using focus groups for qualitative research

Chapter 12. Focus Groups

Introduction.

Focus groups are a particular and special form of interviewing in which the interview asks focused questions of a group of persons, optimally between five and eight. This group can be close friends, family members, or complete strangers. They can have a lot in common or nothing in common. Unlike one-on-one interviews, which can probe deeply, focus group questions are narrowly tailored (“focused”) to a particular topic and issue and, with notable exceptions, operate at the shallow end of inquiry. For example, market researchers use focus groups to find out why groups of people choose one brand of product over another. Because focus groups are often used for commercial purposes, they sometimes have a bit of a stigma among researchers. This is unfortunate, as the focus group is a helpful addition to the qualitative researcher’s toolkit. Focus groups explicitly use group interaction to assist in the data collection. They are particularly useful as supplements to one-on-one interviews or in data triangulation. They are sometimes used to initiate areas of inquiry for later data collection methods. This chapter describes the main forms of focus groups, lays out some key differences among those forms, and provides guidance on how to manage focus group interviews.

Focus Groups: What Are They and When to Use Them

As interviews, focus groups can be helpfully distinguished from one-on-one interviews. The purpose of conducting a focus group is not to expand the number of people one interviews: the focus group is a different entity entirely. The focus is on the group and its interactions and evaluations rather than on the individuals in that group. If you want to know how individuals understand their lives and their individual experiences, it is best to ask them individually. If you want to find out how a group forms a collective opinion about something (whether a product or an event or an experience), then conducting a focus group is preferable. The power of focus groups resides in their being both focused and oriented to the group . They are best used when you are interested in the shared meanings of a group or how people discuss a topic publicly or when you want to observe the social formation of evaluations. The interaction of the group members is an asset in this method of data collection. If your questions would not benefit from group interaction, this is a good indicator that you should probably use individual interviews (chapter 11). Avoid using focus groups when you are interested in personal information or strive to uncover deeply buried beliefs or personal narratives. In general, you want to avoid using focus groups when the subject matter is polarizing, as people are less likely to be honest in a group setting. There are a few exceptions, such as when you are conducting focus groups with people who are not strangers and/or you are attempting to probe deeply into group beliefs and evaluations. But caution is warranted in these cases. [1]

As with interviewing in general, there are many forms of focus groups. Focus groups are widely used by nonresearchers, so it is important to distinguish these uses from the research focus group. Businesses routinely employ marketing focus groups to test out products or campaigns. Jury consultants employ “mock” jury focus groups, testing out legal case strategies in advance of actual trials. Organizations of various kinds use focus group interviews for program evaluation (e.g., to gauge the effectiveness of a diversity training workshop). The research focus group has many similarities with all these uses but is specifically tailored to a research (rather than applied) interest. The line between application and research use can be blurry, however. To take the case of evaluating the effectiveness of a diversity training workshop, the same interviewer may be conducting focus group interviews both to provide specific actionable feedback for the workshop leaders (this is the application aspect) and to learn more about how people respond to diversity training (an interesting research question with theoretically generalizable results).

When forming a focus group, there are two different strategies for inclusion. Diversity focus groups include people with diverse perspectives and experiences. This helps the researcher identify commonalities across this diversity and/or note interactions across differences. What kind of diversity to capture depends on the research question, but care should be taken to ensure that those participating are not set up for attack from other participants. This is why many warn against diversity focus groups, especially around politically sensitive topics. The other strategy is to build a convergence focus group , which includes people with similar perspectives and experiences. These are particularly helpful for identifying shared patterns and group consensus. The important thing is to closely consider who will be invited to participate and what the composition of the group will be in advance. Some review of sampling techniques (see chapter 5) may be helpful here.

Moderating a focus group can be a challenge (more on this below). For this reason, confining your group to no more than eight participants is recommended. You probably want at least four persons to capture group interaction. Fewer than four participants can also make it more difficult for participants to remain (relatively) anonymous—there is less of a group in which to hide. There are exceptions to these recommendations. You might want to conduct a focus group with a naturally occurring group, as in the case of a family of three, a social club of ten, or a program of fifteen. When the persons know one another, the problems of too few for anonymity don’t apply, and although ten to fifteen can be unwieldy to manage, there are strategies to make this possible. If you really are interested in this group’s dynamic (not just a set of random strangers’ dynamic), then you will want to include all its members or as many as are willing and able to participate.

There are many benefits to conducting focus groups, the first of which is their interactivity. Participants can make comparisons, can elaborate on what has been voiced by another, and can even check one another, leading to real-time reevaluations. This last benefit is one reason they are sometimes employed specifically for consciousness raising or building group cohesion. This form of data collection has an activist application when done carefully and appropriately. It can be fun, especially for the participants. Additionally, what does not come up in a focus group, especially when expected by the researcher, can be very illuminating.

Many of these benefits do incur costs, however. The multiplicity of voices in a good focus group interview can be overwhelming both to moderate and later to transcribe. Because of the focused nature, deep probing is not possible (or desirable). You might only get superficial thinking or what people are willing to put out there publicly. If that is what you are interested in, good. If you want deeper insight, you probably will not get that here. Relatedly, extreme views are often suppressed, and marginal viewpoints are unspoken or, if spoken, derided. You will get the majority group consensus and very little of minority viewpoints. Because people will be engaged with one another, there is the possibility of cut-off sentences, making it even more likely to hear broad brush themes and not detailed specifics. There really is very little opportunity for specific follow-up questions to individuals. Reading over a transcript, you may be frustrated by avenues of inquiry that were foreclosed early.

Some people expect that conducting focus groups is an efficient form of data collection. After all, you get to hear from eight people instead of just one in the same amount of time! But this is a serious misunderstanding. What you hear in a focus group is one single group interview or discussion. It is not the same thing at all as conducting eight single one-hour interviews. Each focus group counts as “one.” Most likely, you will need to conduct several focus groups, and you can design these as comparisons to one another. For example, the American Sociological Association (ASA) Task Force on First-Generation and Working-Class Persons in Sociology began its study of the impact of class in sociology by conducting five separate focus groups with different groups of sociologists: graduate students, faculty (in general), community college faculty, faculty of color, and a racially diverse group of students and faculty. Even though the total number of participants was close to forty, the “number” of cases was five. It is highly recommended that when employing focus groups, you plan on composing more than one and at least three. This allows you to take note of and potentially discount findings from a group with idiosyncratic dynamics, such as where a particularly dominant personality silences all other voices. In other words, putting all your eggs into a single focus group basket is not a good idea.

How to Conduct a Focus Group Interview/Discussion

Advance preparations.

Once you have selected your focus groups and set a date and time, there are a few things you will want to plan out before meeting.

As with interviews, you begin by creating an interview (or discussion) guide. Where a good one-on-one interview guide should include ten to twelve main topics with possible prompts and follow-ups (see the example provided in chapter 11), the focus group guide should be more narrowly tailored to a single focus or topic area. For example, a focus might be “How students coped with online learning during the pandemic,” and a series of possible questions would be drafted that would help prod participants to think about and discuss this topic. These questions or discussion prompts can be creative and may include stimulus materials (watching a video or hearing a story) or posing hypotheticals. For example, Cech ( 2021 ) has a great hypothetical, asking what a fictional character should do: keep his boring job in computers or follow his passion and open a restaurant. You can ask a focus group this question and see what results—how the group comes to define a “good job,” what questions they ask about the hypothetical (How boring is his job really? Does he hate getting up in the morning, or is it more of an everyday tedium? What kind of financial support will he have if he quits? Does he even know how to run a restaurant?), and how they reach a consensus or create clear patterns of disagreement are all interesting findings that can be generated through this technique.

As with the above example (“What should Joe do?”), it is best to keep the questions you ask simple and easily understood by everyone. Thinking about the sequence of the questions/prompts is important, just as it is in conducting any interviews.

Avoid embarrassing questions. Always leave an out for the “I have a friend who X” response rather than pushing people to divulge personal information. Asking “How do you think students coped?” is better than “How did you cope?” Chances are, some participants will begin talking about themselves without you directly asking them to do so, but allowing impersonal responses here is good. The group itself will determine how deep and how personal it wants to go. This is not the time or place to push anyone out of their comfort zone!

Of course, people have different levels of comfort talking publicly about certain topics. You will have provided detailed information to your focus group participants beforehand and secured consent. But even so, the conversation may take a turn that makes someone uncomfortable. Be on the lookout for this, and remind everyone of their ability to opt out—to stay silent or to leave if necessary. Rather than call attention to anyone in this way, you also want to let everyone know they are free to walk around—to get up and get coffee (more on this below) or use the restroom or just step out of the room to take a call. Of course, you don’t really want anyone to do any of these things, and chances are everyone will stay seated during the hour, but you should leave this “out” for those who need it.

Have copies of consent forms and any supplemental questionnaire (e.g., demographic information) you are using prepared in advance. Ask a friend or colleague to assist you on the day of the focus group. They can be responsible for making sure the recording equipment is functioning and may even take some notes on body language while you are moderating the discussion. Order food (coffee or snacks) for the group. This is important! Having refreshments will be appreciated by your participants and really damps down the anxiety level. Bring name tags and pens. Find a quiet welcoming space to convene. Often this is a classroom where you move chairs into a circle, but public libraries often have meeting rooms that are ideal places for community members to meet. Be sure that the space allows for food.

Researcher Note

When I was designing my research plan for studying activist groups, I consulted one of the best qualitative researchers I knew, my late friend Raphael Ezekiel, author of The Racist Mind . He looked at my plan to hand people demographic surveys at the end of the meetings I planned to observe and said, “This methodology is missing one crucial thing.” “What?” I asked breathlessly, anticipating some technical insider tip. “Chocolate!” he answered. “They’ll be tired, ready to leave when you ask them to fill something out. Offer an incentive, and they will stick around.” It worked! As the meetings began to wind down, I would whip some bags of chocolate candies out of my bag. Everyone would stare, and I’d say they were my thank-you gift to anyone who filled out my survey. Once I learned to include some sugar-free candies for diabetics, my typical response rate was 100 percent. (And it gave me an additional class-culture data point by noticing who chose which brand; sure enough, Lindt balls went faster at majority professional-middle-class groups, and Hershey’s minibars went faster at majority working-class groups.)

—Betsy Leondar-Wright, author of Missing Class , coauthor of The Color of Wealth , associate professor of sociology at Lasell University, and coordinator of staffing at the Mission Project for Class Action

During the Focus Group

As people arrive, greet them warmly, and make sure you get a signed consent form (if not in advance). If you are using name tags, ask them to fill one out and wear it. Let them get food and find a seat and do a little chatting, as they might wish. Once seated, many focus group moderators begin with a relevant icebreaker. This could be simple introductions that have some meaning or connection to the focus. In the case of the ASA task force focus groups discussed above, we asked people to introduce themselves and where they were working/studying (“Hi, I’m Allison, and I am a professor at Oregon State University”). You will also want to introduce yourself and the study in simple terms. They’ve already read the consent form, but you would be surprised at how many people ignore the details there or don’t remember them. Briefly talking about the study and then letting people ask any follow-up questions lays a good foundation for a successful discussion, as it reminds everyone what the point of the event is.

Focus groups should convene for between forty-five and ninety minutes. Of course, you must tell the participants the time you have chosen in advance, and you must promptly end at the time allotted. Do not make anyone nervous by extending the time. Let them know at the outset that you will adhere to this timeline. This should reduce the nervous checking of phones and watches and wall clocks as the end time draws near.

Set ground rules and expectations for the group discussion. My preference is to begin with a general question and let whoever wants to answer it do so, but other moderators expect each person to answer most questions. Explain how much cross-talk you will permit (or encourage). Again, my preference is to allow the group to pick up the ball and run with it, so I will sometimes keep my head purposefully down so that they engage with one another rather than me, but I have seen other moderators take a much more engaged position. Just be clear at the outset about what your expectations are. You may or may not want to explain how the group should deal with those who would dominate the conversation. Sometimes, simply stating at the outset that all voices should be heard is enough to create a more egalitarian discourse. Other times, you will have to actively step in to manage (moderate) the exchange to allow more voices to be heard. Finally, let people know they are free to get up to get more coffee or leave the room as they need (if you are OK with this). You may ask people to refrain from using their phones during the duration of the discussion. That is up to you too.

Either before or after the introductions (your call), begin recording the discussion with their collective permission and knowledge . If you have brought a friend or colleague to assist you (as you should), have them attend to the recording. Explain the role of your colleague to the group (e.g., they will monitor the recording and will take short notes throughout to help you when you read the transcript later; they will be a silent observer).

Once the focus group gets going, it may be difficult to keep up. You will need to make a lot of quick decisions during the discussion about whether to intervene or let it go unguided. Only you really care about the research question or topic, so only you will really know when the discussion is truly off topic. However you handle this, keep your “participation” to a minimum. According to Lune and Berg ( 2018:95 ), the moderator’s voice should show up in the transcript no more than 10 percent of the time. By the way, you should also ask your research assistant to take special note of the “intensity” of the conversation, as this may be lost in a transcript. If there are people looking overly excited or tapping their feet with impatience or nodding their heads in unison, you want some record of this for future analysis.

I’m not sure why this stuck with me, but I thought it would be interesting to share. When I was reviewing my plan for conducting focus groups with one of my committee members, he suggested that I give the participants their gift cards first. The incentive for participating in the study was a gift card of their choice, and typical processes dictate that participants must complete the study in order to receive their gift card. However, my committee member (who is Native himself) suggested I give it at the beginning. As a qualitative researcher, you build trust with the people you engage with. You are asking them to share their stories with you, their intimate moments, their vulnerabilities, their time. Not to mention that Native people are familiar with being academia’s subjects of interest with little to no benefit to be returned to them. To show my appreciation, one of the things I could do was to give their gifts at the beginning, regardless of whether or not they completed participating.

—Susanna Y. Park, PhD, mixed-methods researcher in public health and author of “How Native Women Seek Support as Survivors of Intimate Partner Violence: A Mixed-Methods Study”

After the Focus Group

Your “data” will be either fieldnotes taken during the focus group or, more desirably, transcripts of the recorded exchange. If you do not have permission to record the focus group discussion, make sure you take very clear notes during the exchange and then spend a few hours afterward filling them in as much as possible, creating a rich memo to yourself about what you saw and heard and experienced, including any notes about body language and interactions. Ideally, however, you will have recorded the discussion. It is still a good idea to spend some time immediately after the conclusion of the discussion to write a memo to yourself with all the things that may not make it into the written record (e.g., body language and interactions). This is also a good time to journal about or create a memo with your initial researcher reactions to what you saw, noting anything of particular interest that you want to come back to later on (e.g., “It was interesting that no one thought Joe should quit his job, but in the other focus group, half of the group did. I wonder if this has something to do with the fact that all the participants were first-generation college students. I should pay attention to class background here.”).

Please thank each of your participants in a follow-up email or text. Let them know you appreciated their time and invite follow-up questions or comments.

One of the difficult things about focus group transcripts is keeping speakers distinct. Eventually, you are going to be using pseudonyms for any publication, but for now, you probably want to know who said what. You can assign speaker numbers (“Speaker 1,” “Speaker 2”) and connect those identifications with particular demographic information in a separate document. Remember to clearly separate actual identifications (as with consent forms) to prevent breaches of anonymity. If you cannot identify a speaker when transcribing, you can write, “Unidentified Speaker.” Once you have your transcript(s) and memos and fieldnotes, you can begin analyzing the data (chapters 18 and 19).

Advanced: Focus Groups on Sensitive Topics

Throughout this chapter, I have recommended against raising sensitive topics in focus group discussions. As an introvert myself, I find the idea of discussing personal topics in a group disturbing, and I tend to avoid conducting these kinds of focus groups. And yet I have actually participated in focus groups that do discuss personal information and consequently have been of great value to me as a participant (and researcher) because of this. There are even some researchers who believe this is the best use of focus groups ( de Oliveira 2011 ). For example, Jordan et al. ( 2007 ) argue that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues. So although I do not recommend the beginning qualitative researcher dive into deep waters before they can swim, this section will provide some guidelines for conducting focus groups on sensitive topics. To my mind, these are a minimum set of guidelines to follow when dealing with sensitive topics.

First, be transparent about the place of sensitive topics in your focus group. If the whole point of your focus group is to discuss something sensitive, such as how women gain support after traumatic sexual assault events, make this abundantly clear in your consent form and recruiting materials. It is never appropriate to blindside participants with sensitive or threatening topics .

Second, create a confidentiality form (figure 12.2) for each participant to sign. These forms carry no legal weight, but they do create an expectation of confidentiality for group members.

In order to respect the privacy of all participants in [insert name of study here], all parties are asked to read and sign the statement below. If you have any reason not to sign, please discuss this with [insert your name], the researcher of this study, I, ________________________, agree to maintain the confidentiality of the information discussed by all participants and researchers during the focus group discussion.

Signature: _____________________________ Date: _____________________

Researcher’s Signature:___________________ Date:______________________

Figure 12.2 Confidentiality Agreement of Focus Group Participants

Third, provide abundant space for opting out of the discussion. Participants are, of course, always permitted to refrain from answering a question or to ask for the recording to be stopped. It is important that focus group members know they have these rights during the group discussion as well. And if you see a person who is looking uncomfortable or like they want to hide, you need to step in affirmatively and remind everyone of these rights.

Finally, if things go “off the rails,” permit yourself the ability to end the focus group. Debrief with each member as necessary.

Further Readings

Barbour, Rosaline. 2018. Doing Focus Groups . 2nd ed. Thousand Oaks, CA: SAGE. Written by a medical sociologist based in the UK, this is a good how-to guide for conducting focus groups.

Gibson, Faith. 2007. “Conducting Focus Groups with Children and Young People: Strategies for Success.” Journal of Research in Nursing 12(5):473–483. As the title suggests, this article discusses both methodological and practical concerns when conducting focus groups with children and young people and offers some tips and strategies for doing so effectively.

Hopkins, Peter E. 2007. “Thinking Critically and Creatively about Focus Groups.” Area 39(4):528–535. Written from the perspective of critical/human geography, Hopkins draws on examples from his own work conducting focus groups with Muslim men. Useful for thinking about positionality.

Jordan, Joanne, Una Lynch, Marianne Moutray, Marie-Therese O’Hagan, Jean Orr, Sandra Peake, and John Power. 2007. “Using Focus Groups to Research Sensitive Issues: Insights from Group Interviews on Nursing in the Northern Ireland ‘Troubles.’” International Journal of Qualitative Methods 6(4), 1–19. A great example of using focus groups productively around emotional or sensitive topics. The authors suggest that focus groups should be considered most useful for illuminating locally sanctioned ways of talking about sensitive issues.

Merton, Robert K., Marjorie Fiske, and Patricia L. Kendall. 1956. The Focused Interview: A Manual of Problems and Procedures . New York: Free Press. This is one of the first classic texts on conducting interviews, including an entire chapter devoted to the “group interview” (chapter 6).

Morgan, David L. 1986. “Focus Groups.” Annual Review of Sociology 22:129–152. An excellent sociological review of the use of focus groups, comparing and contrasting to both surveys and interviews, with some suggestions for improving their use and developing greater rigor when utilizing them.

de Oliveira, Dorca Lucia. 2011. “The Use of Focus Groups to Investigate Sensitive Topics: An Example Taken from Research on Adolescent Girls’ Perceptions about Sexual Risks.” Cien Saude Colet 16(7):3093–3102. Another example of discussing sensitive topics in focus groups. Here, the author explores using focus groups with teenage girls to discuss AIDS, risk, and sexuality as a matter of public health interest.

Peek, Lori, and Alice Fothergill. 2009. “Using Focus Groups: Lessons from Studying Daycare Centers, 9/11, and Hurricane Katrina.” Qualitative Research 9(1):31–59. An examination of the efficacy and value of focus groups by comparing three separate projects: a study of teachers, parents, and children at two urban daycare centers; a study of the responses of second-generation Muslim Americans to the events of September 11; and a collaborative project on the experiences of children and youth following Hurricane Katrina. Throughout, the authors stress the strength of focus groups with marginalized, stigmatized, or vulnerable individuals.

Wilson, Valerie. 1997. “Focus Groups: A Useful Qualitative Method for Educational Research?” British Educational Research Journal 23(2):209–224. A basic description of how focus groups work using an example from a study intended to inform initiatives in health education and promotion in Scotland.

• Note that I have included a few examples of conducting focus groups with sensitive issues in the “ Further Readings ” section and have included an “ Advanced: Focus Groups on Sensitive Topics ” section on this area. ↵

A focus group interview is an interview with a small group of people on a specific topic.  “The power of focus groups resides in their being focused” (Patton 2002:388).  These are sometimes framed as “discussions” rather than interviews, with a discussion “moderator.”  Alternatively, the focus group is “a form of data collection whereby the researcher convenes a small group of people having similar attributes, experiences, or ‘focus’ and leads the group in a nondirective manner.  The objective is to surface the perspectives of the people in the group with as minimal influence by the researcher as possible” (Yin 2016:336).  See also diversity focus group and convergence focus group.

A form of focus group construction in which people with diverse perspectives and experiences are chosen for inclusion.  This helps the researcher identify commonalities across this diversity and/or note interactions across differences.  Contrast with a convergence focus group

A form of focus group construction in which people with similar perspectives and experiences are included.  These are particularly helpful for identifying shared patterns and group consensus.  Contrast with a diversity focus group .

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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Chapter 14: Focus groups

Tess Tsindos

Learning Outcomes

Upon completion of this chapter, you should be able to:

• Assess when to use focus groups in qualitative research.
• Develop questions for a focus group guide.
• Understand how to conduct a focus group.

What are focus groups?

Focus groups are convened to discuss an issue of mutual concern. The purpose of a focus group is to explore the experiences, understandings, opinions or motivations of research participants. 1 While individual interviews explore the experiences of (usually) one participant (see Chapter 13 ), focus groups are conducted with three or more people who share an experience or concern. The conversation between participants in a focus group is mediated and facilitated by the researcher. Focus groups can be used when little is known about the participants or a topic (an exploratory process), when testing new ideas (e.g. acceptability of a program or intervention) or when undertaking an evaluation of a service or product.

The focus of the discussion is on the interaction between participants in the group; some participants may have similar experiences or views, while others have different experiences. The group dynamic is important and therefore it is important that participants lead the discussion and are encouraged to talk through their similarities and differences, so that the researcher might gain a well-rounded perspective and account of the topic. A group might be homogeneous, get along well and share similar experiences. Or the group might be heterogeneous and have differing opinions and experiences. Participants might know each other because they have been recruited from the same program or community, or they could be total strangers. All these elements contribute to the focus of discussion, and to the group dynamic; that is, the interactivity of the focus group.

How many focus group members should there be?

Ideally, a focus group should include 6–10 participants 2 and the conversation should be moderated by the researcher, using a focus group discussion guide. However, the number of participants may vary according to the topic and the number of participants able to be recruited. The data collected from focus groups tends to differ from interview data because people respond and compare their own experiences with those of others in the group. Therefore, the number and composition of group members influence the data gathered.

Having too many people in a group means that discussion can become chaotic and it is unlikely that everyone in the group will have a say. Having too few people means that there may not be sufficient interaction to enable to capture a group perspective. Focus groups have been conducted with as few as two people: in a focus group conducted by one of the authors of this chapter, several participants had been invited, but only two attended. Since participants were difficult to recruit from the target population, it was not feasible to cancel the focus group. The topic was recovery after percutaneous coronary intervention (a cardiac procedure). The focus group discussion developed into an intimate conversation between two older men about their challenges in physical recovery and the psychological effects of not being able to fulfil a traditional male role. The small group size was serendipitous, in that the researcher may not have been able to collect such rich data had the group been larger. 3

The researcher (s)

It is common to have two researchers present in a focus group. One facilitates the group, while the other observes and records the session, and takes notes about who said what, body language and other observable information that contributes to the context of the data being collected. The observer should be as unobtrusive as possible and not participate in the group discussion. Similar to interviews, focus groups are audio-recorded so the conversation can be transcribed for analysis.  The researcher is encouraged to build rapport with focus group participants, which is aided by having a friendly and approachable manner. The focus group method enables the facilitator to probe ideas as they arise and to check their understanding of participants’ responses. This active facilitation enhances the robustness of the data collected. The quality of the data collected will depend greatly on how effective the researcher is at facilitating the group, and thus good interpersonal skills are essential. Conducting effective focus group discussions comes with practice and experience.

How long should a focus group be?

There are no strict rules about how long a focus group should be. Different groups will likely run for different amounts of time because this depends on the research question/s and the types of group members. For example, a group of people who know each other and have a common experience may need no longer than 45 minutes, whereas a group of strangers with different experiences may need up to 2 hours. Additionally, the number of people in the focus group will affect the amount of time needed. A focus group discussion with 6 participants may likely be shorter than a focus group with 12 participants.

Designing the focus group guide

Before the commencement of a focus group, the researchers need to develop a focus group discussion guide, which is similar to an interview guide. Both aim to explore the experiences, understandings, opinions and motivations of participants. If the study’s research methods include interviews and focus groups, the questions will be very similar. T he difference is that the focus group discussion guide do es not typically ask questions to elicit individual storytelling, but rather to ask questions to invite discussion of shared experiences , in which participants confirm or contrast each others ’ views . If focus groups are the sole data collection method, the researcher may consult existing literature, speak to experts, including people with lived experience about the focus of the research, and draw on their knowledge so that the topics and questions can be mapped to the research question/s.

The focus group guide should be developed well in advance of commencing data collection. This provides time for the facilitator and the observer to explore together the language and clarity of questions, the order and flow of the guide, and whether the instructions for participants are clear and comprehensive. To facilitate free-flowing responses, it is important to use open-ended questions that encourage participants to be expansive in their responses. Examples of open-ended question formats include those that start with ‘who’, ‘how’ ‘tell me more about’ and ‘where’.

Pilot interview/s enable the researchers to test the interview guide. However, they are often not conducted because it can be difficult to recruit enough relevant participants. Instead, focus group questions might be reviewed by other members of the research team for clarity and comprehensiveness. The study design will determine the number of questions asked and the extent of the focus group guide. The target population may also determine the extent of the focus group guide; for example, clinicians who are time-poor may need shorter focus groups while patient populations may be interested in exploring their experiences in detail and at length.

Following is a template that can be adapted for the introduction of a focus group. Table 14.1 offers example questions for a focus group discussion guide.

Focus group introduction

‘Hi everyone. My name is [insert name] and I’m from [insert organisation]. I am conducting [describe study]. Thank you for agreeing to be part of this focus group today. You were invited to participate in this focus group because [include reason]. Today we would like to discuss [outline topics]. We anticipate that the session will go for approximately [insert expected time]. Before we get started, I’d like to explain how we would like to structure the discussion. 1. We would like to hear from everyone present. This may mean that I will call on you by name to respond to a question. I may also indicate to you when it’s time to wrap up your thoughts so we can move on to another person or topic. 2. Feel free to respond directly to each other. I’m here to facilitate the discussion, but you are encouraged to respond to the other participants in this group. 3. We are recording the session today. This will ensure that we capture everything discussed. Your names will not be used in the reporting of this data and we will be using pseudonyms or codes instead when writing up results. 4. Please be respectful of what other participants share. Due to the nature of focus groups, we cannot ensure confidentiality, but we do ask that you do not repeat what is discussed in this group to people who were not present. You should feel free to not answer a question if you don’t feel comfortable answering. Do you have any questions before we begin?”

Table 14.1. Focus group guide: Example questions for a descriptive study

An earlier variation of this table has appeared in the Supplementary material for the article Why do students plagiarise? Informing higher education teaching and learning policy and practice . 4

Setting up the f ocus group

In the past, most focus groups were conducted in person. Emerging technologies have enabled the conduct of focus groups online, using teleconferencing and videoconferencing platforms. While it is more challenging to conduct a focus group online – primarily because participants’ body language is often not seen – it can be a very useful method of collecting data. The benefits include low cost, greater access to participants in different locations and time efficiencies. 5 Participants who are less inclined to participate verbally are able to use ‘chat’ functions to contribute their comments. Whether the focus group is face-to-face or online, the facilitator will need to help participants feel as comfortable as possible and encourage discussion.

Focus group activities

Focus groups may incorporate activities in addition to, or to aid discussion; for example, sorting and ranking activities to prioritise topics for discussion in the focus group; or a River of Life 6 activity (see Chapter 18 ).

C onsiderations for the conduct of focus groups

C onfidentiality should be addressed explicitly; for example, using the Chatham House rule, which sets out expectations about repeating what is said in a meeting without revealing the identities of who said it or other participants. 7  It is advisable to provide each participant with an explanatory statement to read, which states that confidentiality is essential to the focus group discussions.

Expectations need to be communicated in advance. Many of the tips for interviews in Chapter 13 apply also to focus groups, but it is important to communicate the researchers’ and the group’s expectations upfront. Some, but not all, of the expectations of focus groups are included in Table 14.2. The facilitator should explain these expectations before the focus group starts. Table 14.3 provides examples of studies using focus groups for data collection.

Table 14.2. Dos and don’ts of conducting focus groups

Power imbalances. When setting up a focus group, the facilitator should pay strict attention to how homogenous the group needs to be concerning the topic, and how possible power imbalances might affect the data collection. For example, if the research question seeks to understand why drug administration errors occur in hospitals, it would not be a good idea to have doctors, nurses and pharmacists in the same group. Why? Because they might not feel comfortable expressing views in front of the very people they have seen make errors. Instead, you could run three separate groups: one with doctors, one with nurses and another with pharmacists. Conducting separate group discussions helps to avoid the chance that a powerful group might dominate the discussion and enables each group member to express their views openly.

Participant identity. The facilitator should invite participants to introduce themselves to other group members, to encourage familiarity; name tags can help participants remember each other’s names. The researchers will need to maintain a list of participants and any necessary demographic details.

Risk. The possibility of distress or harm occurring must always be considered in a focus group. Participants may become distressed because sensitive topics are being discussed, and there is always a risk that some participants might overshare their experiences. The facilitator will need to judge when to stop the discussion if it becomes clear that one or more participants are distressed. 8 Researchers should have a clear protocol developed that provides advice about how to handle distress.

After the f ocus g roup

Once the discussion is concluded, participants should be thanked for their time and contributions. Explain how participants might contact the researcher if they have any questions or would like to provide the facilitator with follow-up information. If the focus group has covered sensitive topics or any participants have become distressed during the discussion, make sure that you spend some time privately with the participant to provide appropriate referrals and follow-up (see Section 6 ). Referrals and follow-up are usually described in the protocol addressing distress.

Data analysis is discussed in Section 4 , but it is important to know what to do immediately after each focus group is completed. Download (or upload) the recording from the audio-recording device to ensure it is saved in a secure location that can only be accessed by people on the research team (see Chapter 34). The recording should be transcribed; that is, reproduced verbatim, for data coding and analysis. The transcription of data is an important step in the analysis process, and it is important to note that this is a highly time-consuming task. Transcribing a 60-minute focus group discussion can take up to 10 hours.

Table 14.3. Examples of focus groups

Focus groups and (individual interviews) are the most common data collection techniques in qualitative research. The success of a focus group depends on the group composition and the effectiveness of the facilitator. It is important to formulate open-ended focus group questions that are understandable and easy for participants to engage with. Setting up the focus group discussion guide, rules and other considerations will enhance the experience of the focus group for the participant and the researchers, as well as the quality of the data collected.

• Gill P, Stewart K, Treasure E et al . Methods of data collection in qualitative research: interviews and focus groups. Br Dent J . 2008;204(6):291-295. doi:10.1038/bdj.2008.192
• Gill, P, Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J . 2018;225:668-672. doi:10.1038/sj.bdj.2018.815
• Soh S-E, Barker AL, Ayton DR et al. What matters most to patients following percutaneous coronary interventions? A new patient-reported outcome measure developed using Rasch analysis. PLoS ONE . 2019;14(9):e0222185. doi.org/10.1371/journal.pone.0222185
• Ayton D, Hillman C, Hatzikiriakidis K, et al. Why do students plagiarise? Informing higher education teaching and learning policy and practice. Stud High Educ . Sep 2 2022;47(9):1921-1934. doi:10.1080/03075079.2021.1985103
• Abrams K, Gaiser T. Online focus groups. In: Field N, Lee R, Blank G, eds. The Sage Handbook of Online Research Methods . Sage Publications, 2016;435–450.
• Moussa Z. Rivers of life. Participatory Learning and Action. Community-based adaptation to climate change, 2009. The International Institute for Environment and Development. Accessed March 24, 2023. https://www.iied.org/g02828
• The Chatham House rule. Chatham House, The Royal Institute of International Affairs, 2023. Accessed March 24, 2023. https://www.chathamhouse.org/about-us/chatham-house-rule#:~:text=The%20Rule%20reads%20as%20follows,other%20participant%2C%20may%20be%20revealed .
• Sim J, Waterfield J. Focus group methodology: some ethical challenges. Qual Quant. 2019;53:3003-3022. doi/10.1007/s11135-019-00914-5
• van der Spek N, Vos J, van Uden-Kraan CF et al. Meaning making in cancer survivors: a focus group study. P LoS ONE . 2013;8(9):e76089. doi.org/10.1371/journal.pone.0076089
• Visser E, Den Oudsten BL, Traa MJ et al . Patients’ experiences and wellbeing after injury: a focus group study. PLoS ONE . 2021;1 6(1):e0245198. doi.org/10.1371/journal.pone.0245198
• Moynihan R, Sims R, Hersch J et al . Communicating about overdiagnosis: learning from community focus groups on osteoporosis. PLoS ONE . 2017;12(2):e0170142. doi.org/10.1371/journal.pone.0170142
• Sabet Sarvestani A, Bufumbo L, Geiger JD et al. . Traditional male circumcision in Uganda: a qualitative focus group discussion analysis. PLoS ONE . 2012;7(10):e45316. doi.org/10.1371/journal.pone.0045316

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Tess Tsindos is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• What Is a Focus Group? | Step-by-Step Guide & Examples

What is a Focus Group | Step-by-Step Guide & Examples

Published on December 10, 2021 by Tegan George . Revised on June 22, 2023.

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest.

Table of contents

What is a focus group, step 1: choose your topic of interest, step 2: define your research scope and hypotheses, step 3: determine your focus group questions, step 4: select a moderator or co-moderator, step 5: recruit your participants, step 6: set up your focus group, step 7: host your focus group, step 8: analyze your data and report your results, advantages and disadvantages of focus groups, other interesting articles, frequently asked questions about focus groups.

Focus groups are a type of qualitative research . Observations of the group’s dynamic, their answers to focus group questions, and even their body language can guide future research on consumer decisions, products and services, or controversial topics.

Focus groups are often used in marketing, library science, social science, and user research disciplines. They can provide more nuanced and natural feedback than individual interviews and are easier to organize than experiments or large-scale surveys .

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Focus groups are primarily considered a confirmatory research technique . In other words, their discussion-heavy setting is most useful for confirming or refuting preexisting beliefs. For this reason, they are great for conducting explanatory research , where you explore why something occurs when limited information is available.

A focus group may be a good choice for you if:

• You’re interested in real-time, unfiltered responses on a given topic or in the dynamics of a discussion between participants
• Your questions are rooted in feelings or perceptions , and cannot easily be answered with “yes” or “no”
• You’re confident that a relatively small number of responses will answer your question
• You’re seeking directional information that will help you uncover new questions or future research ideas
• Structured interviews : The questions are predetermined in both topic and order.
• Semi-structured interviews : A few questions are predetermined, but other questions aren’t planned.
• Unstructured interviews : None of the questions are predetermined.

Differences between types of interviews

Make sure to choose the type of interview that suits your research best. This table shows the most important differences between the four types.

Topics favorable to focus groups

As a rule of thumb, research topics related to thoughts, beliefs, and feelings work well in focus groups. If you are seeking direction, explanation, or in-depth dialogue, a focus group could be a good fit.

However, if your questions are dichotomous or if you need to reach a large audience quickly, a survey may be a better option. If your question hinges upon behavior but you are worried about influencing responses, consider an observational study .

• If you want to determine whether the student body would regularly consume vegan food, a survey would be a great way to gauge student preferences.

However, food is much more than just consumption and nourishment and can have emotional, cultural, and other implications on individuals.

• If you’re interested in something less concrete, such as students’ perceptions of vegan food or the interplay between their choices at the dining hall and their feelings of homesickness or loneliness, perhaps a focus group would be best.

Once you have determined that a focus group is the right choice for your topic, you can start thinking about what you expect the group discussion to yield.

Perhaps literature already exists on your subject or a sufficiently similar topic that you can use as a starting point. If the topic isn’t well studied, use your instincts to determine what you think is most worthy of study.

Setting your scope will help you formulate intriguing hypotheses , set clear questions, and recruit the right participants.

• Are you interested in a particular sector of the population, such as vegans or non-vegans?
• Are you interested in including vegetarians in your analysis?
• Perhaps not all students eat at the dining hall. Will your study exclude those who don’t?
• Are you only interested in students who have strong opinions on the subject?

A benefit of focus groups is that your hypotheses can be open-ended. You can be open to a wide variety of opinions, which can lead to unexpected conclusions.

The questions that you ask your focus group are crucially important to your analysis. Take your time formulating them, paying special attention to phrasing. Be careful to avoid leading questions , which can affect your responses.

Overall, your focus group questions should be:

• Open-ended and flexible
• Impossible to answer with “yes” or “no” (questions that start with “why” or “how” are often best)
• Unambiguous, getting straight to the point while still stimulating discussion
• Unbiased and neutral

If you are discussing a controversial topic, be careful that your questions do not cause social desirability bias . Here, your respondents may lie about their true beliefs to mask any socially unacceptable or unpopular opinions. This and other demand characteristics can hurt your analysis and lead to several types of reseach bias in your results, particularly if your participants react in a different way once knowing they’re being observed. These include self-selection bias , the Hawthorne effect , the Pygmalion effect , and recall bias .

• Engagement questions make your participants feel comfortable and at ease: “What is your favorite food at the dining hall?”
• Exploration questions drill down to the focus of your analysis: “What pros and cons of offering vegan options do you see?”
• Exit questions pick up on anything you may have previously missed in your discussion: “Is there anything you’d like to mention about vegan options in the dining hall that we haven’t discussed?”

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It is important to have more than one moderator in the room. If you would like to take the lead asking questions, select a co-moderator who can coordinate the technology, take notes, and observe the behavior of the participants.

If your hypotheses have behavioral aspects, consider asking someone else to be lead moderator so that you are free to take a more observational role.

Depending on your topic, there are a few types of moderator roles that you can choose from.

• The most common is the dual-moderator , introduced above.
• Another common option is the dueling-moderator style . Here, you and your co-moderator take opposing sides on an issue to allow participants to see different perspectives and respond accordingly.

Depending on your research topic, there are a few sampling methods you can choose from to help you recruit and select participants.

• Voluntary response sampling , such as posting a flyer on campus and finding participants based on responses
• Convenience sampling of those who are most readily accessible to you, such as fellow students at your university
• Stratified sampling of a particular age, race, ethnicity, gender identity, or other characteristic of interest to you
• Judgment sampling of a specific set of participants that you already know you want to include

Beware of sampling bias and selection bias , which can occur when some members of the population are more likely to be included than others.

Number of participants

In most cases, one focus group will not be sufficient to answer your research question. It is likely that you will need to schedule three to four groups. A good rule of thumb is to stop when you’ve reached a saturation point (i.e., when you aren’t receiving new responses to your questions).

Most focus groups have 6–10 participants. It’s a good idea to over-recruit just in case someone doesn’t show up. As a rule of thumb, you shouldn’t have fewer than 6 or more than 12 participants, in order to get the most reliable results.

Lastly, it’s preferable for your participants not to know you or each other, as this can bias your results.

A focus group is not just a group of people coming together to discuss their opinions. While well-run focus groups have an enjoyable and relaxed atmosphere, they are backed up by rigorous methods to provide robust observations.

Confirm a time and date

Be sure to confirm a time and date with your participants well in advance. Focus groups usually meet for 45–90 minutes, but some can last longer. However, beware of the possibility of wandering attention spans. If you really think your session needs to last longer than 90 minutes, schedule a few breaks.

Confirm whether it will take place in person or online

You will also need to decide whether the group will meet in person or online. If you are hosting it in person, be sure to pick an appropriate location.

• An uncomfortable or awkward location may affect the mood or level of participation of your group members.
• Online sessions are convenient, as participants can join from home, but they can also lessen the connection between participants.

As a general rule, make sure you are in a noise-free environment that minimizes distractions and interruptions to your participants.

Consent and ethical considerations

It’s important to take into account ethical considerations and informed consent when conducting your research. Informed consent means that participants possess all the information they need to decide whether they want to participate in the research before it starts. This includes information about benefits, risks, funding, and institutional approval.

Participants should also sign a release form that states that they are comfortable with being audio- or video-recorded. While verbal consent may be sufficient, it is best to ask participants to sign a form.

A disadvantage of focus groups is that they are too small to provide true anonymity to participants. Make sure that your participants know this prior to participating.

There are a few things you can do to commit to keeping information private. You can secure confidentiality by removing all identifying information from your report or offer to pseudonymize the data later. Data pseudonymization entails replacing any identifying information about participants with pseudonymous or false identifiers.

Preparation prior to participation

If there is something you would like participants to read, study, or prepare beforehand, be sure to let them know well in advance. It’s also a good idea to call them the day before to ensure they will still be participating.

Consider conducting a tech check prior to the arrival of your participants, and note any environmental or external factors that could affect the mood of the group that day. Be sure that you are organized and ready, as a stressful atmosphere can be distracting and counterproductive.

Starting the focus group

Welcome individuals to the focus group by introducing the topic, yourself, and your co-moderator, and go over any ground rules or suggestions for a successful discussion. It’s important to make your participants feel at ease and forthcoming with their responses.

Consider starting out with an icebreaker, which will allow participants to relax and settle into the space a bit. Your icebreaker can be related to your study topic or not; it’s just an exercise to get participants talking.

Leading the discussion

Once you start asking your questions, try to keep response times equal between participants. Take note of the most and least talkative members of the group, as well as any participants with particularly strong or dominant personalities.

You can ask less talkative members questions directly to encourage them to participate or ask participants questions by name to even the playing field. Feel free to ask participants to elaborate on their answers or to give an example.

As a moderator, strive to remain neutral . Refrain from reacting to responses, and be aware of your body language (e.g., nodding, raising eyebrows) and the possibility for observer bias . Active listening skills, such as parroting back answers or asking for clarification, are good methods to encourage participation and signal that you’re listening.

Many focus groups offer a monetary incentive for participants. Depending on your research budget, this is a nice way to show appreciation for their time and commitment. To keep everyone feeling fresh, consider offering snacks or drinks as well.

After concluding your focus group, you and your co-moderator should debrief, recording initial impressions of the discussion as well as any highlights, issues, or immediate conclusions you’ve drawn.

The next step is to transcribe and clean your data . Assign each participant a number or pseudonym for organizational purposes. Transcribe the recordings and conduct content analysis to look for themes or categories of responses. The categories you choose can then form the basis for reporting your results.

Just like other research methods, focus groups come with advantages and disadvantages.

• They are fairly straightforward to organize and results have strong face validity .
• They are usually inexpensive, even if you compensate participant.
• A focus group is much less time-consuming than a survey or experiment , and you get immediate results.
• Focus group results are often more comprehensible and intuitive than raw data.

Disadvantages

• It can be difficult to assemble a truly representative sample. Focus groups are generally not considered externally valid due to their small sample sizes.
• Due to the small sample size, you cannot ensure the anonymity of respondents, which may influence their desire to speak freely.
• Depth of analysis can be a concern, as it can be challenging to get honest opinions on controversial topics.
• There is a lot of room for error in the data analysis and high potential for observer dependency in drawing conclusions. You have to be careful not to cherry-pick responses to fit a prior conclusion.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

A focus group is a research method that brings together a small group of people to answer questions in a moderated setting. The group is chosen due to predefined demographic traits, and the questions are designed to shed light on a topic of interest. It is one of 4 types of interviews .

As a rule of thumb, questions related to thoughts, beliefs, and feelings work well in focus groups. Take your time formulating strong questions, paying special attention to phrasing. Be careful to avoid leading questions , which can bias your responses.

There are various approaches to qualitative data analysis , but they all share five steps in common:

• Prepare and organize your data.
• Review and explore your data.
• Develop a data coding system.
• Assign codes to the data.
• Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

Every dataset requires different techniques to clean dirty data , but you need to address these issues in a systematic way. You focus on finding and resolving data points that don’t agree or fit with the rest of your dataset.

These data might be missing values, outliers, duplicate values, incorrectly formatted, or irrelevant. You’ll start with screening and diagnosing your data. Then, you’ll often standardize and accept or remove data to make your dataset consistent and valid.

The four most common types of interviews are:

• Structured interviews : The questions are predetermined in both topic and order. 
• Focus group interviews : The questions are presented to a group instead of one individual.

It’s impossible to completely avoid observer bias in studies where data collection is done or recorded manually, but you can take steps to reduce this type of bias in your research .

Scope of research is determined at the beginning of your research process , prior to the data collection stage. Sometimes called “scope of study,” your scope delineates what will and will not be covered in your project. It helps you focus your work and your time, ensuring that you’ll be able to achieve your goals and outcomes.

Defining a scope can be very useful in any research project, from a research proposal to a thesis or dissertation . A scope is needed for all types of research: quantitative , qualitative , and mixed methods .

To define your scope of research, consider the following:

• Budget constraints or any specifics of grant funding
• Your proposed timeline and duration
• Specifics about your population of study, your proposed sample size , and the research methodology you’ll pursue
• Any inclusion and exclusion criteria
• Any anticipated control , extraneous , or confounding variables that could bias your research if not accounted for properly.

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• Published: 05 October 2018

Interviews and focus groups in qualitative research: an update for the digital age

• P. Gill 1 &
• J. Baillie 2  

British Dental Journal volume  225 ,  pages 668–672 ( 2018 ) Cite this article

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Highlights that qualitative research is used increasingly in dentistry. Interviews and focus groups remain the most common qualitative methods of data collection.

Suggests the advent of digital technologies has transformed how qualitative research can now be undertaken.

Suggests interviews and focus groups can offer significant, meaningful insight into participants' experiences, beliefs and perspectives, which can help to inform developments in dental practice.

Qualitative research is used increasingly in dentistry, due to its potential to provide meaningful, in-depth insights into participants' experiences, perspectives, beliefs and behaviours. These insights can subsequently help to inform developments in dental practice and further related research. The most common methods of data collection used in qualitative research are interviews and focus groups. While these are primarily conducted face-to-face, the ongoing evolution of digital technologies, such as video chat and online forums, has further transformed these methods of data collection. This paper therefore discusses interviews and focus groups in detail, outlines how they can be used in practice, how digital technologies can further inform the data collection process, and what these methods can offer dentistry.

You have full access to this article via your institution.

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Interviews in the social sciences

Professionalism in dentistry: deconstructing common terminology

A review of technical and quality assessment considerations of audio-visual and web-conferencing focus groups in qualitative health research, introduction.

Traditionally, research in dentistry has primarily been quantitative in nature. 1 However, in recent years, there has been a growing interest in qualitative research within the profession, due to its potential to further inform developments in practice, policy, education and training. Consequently, in 2008, the British Dental Journal (BDJ) published a four paper qualitative research series, 2 , 3 , 4 , 5 to help increase awareness and understanding of this particular methodological approach.

Since the papers were originally published, two scoping reviews have demonstrated the ongoing proliferation in the use of qualitative research within the field of oral healthcare. 1 , 6 To date, the original four paper series continue to be well cited and two of the main papers remain widely accessed among the BDJ readership. 2 , 3 The potential value of well-conducted qualitative research to evidence-based practice is now also widely recognised by service providers, policy makers, funding bodies and those who commission, support and use healthcare research.

Besides increasing standalone use, qualitative methods are now also routinely incorporated into larger mixed method study designs, such as clinical trials, as they can offer additional, meaningful insights into complex problems that simply could not be provided by quantitative methods alone. Qualitative methods can also be used to further facilitate in-depth understanding of important aspects of clinical trial processes, such as recruitment. For example, Ellis et al . investigated why edentulous older patients, dissatisfied with conventional dentures, decline implant treatment, despite its established efficacy, and frequently refuse to participate in related randomised clinical trials, even when financial constraints are removed. 7 Through the use of focus groups in Canada and the UK, the authors found that fears of pain and potential complications, along with perceived embarrassment, exacerbated by age, are common reasons why older patients typically refuse dental implants. 7

The last decade has also seen further developments in qualitative research, due to the ongoing evolution of digital technologies. These developments have transformed how researchers can access and share information, communicate and collaborate, recruit and engage participants, collect and analyse data and disseminate and translate research findings. 8 Where appropriate, such technologies are therefore capable of extending and enhancing how qualitative research is undertaken. 9 For example, it is now possible to collect qualitative data via instant messaging, email or online/video chat, using appropriate online platforms.

These innovative approaches to research are therefore cost-effective, convenient, reduce geographical constraints and are often useful for accessing 'hard to reach' participants (for example, those who are immobile or socially isolated). 8 , 9 However, digital technologies are still relatively new and constantly evolving and therefore present a variety of pragmatic and methodological challenges. Furthermore, given their very nature, their use in many qualitative studies and/or with certain participant groups may be inappropriate and should therefore always be carefully considered. While it is beyond the scope of this paper to provide a detailed explication regarding the use of digital technologies in qualitative research, insight is provided into how such technologies can be used to facilitate the data collection process in interviews and focus groups.

In light of such developments, it is perhaps therefore timely to update the main paper 3 of the original BDJ series. As with the previous publications, this paper has been purposely written in an accessible style, to enhance readability, particularly for those who are new to qualitative research. While the focus remains on the most common qualitative methods of data collection – interviews and focus groups – appropriate revisions have been made to provide a novel perspective, and should therefore be helpful to those who would like to know more about qualitative research. This paper specifically focuses on undertaking qualitative research with adult participants only.

Overview of qualitative research

Qualitative research is an approach that focuses on people and their experiences, behaviours and opinions. 10 , 11 The qualitative researcher seeks to answer questions of 'how' and 'why', providing detailed insight and understanding, 11 which quantitative methods cannot reach. 12 Within qualitative research, there are distinct methodologies influencing how the researcher approaches the research question, data collection and data analysis. 13 For example, phenomenological studies focus on the lived experience of individuals, explored through their description of the phenomenon. Ethnographic studies explore the culture of a group and typically involve the use of multiple methods to uncover the issues. 14

While methodology is the 'thinking tool', the methods are the 'doing tools'; 13 the ways in which data are collected and analysed. There are multiple qualitative data collection methods, including interviews, focus groups, observations, documentary analysis, participant diaries, photography and videography. Two of the most commonly used qualitative methods are interviews and focus groups, which are explored in this article. The data generated through these methods can be analysed in one of many ways, according to the methodological approach chosen. A common approach is thematic data analysis, involving the identification of themes and subthemes across the data set. Further information on approaches to qualitative data analysis has been discussed elsewhere. 1

Qualitative research is an evolving and adaptable approach, used by different disciplines for different purposes. Traditionally, qualitative data, specifically interviews, focus groups and observations, have been collected face-to-face with participants. In more recent years, digital technologies have contributed to the ongoing evolution of qualitative research. Digital technologies offer researchers different ways of recruiting participants and collecting data, and offer participants opportunities to be involved in research that is not necessarily face-to-face.

Research interviews are a fundamental qualitative research method 15 and are utilised across methodological approaches. Interviews enable the researcher to learn in depth about the perspectives, experiences, beliefs and motivations of the participant. 3 , 16 Examples include, exploring patients' perspectives of fear/anxiety triggers in dental treatment, 17 patients' experiences of oral health and diabetes, 18 and dental students' motivations for their choice of career. 19

Interviews may be structured, semi-structured or unstructured, 3 according to the purpose of the study, with less structured interviews facilitating a more in depth and flexible interviewing approach. 20 Structured interviews are similar to verbal questionnaires and are used if the researcher requires clarification on a topic; however they produce less in-depth data about a participant's experience. 3 Unstructured interviews may be used when little is known about a topic and involves the researcher asking an opening question; 3 the participant then leads the discussion. 20 Semi-structured interviews are commonly used in healthcare research, enabling the researcher to ask predetermined questions, 20 while ensuring the participant discusses issues they feel are important.

Interviews can be undertaken face-to-face or using digital methods when the researcher and participant are in different locations. Audio-recording the interview, with the consent of the participant, is essential for all interviews regardless of the medium as it enables accurate transcription; the process of turning the audio file into a word-for-word transcript. This transcript is the data, which the researcher then analyses according to the chosen approach.

Types of interview

Qualitative studies often utilise one-to-one, face-to-face interviews with research participants. This involves arranging a mutually convenient time and place to meet the participant, signing a consent form and audio-recording the interview. However, digital technologies have expanded the potential for interviews in research, enabling individuals to participate in qualitative research regardless of location.

Telephone interviews can be a useful alternative to face-to-face interviews and are commonly used in qualitative research. They enable participants from different geographical areas to participate and may be less onerous for participants than meeting a researcher in person. 15 A qualitative study explored patients' perspectives of dental implants and utilised telephone interviews due to the quality of the data that could be yielded. 21 The researcher needs to consider how they will audio record the interview, which can be facilitated by purchasing a recorder that connects directly to the telephone. One potential disadvantage of telephone interviews is the inability of the interviewer and researcher to see each other. This is resolved using software for audio and video calls online – such as Skype – to conduct interviews with participants in qualitative studies. Advantages of this approach include being able to see the participant if video calls are used, enabling observation of non-verbal communication, and the software can be free to use. However, participants are required to have a device and internet connection, as well as being computer literate, potentially limiting who can participate in the study. One qualitative study explored the role of dental hygienists in reducing oral health disparities in Canada. 22 The researcher conducted interviews using Skype, which enabled dental hygienists from across Canada to be interviewed within the research budget, accommodating the participants' schedules. 22

A less commonly used approach to qualitative interviews is the use of social virtual worlds. A qualitative study accessed a social virtual world – Second Life – to explore the health literacy skills of individuals who use social virtual worlds to access health information. 23 The researcher created an avatar and interview room, and undertook interviews with participants using voice and text methods. 23 This approach to recruitment and data collection enables individuals from diverse geographical locations to participate, while remaining anonymous if they wish. Furthermore, for interviews conducted using text methods, transcription of the interview is not required as the researcher can save the written conversation with the participant, with the participant's consent. However, the researcher and participant need to be familiar with how the social virtual world works to engage in an interview this way.

Conducting an interview

Ensuring informed consent before any interview is a fundamental aspect of the research process. Participants in research must be afforded autonomy and respect; consent should be informed and voluntary. 24 Individuals should have the opportunity to read an information sheet about the study, ask questions, understand how their data will be stored and used, and know that they are free to withdraw at any point without reprisal. The qualitative researcher should take written consent before undertaking the interview. In a face-to-face interview, this is straightforward: the researcher and participant both sign copies of the consent form, keeping one each. However, this approach is less straightforward when the researcher and participant do not meet in person. A recent protocol paper outlined an approach for taking consent for telephone interviews, which involved: audio recording the participant agreeing to each point on the consent form; the researcher signing the consent form and keeping a copy; and posting a copy to the participant. 25 This process could be replicated in other interview studies using digital methods.

There are advantages and disadvantages of using face-to-face and digital methods for research interviews. Ultimately, for both approaches, the quality of the interview is determined by the researcher. 16 Appropriate training and preparation are thus required. Healthcare professionals can use their interpersonal communication skills when undertaking a research interview, particularly questioning, listening and conversing. 3 However, the purpose of an interview is to gain information about the study topic, 26 rather than offering help and advice. 3 The researcher therefore needs to listen attentively to participants, enabling them to describe their experience without interruption. 3 The use of active listening skills also help to facilitate the interview. 14 Spradley outlined elements and strategies for research interviews, 27 which are a useful guide for qualitative researchers:

Greeting and explaining the project/interview

Asking descriptive (broad), structural (explore response to descriptive) and contrast (difference between) questions

Asymmetry between the researcher and participant talking

Expressing interest and cultural ignorance

Repeating, restating and incorporating the participant's words when asking questions

Creating hypothetical situations

Asking friendly questions

Knowing when to leave.

For semi-structured interviews, a topic guide (also called an interview schedule) is used to guide the content of the interview – an example of a topic guide is outlined in Box 1 . The topic guide, usually based on the research questions, existing literature and, for healthcare professionals, their clinical experience, is developed by the research team. The topic guide should include open ended questions that elicit in-depth information, and offer participants the opportunity to talk about issues important to them. This is vital in qualitative research where the researcher is interested in exploring the experiences and perspectives of participants. It can be useful for qualitative researchers to pilot the topic guide with the first participants, 10 to ensure the questions are relevant and understandable, and amending the questions if required.

Regardless of the medium of interview, the researcher must consider the setting of the interview. For face-to-face interviews, this could be in the participant's home, in an office or another mutually convenient location. A quiet location is preferable to promote confidentiality, enable the researcher and participant to concentrate on the conversation, and to facilitate accurate audio-recording of the interview. For interviews using digital methods the same principles apply: a quiet, private space where the researcher and participant feel comfortable and confident to participate in an interview.

Box 1: Example of a topic guide

Study focus: Parents' experiences of brushing their child's (aged 0–5) teeth

1. Can you tell me about your experience of cleaning your child's teeth?

How old was your child when you started cleaning their teeth?

Why did you start cleaning their teeth at that point?

How often do you brush their teeth?

What do you use to brush their teeth and why?

2. Could you explain how you find cleaning your child's teeth?

Do you find anything difficult?

What makes cleaning their teeth easier for you?

3. How has your experience of cleaning your child's teeth changed over time?

Has it become easier or harder?

Have you changed how often and how you clean their teeth? If so, why?

4. Could you describe how your child finds having their teeth cleaned?

What do they enjoy about having their teeth cleaned?

Is there anything they find upsetting about having their teeth cleaned?

5. Where do you look for information/advice about cleaning your child's teeth?

What did your health visitor tell you about cleaning your child's teeth? (If anything)

What has the dentist told you about caring for your child's teeth? (If visited)

Have any family members given you advice about how to clean your child's teeth? If so, what did they tell you? Did you follow their advice?

6. Is there anything else you would like to discuss about this?

Focus groups

A focus group is a moderated group discussion on a pre-defined topic, for research purposes. 28 , 29 While not aligned to a particular qualitative methodology (for example, grounded theory or phenomenology) as such, focus groups are used increasingly in healthcare research, as they are useful for exploring collective perspectives, attitudes, behaviours and experiences. Consequently, they can yield rich, in-depth data and illuminate agreement and inconsistencies 28 within and, where appropriate, between groups. Examples include public perceptions of dental implants and subsequent impact on help-seeking and decision making, 30 and general dental practitioners' views on patient safety in dentistry. 31

Focus groups can be used alone or in conjunction with other methods, such as interviews or observations, and can therefore help to confirm, extend or enrich understanding and provide alternative insights. 28 The social interaction between participants often results in lively discussion and can therefore facilitate the collection of rich, meaningful data. However, they are complex to organise and manage, due to the number of participants, and may also be inappropriate for exploring particularly sensitive issues that many participants may feel uncomfortable about discussing in a group environment.

Focus groups are primarily undertaken face-to-face but can now also be undertaken online, using appropriate technologies such as email, bulletin boards, online research communities, chat rooms, discussion forums, social media and video conferencing. 32 Using such technologies, data collection can also be synchronous (for example, online discussions in 'real time') or, unlike traditional face-to-face focus groups, asynchronous (for example, online/email discussions in 'non-real time'). While many of the fundamental principles of focus group research are the same, regardless of how they are conducted, a number of subtle nuances are associated with the online medium. 32 Some of which are discussed further in the following sections.

Focus group considerations

Some key considerations associated with face-to-face focus groups are: how many participants are required; should participants within each group know each other (or not) and how many focus groups are needed within a single study? These issues are much debated and there is no definitive answer. However, the number of focus groups required will largely depend on the topic area, the depth and breadth of data needed, the desired level of participation required 29 and the necessity (or not) for data saturation.

The optimum group size is around six to eight participants (excluding researchers) but can work effectively with between three and 14 participants. 3 If the group is too small, it may limit discussion, but if it is too large, it may become disorganised and difficult to manage. It is, however, prudent to over-recruit for a focus group by approximately two to three participants, to allow for potential non-attenders. For many researchers, particularly novice researchers, group size may also be informed by pragmatic considerations, such as the type of study, resources available and moderator experience. 28 Similar size and mix considerations exist for online focus groups. Typically, synchronous online focus groups will have around three to eight participants but, as the discussion does not happen simultaneously, asynchronous groups may have as many as 10–30 participants. 33

The topic area and potential group interaction should guide group composition considerations. Pre-existing groups, where participants know each other (for example, work colleagues) may be easier to recruit, have shared experiences and may enjoy a familiarity, which facilitates discussion and/or the ability to challenge each other courteously. 3 However, if there is a potential power imbalance within the group or if existing group norms and hierarchies may adversely affect the ability of participants to speak freely, then 'stranger groups' (that is, where participants do not already know each other) may be more appropriate. 34 , 35

Focus group management

Face-to-face focus groups should normally be conducted by two researchers; a moderator and an observer. 28 The moderator facilitates group discussion, while the observer typically monitors group dynamics, behaviours, non-verbal cues, seating arrangements and speaking order, which is essential for transcription and analysis. The same principles of informed consent, as discussed in the interview section, also apply to focus groups, regardless of medium. However, the consent process for online discussions will probably be managed somewhat differently. For example, while an appropriate participant information leaflet (and consent form) would still be required, the process is likely to be managed electronically (for example, via email) and would need to specifically address issues relating to technology (for example, anonymity and use, storage and access to online data). 32

The venue in which a face to face focus group is conducted should be of a suitable size, private, quiet, free from distractions and in a collectively convenient location. It should also be conducted at a time appropriate for participants, 28 as this is likely to promote attendance. As with interviews, the same ethical considerations apply (as discussed earlier). However, online focus groups may present additional ethical challenges associated with issues such as informed consent, appropriate access and secure data storage. Further guidance can be found elsewhere. 8 , 32

Before the focus group commences, the researchers should establish rapport with participants, as this will help to put them at ease and result in a more meaningful discussion. Consequently, researchers should introduce themselves, provide further clarity about the study and how the process will work in practice and outline the 'ground rules'. Ground rules are designed to assist, not hinder, group discussion and typically include: 3 , 28 , 29

Discussions within the group are confidential to the group

Only one person can speak at a time

All participants should have sufficient opportunity to contribute

There should be no unnecessary interruptions while someone is speaking

Everyone can be expected to be listened to and their views respected

Challenging contrary opinions is appropriate, but ridiculing is not.

Moderating a focus group requires considered management and good interpersonal skills to help guide the discussion and, where appropriate, keep it sufficiently focused. Avoid, therefore, participating, leading, expressing personal opinions or correcting participants' knowledge 3 , 28 as this may bias the process. A relaxed, interested demeanour will also help participants to feel comfortable and promote candid discourse. Moderators should also prevent the discussion being dominated by any one person, ensure differences of opinions are discussed fairly and, if required, encourage reticent participants to contribute. 3 Asking open questions, reflecting on significant issues, inviting further debate, probing responses accordingly, and seeking further clarification, as and where appropriate, will help to obtain sufficient depth and insight into the topic area.

Moderating online focus groups requires comparable skills, particularly if the discussion is synchronous, as the discussion may be dominated by those who can type proficiently. 36 It is therefore important that sufficient time and respect is accorded to those who may not be able to type as quickly. Asynchronous discussions are usually less problematic in this respect, as interactions are less instant. However, moderating an asynchronous discussion presents additional challenges, particularly if participants are geographically dispersed, as they may be online at different times. Consequently, the moderator will not always be present and the discussion may therefore need to occur over several days, which can be difficult to manage and facilitate and invariably requires considerable flexibility. 32 It is also worth recognising that establishing rapport with participants via online medium is often more challenging than via face-to-face and may therefore require additional time, skills, effort and consideration.

As with research interviews, focus groups should be guided by an appropriate interview schedule, as discussed earlier in the paper. For example, the schedule will usually be informed by the review of the literature and study aims, and will merely provide a topic guide to help inform subsequent discussions. To provide a verbatim account of the discussion, focus groups must be recorded, using an audio-recorder with a good quality multi-directional microphone. While videotaping is possible, some participants may find it obtrusive, 3 which may adversely affect group dynamics. The use (or not) of a video recorder, should therefore be carefully considered.

At the end of the focus group, a few minutes should be spent rounding up and reflecting on the discussion. 28 Depending on the topic area, it is possible that some participants may have revealed deeply personal issues and may therefore require further help and support, such as a constructive debrief or possibly even referral on to a relevant third party. It is also possible that some participants may feel that the discussion did not adequately reflect their views and, consequently, may no longer wish to be associated with the study. 28 Such occurrences are likely to be uncommon, but should they arise, it is important to further discuss any concerns and, if appropriate, offer them the opportunity to withdraw (including any data relating to them) from the study. Immediately after the discussion, researchers should compile notes regarding thoughts and ideas about the focus group, which can assist with data analysis and, if appropriate, any further data collection.

Qualitative research is increasingly being utilised within dental research to explore the experiences, perspectives, motivations and beliefs of participants. The contributions of qualitative research to evidence-based practice are increasingly being recognised, both as standalone research and as part of larger mixed-method studies, including clinical trials. Interviews and focus groups remain commonly used data collection methods in qualitative research, and with the advent of digital technologies, their utilisation continues to evolve. However, digital methods of qualitative data collection present additional methodological, ethical and practical considerations, but also potentially offer considerable flexibility to participants and researchers. Consequently, regardless of format, qualitative methods have significant potential to inform important areas of dental practice, policy and further related research.

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Gill, P., Baillie, J. Interviews and focus groups in qualitative research: an update for the digital age. Br Dent J 225 , 668–672 (2018). https://doi.org/10.1038/sj.bdj.2018.815

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Accepted : 02 July 2018

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Issue Date : 12 October 2018

DOI : https://doi.org/10.1038/sj.bdj.2018.815

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Qualitative Research: Introducing focus groups

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• a Glasgow University Media Group, Department of Sociology, University of Glasgow, Glasgow G12 8LF

This paper introduces focus group methodology, gives advice on group composition, running the groups, and analysing the results. Focus groups have advantages for researchers in the field of health and medicine: they do not discriminate against people who cannot read or write and they can encourage participation from people reluctant to be interviewed on their own or who feel they have nothing to say.

This is the fifth in a series of seven articles describing non-quantitative techniques and showing their value in health research

**FIGURE OMITTED**

Rationale and uses of focus groups

Focus groups are a form of group interview that capitalises on communication between research participants in order to generate data. Although group interviews are often used simply as a quick and convenient way to collect data from several people simultaneously, focus groups explicitly use group interaction as part of the method. This means that instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another: asking questions, exchanging anecdotes and commenting on each other's experiences and points of view. 1 The method is particularly useful for exploring people's knowledge and experiences and can be used to examine not only what people think but how they think and why they think that way.

Focus groups were originally used within communication studies to explore the effects of films and television programmes, 2 and are a popular method for assessing health education messages and examining public understandings of illness and of health behaviours. 3 4 5 6 7 They are widely used to examine people's experiences of disease and of health services. 8 9 and are an effective technique for exploring the attitudes and needs of staff. 10 11

The idea behind the focus group method is that group processes can help people to explore and …

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Home » Focus Groups – Steps, Examples and Guide

Focus Groups – Steps, Examples and Guide

Table of Contents

Focus Group

Definition:

A focus group is a qualitative research method used to gather in-depth insights and opinions from a group of individuals about a particular product, service, concept, or idea.

The focus group typically consists of 6-10 participants who are selected based on shared characteristics such as demographics, interests, or experiences. The discussion is moderated by a trained facilitator who asks open-ended questions to encourage participants to share their thoughts, feelings, and attitudes towards the topic.

Focus groups are an effective way to gather detailed information about consumer behavior, attitudes, and perceptions, and can provide valuable insights to inform decision-making in a range of fields including marketing, product development, and public policy.

Types of Focus Group

The following are some types or methods of Focus Groups:

Traditional Focus Group

This is the most common type of focus group, where a small group of people is brought together to discuss a particular topic. The discussion is typically led by a skilled facilitator who asks open-ended questions to encourage participants to share their thoughts and opinions.

Mini Focus Group

A mini-focus group involves a smaller group of participants, typically 3 to 5 people. This type of focus group is useful when the topic being discussed is particularly sensitive or when the participants are difficult to recruit.

Dual Moderator Focus Group

In a dual-moderator focus group, two facilitators are used to manage the discussion. This can help to ensure that the discussion stays on track and that all participants have an opportunity to share their opinions.

Teleconference or Online Focus Group

Teleconferences or online focus groups are conducted using video conferencing technology or online discussion forums. This allows participants to join the discussion from anywhere in the world, making it easier to recruit participants and reducing the cost of conducting the focus group.

Client-led Focus Group

In a client-led focus group, the client who is commissioning the research takes an active role in the discussion. This type of focus group is useful when the client has specific questions they want to ask or when they want to gain a deeper understanding of their customers.

The following Table can explain Focus Group types more clearly

How To Conduct a Focus Group

To conduct a focus group, follow these general steps:

Define the Research Question

Identify the key research question or objective that you want to explore through the focus group. Develop a discussion guide that outlines the topics and questions you want to cover during the session.

Recruit Participants

Identify the target audience for the focus group and recruit participants who meet the eligibility criteria. You can use various recruitment methods such as social media, online panels, or referrals from existing customers.

Select a Venue

Choose a location that is convenient for the participants and has the necessary facilities such as audio-visual equipment, seating, and refreshments.

Conduct the Session

During the focus group session, introduce the topic, and review the objectives of the research. Encourage participants to share their thoughts and opinions by asking open-ended questions and probing deeper into their responses. Ensure that the discussion remains on topic and that all participants have an opportunity to contribute.

Record the Session

Use audio or video recording equipment to capture the discussion. Note-taking is also essential to ensure that you capture all key points and insights.

Analyze the data

Once the focus group is complete, transcribe and analyze the data. Look for common themes, patterns, and insights that emerge from the discussion. Use this information to generate insights and recommendations that can be applied to the research question.

When to use Focus Group Method

The focus group method is typically used in the following situations:

Exploratory Research

When a researcher wants to explore a new or complex topic in-depth, focus groups can be used to generate ideas, opinions, and insights.

Product Development

Focus groups are often used to gather feedback from consumers about new products or product features to help identify potential areas for improvement.

Marketing Research

Focus groups can be used to test marketing concepts, messaging, or advertising campaigns to determine their effectiveness and appeal to different target audiences.

Customer Feedback

Focus groups can be used to gather feedback from customers about their experiences with a particular product or service, helping companies improve customer satisfaction and loyalty.

Public Policy Research

Focus groups can be used to gather public opinions and attitudes on social or political issues, helping policymakers make more informed decisions.

Examples of Focus Group

Here are some real-time examples of focus groups:

• A tech company wants to improve the user experience of their mobile app. They conduct a focus group with a diverse group of users to gather feedback on the app’s design, functionality, and features. The focus group consists of 8 participants who are selected based on their age, gender, ethnicity, and level of experience with the app. During the session, a trained facilitator asks open-ended questions to encourage participants to share their thoughts and opinions on the app. The facilitator also observes the participants’ behavior and reactions to the app’s features. After the focus group, the data is analyzed to identify common themes and issues raised by the participants. The insights gathered from the focus group are used to inform improvements to the app’s design and functionality, with the goal of creating a more user-friendly and engaging experience for all users.
• A car manufacturer wants to develop a new electric vehicle that appeals to a younger demographic. They conduct a focus group with millennials to gather their opinions on the design, features, and pricing of the vehicle.
• A political campaign team wants to develop effective messaging for their candidate’s campaign. They conduct a focus group with voters to gather their opinions on key issues and identify the most persuasive arguments and messages.
• A restaurant chain wants to develop a new menu that appeals to health-conscious customers. They conduct a focus group with fitness enthusiasts to gather their opinions on the types of food and drinks that they would like to see on the menu.
• A healthcare organization wants to develop a new wellness program for their employees. They conduct a focus group with employees to gather their opinions on the types of programs, incentives, and support that would be most effective in promoting healthy behaviors.
• A clothing retailer wants to develop a new line of sustainable and eco-friendly clothing. They conduct a focus group with environmentally conscious consumers to gather their opinions on the design, materials, and pricing of the clothing.

Purpose of Focus Group

The key objectives of a focus group include:

Generating New Ideas and insights

Focus groups are used to explore new or complex topics in-depth, generating new ideas and insights that may not have been previously considered.

Understanding Consumer Behavior

Focus groups can be used to gather information on consumer behavior, attitudes, and perceptions to inform marketing and product development strategies.

Testing Concepts and Ideas

Focus groups can be used to test marketing concepts, messaging, or product prototypes to determine their effectiveness and appeal to different target audiences.

Gathering Customer Feedback

Informing decision-making.

Focus groups can provide valuable insights to inform decision-making in a range of fields including marketing, product development, and public policy.

Advantages of Focus Group

The advantages of using focus groups are:

• In-depth insights: Focus groups provide in-depth insights into the attitudes, opinions, and behaviors of a target audience on a specific topic, allowing researchers to gain a deeper understanding of the issues being explored.
• Group dynamics: The group dynamics of focus groups can provide additional insights, as participants may build on each other’s ideas, share experiences, and debate different perspectives.
• Efficient data collection: Focus groups are an efficient way to collect data from multiple individuals at the same time, making them a cost-effective method of research.
• Flexibility : Focus groups can be adapted to suit a range of research objectives, from exploratory research to concept testing and customer feedback.
• Real-time feedback: Focus groups provide real-time feedback on new products or concepts, allowing researchers to make immediate adjustments and improvements based on participant feedback.
• Participant engagement: Focus groups can be a more engaging and interactive research method than surveys or other quantitative methods, as participants have the opportunity to express their opinions and interact with other participants.

Limitations of Focus Groups

While focus groups can provide valuable insights, there are also some limitations to using them.

• Small sample size: Focus groups typically involve a small number of participants, which may not be representative of the broader population being studied.
• Group dynamics : While group dynamics can be an advantage of focus groups, they can also be a limitation, as dominant personalities may sway the discussion or participants may not feel comfortable expressing their true opinions.
• Limited generalizability : Because focus groups involve a small sample size, the results may not be generalizable to the broader population.
• Limited depth of responses: Because focus groups are time-limited, participants may not have the opportunity to fully explore or elaborate on their opinions or experiences.
• Potential for bias: The facilitator of a focus group may inadvertently influence the discussion or the selection of participants may not be representative, leading to potential bias in the results.
• Difficulty in analysis : The qualitative data collected in focus groups can be difficult to analyze, as it is often subjective and requires a skilled researcher to interpret and identify themes.

Characteristics of Focus Group

• Small group size: Focus groups typically involve a small number of participants, ranging from 6 to 12 people. This allows for a more in-depth and focused discussion.
• Targeted participants: Participants in focus groups are selected based on specific criteria, such as age, gender, or experience with a particular product or service.
• Facilitated discussion: A skilled facilitator leads the discussion, asking open-ended questions and encouraging participants to share their thoughts and experiences.
• I nteractive and conversational: Focus groups are interactive and conversational, with participants building on each other’s ideas and responding to one another’s opinions.
• Qualitative data: The data collected in focus groups is qualitative, providing detailed insights into participants’ attitudes, opinions, and behaviors.
• Non-threatening environment: Participants are encouraged to share their thoughts and experiences in a non-threatening and supportive environment.
• Limited time frame: Focus groups are typically time-limited, lasting between 1 and 2 hours, to ensure that the discussion stays focused and productive.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Qualitative study design: Focus groups

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Focus Groups

Focus groups bring individuals from the study population together in a specific setting in order to discuss an issue as a group. The discussion generates research data.

Focus groups typically have these features:

• Four to ten participants meeting for up to two hours
• A facilitator or facilitators to guide discussion using open-ended questions
• An emphasis on the group talking among itself rather than to the facilitator
• Discussion is recorded and then transcribed for analysis by researchers

Researchers conduct several individual focus group meetings to produce a series. The number of focus groups in the series depends on the study’s aim, methods and resources.

Focus groups use a group setting to generate data different to that obtained in a one-to-one interview. The group context may allow for better examination of beliefs, attitudes, values, perspectives, knowledge and ideas.

Focus groups can be useful in action research methodology and other study designs which seek to empower research participants. Focus groups are also useful in multimethod studies utilising different forms of data collection.

• Quick way to collect data from several people 
• Produces data unique to group setting (e.g. teasing, arguing and non-verbal behaviour) due to the interaction between participants. This is a unique feature of focus groups. 
• Unlike written questionnaires, focus groups don’t rely on participant literacy to generate data 
• Can encourage participation from marginalised groups 
• Can facilitate discussion of stigmatised or counter-cultural topics due to feeling of mutual support among focus group participants 
• Can generate more critical comments than individual interviews. This is valuable for research aimed at improving products or services. 
• Can be used to validate findings from quantitative research methods by providing a deeper understanding that statistics cannot.

Limitations

• Individual perspectives that dissent from the focus group’s majority may remain hidden due to overriding behavioural or cultural norms, or a desire to be seen as conforming. 
• Confidentiality of individual responses is compromised due to the existence of the group 
• Only applicable when the population of interest has shared social and cultural experience or share common areas of concern. 
• Group discussion does not provide enough depth for researchers to understand experiences, especially in comparison to in-depth interviews. 
• Data is representative of the range of views in a population, not the prevalence of such views. 
• The facilitator has a strong effect on the focus groups behaviour and can therefore influence the extent to which issues or views are explored. 
• Data analysis is usually very time consuming due to the quantity produced.

Example questions

• What are the experiences, needs and wishes of mothers who received midwifery care at tertiary hospitals in Victoria, Australia?
• How useful is the patient perspective for the creation of an information information booklet for patients with liver cancer?
• What factors influence nursing students' development of end-of-life communication skills?

Example studies

Harrison, M., Ryan, T., Gardiner, C., & Jones, A. (2017). Psychological and emotional needs, assessment, and support post-stroke: a multi-perspective qualitative study . Top Stroke Rehabil, 24 (2), 119-125. doi: 10.1080/10749357.2016.1196908

Shilubane, H. N., Ruiter, R. A., Bos, A. E., Reddy, P. S., & van den Borne, B. (2014). High school students' knowledge and experience with a peer who committed or attempted suicide: a focus group study . BMC Public Health, 14 , 1081. doi: 10.1186/1471-2458-14-1081

Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. (2012). The meaning of "aging in place" to older people . Gerontologist , 52(3), 357-366. doi: 10.1093/geront/gnr098 

Kitzinger, J. (1995). Qualitative research: introducing focus groups . BMJ, 311 (7000), 299. doi: 10.1136/bmj.311.7000.299 

Rice, P. L., & Ezzy, D. (1999). Qualitative research methods: a health focus . South Melbourne, Australia: Oxford University Press.  

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The definitive guide to focus groups.

15 min read Interested in focus groups but not sure where to start? Use our definitive guide to grasp the essentials and learn how you can leverage focus groups to better know your audience.

Written by : Will Webster

Fact Checked by : Karen Goldstein

What is a focus group?

Focus groups are a type of qualitative research that bring together a small group of people representing a target audience. In a conversation usually guided by a moderator, this group will discuss a specific topic, products, services or concepts in a controlled environment.

The purpose of focus groups is to have a relaxed, open-ended conversation to gain insights that may not be possible from a survey or individual interview. They’re a very valuable tool in the research toolkit.

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Focus group roles

In any focus group there are typically three main roles being played.

When should a focus group be used?

Focus groups are a very popular type of research method that’s used in virtually every sector, from tech to academia, and marketing to political science.

Focus groups are a great choice if you want to go deep into a particular topic. If surveys are a brilliant tool for understanding what someone feels about something, focus groups help us to explore why – which is why the two work great in tandem. Focus groups give us an opportunity to capture the human element – the emotions and non-verbal cues that numbers often miss – and help us to explore underlying motivations.

Here are some of the most common focus group use cases.

New product or concept testing

If you’ve got a new product or concept in the works, a focus group can provide valuable feedback before you launch it into the market. You can get a sense of how people might react to it, what they like or dislike, and any improvements they might suggest.

In fact, focus groups are often used by brands to improve on and even co-create products in real time, with concepts discussed and iterated over the course of the session.

Understanding customers better

Focus groups are a great market research tool to help you better understand why customers think and behave the way they do. If, for example, a product isn’t selling as expected, a focus group with your customers can shine light on their barriers to purchase.

Beyond current customers, businesses can also use focus groups to better understand new prospects and bring their target customer segments to life.

Marketing and advertising

Before you invest a lot of money into a marketing or advertising campaign, you could use a focus group to test your messaging and visuals. Once any tweaks are made, you should be left with a campaign that will better resonate with your target audience.

Exploratory research

Focus groups are great when you don’t know what you don’t know. If you’re entering a new market or targeting a new customer segment, they can help you explore and understand the landscape.

When quantitative data isn’t enough

Sometimes, numbers and stats don’t tell the whole story. If you have quantitative data but want to delve deeper into the ‘why’ and ‘how’, focus groups are a great way to do that.

Focus groups can provide rich, qualitative insights that quantitative research methods might miss. But it’s important to remember that they aren’t right for every situation.

If you need to make definitive conclusions about a large population, a quantitative survey will be a better option. The same applies if you’re focusing on sensitive topics that people may not feel comfortable discussing in a group setting, such as financial or health matters.

At the end of the day, the best research method for your use case really depends on your specific goals, who you’re collecting insights from and the nature of the information you’re seeking.

Types of focus groups

Focus groups can take different forms depending on the objectives of the study, the participants, and the nature of the topic being discussed. Ranging from the common to the seldom used, here are the different types of focus group methods.

One-way focus groups

The classic focus group format: a moderator leads a discussion among a group of participants about a particular topic.

Two-way focus groups

Here one group watches another , observing the discussion, interactions and conclusions. This format is used to provide additional insights and a deeper understanding of the topic.

Dual-moderator focus groups

A focus group with two moderators. One ensures the session runs along smoothly; the other makes sure all topics are covered. The aim of this format is to create a more comprehensive discussion.

Dueling-moderator focus groups

Like dual moderator focus groups in that there are two moderators, but here the moderators take opposing viewpoints on the topic. The purpose of this format is to help the participants consider and discuss a wider range of points.

Respondent-moderator focus groups

Where one respondent – or several – plays the role of moderator. This format counters the unintentional bias that can come from a single moderator, and encourages variety in the discussion,

Mini focus groups, dyads and triads

Exactly as they sound, mini focus groups involve fewer participants than usual. These smaller groups – typically made up of 4 to 5 participants – are well suited to complex topics.

There are also focus groups involving two participants and a moderator – known as dyads – and groups with three participants and a moderator, which are known as triads.

Remote focus groups

An online focus group. This format is a great way to give your research a wider geographical reach and access a greater pool of people.

How to run a focus group: Step-by-step guide

The focus groups that generate the best insights are often those that are planned best. Here’s our guide for every step of the process.

1. Research and define your goal

The first step is to identify what you want to learn from the focus group. Are you testing a new product or exploring consumer behavior? Maybe you’re seeking feedback on a marketing campaign or getting to know a new target market?

2. Choose a moderator

If planning is the key ingredient for a great focus group, a good moderator is a close second.

The moderator is the most important person in the room, and needs to be someone who can facilitate discussions, manage a group of strangers, and keep the conversation on track and be able to elicit the feedback desired..

3. Choose a location

The most important consideration here is how you create a comfortable, non-judgmental environment where participants feel safe to share their thoughts and opinions.

And you also need to answer the big question: in-person or online? In-person sessions typically enable better conversation and group chemistry, while online focus groups give you access to a much bigger, broader pool of potential participants.

4. Recruit the right participants

Next, work out who you need to participate in the focus group to reach your goal. Whatever your target audience is, you want the respondents to meet the baseline criteria – noting that the ideal size for a focus group is typically between 6 and 8 participants, and that none of your participants should know each other.

Once you’ve worked out who you want there, you need to recruit them. This is often done via ads, invitations to your CMS database or a third party. Incentives, like cash or gift cards, are typically used to encourage participation.

5. Create a discussion guide

In tandem with step four, it’s time for the moderator to develop a document that will guide the discussion. Based on your research goal or goals, this guide should include a list of focus group questions or topics you want to cover during the session, and strike a good balance between structured and flexible – so you can gather the data you need while not discouraging spontaneous conversation.

6. Conduct the focus group

The big day has arrived. With everything in place, all you need to do is make sure that every participant is given an opportunity to speak.

Don’t forget to record the focus group (with the participants’ consent) and make efforts to capture non-verbal cues from participants.

7. Debrief and iterate

Debrief after each session to understand your key findings, and if necessary, edit the discussion guide for future focus groups based on your learnings and observations so far.

8. Analyse and report on the findings

Now’s time to transcribe your recordings and analyse them for key themes and insights. The aim here is to interpret your findings in the context of your initial goal.

It’s best practice to present your key focus group results and findings in a report, alongside recommendations based on them.

How many people should be in a focus group?

The ideal size of a focus group is generally said to fall between 6 and 8 participants .Why is this the sweet spot? Because it’s small enough to ensure that everyone has a chance to speak and share their views, but large enough to provide a variety of perspectives.

That said, the goal of your research and the topic(s) you’re focusing on can change things. For instance, if the topic is particularly complex or sensitive, a smaller group may be better.

If you have a larger pool of potential focus group attendees, best practice would be to split them up and conduct multiple focus groups, instead of one focus group with too many people.

Focus groups vs in-depth interviews

Focus groups and in-depth interviews are two of the most popular forms of qualitative research . They do, however, differ in what they can bring to your research – which is why they’re often used in tandem to answer a single research question.

The benefits of focus groups over in-depth interviews

Focus groups are designed to encourage interaction between a collection of people, often revealing insights that may not surface in a one-on-one conversation. They give researchers an opportunity to observe group dynamics and how individuals influence each other and can be influenced themselves.

A big advantage of focus groups is their efficiency – in one session you can gather a broad range of insights from multiple individuals.

The benefits of in-depth interviews over focus groups

In-depth interviews are one-on-one discussions between a researcher and participant.

Whereas focus groups are by definition a group discussion, in-depth interviews provide a more personal and detailed exploration of an individual’s perspectives and experiences. Because of this, interviews are great for sensitive or personal topics, and the interviewee won’t be as influenced by others when giving their honest opinions – which is a risk with focus groups.

Another benefit of in-depth interviews is that the researcher/interviewer has greater control over the conversation, which gives you a greater chance of covering all topics thoroughly.

Advantages and disadvantages of focus groups

Like any research method, focus groups come with a variety of pros and cons that are typically associated with any type of qualitative research.

Advantages of focus groups

• They give you qualitative insights . Exploring the ‘why’ behind people’s behaviors, views and decisions
• They enable interactive discussions . Often leading to deeper insights as participants explore topics and ideas
• They give immediate findings . Observing real-time reactions means you can quickly implement them on a concept, product or campaign
• You can capture non-verbal data . Non-verbal cues and body language often give a further layer of insight into participants’ attitudes and feelings
• You have real-time flexibility . The moderator can steer the conversation to explore new points and topics if they arise

Disadvantages of focus groups

• Your sample size is small . And less likely to represent how the total population feels
• You’re at risk of conforming beliefs . Meaning that participants may change what they’re saying to match the majority opinion or the loudest voice
• They require a skilled moderator . Your findings could be a lot less valuable without one
• Data analysis can be time consuming . If you’re hosting multiple groups, transcribing and deciphering data can be labour-intensive and complex
• They can be expensive (especially if done in person) . You may need to pay for participant travel, accommodation and incentives, venue rent and even moderator fees

Related resources

Market intelligence 10 min read, marketing insights 11 min read.

Analysis & Reporting

Thematic Analysis 11 min read

Ethnographic research 11 min read, post event survey questions 10 min read, data saturation in qualitative research 8 min read, how to determine sample size 12 min read, request demo.

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• v.3; Jan-Dec 2016

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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Focus Groups in Qualitative Research

• By qualitasresearch

Focus Group Methodology: Harnessing Group Dynamics for Insightful Data

In qualitative research, focus groups stand out as a dynamic and powerful method for gathering rich, nuanced insights into human behaviors, attitudes, and perceptions. By bringing together a diverse group of participants in a structured discussion, focus groups leverage the dynamics of group interaction to uncover deeper understandings of complex topics. In this blog post, we explore the methodology of focus groups, highlighting their benefits, key components, and best practices for conducting insightful research.

Understanding Focus Group Methodology

Focus group methodology involves bringing together a small group of participants—typically between 6 to 12 individuals—for a facilitated discussion on a specific topic of interest. The goal of a focus group is to explore participants’ attitudes, beliefs, experiences, and perceptions in a collaborative and interactive setting. Unlike individual interviews, focus groups capitalize on the dynamics of group interaction to elicit diverse perspectives, stimulate discussion, and uncover shared meanings and experiences.

Key Components of Focus Group Methodology

• Participant Selection: Selecting participants who represent the target population and possess relevant perspectives is crucial for the success of a focus group. Researchers should consider demographic diversity, relevant experiences, and knowledge of the topic when recruiting participants.
• Moderator Facilitation: A skilled moderator plays a central role in guiding the focus group discussion, maintaining group dynamics, and ensuring that all participants have an opportunity to contribute. The moderator facilitates the discussion using a semi-structured interview guide, probing for insights and encouraging participation from all participants.
• Structured Discussion: The focus group discussion is structured around a set of predetermined topics or questions, designed to elicit insights into the research topic. The moderator guides the conversation, ensuring that each topic is explored in depth while allowing for spontaneous interactions and exchanges among participants.
• Group Interaction: The dynamic interaction among focus group participants is a key component of the methodology. Participants may build on each other’s ideas, challenge assumptions, and provide different perspectives, leading to a deeper understanding of the topic under investigation.
• Data Collection: Focus group discussions are typically audio or video recorded to capture the richness and complexity of group interactions. In addition to audio/video recordings, researchers may take notes, document nonverbal cues, and record observations to supplement the data collected.

Benefits of Focus Group Methodology

• Richness of Data: Focus groups generate rich, qualitative data that capture the complexity and diversity of participants’ perspectives. The interactive nature of focus group discussions allows researchers to uncover insights, nuances, and contradictions that may not emerge through other research methods.
• Exploration of Group Dynamics: Focus groups provide a unique opportunity to explore group dynamics and interpersonal relationships within a social context. By observing how participants interact with each other, researchers gain insights into social norms, shared values, and power dynamics that influence decision-making and behavior.
• Cost-Effectiveness: Compared to individual interviews, focus groups are often more cost-effective, as they allow researchers to gather data from multiple participants in a single session. This efficiency makes focus groups particularly valuable for exploring topics that benefit from group discussion and interaction.

Best Practices for Conducting Focus Groups

• Establish Ground Rules: Set clear ground rules for the focus group, including guidelines for respectful communication, confidentiality, and participation. Create a supportive and inclusive environment where all participants feel comfortable expressing their views.
• Maintain Balance and Control: Balance the discussion to ensure that all participants have an opportunity to contribute, while also maintaining control over the conversation to stay focused on the research objectives. Use probing questions, redirection, and facilitation techniques to guide the discussion as needed.
• Ensure Diversity: Aim for diversity in participant demographics, perspectives, and experiences to capture a range of viewpoints and insights. Consider factors such as age, gender, ethnicity, socioeconomic status, and relevant characteristics when recruiting participants.
• Transcribe and Analyze Data: Transcribe focus group recordings and analyze the data using qualitative analysis techniques such as thematic analysis, coding, and interpretation. Look for patterns, themes, and insights that emerge from the data, and use these findings to inform research conclusions and recommendations.

In conclusion, focus group methodology offers a dynamic and insightful approach to qualitative research, harnessing the dynamics of group interaction to uncover rich, nuanced insights into human behavior and perceptions. By bringing together diverse participants in a structured discussion, focus groups provide researchers with a unique opportunity to explore complex topics, understand group dynamics, and generate actionable insights that inform theory, policy, and practice.

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Qualitative research is a fact-finding method for exploring and understanding people's beliefs, attitudes, experiences, and behaviors.

It involves collecting and analyzing data for insights into complex phenomena and social issues.

Researchers take this detailed data and analyze it using techniques such as content analysis, thematic analysis, or grounded theory to identify patterns and themes in the data.

Qualitative research can inform policies, design interventions, or improve services. 

Analyze focus group sessions

Dovetail streamlines focus group research to help you understand the responses and find patterns faster

• What is a focus group?

A focus group is a qualitative fact-finding method involving a small group of five to 10 people discussing a specific topic or issue. A moderator leads the group, poses open-ended questions, and encourages participant discussion and interaction.

A focus group aims to gain insights into participants' opinions, attitudes, beliefs, and behaviors about the discussed topic. 

Marketing research, product development, and social sciences use focus groups to understand consumer behavior, attitudes, and preferences. They can also explore social issues, gather feedback on new ideas, or evaluate the effectiveness of a program or intervention.

You can conduct in-person or online focus groups and record and transcribe the sessions for analysis. You use thematic or content analysis to analyze the data and identify patterns in the participants' responses.

• Why do researchers use focus groups?

Researchers use focus groups for various reasons, primarily to gain qualitative insights and opinions from people with similar characteristics. 

Here are other reasons for focus groups:

Understand consumer behavior

Focus groups are ideal in marketing research for gathering insights into consumer preferences and behavior. Researchers can better understand what motivates their target audience, needs, wants, and what drives their purchasing decisions.

Gather feedback on new ideas

Focus groups can gather feedback on new products, services, or ideas. Researchers can present a new concept to a focus group and ask for their opinions to see how well they receive the idea. They can also learn what changes might be necessary and the potential market.

Evaluate the effectiveness of programs or interventions

Focus groups can help evaluate the effectiveness of a program or intervention. Researchers can ask participants to share their experiences and opinions to gain insights into their experience with the program. They can determine what aspects of the program work well, what could be improved, and its impact on participants.

Explore social issues

Focus groups can help explore social issues, such as attitudes toward a particular topic or the impact of a social program. Bringing together a diverse group of people can help researchers gain a more nuanced understanding of the issue and identify potential solutions or interventions.

Focus groups are a helpful tool for gaining qualitative insights and opinions from people with shared attributes. You can use these groups in different settings, and they’re handy for exploring complex issues that require in-depth understanding.

When should you use a focus group?

Here are some situations where a focus group might be appropriate:

If you’re launching a new product or service and want to gather feedback on your concept, features, and branding

To better understand your target audience's behavior, attitudes, and partiality by helping you identify patterns and trends in their decision-making

When you want to evaluate the effectiveness of a program or intervention by understanding the participant's experiences and opinions

If you want to develop effective marketing strategies with insights into what resonates with your target audience

When you want to explore social issues, such as the impact of a social program, and gain a deeper understanding of the issue at hand

Focus groups are less useful for situations where you need quantitative data or a representative sample of the broader population. It's essential to carefully plan your focus group, including selecting willing participants, choosing a moderator, and developing a discussion guide to achieve your research goals.

• 7 examples of focus groups

Researchers can use focus groups in different settings to gather feedback and opinions on products, services, or topics. Here are some examples of focus groups:

1. Product testing

Marketers can use a focus group to test a new product. For example, a company plans to launch a new line of skincare products and wants to get feedback from potential customers before the launch. The company organizes focus groups with participants who match their target market demographic and supplies a moderator with a discussion guide.

The moderator asks the focus group participants to try the products and provide feedback on the product's packaging, scent, texture, effectiveness, and overall appeal. 

They question participants about their current skincare routine, what products they use, and what they look for in skincare products.

The company changes the product packaging, ingredients, and pricing based on feedback. This ensures the product meets the needs and preferences of the target market. 

Now, the company can launch the new skincare line with confidence that its target market will love the product.

2. Advertising campaigns

Focus groups can test the success of advertising campaigns. Participants provide feedback on the ad's messaging, visuals, and tone, helping a company refine the campaign before launch.

For example, a brand organizes a focus group with participants who match their target demographic before launching their new advertising campaign.

If the focus group participants find the ad's message too complicated or unclear, the company can simplify the message based on feedback. This makes the ad more attractive and digestible for its target audience.

3. Political campaigns

Political participants can use focus groups to gather information about: 

What issues are most important to voters

How voters feel about the candidate and their message

How the candidate can improve their message and campaign strategy

For example, a political campaign might convene a focus group of voters from a particular demographic, such as suburban women or young adults. 

The leader might ask the focus group questions about their feelings and attitudes towards the candidate, the issues they care about most, and how they perceive the candidate's stance.

4. Market research

Marketers can use focus groups to gather information about consumers' likes and dislikes about a particular product or service. They can use this information to guide product development, marketing, and advertising strategies.

For example, a company forms a focus group to gather feedback on a new product concept, such as a new type of food packaging. 

The moderator asks the focus group questions about their perceptions of the product, the likelihood of purchasing it, and any suggestions they have for improving it. 

5. Product development

Focus groups can gather qualitative data from potential users or customers to understand their needs, preferences, and experiences with the product.

Companies can use focus groups at different stages, from the initial concept development to the testing and refinement of prototypes. 

For example, a business gathers a focus group to provide feedback on a new music streaming service app, and participants answer questions about: 

Their experiences with their current music streaming experiences

Preferences for layout

Impressions of the new streaming service

Product development teams can use this feedback to ensure the product meets the needs and expectations of the target market.

6. Healthcare

Healthcare focus groups can gather feedback and insights from patients, healthcare providers, and other stakeholders. 

Healthcare providers can use focus groups to gather qualitative data on various topics, including patient experiences, healthcare delivery, policies, and products.

For example, a provider uses a focus group to gather feedback on a new healthcare policy related to access to care. Participants answer questions about their experiences accessing healthcare, opinions on the policy, and any suggestions for improvements.

7. Education

Educators can use focus groups to get insights into student experiences and preferences to improve the quality of education and student engagement. 

Focus groups can also collect feedback from teachers and parents on issues such as teaching methods, parental involvement, and student performance.

Decision-makers can use this feedback to improve curriculum development, teaching methods, school policies, and educational products to meet the needs of students and educators.

• The pros and cons of focus groups

Focus groups are a popular research method to gather feedback and opinions from small, diverse groups. While focus groups can provide valuable insights, they also have drawbacks.

Provides in-depth insights

Focus groups allow in-depth discussions and more comprehensive insights into a topic. Participants can provide detailed feedback and share their opinions, attitudes, and experiences.

Encourages group dynamics

Focus groups encourage participants to interact and discuss the topic with each other, generating new ideas and insights. Participants can build on each other's thoughts and ideas, leading to a more extensive and nuanced discussion.

Cost-effective

Conducting a focus group can be less expensive than other research methods, such as one-on-one interviews or surveys . It can be more cost-effective to gather a group in one location rather than travel to different locations to conduct individual interviews.

Can be used to test ideas

Focus groups can test new ideas, products, or services before they launch. It allows companies to gather feedback from potential customers, enabling more informed decisions.

Flexibility

Researchers can adapt focus groups to various topics and settings, from academic research to market research.

The moderator can conduct focus groups quickly, making them a valuable tool for gathering data in a short amount of time.

Small sample size

Focus groups usually involve a small number of participants. The opinions of a focus group may not represent the broader population.

Potential bias

Group dynamics can influence the opinions and attitudes of a focus group, so they may not reflect the opinions of individual participants. 

Limited scope

Focus groups may only provide insights into a specific topic or product instead of broader insights into consumer behavior or attitudes.

Time-consuming

Conducting a focus group can be time-consuming, as it requires organizing and scheduling participants, setting up a location, and analyzing the data.

Interpretation

The interpretation of focus group data can be subjective and dependent on the researcher's perspective and biases.

Researchers should use focus groups and other research methods to ensure comprehensive and accurate findings.

• How do you run a focus group?

Here are some steps to follow when running a focus group:

Before planning your focus group, define your research objectives and determine what you hope to achieve through the focus group.

Determine your target audience by categorizing them with common characteristics to provide the necessary insights.

Identify potential participants that fit your target audience, offer an incentive to encourage participation, and recruit them for the focus group. 

Select a skilled moderator to facilitate the discussion and keep it focused. The moderator should understand qualitative research techniques and have good interpersonal skills.

Develop a discussion guide outlining the questions for the focus group. The questions should elicit insights and opinions from participants on the research objectives.

Hold the focus group in a comfortable, quiet location. Introduce the moderator and explain the purpose of the focus group. The moderator should guide the discussion, asking questions from the discussion guide and encouraging participation from everyone.

Record the discussion using audio or video recording equipment. Consider taking notes during the discussion to capture critical points.

Transcribe the audio or video recording and analyze the data to identify patterns and themes. 

Use the data to draw conclusions and make recommendations based on the research objectives. Use techniques such as content analysis , thematic analysis , or grounded theory to identify patterns and themes in the data.

Prepare a report summarizing the findings of the focus group and provide recommendations based on the research objectives.

Follow these steps to conduct a successful focus group, uncover valuable insights, and achieve your research objectives.

• Five sample focus group questions

Here are some sample focus group questions that you could use in different research contexts avoiding leading questions and emphasizing open-ended questions:

1. Exploring a new product or service:

What are your first impressions of this product/service?

What do you like/dislike about the product/service?

How does this product/service compare to similar products/services?

What improvements could we make to the product/service?

2. Understanding consumer behavior:

What factors influence your decision to purchase a product/service?

How do you typically research products/services before making a purchase?

How do you feel about the pricing of products/services?

How do you use technology when shopping for products/services?

3. Evaluating the effectiveness of a program or intervention:

What do you think are the strengths of the program/intervention?

What challenges have you faced in participating in the program/intervention?

How has the program/intervention impacted your life?

What changes would you recommend to improve the program/intervention?

4. Developing marketing strategies:

What messages do you think would resonate with your target audience?

What channels do you think are most effective for reaching your target audience?

What motivates your target audience to make a purchase?

How do you think your target audience perceives your brand?

5. Exploring social issues:

What are your attitudes toward [topic]?

How has [topic] impacted your life or those you know?

What are some potential solutions to address [topic]?

What are some barriers to addressing [topic]?

These are just a few examples of questions that you could use in focus groups. Carefully design questions relevant to the research objectives that elicit meaningful participant insights.

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• Open access
• Published: 26 August 2024

Health care needs and barriers to care among the transgender population: a study from western Rajasthan

• Tanvi Kaur Ahuja 1 ,
• Akhil Dhanesh Goel 1 , 2 ,
• Manoj Kumar Gupta 1 , 2 ,
• Nitin Joshi 1 ,
• Annu Choudhary 1 ,
• Swati Suman 1 ,
• Kajal Taluja 1 ,
• Madhukar Mittal 3 ,
• Navdeep Kaur Ghuman 4 ,
• Navratan Suthar 5 &
• Pankaj Bhardwaj 1 , 2  

BMC Health Services Research volume  24 , Article number:  989 ( 2024 ) Cite this article

Metrics details

Transgender people comprise an estimated 0.3–0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. Methodology: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. Results: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual’s health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. Conclusion: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

Peer Review reports

Introduction

Universal Health Coverage (UHC) means that all people have access to quality healthcare services (service coverage) without any financial hardships (catastrophic health expenditure) [ 1 ]. To achieve UHC, National Health Policy 2017 projects to increase the government’s health expenditure to 2.5% of GDP by 2025 [ 2 ]. In alignment with this objective, the budgeted health sector spending has increased from 1.3% (2019-20) to 2.1% of GDP (2021–2022). According to National Health Accounts 2018-19, Out of Pocket Expenditure per capita (in Rupees) is 2155 [ 3 ].

Incidence of catastrophic health spending is felt at a higher rate by vulnerable communities due to gender, socio-economic position, disability status, or sexual orientation, besides other characteristics. The Transgender (TG) community is one such community whose gender expression (masculine, feminine, other) differs from their assigned sex (male, female) at birth. They can be identified as trans-man or trans-woman [ 4 ]. In the Indian context, transgender individuals identify themselves differently including Hijras, Aravanis, Kothis, Jogtas/Jogappas, and Shiv-Shakthis. For the first time, this population was included in India’s 2011 census. Reports suggest that 4.8 million Indians identified themselves in the ‘other’ category.

Recent legal and policy changes in India have significantly affected gender-diverse communities. The Transgender Persons (Protection of Rights) Bill formulated in 2014 went through changes over a period of 5 years and was finally declared an Act in 2019. The Act highlighted the need to prohibit discrimination including denial of service or unfair treatment in relation to healthcare [ 5 ]. With respect to UHC, there are evident disparities in service coverage across the transgender population [ 6 ]. Transgender persons face a disproportionate burden of certain diseases, including HIV, viral hepatitis, and other sexually transmitted infections. They also pose a higher risk for mental health issues or substance abuse. Literature also suggests that transgenders may seek gender-affirming health services apart from general healthcare services. This might involve counseling support for themselves and their family related to gender id entity or undergoing gender transitioning procedures and surgeries. Transition-related treatment may include cross-sex hormonal therapy, hair removal, and gender-affirming surgeries.

In India, there are significant disparities in the availability and accessibility of healthcare. Existing research has identified various challenges and barriers encountered by transgenders in accessing and navigating the healthcare system. These include a lack of provider expertise in transgender care, the gap in health systems delivery mechanisms, lack of culturally sensitive healthcare training, inadequate financial coverage or low socio-economic condition, and poor community health-seeking behavior [ 7 ]. Rajasthan is one of the high focus states under the National Health Mission [ 8 ]. Since Western Rajasthan is a desert area, healthcare becomes even more challenging [ 9 ]. It further causes adverse impact on the desire and ability of transgender people to access healthcare. Poor healthcare access and health outcomes among the transgender population can also be attributed to lower levels of health literacy [ 10 ]. Rajasthan is one of the states with the lowest literacy rates among the transgender population [ 11 ].

In order to improve the health of transgenders and address the barriers to healthcare, it is crucial to identify the health priorities. A growing body of research regarding the healthcare experiences of transgenders exists worldwide, but there is still a paucity of research in the Indian context. This study has been conducted with the aim of reviewing the health issues and challenges faced by them in the existing healthcare system in Western Rajasthan. Although behavioral and social factors play a pivotal role in transgender health, this research focused on health needs and healthcare system-related barriers and challenges.

Research questions:

What are the basic health needs of the transgender community?

What are the barriers they encounter in the process of obtaining healthcare services?

How are the experiences of transgender persons in healthcare facilities?

What is the level of knowledge among healthcare providers regarding health of transgender persons?

How can healthcare services be enhanced for the transgender population?

Methodology

The study was conducted in the state of Rajasthan during the year 2022.

Research Design: This study utilizes a descriptive qualitative research design to allow in-depth insight into the existing health-related needs of transgender persons, their experiences in healthcare facilities and the barriers they encounter in meeting their needs. The study was approved by the Institutional Review Board of All India Institute of Medical Sciences, Jodhpur in July 2022.

Setting: The study was conducted in a community-based organization.

Sampling and sample size: Purposive sampling was utilized for this research. Transgender people above or equal to 18 years of age residing in different geographical region of western Rajasthan were approached with the help of established Civil Service Organizations (CSO). People who responded back were included in the study.

Data collection: All recruitment and data collection procedures were completed by public health scholars trained in research under the supervision of a community medicine professor. Multi-stakeholder interviews were conducted. It includes identification of relevant stakeholders to understand facilitators and barriers of the topic of interest. The identified stakeholders included specialist healthcare providers, representatives of civil service organizations and transgender persons (target population). All the individuals who agreed to participate in the study were approached by the interviewer. They were explained the purpose of the study and an appropriate time was decided to ensure active participation. This was also done keeping in view the sensitivity of the subject matter. All the interviews and the focus group discussion were conducted face-to-face in English and translated to Hindi for participants who did not understand English. Key informant interviews ( n  = 7) of specialist healthcare providers central to providing transgender care were conducted. The specialists included of a psychiatrist, plastic surgeon, endocrinologist, gynecologist, and community medicine experts. All interviews with specialist healthcare providers had a duration of 20–30 min. Transgenders residing in different geographical region of western Rajasthan were invited for a focus group discussion (FGD). Informed consent was taken from all the study participants who agreed to participate in the study. Audio and video recordings were done for focus group discussion as well as key informant interviews. The focus group discussion lasted for 2 h. Apart from this, CSO representatives were also interviewed ( n  = 3) i.e., a nurse, social worker and the administrative head of the organization. Data was collected over a period of 2 months.

Before the focus group, socio-demographic data was recorded, including age, gender, education, and income. An FGD guide and interview schedules were prepared and used for focus group and key informant interviews, respectively. They were designed to cover information about:

Knowledge and experience on transgender issues.

Challenges in providing transgender care.

Methods for improvement of the healthcare system.

Analytic approach: Audio-recorded focus group data and key informant interviews were transcribed and translated into English by four researchers. The data obtained through key informant interviews were also transcribed. The data was analyzed manually using thematic analysis. The available data was actively and repeatedly read to familiarize and valuably orient towards the available raw data. Subsequently, codes were identified using an inductive approach i.e., they were reflective of the issues that were apparent in the data and were not dependent or guided by any existing theoretical frameworks. In the next step, themes were constructed by analyzing, combining, and comparing codes. The developed themes were such that they reflected the significance of the entire dataset. Lastly, the themes were reviewed, defined, and named, along with the identification of narratives that justify and explain all the mentioned themes. In the final stage of analysis, the identified themes from the coded data were used to construct a framework using grounded theory approach such that it accurately represents a concise picture of the data.

Ethical considerations: Confidentiality emerged as an ethical concern in this study. All transgender individuals were provided with detailed information about the purpose, procedures, potential risks, and benefits of research. Participants were ensured that their participation was voluntary, and they had the right to withdraw at any time without consequence. All data and identifying information collected during the discussion was restricted to the research team and anonymized to prevent identification of individual participants.

A total of 12 transgenders participated in the FGD. Their socio-demographic characteristics are summarized in Table  1 . All Participants in the study belonged to Rajasthan, India. Eleven out of the total 12 participants self-identified themselves as transgender woman. The mean age of transgender individuals who participated in the study was 23.8 ± 3.6. The selected cohort represented a range of educational qualifications from secondary school to post-graduation. The majority of the participants were employed, but none was employed in the government sector. More than half of the participating individuals had an income of less than INR 10,000 (66.7%) (Table  1 ).

Health needs of the transgender community

The need for regular screening of non-communicable diseases at peripheral healthcare centers was expressed by the transgender participants. Lack of accessible and/or affordable health services and social barriers contribute to anxiety and depression among them, which further leads to their inability to control the use of tobacco and alcohol. This indicates the need for mental health support tailored specifically for this population.

Healthcare provider 1 (HCP-1) “ Gender dysphoria is diagnosed in later stages of life, late adolescence, or early adulthood because individuals are not able to seek help due to a lack of knowledge on available medical options and familial pressure.”

Specifically, they expressed the need for public healthcare facilities to provide gender transitioning procedures ranging from hormone replacement therapies to sex reassignment surgeries.

Figure  1 illustrates coding tree for health needs of transgender participants.

Coding tree for health needs of transgender participants

Barriers enumerated by transgenders in accessing healthcare services were segregated into personal, healthcare system and social barriers (Table  2 ).

Personal barriers

Transgender participants revealed a lack of awareness regarding the provision of transgender identity cards being issued by the Ministry of Social Justice and Empowerment. Moreover, the growing need was identified to educate them regarding their entitlements which may have implications on health. These include but are not limited to recognition of their gender identity, provision of medical facilities for their surgical and hormonal needs, and facilitation of access in hospitals and other healthcare facilities. (Transgender Act 2019)

During a key informant interview, one of the medical practitioners highlighted the need to introduce and explain the range of medical options available to transgenders for their transition.

HCP-2 “ Internationally, I have worked in fertility clinics. Before undergoing hormonal therapies or surgeries, transgender patients usually preserve oocytes and sperms to bear children in the future. The basket of available options must be known to the community. This also improves their quality of life.”

The health outcomes of an individual are dependent on their timely health-seeking behaviors. An interview revealed that many transgenders prefer the traditional removal method of male genitals rather than conventional gender affirming surgery. This reflects multiple dimensions such as lack of awareness regarding appropriate health practitioners and discrimination by the qualified professionals. Other underlying reasons for this include the lack of public hospitals providing these services and the unaffordable costs of surgeries. A study participant has also revealed being comfortable getting the surgery done by the ‘guru’ . Moreover, the distance between their households and healthcare facility makes it inaccessible for them.

Health system barriers

Both transgender persons and healthcare providers reported a lack of knowledge of any insurance schemes specifically for transgenders or insurance coverage for the minority population under the available schemes. Their awareness regarding the inclusion of gender-specific needs such as sexual reassignment surgeries or hormonal therapies in the existing insurance schemes was limited.

The study participants also addressed the need for the inclusion of a third gender column in the patient information / outpatient cards across all the hospitals. This is in alignment with the Transgender Persons (Protection of Rights) Bill, 2019, which prohibits discrimination against them in healthcare [ 5 ]. It would also lead to a transgender-inclusive environment in the hospital and greater acceptance by other people.

TG participant 7 “ Whenever we go to the hospital, we are asked whether to write male or female. There is no option of transgender in the OPD cards.”

In India, nationally recognized identity cards are being provided by the Ministry of Social Justice and Empowerment as a step towards mainstreaming their identity. One participant revealed that recently when she visited a hospital, the authorities denied accepting the TG identity card. This incident reflects the need of generating awareness across all sectors, including healthcare, to prevent the exclusion of transgender people in society.

TG participant 8 I had fever for a few days, I went to a hospital for treatment. I gave my transgender ID card issued by the ministry. They said this is not valid.

Accessibility

Majority of the participants revealed having negative experiences in healthcare settings. They reported that they had to wait very long to access health services.

One participant complained about the long counselling procedure and time to access hormone replacement therapy. Furthermore, many qualified practitioners discourage and demotivate the use of hormones. This reluctance among medical practitioners to prescribe hormones often compels transgenders to refer to the unfiltered content on the internet, resulting in the self-administration of hormones. Since transgenders are unaware of the side effects of unregulated dosages of hormones, it can result in adverse health outcomes.

Sometimes, the health facilities with available resources are situated far away from the residence of transgenders leading to difficulty in access. In one of the key informant interviews, a medical practitioner shared her experience with a transgender patient whose vaginal canal got stenosed as a complication of post Sex Reassignment Surgery (SRS). Since the health facility was around 500 km from her hometown, she could not reach the hospital on time.

Availability

One of the most significant barriers to healthcare reported by transgenders was a dearth of healthcare providers trained to address their specific health problems. Healthcare providers also emphasized the need for training to understand the best practices for their care. Some parts of clinical training should also include the importance and impact of physician-patient communication. The use of correct pronouns should be taught to collect sufficient and accurate information on their gender identity and thus, making the hospital settings friendly for them. Additionally, awareness sessions should also be conducted for medical professionals to make them comfortable and culturally competent while dealing with this section of society.

Some participants also shared that there is a need for designated facilities in healthcare, such as separate queues in OPDs and dedicated wards or beds in hospitals. It was felt that these facilities’ absence contributed to their fear and delay in access and utilization of desired appropriate care. Due to contributory social factors, such as real or perceived stigma, it is challenging for them to accommodate within the general ward. Medical providers had contrasting views in lieu of the unavailability of designated facilities. While most believed that providing separate queues and beds for them in hospitals was essential, one of the doctors felt this would promote social exclusion.

TG participant 1 Where should we stand in hospitals? Queues made for males or females? Separate beds shall be assigned for us so that we can access the services without hesitancy or fear of discrimination . HCP-3 Providing them separate facilities for all services cannot be the ultimate solution. Will this promote equity or rather advance social exclusion? We should think about it.

Moreover, there is a lack of specialist care in hospitals that are accessible to them. There is no provision to address transgender-specific health problems at the primary healthcare level. Lack of robust referral mechanisms leading to delayed or denied care was also reported.

Affordability

Transgenders are not registered and do not have access to benefits under the insurance schemes functioning in the country. All hospitals in the country do not provide gender transition services. Those services provided by the private sector often have charges beyond their paying capacity. As a result, accessing and affording healthcare becomes a challenge for them. This is one reason that urges them to go to unqualified traditional medical practitioners for gender transitioning surgeries or ‘Dai Nirwan.’

Breast augmentation is another common procedure utilized by transgenders. One participant discussed the availability of various implant materials and how their costs vary depending on the quality. Additionally, due to financial reasons and lack of awareness, low-quality implant materials are utilized in surgeries, which increases their risk for breast cancer.

Social barriers

The non-medical factors play a crucial role in impacting health outcomes. Addressing social determinants is central to reducing existing health inequities. In this study, all the participants reported stigma and discrimination while sharing their experiences in healthcare settings. They further added that this discouraged them from utilizing available health services.

The participants reported that even the healthcare providers were uncomfortable with their presence and did not treat them like other patients.

Poor housing conditions and lack of job opportunities further push them into this vicious cycle of stigma and sickness. Transgenders have also reported experiencing psychological distress due to a lack of social support. Positive attitude and gender-supportive relationships in society can promote their well-being. The need for their inclusion in society through awareness generation by government initiatives was emphasized.

TG participant 3 We can promote family planning through condom advertisements, so why not involve transgender figures in government health awareness advertisements and campaigns .

Healthcare provider expertise in TG health

All the healthcare providers felt the need for training to improve physician-patient communication and transgender persons care. A culturally competent healthcare perspective is fundamental for treating the transgender population. Those providers who had experience with such patients were more likely to provide perspectives on their care and barriers than those who had never encountered such cases. They highlighted that very few transgender patients are registered in the hospitals of Rajasthan. This can be attributed to the stigma associated with their presence rather than assuming they do not wish to seek healthcare services.

This study sought to investigate and fill the gap in the domain of transgender healthcare. The purpose of the research was to characterize the health needs and barriers faced by transgender individuals in navigating through the health system. Previous international and Indian studies have reported a lack of transgender-sensitive care. The findings of this research corroborate this premise. There is a wide and serious gap between the population’s needs and the healthcare system’s ability to respond to these needs.

The socio-demographic profile of the participants in this study revealed that the income of the majority of the participants was below INR 10,000. This finding is in alignment with the results (70%) of a study conducted among transgenders in Vadodara, Gujarat, India [ 12 ].

The FGD gave an opportunity to the study participants to express their general and gender-specific health needs. The health needs of the participants in this study included available medical services common to the general population and certain specific transgender needs, particularly psychiatric support, hormonal therapies, and sex-reassignment surgeries. This is in accordance with the previous studies, which also identified general health problems that need to be addressed, including the high prevalence of diabetes and hypertension, substance abuse, anxiety, and depression [ 13 ].

Transgender individuals discussed a range of experiences and barriers encountered in the healthcare system in accessing the available services. The barriers were categorized at the healthcare system, social and individual levels. The system-level barriers ranged from policy issues to hospital or organizational problems. It included a lack of coverage for the transgender population in government health insurance schemes. The introduction of a comprehensive package master in the Ayushman Bharat scheme has now addressed the lack of coverage for transgenders in the existing insurance schemes. It includes the existing packages as well as specific packages for transgenders [ 14 ]. This paves the way for a new chapter in their care. The unavailability of trained healthcare providers is another major problem. In 2019, National Medical Commission (NMC) updated the medical education curriculum and added a new module on Attitude, Ethics, and Communication (AETCOM) competencies [ 15 ]. It could be used as an opportunity to introduce culturally sensitive communication training for medical professionals, especially focusing on LGBTQ + community, to advance our aim to achieve equity. In addition to the unavailability of trained doctors, the inaccessibility of healthcare facilities and unaffordability also negatively impact the people’s health. All these underlying factors contribute to their practice of getting surgeries done by traditional and untrained medical practitioners. These findings are consistent with another study conducted in India to assess the health-seeking behavior of transgender people. They also reported long waiting times in hospitals affecting their health behaviors and are confirmed to have undergone medical procedures performed by gurus or technicians [ 16 ].

The finding of concern that emerged in our study sample was the use of unprescribed hormone therapy. This finding is similar to a study conducted in Maharashtra to assess the practices related to hormonal therapy [ 17 ]. It states that participants reported going for unsupervised hormone replacement therapy due to unaffordability, lack of trained healthcare providers and prior experiences in healthcare settings [ 17 ]. In order to avail the hormonal therapy, transgender patients require to undergo psychological counseling’s for confirmation of gender dysphoria. In our study, transgender individuals felt that the psychotherapy sessions are too long, leading to a delay in the initiation of hormone replacement therapy. World Professional Association for Transgender Health (WPATH) mentioned in their Standards of Care (SOC) that any minimum number of sessions cannot be fixed and is an individualistic approach. It depends whether someone wishes to avail psychological support before, during, or throughout the transition process [ 18 ]. Gender transitioning may involve but not be limited to procedures such as hormonal therapy and sex reassignment surgeries. Moreover, there are only a few public health facilities providing gender-transition services and there is no government support in the form of subsidies to avail these services from a private hospital. The government, is however, working on extending and empaneling public and private hospitals in order to make these services accessible to the population.

This need assessment study also attempted to address the social determinants barring healthcare access. Stigma, discrimination, support from family and friends, and difficulty in seeking housing determine health and healthcare accessibility. These factors have also been highlighted by the study conducted in Vadodara, India [ 12 ]. It re-emphasizes the findings from our study that social determinants such as lack of economic and educational opportunities, rejection, and isolation from society have an impact beyond gender identity issues, rather, they pose a risk to the psychological status of the transgender population.

The health disparities and barriers to care faced by transgenders should be addressed to promote health equity and justice. Comprehensive approaches to improve access, utilization, and quality of healthcare services are currently lacking. These challenges can also be addressed at the following levels:

Individual Level.

Healthcare system Level.

Community Level.

Garima Greh facilities have been introduced as shelter homes for transgender individuals where basic amenities are being provided to them [ 19 ]. They can be utilized as launchpad sites to improve their awareness of their rights and available entitlements and medical interventions. IEC materials can be displayed at Garima Greh facilities for health promotion and modification of their health-seeking behaviors. Similar to ASHA workers who are community members working for their healthcare, volunteers can be appointed from their community. Training of these volunteers can be done (Training of Trainers) so that they can improve their health-seeking behavior, increase awareness, and aid in the overall empowerment of the community.

All hospitals and clinical settings shall provide a safe and welcoming environment for gender-diverse people [ 20 ]. The fact that their physical, mental, and cultural differences affect their behaviors must be known but, more importantly, understand these differences and assigning them value is the key. Actions can be taken to promote transgender identity across healthcare settings by displaying Information, Education and Communication (IEC) material regarding their health needs and promoting their acceptance in society – ‘This hospital is LGBTQIA + friendly.’ Transgenders can also be part of the healthcare system, whereby; they can act as resource persons and promote the inclusivity of gender-diverse individuals. Medical students shall be trained to communicate sensitively to the needs of transgenders, and doctors shall be trained in a culturally competent way to treat their gender-specific needs. To promote access and utilization of health services, specific transgender clinics are being set up across the country. All participants in the study felt this would help them to access available services without hesitancy. Separate general health camps for regular and dental check-ups can also aid in health promotion and equity. Another potential solution to promote transgender health is through digital solutions. Tele-consultation can be an effective way to address their needs as well as to protect them from social stigma and discrimination that hinder their access and utilization of available services.

According to World Health Organization (WHO), social determinants account for 30–55% of health outcomes [ 21 ]. The most effective way to address SDH is by action at the community level. General campaigns and community awareness sessions are essential to promote acceptance by the general population. Moreover, the study suggests that there is a need for awareness and sensitization of transgenders regarding the basket of medical options available for them such as techniques for fertility preservation.

In summary, the study demonstrates the health issues of transgenders and reflects upon the various factors influencing health and access to care. It urges the stakeholders to contemplate the need to safeguard the rights of transgenders by providing equitable access to the available resources.

This study is an attempt to explore health needs from beneficiary as well as service provider perspectives. Our findings are consistent with the previous literature. Findings from this study provide evidence base for future research and a helpful tool for the policymakers and advocates to better address the needs of transgender people.

The study’s major limitation was that only one focus group discussion was undertaken due to limited time and difficulty in accessing the desired population. However, one FGD allowed for exploration of issues related to transgender experiences and healthcare needs. It allowed the researchers to gather detailed narratives that might not emerge from individual interviews. Given the paucity of literature in the Western Indian context, a single focus group discussion can be valuable for informing advocacy efforts and policy reforms. Participants in the study were recruited through purposive sampling and did not differentiate between cultural identities of transgender persons; therefore, the results might vary geographically and according to the social context, thus, limiting the external validity. The health needs might vary between transgender male and female populations, but there was only one transgender male participant in our study. Additionally, the service providers’ knowledge was not directly assessed by explicitly questioning the standards of care.

Proposed framework

Based on study findings, a Gender Responsive Healthcare System Framework is designed. (Fig.  2 ) This framework illustrates and emphasizes on the need for planning, interventions, and actions at 3 levels – policy (a), health system (b), social, and individual (c) in alignment with the identified themes represented in Table  1 . The framework describes how the barriers can be addressed at these 3 levels to have a robust and gender-responsive healthcare delivery system in India.

The concept of healthcare is multi-dimensional. Combined action is required at the administrative, service provider and beneficiary level for a gender responsive healthcare system. Inclusion of the transgender population in existing health insurance schemes is central to reducing their out-of-pocket expenditure and helping them gain recognition in the society through the treatments that they wish to access. Outpatient cards in hospitals should include options of male, female and transgenders/others (gender diverse) creating a safe and welcoming environment. Existing health programs shall also target transgender population for reducing the burden of infectious diseases such as tuberculosis and non-communicable diseases. At the healthcare system level, medical professionals competent to provide transgender specific care and availability of specialists shall be ensured. A robust referral mechanism from primary healthcare centers to higher levels could ensure uninterrupted care for the transgender population. Moreover, hospitals have distinct queues, for men and women. There is a need to understand that gender is not a visibly readable or unchanging phenomenon, rather it is a social construct. Proper queue management can address not only the issues of stigma, but also make healthcare accessible to them. At an individual level, good health seeking behavior and familial support can aid in improving health outcomes. Altogether, these efforts at the policy, health system and individual level can lead to improvement in accessibility, availability, affordability and acceptability of services by the transgender people.

Gender Responsive Healthcare System Framework

This study has explored experiences of transgender people navigating through the healthcare system. These accounts have highlighted their health needs and the barriers they face in accessing care. They expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified ranging from absence of targeted policies to individual behavior. Targeted efforts and intersectoral collaboration are required for effective establishment and delivery of healthcare services.

Data availability

The data generated and reviewed are fully available in this article and its supplementary files. For any further data, Dr. Tanvi Kaur Ahuja ([email protected] could be contacted).

All relevant data analyzed during this study are included in this published article and its Supplementary Information files.

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Acknowledgements

The authors would like to acknowledge the contribution of Sambhali trust, Jodhpur and Nai Bhor Sanstha, Jaipur for helping us to get in touch with the transgender participants.

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Tanvi Kaur Ahuja, Akhil Dhanesh Goel, Manoj Kumar Gupta, Nitin Joshi, Annu Choudhary, Swati Suman, Kajal Taluja & Pankaj Bhardwaj

Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India

Akhil Dhanesh Goel, Manoj Kumar Gupta & Pankaj Bhardwaj

Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur, India

Madhukar Mittal

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, India

Navdeep Kaur Ghuman

Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, India

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T.A., A.G. Conceptualized the research study done, A.G., M.G., N.J., P.B. framed the Methodology was framed, T.A., N.K., M.M., N.S., N.G., A.C. contributed in collection of data; T.A., A.G. prepared the Original draft; T.A., A.G., S.S., K.T. Reviewed and edited the manuscript; P.B. M.G., N.J. Supervised the research study, All authors have read and agreed to the published version of the manuscript.

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Correspondence to Tanvi Kaur Ahuja or Akhil Dhanesh Goel .

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Ahuja, T.K., Goel, A.D., Gupta, M.K. et al. Health care needs and barriers to care among the transgender population: a study from western Rajasthan. BMC Health Serv Res 24 , 989 (2024). https://doi.org/10.1186/s12913-024-11010-2

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Received : 29 May 2023

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Published : 26 August 2024

DOI : https://doi.org/10.1186/s12913-024-11010-2

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