the children under pressure. It’s obviously important for these things to be clear. The issue thus often goes beyond children and their direct caregivers to include the environment as well. (Focus group 4, R4, Pos. 53).

Finally, the participants noted that it is helpful to consider the environment of the family (e.g. social support, the networks of the parents, perception of weight by peers and culture).

And there should also be a cultural connection: the meaning of food in a family, sociability, hospitality, et cetera. (Focus group 2, R5, Pos. 96).

Participants noted the importance of considering whether parents have a job and what their work situation is. They also considered it important to talk about the financial possibilities, stress and relaxation of the parents.

I would like to see more attention to stress and relaxation, and what they need in that regard. This refers to factors that children experience as stressful, as well as those that parents see as stressful, as they are not necessarily the same. This is an important distinction. (Focus group 4, R4, Pos. 77).

Given that the focus groups centred on psychosocial factors, and given that participants felt that the current psychosocial and lifestyle assessment places sufficient emphasis on lifestyle factors, no additional lifestyle factors were mentioned.

It can be tempting to focus more on lifestyle issues and less on the underlying psychosocial issues or factors. I think people need more help in order to consider the issue more broadly. (Focus group 1, R4, Pos. 31)

The experiences and views of HCPs with regard to the assessment of psychosocial and lifestyle factors also addressed the issue of how to conduct the assessment of psychosocial and lifestyle factors. The findings emerging from the analysis of the focus-group discussions were classified according to the three most prominent themes: (a) talking about psychosocial factors, lifestyle and weight; (b) the professional-patient relationship; and (c) attitudes of healthcare professionals.

Participants emphasised the importance of talking about psychosocial factors, lifestyle and weight in order to gain insight into the factors that may contribute to the development and maintenance of obesity and to ensure a contextualised and comprehensive understanding of children with obesity and their circumstances. They specifically highlighted the sensitivity of the topic of obesity and some psychosocial factors. According to the participants, children and their parents may feel guilt and shame because of their weight, possibly leading them to avoid talking about obesity, psychosocial factors, lifestyle and weight, in addition to avoiding future appointments.

The way you introduce the conversation is important, given the vulnerability associated with obesity. The words used and questions asked are very important, as it can quickly seem like an interrogation. (Focus group 3, R6, Pos. 170).

The way you introduce the conversation is important, given the vulnerability associated with obesity. The words used and questions asked are very important, as it can quickly seem like an interrogation. (Focus group 2, R5, Pos. 159).

In order to prepare children and parents, participants stressed the crucial importance of explaining the need to assess the broader circumstances of children and their families, as they are likely to expect the assessment to focus only on weight and lifestyle. The participants also highlighted the need for CPs to acknowledge and explain the complexity of obesity. More specifically, children and parents should be aware of factors that influence their behaviour and weight. According to the participants, practical tools may help professionals to present interacting factors in a visual, non-judgmental manner, thereby facilitating conversations about psychosocial factors, lifestyle and weight.

Even if you already know the families, it’s important to explain why you want to take a broader look at the family at that particular moment. (Focus group 5, R8, Pos. 65).

We all know that conversations on this topic are difficult. It’s extremely important to explain why we’re asking these questions and what they actually have to do with each other. This is obvious to us, but not necessarily to parents. (Focus group 3, R6, Pos. 114).

Sufficient knowledge about the complexity of obesity, healthy food and the tools that are available were mentioned as important means of enabling professionals to conduct psychosocial and lifestyle assessments. Communication skills (e.g. applying various conversational techniques, such as motivational interviewing and solution-focused counselling) were also identified as a key element.

It requires interviewing skills to make contact in an interested, professional manner without going straight for the target. (Focus group 1, R2, Pos. 166).

Participants felt that it is more difficult to discuss psychosocial factors, lifestyle and weight with families with different cultural backgrounds who either have low literacy or face language barriers, and that the assessment thus needs more attention.

For parents with language problems, it is sometimes not until the second or third session that they start to understand what I meant when I asked if a dietician had already visited them or if they have had any previous help. I would actually have liked for that to have been the case at the first session. (Focus group 2, R5, Pos. 62) I’ve noticed that assessments are quite difficult when dealing with other cultures. It requires a lot of explanation, especially for people with a different background who don’t speak Dutch. This obviously makes the conversation quite different. (Focus group 2, R3, Pos. 22).

The participants regarded the professional-patient relationship as important to both the assessment and the management of childhood obesity. Given that it often takes considerable time to build rapport and a trusting relationship with children and their parents, the participants noted that multiple consultations may be required in order to conduct psychosocial and lifestyle assessments. I’ve also noticed that questions can be too daunting for a first conversation. There might still be some resistance if I were to try to address that right away. It sometimes takes several sessions before it’s safe enough. (Focus group 2, R4, Pos. 80).

With regard to the professional-parent relationship, CPs should 1) introduce their role and take time to explain the value of talking about psychosocial and lifestyle factors for both the child and the parents; 2) get to know the family better by asking about and trying to understand their living circumstances; and 3) create clear expectations about the care process.

I also think it’s good for coordinating professionals to introduce themselves: who I am and what I can do for them. This is not always clear to parents. (Focus group 5, R7, Pos. 70).

It’s really helpful to create a bond of trust and to help children and their parents to feel that you’re genuinely interested in them, and not just in the excess weight or how the child is eating and exercising. This completely changes the conversations. (Focus group 4, R4, Pos. 59).

Participants expressed that conducting a psychosocial and lifestyle assessment requires an attitude shift for most CPs. They stressed the need for CPs to be ‘demand-oriented’ and patient with regard to the priorities and requests of children and their families. Adopting an interested, curious and empathic attitude was considered helpful during the assessment. The participants highly endorsed the use of open-ended questions and engaging in active listening with a non-patronising attitude.

You have to have a particular mindset. You’re asking something completely different of professionals. Everyone might say, ‘Yeah, we know’. They might hear it, and it might sound good, but translating it into action really does ask something of them. (Focus group 1, R6 Pos. 39).

This article is based on scientific literature on childhood obesity assessments and information obtained from focus groups on the experiences and views of healthcare professionals (HCPs) with regard to assessing psychosocial and lifestyle factors that influence the development and maintenance of obesity. The results provide an overview of relevant psychosocial and lifestyle factors classified into four categories—child, family, parents and lifestyle—and structured into psychological and social aspects. The article also highlights the importance of paying attention to sensitivity when talking about psychosocial factors, lifestyle and weight within the context of such assessments, as well as the importance of a good professional-patient relationship and an emphatic, supportive, non-judgmental and collaborative attitude on the part of the HCP.

The scientific literature included in the scoping review reflected differences in the extent of detail in which various assessments address psychosocial and lifestyle factors, as well as with regard to other aspects that are addressed, including the management of obesity and how HCPs should conduct the assessment. Moreover, some of the literature provided an overview of principles of childhood obesity management, in addition to the psychosocial and lifestyle assessment [ 26 , 28 , 29 ]. One explanation for such differences could be that the articles included in the review were targeted at audiences in different healthcare disciplines and settings (e.g. medical professionals and mental healthcare professionals). Furthermore, the information obtained through the assessment might change throughout the healthcare process. In order to identify changes in the circumstances of children and their families, as well as to evaluate intervention outcomes and reconsider treatment goals, it would seem useful to integrate the assessment into the care process and assess psychosocial and lifestyle factors at several different points, rather than using such assessment exclusively as a diagnostic tool [ 36 ]. An appropriate assessment aimed at understanding factors that might contribute to the development and maintenance of obesity is essential to improving the efficacy of obesity management [ 37 ]. Such assessments can help to identify and address various facilitators and barriers. Studies have indicated that this can enhance the success of obesity treatments, in addition to increasing compliance with and adherence to treatment [ 38 ].

As indicated by the results of both the scoping review and focus groups, it is important to facilitate the work of HCPs by explaining how to conduct a psychosocial and lifestyle assessment. This finding is remarkable, given that the study was intended to search for available scientific literature on psychosocial and lifestyle assessments for childhood obesity, and experiences and views of healthcare professionals with regard to assessing psychosocial and lifestyle factors within Dutch integrated care, rather than to generate insight into how such an assessment should be conducted. One possible explanation could be that the notion of addressing psychosocial factors was unfamiliar to HCPs, as well as to children and their families, as standard obesity care to date has not devoted sufficient attention to such factors [ 39 , 40 ]. The participants in this study felt that conducting a psychosocial and lifestyle assessment is difficult. This might be due to the sensitive nature of the child’s weight and the risk that raising the issue of weight might alienate families or lead them to drop out of treatment [ 41 , 42 ]. In addition, the results of the scoping review and extensive research has documented the pervasive presence of implicit and explicit bias and stigma relating to weight, including amongst HCPs, and this has an impact on the care that they provide [ 43 , 44 , 45 , 46 , 47 , 48 ]. It could also lead children and their parents to avoid or delay healthcare services [ 45 , 49 ]. Given that bias and stigma relating to weight are driven by insufficient acknowledgement of the complex aetiology of obesity, efforts to build awareness and understanding concerning the complexity of obesity could help to reduce the prevalence of bias against obesity [ 47 ]. Visual materials that explain the complexity of obesity could be helpful in this regard, for instance an illustrated tool to support conversation [ 50 ]. The results of the scoping review and focus groups further highlight the importance of sensitive communication and a respectful and trustful patient-professional relationship when conducting psychosocial and lifestyle assessments, as these aspects could decrease the likelihood of stigmatisation, thereby making support and care more accessible to children and their parents [ 51 ].

The extent to which HCPs feel that they are able to conduct a psychosocial and lifestyle assessment seems to be related to years of work experience, affinity with the issues relating to overweight and obesity, level of knowledge, confidence in one’s own professional skills and the ability to adjust one’s attitude to correspond to individual children and their parents [ 19 ]. The role of these elements is well documented in the literature of the scoping review and other literature with regard to discussing a child’s weight, as well as when referring children to treatment and obesity counselling [ 19 , 46 , 52 ]. This is supported by the results of the scoping review and focus groups.

Limitation and strengths

A limitation of the scoping review is that it did not assess the methodological quality of the included studies as this did not add to the aims of the study. This stud intended to receive as many input and inspiration as possible with regard to psychosocial and lifestyle assessments which can be seen as a strength. In addition, a limitation of the focus groups is that the participants were not randomly selected as the inclusion criteria for participation were knowledge of the supporting assessment tool and, preferably, the Dutch integrated care. Since many of the participants had prior experience within the integrated care, they may not have been representative of all HCPs. Given the possibility of selection bias, the topics of this study might have been perceived differently by professionals with less experience with integrated care (e.g. because they need more support or guidance). However, the qualitative data reflect a variety of HCPs in terms of disciplines and professional experience. Moreover, the use of the Mentimeter interactive presentation software during the focus groups ensured the collection of a wide variety of input, as it allowed for obtaining additional information from each individual participant. Finally, data saturation was achieved, as indicated by the confirmation of the themes and conclusions in the final focus group.

One strength of this study is that two methods were used involving the use of qualitative data from focus groups to expand on and add depth to the results of a systematic literature review. In addition, the use of databases for the fields of healthcare, social work and psychology ensured that the scoping literature review reflects a wide range of literature, thereby enhancing the generalisability of the findings.

Implications for practice and future research

Although the role of the coordinating professional (CP) is specific to the context of the healthcare system in the Netherlands, the findings may also be relevant to childhood obesity care in other Western countries. Given that the results reflect lessons learned with regard to what should be included in psychosocial and lifestyle assessments and how such assessments should be conducted, they might also be applicable to for adults and for other chronic diseases.

The results of the scientific literature and experiences and views of HCPs are synthesized and used to develop practical tools for HCPs within the context of integrated care in the Netherlands [ 50 , 53 , 54 ]. Developing practical tools for HCPs based on the results of the scoping review and focus groups of this study that corresponds to the national and local contexts within which they provide obesity care might also be relevant for other integrated care contexts, including: (1) examples of questions concerning psychosocial and lifestyle factors; (2) inspiration for obtaining deeper insight into psychosocial and lifestyle factors (e.g. health related quality of life) [ 55 ]; (3) suggestions concerning how to talk about psychosocial and lifestyle factors in a positive and structured manner; and (4) guidance for what HCPs should do after the assessment. The involvement of HCPs as well as children and parents in the development of appropriate tools could increase the likelihood of successful implementation. Another practical implication is that age-appropriate visual materials that provide insight into the complexity of obesity should be developed in order to support the process of conducting psychosocial and lifestyle assessments. Finally, it is important for HCPs to be trained to conduct psychosocial and lifestyle assessments, as this could enhance their confidence and skills, while contributing to de-stigmatisation. HCPs will need time to experiment with the tool, and they will need to gain experience with how to personalize to the needs and priorities of individual children and their parents. The practical implications of this study are already being applied within the context of integrated care in the Netherlands [ 50 , 53 , 54 , 56 , 57 ].

Future research should focus on evaluating psychosocial and lifestyle assessments with HCPs, as well as with children and their parents, in order to identify their needs and wishes, as current research does not adequately reflect their voices. Studies should also address the impact of conducting a psychosocial and lifestyle assessment as part of the integrated care process on the outcomes of care.

This study provides an overview of psychosocial and lifestyle factors that should be identified and how they should be addressed in order to personalise childhood obesity care as part of integrated care for childhood overweight and obesity. These insights can be translated into practical tools for facilitating HCPs in the process of conducting psychosocial and lifestyle assessments in a sensitive and adequate manner. Future research should evaluate the needs, wishes and experiences not only from the perspective of HCPs, but also from the perspective of children and their families. This will promote continuous learning and thereby the further development of the integrated care and the tools associated with it. In addition, the impact of such developments on the outcomes of care should be monitored.

Availability of data and materials

All data generated or analysed during this study are included in this published article and the supplementary information files. The data analysed during the current study are available upon reasonable request from the corresponding author ( [email protected] ).

Abbreviations

Coordinating professional

Youth healthcare

Healthcare professional

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Acknowledgements

We are grateful to the healthcare professionals who took part in the study. We would like to thank Minke Eilander for her support during the research, Lamyae Boutalab for her support during the additional search and in writing the manuscript and Bibian van der Voorn for her support in writing the manuscript.

This project was carried out as part of the Care for Obesity project, which was funded by the Dutch Ministry of Health, Welfare and Sport (grant number 328544, 329657, 977473, 332401). The funder did not have any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This study was carried out by Care for Obesity (Vrije Universiteit Amsterdam).

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Contributions

LK, EvdE and JH contributed to the conception and design of the study with additional input from CB and JS. RdV identified all relevant publications for the literature search in collaboration with LK and EvdE. LK and EvdE performed the literature search, in collaboration with RdV. LK and EvdE conducted the focus groups. LK and EvdE performed data analysis, with additional input from CB, JS and JH. LK led the writing of the manuscript. All authors (LK, EvdE, EvM, MvdV, RdV, CB, JS and JH) edited, read and approved the final manuscript.

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LK: she is a PhD student at the Department of Health Sciences, Vrije Universiteit Amsterdam.

EvdE: she is a PhD student at Erasmus MC, University Medical Center Rotterdam.

EvM: he is a pediatric endocrinologist at the Jeroen Bosch Hospital in ‘s-Hertogenbosch and a professor of Nutrition and Health at the Maastricht University.

MvdV: she (MSc) is a manager of the childhood overweight and obesity approach at the Municipal Health Services of the municipality Amsterdam.

RdV: he (Msc) is an information specialist at the Medical Library, Vrije Universiteit Amsterdam.

CB: she is a professor of Integrated Health care at Tranzo, Tilburg University.

JS: he is a professor of Nutrition and Health at the Department of Health Sciences, Vrije Universiteit Amsterdam.

JH: she is an assistant professor childhood obesity at the Department of Health Sciences, Vrije Universiteit Amsterdam.

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All methods were carried out in accordance with relevant guidelines and regulations. Each participant received an information letter stating the reasons for conducting the research, and all gave recorded informed consent within the Zoom session to participate in this study. The study protocol was approved by the Medical Ethical Committee of the Amsterdam University Medical Center (METC number 2019.511).

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Supplementary Information

Additional file 1. .

Focus group sessions topic guides.

Additional file 2. 

Literature search results.

Additional file 3. 

Extensive table containing the original descriptions of factors that may contribute to the development and maintenance of childhood obesity and that should therefore be identified.

Additional file 4. 

Additional file 5. .

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

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Koetsier, L.W., van den Eynde, E., van Mil, E.G.A.H. et al. Scoping literature review and focus groups with healthcare professionals on psychosocial and lifestyle assessments for childhood obesity care. BMC Health Serv Res 23 , 125 (2023). https://doi.org/10.1186/s12913-022-08957-5

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The key success factors in focus group discussions with the elderly for novice researchers: a review

Journal of Health Research

ISSN : 2586-940X

Article publication date: 6 March 2020

Issue publication date: 7 August 2020

This study aimed to discuss the key success factors in focus group discussions among the elderly as a means of supporting novice researchers and also to share the experiences of novice researchers with focus group discussions.

Design/methodology/approach

This study used a literature review of previous studies that revealed three themes regarding the key success of focus group discussions with the elderly. Focusing on issues published between 2009 and 2019, four health-related databases, namely the Cumulative Index of Nursing and Allied Health Literature (CINAHL), ScienceDirect, PsycARTICLES and Thaijo were investigated using keyword searches, both individually and in combination, and the inclusion criteria used in selecting relevant articles as primary sources included research written in the English and Thai languages.

The literature review involved eight published articles related to this topic in the nursing field. Three themes for key successes were identified as follows: good planning and convenient organization, being accepting and flexible concerning their opinions and good management.

Originality/value

Focus group discussions with the elderly are complex and challenging for novice researchers. It is necessary that a novice researcher in the nursing field builds up the skills of a moderator in conducting focus group interviews if he or she wishes to obtain rigorous data.

• Focus group discussion
• Novice researcher

Muijeen, K. , Kongvattananon, P. and Somprasert, C. (2020), "The key success factors in focus group discussions with the elderly for novice researchers: a review", Journal of Health Research , Vol. 34 No. 4, pp. 359-371. https://doi.org/10.1108/JHR-05-2019-0114

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Copyright © 2019, Kasorn Muijeen, Puangpaka Kongvattananon and Chomchuen Somprasert

Published in Journal of Health Research. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) license. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this license may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Qualitative research on the elderly population requires understanding on the part of the researcher perhaps more than that required for other age groups because these members of the population have had a great deal of life experience, and some are very knowledgeable. Some, however, have not been very successful in life. This range makes focus group discussions a challenge. Collecting the qualitative research data for the present study focused on methods that were consistent with the natural way of life of people in society. In Thai society, especially in Thai villages, people often talk in groups at leisure or while carrying out activities where they can carry on a conversation at the same time. Therefore, group discussion is a normal social behavior in communities or societies that are familiar with each other. Qualitative researchers sometimes use this activity as a data collection method [ 1 ]. Focus group discussion in qualitative research refers to a data collection method that focuses on discussing and exchanging opinions and experiences with the participants. Moreover, with this method, the researcher can observe the participants' interactions with each other and talk to them, thus covering the various issues that have emerged during the conversation and using them for further analysis [ 2 ].

Research on the elderly in Thailand has generally focused on illness and disability. However, for the past decade, this trend has been expanded and now, “successful or healthy aging” or “healthy elderly” are issues that are discussed [ 3 ]. The increasing number of elderly people in the world has resulted in the need to study more deeply the factors that influence the health of older people [ 4 ] and perhaps especially understand why some older people seem to adapt to the challenges of the aging process whilst others cannot despite interventions and policies targeted at them. Therefore, qualitative research on the elderly is often focused on certain aspects, such as health awareness or the health literacy of the elderly [ 5 ]. Focus group discussions with the elderly, on the other hand, are a popular method of collecting data for qualitative research purposes. However, focus groups represent a challenge for new researchers in terms of collecting qualitative data. Novice researchers are typically concerned about the process of focus groups with the elderly and need to understand the characteristics of this special group. The main responsibility of the moderator in this context is to create discussions that offer useful responses got from the participants [ 6 ]. Moreover, the novice researcher needs to be aware of these factors because the focus group discussion provides a quick approach to research which may require considerable time for analysis. Careful planning regarding the moderation of focus group discussions is the basis for successful qualitative research [ 7 ] in this area. When using the discussion group method, preparation has many aspects, and effort must be made so that the time and effort will not be wasted [ 8 ].

The processes of focus group discussions with the elderly are challenging for new researchers who need previous experience on conducting such discussions or previous experience with being a moderator, all of which are a part of the data collection method in qualitative research. Addressing issues such as good planning and organizing the participants and facilities, as well as training, to understand the characteristics of being a good moderator, as well as having an accepting attitude and being flexible are key to the success of group discussions for novice researchers. In addition, several studies have shown that success in conducting focus groups mainly derives from the characteristics of an effective facilitator or moderator. In addition, training and personal readiness are essential in order to enhance the moderator's skills [ 9 , 10 ].

This study has two main points of interest. The first is to understand the factors required in order to conduct focus group discussions amongst the elderly for novice researchers. The second is to describe the researcher's experience with others by sharing the experience of the following published project: “The Effects of Using a Knowledge-management Development Program on Knowledge Management Behaviors for the Health Promotion of Elderly Leaders in the Romyen Community in Thailand” [ 11 ]. The study's objective provides a discussion of the key success factors of focus group discussions with the elderly for novice researchers.

Selection criteria and search strategy

A systemic review was used on articles published between 2009 and 2019, using four health-related databases, namely the Cumulative Index of Nursing and Allied Health Literature (CINAHL), ScienceDirect, PsycARTICLES and Thaijo, which were investigated using keyword searches.

Systemic and critical reviews used the guiding framework based on the PRISMA 2009 flow diagram [ 12 ], which is composed of four steps as follows: identification, screening, eligibility, and included. From the database, 377 studies published from January 2009 to March 2019 were identified that could be adapted as a PRISMA 2009 flow diagram for the article selection process, as shown in Figure 1 . The process of searching began with step 1 as follows: identification using the keywords used within the database search, both individually and in combination, including the terms “key success,” “moderator,” “facilitator,” “conduct,” “focus group discussion with the elderly,” “focus group discussion with older adults,” “novice researchers” and “experience novice researchers.” Step 2 included the screening of articles from the inclusion criteria used in selecting relevant articles as primary sources. This was research written in the English and Thai languages, while the exclusion criteria were articles written in other languages and that were not related to the novice or new researcher as a moderator in focus group discussions with the elderly or focus group discussions with older individuals. Step 3 concerned eligibility, where the full text of the article was examined by checking the content or details of the investigation, as depicted in Figure 1 , for a total of 25 full articles repossessed and checked for eligibility. Step 4 included twenty-five eligible articles to be considered; however, sixteen articles did not have a moderator in the focus group. Finally, the nine remaining articles were qualitative and quantitative studies synthesized by the author, as shown in Figure 1 .

Study selection and data extraction

The data extracted from the studies were tabulated independently by the authors, with data including the study design, purpose and key content or findings of the studies. The findings or the key content were related to the factors connected with focus group discussions, such as the skill of the moderator and how to conduct a focus group discussion.

Ethical consideration

This study did not involve human participants but rather used a literature review of previous studies.

The main results were derived from information gathered from nine articles related to the key success factors regarding focus group discussions among the elderly with novice researchers. These nine articles were divided into two parts as follows: the first part concerned the research and literature related to focus group discussions, as can be seen in the seven articles presented in Table I ; and the second part concerned research that used focus group discussion strategies with the elderly, as shown in Table II .

The main messages from each paper were presented after a thorough analysis, as seen in Tables I and II . According to the information in Table I , the study [ 13 , 15 ] presented the steps of a focus group, including planning and good communication skills for conducting focus group discussions consistent with Doody [ 9 ], who mentioned the environment and duration of the focus group as being important factors. An effective moderator should be a good listener and possess good communication skills. Moreover, Wilson [ 16 ] described planning and the role of the moderator as being important as well. As indicated, the size of the focus group depends on the complexity of the topic and the skill of the moderator [ 14 ]. A skillful moderator needs to know the topic in depth or should be an expert in the subject of discussion [ 17 ]. Technology can also affect the focus group [ 18 ]. Table II [ 19 , 20 ] supports the characteristics of the elderly participant group and how to create a successful focus group discussion. According to the data, the relevant information concerning how to successfully complete a focus group discussion with the elderly can be summarized according to three key success factors as follows: 1) Good planning and event organization, 2) Be accepting and flexible concerning their opinions and 3) Have good management skills.

Good planning and event organization

The stage of good planning and event organization includes preparation, the presession and the session itself. These are important points for novice researchers in terms of conducting a successful focus group discussion. Good planning and event organization should cover the researcher's team, the participants, the environment and question creation in line with the objectives of the focus group. The participants should be contacted in advance and be made aware of the objectives of the activity. It is important to select suitable persons for the focus group. The researcher has to give careful attention to time and provide enough time to prepare. This covers the duration of the focus group, the selection of the participants, the size of the group, preparing the environment, conducting the focus group, supporting the participants during the interview and the participants’ role as a moderator. Wilson [ 16 ] recommends that the moderator reviews the literature on the topic, prepares to take field notes and prepares his or her role in advance. Questions should also be prepared in advance with the research team, considering the purpose of the study, and especially for the elderly, the questions should be relatively easy. In addition, in order to collect comparable data from all of the focus group discussion participants, a list of broad questions or predetermined probes can be developed as a guide for the moderators in order to facilitate the discussion among the participants. Some of the questions in a focus group discussion from Reichstadt's study [ 21 ] are, for example, “How would you define successful aging?” and “What are the necessary components of successful aging?” These questions can guide the moderator in conducting the group and will help him or her explore the research problem. In each focus group, the moderators can begin with these broad questions, with further questions asked based on the participants' responses, in order to elicit additional opinions from the group. This ensures that the participants are provided with an opportunity to discuss their personal attitudes and beliefs [ 1 ]. For the conclusion stage, the moderator should choose approximately five factors related to how to be successful in the focus group discussion, including the size of the focus group, the timing, the environment and location, the selection of participants and understanding the participants and focus group scripts and materials.

Size of the focus group

Variations exist in the literature regarding the optimum size of a focus group, depending on the complexity of the topic, the type of participants and the skills of the moderator. Most researchers suggest that the appropriate group size ranges from 4 to 12 participants [ 1 , 2 , 6 ]. A large group can generate more opinions and/or feelings about the topic, while a smaller group may be more beneficial when sensitive issues are concerned. Moreover, the number of participants in the focus group can depend on the participants having the same experience because some experiences take a long time to discuss and, for this reason, the group should be a small group [ 22 ]. Therefore, the size of a focus group can vary according to the research objective, can be flexible and should be large enough to create a group discussion. For example, most focus group discussions with the elderly in Thailand have 6–12 participants [ 19 – 21 ].

Time of the focus group

The period of time for conducting the focus group depends on the complexity of the topic, the number of questions asked and the size of the group. The duration of the focus group discussion should be in the range of 1 to 2 hrs and should not be longer than 2 hrs because this can affect the physical and mental health of the participants, especially among the elderly, who often have problems with their physical health and are tired from the effects of old age [ 21 ]. Barbour [ 2 ] recommends that the time for discussion be limited to 45 to 90 mins because outside this time period, the participants may lose their ideas and thoughts about the topic, or the session time would have been reached. However, a period of less than 1 hr may prevent the discussion of important issues in accordance with the research objectives. Therefore, it is recommended to use a flexible time period of one hr to no more than 2 hrs.

The environment and location

The environment and location are important as they can have a significant impact on the discussion of a focus group. The following have been suggested concerning the environment and location of a focus group discussion among the elderly: (1) the room should be of adequate size, lighting and temperature; (2) the seating should be arranged in a circle format to ensure that all the participants can see one another, and the ergonomic characteristics of the elderly should be considered; for example, chairs should not be too high or too low because most older people have problems with their knees; (3) the moderator should create a relaxing atmosphere, comfortable and nonthreatening, and the participants should not feel that the questions are too abstract, for example using academic language and (4) the location or setting should be a safe environment where disturbances from other people or external noise [ 14 , 15 ] are not present.

Selection of participants and understanding the participants

The groups can be homogeneous or heterogeneous, depending upon the purpose of the research; yet, attendees should have previous experience or prior knowledge of the topic. Homogeneous groups have similar characteristics, such as being from the same background, being close to the same age, of the same gender, social status or occupation and having experience with the topic as these factors may influence the group discussion. However, heterogeneous groups could be used for exploratory purposes where varieties of groups are preferred. Moreover, it is important to make sure that the focus group participants are not in conflict with one another or are incompatible. Pawi [ 17 ], for example, discussed the differences in the research outcomes obtained from homogeneous and heterogeneous groups, as well as the differences between groups of individuals that were familiar with each other or intimate and those that were strangers. Therefore, novice researchers need to understand all of the steps of the focus group discussion. The novice researcher should carefully select the participants in the group because this will help him or her achieve the research objectives and make it easier to control the focus group discussion. In the Thai context, the novice researcher can use respectful pronouns instead of calling people by their proper names, such as uncle and aunt, when they conduct a group. In addition, the novice researcher must try to find out which of the elderly participants have hearing problems, and while he or she is moderating a focus group discussion his or her speaking volume must not be too loud or too low, and questions may have to be repeated [ 19 , 20 ].

Focus group scripts and materials

Nagle and Williams [ 22 ] stated that the lack of important equipment or materials could interrupt or even stop the discussion from flowing smoothly, causing participants to feel uncomfortable and limiting the discussion. The moderator could prepare a script as an outline for the focus group discussion. The scripts for introducing the group discussion can include, for example, the following: (1) welcoming statements, including the process of self-introduction and group member introductions, with members providing general stories about themselves; (2) overviewing the topic; they can begin by explaining the purpose of the study and of the focus group; (3) stating the ground rules, reviewing the group discussion rules and other information that the participants need to know prior to the group interview and (4) beginning with the first question. It is also important that the questions in the scripts move from the general to the more specific or in order of importance. The research team should brainstorm in order to develop a list of questions based on the purposes of the research. These should be open-ended rather than yes–no questions, to generate more useful information from the group discussion.

O'Connor and Murphy [ 15 ] suggested that creating focus groups for the elderly has nine components that help to complete the group, which can be summarized as follows: (1) audiotapes or audio cassettes used to record the data; (2) participant information form and consent form; (3) labels for the participants and moderators; (4) a watch (5) coffee and bakery goods or drinks; (6) a sign-in consent form and a document listing the participants; (7) flip charts and markers and (8) notebooks, pens and audio cassettes that can be used for recording the data. Digital voice recorders are important because recording focus group discussions is not easy. Focus groups are notoriously difficult to manage and control, especially amongst the elderly, who may speak softly, which makes for poor recording [ 18 ].

Being accepting and flexible concerning their opinions

By recognizing the importance of the moderator role, the novice researcher should gain insight into the requirements of this role in order to promote his or her effectiveness. One's life and work experience may provide a level of preparation, but the development of additional skills can be carried out with the following: theoretical knowledge practice using open-ended questions and rewriting; being familiar with many group conversations; conducting a pilot study; talking to researchers that have had experience in using group discussion methods and participation in focus group discussions for the purpose of critical analysis. A novice researcher should understand that teamwork is important, and various techniques can be used to help solve the problems that may arise during the decision-making process because it is difficult for only one person to manage and conduct a complete focus group. Conducting a focus group is difficult for a novice researcher, especially regarding the data collection and the work process of the focus group. Accepting comments and being flexible are the challenges for moderators to improve their skills, including the following; good interpersonal skills, being good listeners and being non-judgmental and adaptable.

Good interpersonal skills

The interpersonal skills of the moderator are crucial to success in conducting a focus group. Shaha et al. [ 13 ] agree that interpersonal and group leadership skills are essential. At the beginning of the group interview, a moderator welcomes all participants and introduces himself or herself and the team. He or she then requests the participants to introduce themselves and to put on a name label. Then, he or she identifies the purpose of the interview, asks an introductory question as a warm-up to create a relaxing atmosphere and thanks them afterward for sharing their experience. Moreover, Krueger and Casey suggest that light refreshments and eating together tend to promote conversation, discussion and communication within the focus group. Nagle and Williams [ 22 ] suggest that the communication skills of the moderator also involve how to deal with interruptions when someone is providing an opinion. In this regard, the moderator should provide some signals for them to wait, explaining that they will be given an opportunity to speak next. In Thailand, most focus group discussions with the elderly are significant because of research carried out by the moderator and his or her relationship with the group [ 20 ]. If the relationship between the group participants and the moderator is good, insightful information can be received and the research questions can be answered. On the other hand, if the relationship is not good at the outset, the group operation will have obstacles.

Being good listeners

A moderator must be a good listener and a thinker at the same time. Curtis and Redmond [ 23 ] stated that a moderator is required to concentrate on the discussion and to observe the level of the participants' interaction during a group discussion. Packer–Muti [ 10 ] suggested that a moderator should listen attentively with sensitivity and empathy, and Mack et al. [ 24 ] pointed out the importance of reading the body language of the participants, including crying, which can be related to the content of the discussion, in which case the moderator must not join in the emotion or outwardly express sympathy. In addition, the moderators must listen intently while engaging with the other participants, without expressing emotions themselves. If a problem occurs in a dynamic group, the group of responders will respond accordingly, with the moderator warning the participants about the rules of participation in the focus group. However, the important thing to consider is that the participants are elderly and when they speak the moderator must actively listen.

Be non-judgmental and adaptable

The moderator must accept that the participants may be inclined to divert from the expected answers or thought patterns, in response to questions. Mack et al. [ 24 ] mentioned that a moderator should believe that all participants have ideas on the topic and that the moderator should be impartial with his or her general opinions. Nagle and Williams [ 22 ] recommend that a moderator avoid head nods or responses such as “yes,” “I agree” and “OK.” These responses convey acceptance of the answers, which can limit the findings and/or any new ideas or opinions that may come later from other participants in a group. A good moderator needs to have an adaptable and non-judgmental attitude with no partiality or bias toward any of the group participants.

Good management of group dynamics

During a focus group, the researcher recognizes the potential tension between participants with certain characteristics or attitudes. Unfortunately, occasionally, group dynamics cannot be identified at the beginning of a session. The moderator plays the important role of the manager in creating the appropriate group process in which all the participants can participate in the discussion and exchange ideas. However, some group dynamics cannot be predicted. There have been many suggestions for moderators concerning how to deal with disruptive group dynamics, such as countering dominating or disruptive group members and concerning shy or silent participants. However, the researcher's experience will help to resolve problems with disruptive members or barriers in the group dynamics. This study provides details of the experience of novice researchers in the implementation of focus group discussions for the elderly, as detailed below.

The experience of novice researchers in focus groups for the elderly

This section of the present paper explains theresearcher's experience with other researchers by sharing her direct experience from the project mentioned above. The feeling of the author during the first focus group amongst the elderly was one of excitement. The author strongly agrees that good planning and convenient event organization, being accepting and flexible and practicing good management of the group's dynamics are important factors to make the focus group a success for new researchers. However, in conducting that focus group, where the elderly expressed all of their opinions, the data were still incomplete in relation to the objectives, which will be discussed in greater detail in the next section.

As Thai society is developing into an aging population, the elderly population is an important group. Therefore, there has been a great deal of education about elderly groups, and it can be said that qualitative research has allowed researchers to find answers concerning the elderly in profound ways. Based on the literature review and the shared experiences of the author in conducting focus groups with the elderly, it can be concluded that the keys to success include all of the three steps discussed above because they represent the sequence of events that will occur in focus group discussions.

Good planning and convenient event organization represent the preparation process, and these are important for a successful group discussion. The experience of the author in the research project mentioned above can be described as follows: the size of the group from this research comprised five elderly participants in a homogenous group of females who had the same experience with knowledge management training projects. It was concluded that the research team should meet and prepare itself before beginning the focus group, including reading about and understanding the research objectives and sharing the duties for preparation in various steps [ 14 , 20 ].

The skill of being a good listener and being non-judgmental needs to be practiced, and more experience in conducting focus groups is required [ 20 , 21 ]. The experience of this author could provide an example of the skills of the moderator and suggests that creating a focus group with the elderly also requires building relationships rather than just using friendly questions. Moreover, being a good listener and being non-judgmental and adaptable are important examples from the author's experience, and the moderator would be advised to be a quick decision-maker, especially when the participants talk too much. The moderator should make conclusions and lead to the next topic, and he/she should invite other participants to share their opinions. An example can be seen in the words of a participant: “You must try to eat lemon when you wake up the morning; it will be good for the digestive system.” The moderator concluded the conversation as follows: “You think that lemons are good for the digestive system. The other participants agree or disagree? Why?” Good management of group dynamics is consistent with the role of the moderator [ 16 , 19 ].

In addition, the popularity of the Internet and technology including online or Facebook can facilitate the process of focus group discussions. For example, the researcher can use online methods or Facebook to make an appointment with the participants [ 25 ]. Some studies [ 18 , 26 ] have mentioned the benefits of new approaches, such as the use of online focus groups that give individuals that are difficult to reach the ability to participate and that give researchers access to a greater variety of participants. However, there are still limitations in using technology for the elderly in terms of preparing focus groups [ 27 ]. The novice researcher should be careful about using technology with elderly sample groups because they are often limited in their ability in using the Internet and technology.

Focus group discussions with the elderly are complex and challenging for novice researchers, and a variety of skills are required when conducting a focus group. Therefore, the novice qualitative researcher needs to have confidence in the skills discussed in this paper so that he or she can obtain rigorous data. A novice researcher should also understand the strengths and limitations of a focus group discussion with the elderly, as this can have an impact on how to lead the group in order to generate quality data.

PRISMA 2009 flow diagram adapted to examine “key success of focus group discussion with the elderly for novice researchers” (adapted from Moher, Liberati, Tetzlaffand Altman [ 12 ])

Research or literature related to focus group discussions

Research on focus group discussions with the elderly

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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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The Guide to Thematic Analysis

• What is Thematic Analysis?
• Advantages of Thematic Analysis
• Disadvantages of Thematic Analysis
• Thematic Analysis Examples
• How to Do Thematic Analysis
• Thematic Coding
• Collaborative Thematic Analysis
• Thematic Analysis Software
• Thematic Analysis in Mixed Methods Approach
• Abductive Thematic Analysis
• Deductive Thematic Analysis
• Inductive Thematic Analysis
• Reflexive Thematic Analysis
• Thematic Analysis in Observations
• Thematic Analysis in Surveys
• Thematic Analysis for Interviews
• Introduction

Collecting data from focus groups

How do you analyze focus group data using thematic analysis, challenges and limitations.

• Thematic Analysis for Case Studies
• Thematic Analysis of Secondary Data
• Thematic Analysis Literature Review
• Thematic Analysis vs. Phenomenology
• Thematic vs. Content Analysis
• Thematic Analysis vs. Grounded Theory
• Thematic Analysis vs. Narrative Analysis
• Thematic Analysis vs. Discourse Analysis
• Thematic Analysis vs. Framework Analysis
• Thematic Analysis in Social Work
• Thematic Analysis in Psychology
• Thematic Analysis in Educational Research
• Thematic Analysis in UX Research
• How to Present Thematic Analysis Results
• Increasing Rigor in Thematic Analysis
• Peer Review in Thematic Analysis

Thematic Analysis for Focus Groups

Thematic analysis is a powerful tool in qualitative research , particularly when applied to interview or focus group data. This method enables researchers to identify, analyze, and report patterns (themes) within data, providing insightful interpretations of various perspectives shared among group participants. When thematic analysis is employed in focus group research, it helps illuminate shared experiences, viewpoints, and the underlying dynamics that might not be as apparent in other research settings. This introduction to thematic analysis for focus groups aims to guide researchers through the practical steps and considerations essential for extracting meaningful insights from group discussions. By focusing on the specific application within focus groups, this article will provide knowledge to researchers who want to use thematic analysis to identify patterns and themes in their research.

Collecting qualitative data from focus groups is a critical step in qualitative research that requires careful attention to detail and methodical execution. To ensure the data's usefulness for thematic analysis, researchers must adeptly navigate through the stages of preparation, execution, and post-session processing. Each phase plays a vital role in securing high-quality data that is both rich and relevant for thematic exploration.

Preparing for the session

Effective data collection includes defining the focus group's objectives, selecting a diverse and representative sample of participants, and crafting clear, open-ended questions that encourage in-depth discussion. The preparation stage also involves logistical considerations, such as choosing a comfortable and neutral location and ensuring all necessary recording equipment is tested and functional.

Conducting the session

The execution phase centers on facilitating the focus group discussion in a way that encourages active and balanced participation from all attendees. The facilitator must manage the session with skill, fostering an inclusive atmosphere and guiding the conversation to maintain relevance to the research questions. It's crucial to record the session accurately, using audio or video equipment, to capture the full spectrum of interactions, expressions, and nuances in communication.

Processing the data

After the focus group session, processing data sources involves transcribing the recordings , a task that requires attention to detail to ensure accuracy and completeness. Researchers should also anonymize focus group transcripts to maintain participant confidentiality . These transcribed texts then become the primary source material for the subsequent thematic analysis, laying the foundation for a thorough and insightful examination of the collected data.

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Qualitative data analysis on focus groups using thematic analysis involves a systematic and rigorous approach to uncovering and understanding patterns, themes, and insights within the rich narratives shared by participants. This method enables researchers to delve beyond surface-level information, identifying deeper meanings and connections that can inform and enrich research findings.

Coding and categorizing data

The first step in analyzing focus group data is to start coding and categorizing the entire data set. This involves reading through all the data meticulously and assigning initial codes to significant or relevant segments of text. A code is a short but descriptive label that represents the essence of a response or discussion point, making it easier to organize and examine the data. Researchers should approach this process iteratively, refining and consolidating codes into broader categories as patterns begin to emerge. This categorization lays the groundwork for the next phase of analysis, facilitating a structured and comprehensive examination of the data.

Identifying patterns and themes

Once the data are coded and categorized, researchers can begin identifying potential themes and sub-themes. This involves examining the categorized data for recurring concepts, relationships, and structures that reveal the underlying context and significance of the participants' discussions. Themes are not just common topics but also convey something important about the data in relation to the research question. They should be distinct yet interconnected, providing a coherent narrative that captures the complexities and nuances of the focus group data. This stage often requires multiple rounds of review and refinement to ensure that the identified themes accurately and comprehensively represent the dataset.

Interpreting and presenting findings

The final step of thematic analysis is interpreting and presenting the findings. Interpretation involves examining the themes in relation to the research question , the broader literature, and the specific context of the study, providing a nuanced understanding of the data's significance. Researchers should consider how the themes interrelate, what they reveal about the research topic, and how they contribute to a deeper understanding of the subject matter.

Presenting the findings effectively is crucial for communicating the research insights to a wider audience. This typically involves describing the thematic analysis process, detailing how themes were derived, and illustrating each theme with relevant quotes or examples from the focus group data. The presentation should provide a clear, coherent narrative that conveys the richness and depth of the participants' experiences and perspectives, offering valuable contributions to the field of study.

While thematic analysis of focus group data can yield profound insights, researchers must navigate various challenges and limitations inherent in this methodology. Recognizing and addressing these issues is crucial to enhance the quality of the research findings.

• Data richness vs. manageability : Focus groups generate a wealth of data, which can be both an asset and a challenge. The sheer volume and complexity of the data require careful management and can be time-consuming to analyze comprehensively.
• Group dynamics : The interaction among focus group participants can influence the data collected. Dominant personalities may skew the discussion, while quieter members might provide less input, potentially affecting the balance and depth of insights gathered.
• Moderator influence : The facilitator's skills and preconceptions can impact the discussion flow and data quality. An effective moderator must be neutral, encouraging balanced participation without leading the conversation or influencing the content.
• Participant diversity : While diversity within a focus group can enrich discussions, it can also introduce variations in understanding and engagement levels, which may affect the consistency and comparability of data across groups.
• Interpretation subjectivity : Thematic analysis involves a degree of interpretation, which necessitates recognizing the role of the researcher's subjectivity. Ensuring transparency in the coding and analysis process by making notes during data collection and seeking peer verification can help convey the credibility and rigor of the findings.
• Contextual understanding : It is crucial to consider the data within the context of the focus group setting. Researchers must be mindful of the specific conditions and dynamics that may influence participant responses and perceptions.

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