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Use of focus groups for the environmental health researcher.


Qualitative research techniques are under-utilized by environmental health researchers; yet, when used properly, these methods can provide an incomparably rich source of data that are essential for rounding out a researcher's understanding of complex phenomena. The challenge is that most environmental researchers, who may be formally trained in the laboratory sciences, are generally unfamiliar with the rules of evidence associated with qualitative techniques. Without training or experience, researchers may not understand the conditions under which it is appropriate to use qualitative methods and as a result may be reluctant to use them.

Qualitative research techniques have been a mainstay in the social sciences for almost half a century. In the social sciences, where the phenomena under study must inherently include some degree of self-reported data, methodological researchers have been able to refine their techniques to yield valid data collected in reliable ways (Harding & Gantley, 1998). The key has been in emphasizing interpretation (Ezzy, 2001)--how researchers should utilize findings from qualitative methods to complement data from other, more quantitative techniques. The power of qualitative methods is that they help the researcher explore the "how" and the "why" of a phenomenon, while quantitative methods rely on "how much" or "how many" questions (Power, 2002). Several of the more popular qualitative research methods include ethnographic observation, semistructured interviews, in-depth interviews, group interviews, and focus groups. Focus groups, in particular, can be especially useful for the environmental health researcher. The purposes of this paper are a) to describe the value that focus groups may have for the environmental health researcher and b) to provide information and resources for their conduct.

Focus Groups Defined

A focus group, as the name implies, consists of volunteers gathered together to be interviewed as a group, with the discussion concentrating on a particular issue or topic (the "focus"). The investigator, who has a specific research agenda, uses the responses from the group interview as data (Morgan, 1996). Market researchers in the 1950s recognized that many consumer decisions resulted from group discussions and that the use of group interview settings would help more adeptly generate information about consumer practices (Higginbotham & Cox, 1979; Patton, 2002). The social sciences, especially sociology, saw the advantage of the focus group methodology for exploring a wide range of issues beyond consumer markets (Morgan, 1996). Since their expansion into academic research, focus groups have been incorporated into a wide variety of public health and medical research areas such as HIV/AIDS (Brimlow, Ross, & Rankin, 2000; Oliva, Rienks, & McDermid, 1999; Palmer, Boardman, & Bauchner, 1996; Ramirez, Gossett, Ginsburg, Taylor, & Slap, 2000; van Wissen & Woodman, 1994), smoking cessation (Anderson, 2002; Hotham, Atkinson, & Gilbert, 2002; Kinoshita et al., 2002; Plano Clark et al., 2002; Woods et al., 2002), cancer prevention and treatment (Bener et al., 2002; Dunwoody, Smyth, & Davidson, 2002; Horowitz, Siriphant, Canto, & Child, 2002; Lantz, Dupuis, Reding, Krauska, & Lappe, 1994), and pain management (Carter, Lambrenos, & Thursfield, 2002; Cottrell et al., 2002; Mortimer, Steedman, McMillan, Martin, & Ravey, 2002; Strickland, Jackson, Gilead, McGuire, & Quarles, 2001).

Uses of Focus Groups for the Environmental Health Researcher

Focus group methods can be used by environmental health researchers at a number of points in the research enterprise, from planning studies to assessing quality during implementation to deciphering the meaning of quantitative results. For example, one of the limitations of large-scale, epidemiological studies is that answers to questions must be standardized to support meaningful reporting. Large-scale surveys use "closed-ended" questions to make answers quantifiable. Closed-ended questions are questions that can be answered by a respondent with a fixed set of response options such as "yes/no" or "agree/disagree." Focus groups can be used during the planning phase of a study to be sure that respondents interpret the closed-ended questions in predictable ways (Sudman, Bradburn, & Schwarz, 1996). During the analysis phase, focus groups can be convened to provide context and meaning to otherwise meaningless statistical trends. Focus groups can also provide a data check at the end of a long study so that researchers can be sure that the implied meaning of a question has not changed over time.

In this review, the authors discuss four possible uses of focus groups in environmental health research:

1. planning and implementation phases of studies;

2. identifying risk perceptions among targeted populations;

3. development of programs and policies, social campaigns, and strategies for limiting exposures; and

4. focusing directions for further research (especially in situations in which there is not a concrete explanation for unusual quantitative results).

Research Planning and Implementation Phases

In a number of disciplines, focus groups are used during the planning and implementation phases of research. The development, testing, or validation of questionnaires is one common use, and a number of examples are found in the environmental health literature (Cooper et al., 2001; Flocks et al., 2001; Ing, Ashbury, Marrett, From, & Perry, 2002). Focus group sessions can be hypothesis generating. For example, the group discussion can be used to identify environmental health concerns or exposures, as well as exposure sources within a particular community or region that may not be apparent to the researcher. Focus groups can also explore ways of enhancing recruitment of participants into environmental health studies as well as obstacles to participant retention for longitudinal studies. One framework that can be used to guide focus groups examining recruitment and retention is based on three major themes:

* awareness--making the right candidates aware of an opportunity,

* acceptance--creating a persuasive message that candidates will accept, and

* access--creating access by removing obstacles to participatory behavior (Brown, Long, Gould, Weitz, & Milliken, 2000).

Within this context, issues related to incentives, participant burden, and other study characteristics can be explored before full implementation of the study. Focus groups can even be utilized during study implementation to explore problems that may arise. Explanations for and solutions to unanticipated problems such as low recruitment rates into an environmental health study and a large number of unanswered questions on a questionnaire can be sought through focus group discussions.

Identifying Risk Perceptions

Understanding popular perceptions of environmental risks can be crucial to the design and implementation of research projects, as well as the success of environmental and public health policies and programs. Environmental health researchers have used focus groups to explore issues related to the perception of risk with respect to a wide variety of exposures (e.g., application of pesticides to mosquito nets, radon testing, and air pollution) (DiPofi, LaTour, & Henthorne, 2001; Green, Fullilove, Evans, & Shepard, 2002; Johnson & Slovic, 1995; Miller, Jones, Ndunguru, Curtis, & Lines, 1999; Slachtova, Tomasek, Jones, Vasina, & Volf, 1998). For instance, Slachtova and co-authors used focus groups to ascertain risk perceptions about air pollution and respiratory health among parents living in a central European city, and those perceptions were compared with the response of community stakeholders (a government official, an environmentalist, an industrial manager, a trade unionist, a nongovernmental-organization representative, a physician, and a journalist) in semi-structured interviews (1998). The investigators found that perceptions of environmental and safety risk diverged between the community stakeholder group and the group of parents. A risk perception questionnaire (sent beforehand to the focus groups) was found to provide less information about important issues such as indoor air quality (the question was skipped by most of the respondents). This case was an example of a situation in which a standard questionnaire was unable to ask or analyze the questions necessary to understanding risk perceptions within a population. Other researchers have utilized focus groups to understand risk perceptions among households that used insecticide-treated mosquito netting in urban Dar es Salaam (Miller et al., 1999). The standard procedure promoted in the community was to treat the mosquito net with insecticide every 6 to 12 months and to avoid washing the net until just before retreatment. Focus groups conducted with 100 community members, however, revealed that people generally preferred to wash their nets more frequently (without reapplication of insecticide), because unwashed nets were perceived as dirty and unhealthy; exposure to the insecticide itself was not perceived as a health risk. As a result of understanding the perceptions of risks expressed by the focus group participants, a new standard procedure of low-dose frequent treatment was proposed, which would allow for more frequent washing of nets and re-application of lower doses of insecticide following each washing.

Development of Programs and Policies, Social Campaigns, and Strategies for Limiting Exposures

Environmental health researchers have utilized focus group methods in the development of programs and policies, social campaigns, and strategies for limiting exposures (Adams et al., 2001; Auer & Andersson, 2001; Green et al., 2002; Haines, Brentnall, Stansfeld, & Klineberg, 2003; Hanchett, Nahar, Van Agthoven, Geers, & Rezvi, 2002; Harber, King, Tipton, & Chen, 1997; Taylor et al., 1991; Tinker, Zook, & Chapel, 2001; Witte et al., 1998). Before the implementation of programs, policies, or social campaigns, feedback on acceptability can be elicited from focus groups, allowing the policy makers to understand the potential obstacles. This approach has been used before implementation of exposure mitigation strategies as well. Hanchett and co-authors (2002) conducted focus groups in several villages in Bangladesh to explore the villagers' understanding and awareness of arsenic in their drinking water as well as strategies to reduce the villagers' exposure to the metal. In New York City, community environmental action campaigns have been launched as a result of 14 focus groups of women of childbearing age (Green et al., 2002). The relevance of five proposed strategies for preventing and reducing the risk of children's exposure to environmental hazards (keep the home free of tobacco, make sure the child eats a balanced diet, ask the doctor about the child's exposure to lead, take steps to keep cockroaches and rodents out of the apartment, get involved in the community's Clean Air Campaign) were tested among the focus group participants. Based on the feedback of the focus group participants, the environmental action campaign was modified to incorporate additional strategies such as fighting drug and alcohol abuse, controlling pests safely, managing garbage properly, and considering the importance of family and friends in encouraging and fostering a well-balanced diet. In Canadian Aboriginal communities, a framework for an injury surveillance program was developed through focus groups at national and community levels (Auer & Andersson, 2001). Auer and Andersson would argue that standard surveillance systems, by virtue of their structure, often foster a disassociation between data and community action. In contrast, the Aboriginal framework suggested placing the locus of control for the system within the community by locating data management and dissemination within the jurisdiction.

Directing Future Research

Focus groups can be a convenient way to elucidate study results (Freeman & Saenz de Tejada, 2002; Power, 2002) and can help direct future research efforts. No examples of this use were found in the environmental health research, but the approach has been taken by other public health researchers (French, Power, & Mitchell, 2000; Kulsoom & Saeed, 1997). Focus group discussions can help clarify strange or unexpected results from questionnaire data or environmental monitoring. By raising issues related to the sources or locations of exposures, health concerns within the community, or other events (such as a major weather event that may affect exposure or outcome estimates), the participants provide researchers with additional information that was not noted or known during the collection of study data. If results from the quantitative study seem to differ by participant characteristics that may not make sense, a focus group study (in which each group is defined by the specific characteristics at issue) can be conducted with a random sample of participants from the previously conducted quantitative study.

The examples the literature provides of the application of focus groups in environmental health research largely have been confined to population-based environmental epidemiology research. Yet it should be emphasized that focus groups can easily be incorporated into environmental research that would otherwise be largely laboratory based. Biological specimens, for example, can be analyzed for biomarkers of environmental exposure, susceptibility, and adverse health effects; researchers who collect and analyze human samples can hold focus groups to determine which biological specimens (e.g., blood, urine, fingernails, hair, placenta, meconium) would be acceptable to collect. The responses from the focus groups will be critical in determining which samples will ultimately be collected and analyzed, and how the rationale for that collection will be explained to potential participants.

Nuts and Bolts of Focus Groups-The How-To for the Environmental Health Researcher

Conducting Focus Groups

The composition of a focus group generally includes moderator(s), participants, and observer(s). The moderator directs the discussion, often specifying a scenario, asking open-ended questions (i.e., questions that provide no predetermined response options, giving the respondents flexibility in how they respond), and prompting participants from a prearranged script or set of topic areas. The moderator guides the group through a discussion of each of the topic areas. Participants are representative of the target population for the research efforts. The observer records comments, notes nonverbal reactions and the body language of participants, and assesses the overall tone of the focus groups.

Study design and quality control measures are paramount for successful focus groups. An array of handbooks are available to help foster the planning and implementation of focus groups, providing a variety of options and techniques (Barbour & Kitzinger, 1999; Brown, 1999; Edmunds, 1999; Fern, 2001; Greenbaum, 1988; Kitzinger, 1999; Krueger, 1994; Morgan, 1992, 1993, 1997; Morgan & Krueger, 1998; Patton, 2002; Stewart, 1990).

Morgan (1996) has classified the design issues of focus group research into project-level issues (standardization, sampling, and number of groups) and group-level issues (group size, moderator traits). Standardization determines the degree to which procedures and question sets will be constant across the different focus groups. Sampling involves group composition--that is, the homogeneous characteristic(s) within each group, which may vary between groups. Determination of the number of focus groups that need to be conducted is dependent on the decisions made regarding standardization and sampling; however, a typical rule of thumb, as suggested by Morgan, is that most projects consist of four to six groups (1996).

The size of a single focus group session should be determined by how much input and involvement the researcher would like each participant to have (Morgan, 1996). The fewer the participants, the greater likelihood is that each participant will have adequate time to express his or her views. Larger groups, which may provide less opportunity for input from each participant, may yield a more diverse range of ideas.

The level of moderator involvement, both in topical control (e.g., through use of a structured/unstructured question set) and in group dynamics (e.g., facilitating participant interaction) depends on the goals of the research (Fern, 2001; Morgan, 1996). The goals of the focus group need to be clarified in advance by the environmental health researcher. These goals will determine desired group characteristics (e.g., members of households that live near an environmental exposure, mothers of children under five years of age with a certain disease). Creation of a moderator's guide will help advance the goals of the research. The guide may include a description of the target population; overall rationale for the groups, including a discussion of how the focus groups may relate to the goals of the larger research study; question sets for the groups; and additional materials such as hand cards or information posters for display during the focus group session.

These considerations lead to a very important point about moderators; despite promoting different techniques, all guides and manuals emphasize the importance of the moderator in the success of the focus group. The moderator is the person with whom participants interact. The quality of the data generated within the focus groups largely depends on the interaction between the moderator and the participants. Thus, the moderator must elicit trust and provide a sense of competence so that the members of the group have the confidence to be able to openly give their opinions. The moderator does not want to stand out from or look different from the group he or she is leading (Fern, 2001; Morgan & Krueger, 1998).

No consensus has been reached in the sociology literature as to use of a professional moderator versus use of an amateur one (Fern, 2001). In most research scenarios, an experienced and knowledgeable professional moderator is considered the optimal choice (Fern, 2001). There are circumstances, however, in which the use of a professional moderator may not be advantageous. Reasons for use of a non-professional moderator may include the following situations:

* the professional moderator may not have the level of knowledge or technical expertise on the research topic needed to answer technical questions and help guide discussions (Fern, 2001; Morgan, 1993);

* monetary constraints may limit the ability of researchers to hire a professional moderator (Fern, 2001); and

* a professional moderator may not be available with the knowledge or sensitivity to inspire the trust needed to work with a group of a particular ethnic, racial, or gender composition (Fern, 2001).

Regardless of the status of the moderator, whether professional or amateur, training sessions are paramount so that the moderator is equipped to elicit the needed data from the focus groups. Training should include the moderator(s), the observer(s), and the research investigator(s), so that all are in agreement on the objectives of the focus groups. Training sessions should include an overview of the background and goals of the focus groups, a read through of the moderator's guide (or focus group question sets), a review of the moderator's and observer's roles, and a question-and-answer segment with the study investigators. In addition, if the moderator is not a professional, examination of general moderating techniques would be advantageous; the literature provides additional information on these techniques (Barbour & Kitzinger, 1999; Edmunds, 1999; Fern, 2001; Greenbaum, 1988; Kitzinger, 1999; Krueger, 1994; Morgan & Krueger, 1998; Patton, 2002; Stewart, 1990).

Data Analysis

Focus groups can be used to answer a wide variety of research questions. The analytic methods chosen to answer those questions will depend on the nature of the inquiries and the purpose the analyses are intended to serve. At one end of the spectrum, focus group methodologies used at the beginning of a research process can serve much the same purpose as early field-based observations--that is, they can be used to generate theories and hypotheses. The analytic techniques to be derived from these early observations should serve to systematize the data collection process and to facilitate the inductive process of developing categories and linkages from unbiased interpretations of the data. At the other end of the spectrum, focus groups can be utilized, after application of more quantitative methods, to add texture and meaning to what might otherwise be an abstract set of numeric patterns. The emphasis in this case is on asking questions that are derived directly from the statistical relationships observed in the numeric data, and on imbuing those data with verbal meaning. In the middle of the spectrum, focus group interactions can themselves be the object of quantitative analysis. Transcripts from the group interactions can be subjected to content analytic techniques, videotapes and audio-tapes can be subjected to rigorous behavioral coding techniques, and questions can be asked and answers tallied much as they might be in a survey.

The point is to recognize that analyses based on focus group data are not necessarily less valid than analyses based on more quantitative techniques. Both qualitative and quantitative analyses have epistemological properties that complement each other when taken within the context of a programmatic line of research (Rossi & Freeman, 1999). Both quantitative and qualitative analytic techniques involve certain assumptions about rigor, and violation of those assumptions will lead to bias and unpredictability. Below are some of the popular techniques for analyzing focus group data.

General Methods

Meaningful analyses use input from the moderator(s) and observer(s). Moderator and observer meet right after the completion of the focus group session while the group's input is still fresh in their minds. They discuss salient themes from the session by reviewing the observer's recorded notes (such as participant quotes, key points and themes from each question area, or even tallies of participant responses to key questions). The observer drafts a summary of the notes soon afterwards and again reviews the completed summary for accuracy. This process of tallying participants' answers to specific questions and distilling prevailing themes from each discussion group is the first level of data analysis.

The second level of analysis consists of a note-based qualitative analysis with possible audio- or videotape backup of the observer data sheets, following a data reduction process (Krueger, 1994). The data reduction process involves the following: reviewing the observer data sheets from all sessions at one time; reviewing observer data sheets from all focus group interview sessions in a question-by-question iterative method; comparing primary themes identified by the moderator and observer for each question among interview groups; developing an integrated paragraph for each question, describing themes that were consistently discovered across focus group interviews; selecting key quotes that were typical of the primary themes identified; and allowing the focus group moderator(s) and observer(s) to review analyses to ensure that themes were not over- or under-interpreted. A common rubric for coding answers to individual questions is developed, which can be used to identify themes and tally responses. Selected quotations from the focus group sessions can be extracted to complement the analyses.

Analyzing Focus Group Data Quantitatively--Content Analysis

There are certain limitations to the ways in which focus group data are collected that must be acknowledged and overcome before any conclusions of a quantitative nature are made from focus group data. Dietz argues that the researcher must recognize the limitations of the sampling strategy and not make conclusions that outstrip the strategy being used (1992). Content analysis techniques can be used to quantify participants' input, either individually or as a group. "Content analysis" refers to a system of procedures used heavily in the social sciences to extract meaning from text (Weber, 1983). Application of content analysis offers a detailed accounting of the number of times certain themes emerge from an analysis of the focus group transcripts. Because content analysis converts textual descriptions into numeric data, the resulting counts can be submitted to a broad spectrum of statistical analyses including statistical comparisons between groups and cross-tabulations by type of participant. Generally, focus group sessions are recorded, and thus, any number of verbal or even nonverbal behaviors can be coded and quantified in postsession analysis. Very sophisticated applications of behavioral coding software have been introduced recently (e.g., Noldus Observer, a software suite used heavily by ethnologists) that will allow researchers to code down to individual frames when reviewing videotape. Developing a coding strategy for tallying responses to facilitator's questions is another way to quantify the groups' behavior. At predetermined points in the focus group discussion, the facilitator may stop and poll participants on their individual answers to specific questions, in a manner that should conform to best practice in interviewing and survey methodologies (Sudman et al., 1996). Not only can results be counted across individual members within a particular discussion group, but they even can be aggregated across multiple focus groups.

Computer-Assisted Qualitative Data Analysis Software

The process of reviewing qualitative data and, from the data, deriving themes and conclusions can be facilitated by the use of computer-assisted qualitative data analysis software (CAQDAS). The purpose of relying on computer assistance during the review and coding process is to ease the burden of note taking and memo writing, thus freeing up the researcher's attention to focus on issues of synthesis and integration. CAQDAS applications offer suites of powerful annotation tools that allow users to import textual data from a variety of formats, to review and analyze passages of text on screen, and then to parse the text into "nodes" of individual meaning and thought. Data manipulation tools allow the analyst to identify linkages between nodes and, if appropriate, to tally the number of times that a particular thought occurs within a passage and to compute ratios of occurrence from one theme to the whole, or of one theme to another. Frequency of occurrence can also be computed separately for different demographic strata, thus allowing for subgroup comparisons.

Over the years, a number of CAQDAS applications have been developed, but by far the most popular applications are NUD*IST (the acronym derives from "Non-numerical Unstructured Data by techniques of Indexing, Searching, and Theorizing") from QSR International, and Atlas/ti from Scientific Software Development. In a 1998 review, Barry conceptualized differences between the two software packages (1998). Atlas/ti, Barry argued, is a highly evolved user interface, immediately accessible to a broad spectrum of users, allowing for a very visual manipulation of nodes and relationships on screen. NUD*IST, on the other hand, offers a more sophisticated set of project management and data-querying tools but requires more time for analysts to learn. Barry concluded that Atlas/ti would be especially useful to analysts who have a relatively straightforward coding project and do not have the time to invest in mastering a complicated suite of data analysis tools, while NUD*IST would be better suited to analysts confronted with a more sophisticated set of data analysis needs.


Qualitative research methods such as focus groups, a mainstay of scientific inquiry in fields such as sociology, anthropology, and linguistics (fields that rely on a contextual understanding of phenomena), have a clear role to play in environmental health research. Examples from the literature demonstrate the effective use of focus groups in a variety of environmental health research settings, but there is clearly room for an increased application of this and other qualitative methods in environmental health research.


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Danelle T. Lobdell, M.S., Ph.D.

Suzanne Gilboa, M.H.S.

Pauline Mendola, M.S., Ph.D.

Bradford W. Hesse, M.S., Ph.D.

Corresponding Author: Danelle T. Lobdell, Epidemiologist, U.S. Environmental Protection Agency (U.S. EPA's) Office of Research and Development, National Health and Environmental Effects Research Laboratory, MD58A, Research Triangle Park, NC 27711. Email:

Disclaimer: This document has been reviewed by the U.S. Environmental Protection Agency's National Health and Environmental Effects Research Laboratories and approved for publication. Approval does not signify that the contents reflect the view of U.S. EPA, nor does mention of trade names or commercial products constitute endorsement or recommendation for use.
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Title Annotation:FEATURES
Author:Hesse, Bradford W.
Publication:Journal of Environmental Health
Geographic Code:1USA
Date:May 1, 2005
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