Semi-structured focus groups 65

Focus groups are facilitated group discussions designed to uncover experiences, ideas, feelings, and insights about a topic through interaction with others. Commonly held with four to eight participants, focus group discussions are guided by a moderator (often the researcher) who facilitates and directs the discussion to gain insight on a particular topic. Because of their conversational nature, focus groups tend to uncover different elements of lived experience than one-to-one interviews, and can reveal new insights for understanding and relating to a topic or experience. Wilkinson (2004) discussed benefits of generating data using focus groups, stating, “focus groups are more ‘naturalistic’ than interviews (i.e., closer to everyday conversation), in that they typically include a range of communicative processes – such as storytelling, joking, arguing, boasting, teasing, persuasion, challenge, and disagreement” (p. 180). The

communicative processes that occur within focus groups reveal not only lived experiences, but also habitual ways of defining, describing, and relating to the phenomenon/lived experience in a group setting (Green & Thorogood, 2009). For example, by examining the use of language and tone, what is shared and not shared, body gestures, responses to others, levels of detail used, disagreements, strong opinions, etc., the researcher can gain new insight into the complexities and multiple dimensions of the research topic. In addition, the conversational nature of focus groups “allow respondents to react to and build upon the responses of other group members, creating a ‘synergistic effect’. This often leads to the production of more elaborated accounts

than are generated in individual interviews” (Wilkinson, 2004, p. 180). Because focus groups bring people with different and potentially diverse experiences together, insights can be revealed and explored in the group setting that may not emerge in a one-to-one interview.

Focus group discussions can also be useful for breaking down and reducing power dynamics between the researcher and the participant because they remove pressure on the individual that may exist in a one-on-one interview setting, and create an environment where others are also sharing personal experiences (Fossey et al., 2002; Wilkinson, 2004). For this reason, they tend to be an effective method for exploring sensitive subject matter (Green & Thorogood, 2009; King & Horrocks, 2010; Wilkinson, 2004). Wilkinson (2004) acknowledges that, “focus groups are well suited to exploring ‘sensitive’ topics, and the group context may actually facilitate personal disclosures” (p. 180). A major benefit of focus groups is that the group atmosphere can improve the comfort experienced by participants allowing for new depths and dimensions of experience to emerge.

Of course, the opposite can also be the case if a participant feels uncomfortable, unwelcome, negatively judged, or disrespected in a focus group. To avoid this, the moderator must lay out ground rules for respectful dialogue at the beginning of each discussion to ensure standards of respect are upheld, however, because the moderator does not have complete control over what respondents say or how they behave, it is always possible for a respondent to feel less comfortable in a group setting than in a private interview. Similarly, there is loss of anonymity and an increased risk to loss of confidentiality in focus groups if a participant discusses the focus group with others following the discussion. The moderator should communicate the importance of confidentiality to all participants before each focus group begins, however because they

cannot control how participants behave once they leave, participants risk a potential loss of confidentiality through participation.

Another downside to collecting data using focus groups is that participants can easily influence one another, which can shape which aspects of experience are shared and discussed and which are not, and how lived experiences are described. This can especially be the case if a respondent feels that their experience or feeling about a topic will not be accepted or understood by other group members (Green & Thorogood, 2009). Also, due to their conversational nature, it may be difficult or even impossible to explore the experience of any one participant in great depth, even if that experience is of great interest to the researcher. Additionally, participants might interrupt one another and might share experiences that take the conversation off topic (Krueger, 1994). While it is the responsibility of the moderator to keep the conversation on track, it can be difficult to return to narrative or personal experience that has been interrupted. Despite these limitations, the ability of focus groups to breakdown power dynamics, generate high-quality data about lived experience, capture habitual ways of interacting and relating to the research topic, and reveal sensitive subject matter; makes them a valuable method for use in qualitative research.

In this research, three focus group discussions were held with groups of four to six mothers who gave birth at the Janeway Children’s Hospital/Health Sciences Centre within one year of data collection. Each discussion ran between 60 and 90 minutes in length, was audio recorded, and moderated by the principal investigator. Discussion questions were semi-

structured and designed to assess hospital compliance with Step 3-10 of the BFI, and the health care experiences of mothers. Flexibility was provided for the content and direction of the conversation to be shaped by group discussion. The number of focus groups held was

determined by the point at which thematic saturation was reached. This occurred during the third focus group.

To be eligible for participation, mothers had to be over 18 years of age, have delivered a baby at the Janeway Children’s Hospital/Health Sciences Centre between May 1st, 2011 and May 1st, 2012, have fluent English speaking skills, have and intend to keep and raise their infant, and have the ability to provide free and informed consent. Focus group participants were not excluded from the study based on the gestational age of the infant (carrying infant to full term not required for participation), the delivery of a healthy baby, or the presence of severe maternal health issues or disability. This provided greater diversity and experience in the research sample, as some focus group participants delivered pre-mature infants with health complications, which provided a greater scope of experience with hospital infant feeding.

All focus group participants were recruited through word of mouth and snowball sampling. Snowball sampling is a technique that involves gaining access to study participants with the help of current research participants. To encourage participation from those with different schedules and geographical locations, discussions were held on different days of the week, different times of day, and in different locations. To reduce recall bias (the

communication of inaccurate information due to memory loss over time), only participants who delivered within twelve months of the focus group date were invited to participate. Of the 16 focus group participants, 1 participant from the second focus group delivered her baby before May 1st, 2011. She was included in the discussion to avoid social exclusion in her group of friends, however in order to limit recall bias and maintain consistency with inclusion criteria, all comments made by this participant were removed from the transcript and were not included in the research.

Participants for the first focus group were invited to participate by a friend of the

researcher. They were each contacted directly by the researcher’s friend in an email, informed of the study, and invited to contact the researcher if interested in participating. Of the four mothers contacted, three replied and one of the three indicated that her friend (who was not originally contacted) was also interested in participating. The researcher followed up with each interested mother by email and telephone, and arranged for the discussion to take place on March 29, 2012 at 10:30am in the Health Sciences Centre. All four mothers attended the discussion with their baby. Two of the four participants in this group knew each other.

The second focus group was organized by a mother who had recently delivered and offered to host a focus group discussion with her friends in her home. She contacted her friends through email to inform them of the research and invite them to participate. Each interested participant was then contacted directly by the researcher. The focus group discussion was held on April 11, 2012 at 3:30pm in the home of the host in Torbay. Of the eight people contacted by email and invited to participate, seven mothers indicated interest. Six attended the discussion and five brought their baby to the discussion. All mothers in this group knew each other.

Participants for the third focus group were recruited through the La Leche League of St. John’s, NL. The researcher contacted the leader for the St. John’s group with information about the study and requested that the information be circulated to mothers in the group. Details about the study were posted by the La Leche League on their regional Facebook group and interested mothers were instructed to contact the researcher. Seven mothers responded with interest, and six mothers attended the discussion. This focus group was held on April 16, 2012 at 7pm in the Sobey’s Community Room in Torbay. All mothers in attendance brought their baby to the discussion, and four knew each other prior to the discussion.

Although the recruitment technique of snowball sampling resulted in a high

representation of breastfeeding mothers, the research sample and hospital infant feeding and healthcare experiences of mothers were relatively diverse. The sample included first, second and third time mothers, mothers with vaginal deliveries and caesarian section deliveries, mothers who ranged in age from their early 20’s to late 30’s, who were married, unmarried, in a committed relationship and single, mothers who were exclusively breastfeeding and combination feeding, and mothers living in rural and urban areas. Because carrying their infant to full term (37 weeks) was not required for participation in a focus group, some focus group participants had premature infants who were cared for in the hospital NICU before discharge. There were no exclusive formula feeding mothers in the focus groups, however a number of mothers combination fed their infant from infancy or switched to exclusive formula feeding shortly after delivery. Because focus groups were held to engage with hospital infant feeding practices and maternal hospital experiences in a group setting, rather than to provide a diverse sample of the maternal population, snowball sampling was an appropriate recruitment strategy.