Keim et al.

/ FOCUS GROUP METHODOLOGY FAMILY AND CONSUMER SCIENCES RESEARCH JOURNAL

Focus Group Methodology: Adapting the Process for Low-Income Adults and Children of Hispanic and Caucasian Ethnicity
Kathryn S. Keim Oklahoma State University Marilyn A. Swanson South Dakota State University Sandra E. Cann Altragracia Salinas University of Idaho

Focus group discussions are being used more often during the formative phase of nutrition education program development. This article discusses focus group procedure adaptations to increase effectiveness with low-income Caucasian and Hispanic audiences for adults and thirdgrade children. Recruitment is more effective if the target audience knows the recruiter. Methods such as posters and letters do not work. The facility needs to be considered safe and easy to get to. Some children need focus group discussions of less than 1 hour in length or some type of activity to break the monotony of the session. The use of a talking stick is also helpful to allow all children to be heard. It was observed that the Hispanic participants were not as verbal as the Caucasian participants. More Hispanic focus groups needed to be conducted to obtain the same amount of diversity in information as was obtained from the Caucasian groups.

Focus group interviews are being used more often by nutrition educators interested in collecting qualitative information during the exploratory, formative, or process evaluation phases of research or program development (Betts, Baranowski, & Hoerr, 1996; Hartman, McCarthy, Park, Schuster, & Kushi, 1994; Kirby, Baranowski, Reynolds, Taylor, & Binkley, 1995; McCarthy, Lansing, Hartman, &
Authors Note: This project was funded by the NRI Competitive Grants Program/USDA Award Number 9404164 and in part by the University of Idaho, Agricultural Experiment Station. We would like to give thanks to Irma Salinas, who was instrumental in the recruitment of Hispanic participants and the success of this study.
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Himes, 1992; Schwaller & Shepherd, 1992; Shepherd, Sims, Cronin, Shaw, & Davis, 1989; Trenkner & Achterberg, 1991). Focus groups provide a means of obtaining in-depth information from representatives of a target audience in an atmosphere that encourages discussion of attitudes and perceptions about a specific topic; groups are composed of a small number of participants who are asked an organized set of questions in a consistent manner. Focus group interviews provide insights into (a) complex behavior such as food consumption patterns, (b) consensus concerning a topic, and (c) gaps in communication between consumers and providers; (d) they allow participants to refine their views based on the responses of other participants (Krueger, 1994; Shepherd et al., 1989). Focus groups with children, low-income individuals, and nonnative English-speaking participants are relatively unstudied areas in nutrition education and present unique challenges and opportunities (Hartman et al., 1994; Reed, Meeks, Nguyen, Cross, & Garrison, 1998). This article describes the processes used and lessons learned when conducting focus groups with low-income Caucasian and Hispanic adults and third-grade children. The topics addressed in this article include: (a) reasons to use focus groups, (b) concerns of focus group question development, (c) kinds of incentives to use, (d) the best place to conduct a focus group, (e) ways to recruit participants, (f) determination of eligibility of subjects, (g) conduct of focus groups, (h) determination of the number of focus groups to conduct, (i) transcription of focus groups in two languages, and (j) analysis of focus group transcripts. The purpose of the research study was to discover factors that shape decisions about fruit and vegetable consumption of lowincome Caucasian and Hispanic families within the constructs of the social cognitive theory (Bandura, 1986).

WHY USE FOCUS GROUPS?

To effectively research factors that influence fruit and vegetable consumption among low-income families, a technique was required that would not intimidate these participants, who reportedly are apprehensive about sharing information with strangers (Krueger, 1994; White & Maloney, 1990). Researchers familiar with qualitative inquiry acknowledge the usefulness of focus groups to find out why people hold certain opinions or views and the effectiveness of small

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focus groups to reach disenfranchised individuals (Bers, 1989; Kirk & Gillespie, 1990; Krueger, 1994). The focus group format was chosen specifically for this study because it was known that low literacy and limited knowledge of the English language were going to be issues. These limitations ruled out any type of pencil and paper survey. There was also some concern that structured individual interviews would not be well received by the migrant Hispanic respondents. It was felt that respondents would feel more secure with a group situation. Additional reasons for choosing a focus group format were to provide researchers time for personal contact with the respondents, which is a helpful aspect in qualitative data collection (Langer, 1991), and to assess the face validity of the qualitative data collected (Bers, 1989; Javidi, Long, & Vasu, 1991).

CONCERNS OF FOCUS GROUP QUESTION DEVELOPMENT

To develop a program that targeted vegetable and fruit consumption in low-income Caucasian and Hispanic families, it was decided to start the process by learning more about the population through focus groups. The framework for the questions needs to be based on the same theory as the eventual intervention, and the plan was to use the social cognitive theory as the framework for the intervention (Betts et al., 1996; Miles & Huberman, 1984). With this in mind, the focus group questions for this study were adapted from a set of questions that Dr. Tom Baranowski and Dr. Susan Domel developed based on the social cognitive theory and used with middle-income and low-income adults and fifth-grade children (Baranowski et al., 1993; Kirby et al., 1995). The questions were written to determine the behaviors, personal characteristics, and environmental factors that could influence fruit and vegetable intake. Professionals familiar with nutrition, ethnic diversity, limited resource audiences, and the developmental level of third-grade children assisted with the adaptation of the questions. Question changes were made after consideration of the potential lack of educational background, lack of familiarity with the English language, and unfamiliarity with foods in the United States. An undergraduate Hispanic student who was familiar with the Hispanic people of Idaho, and specifically migrant laborers, reviewed translations of the questions for Hispanic adults and children. This was to ensure that Hispanic adults

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and children would understand the meaning of the vocabulary and sentence structure of the questions. As the childrens focus group questions were developed, a third-grade teacher and a college professor of child development evaluated the age appropriateness of the questions. The time spent in question development and consultation with those knowledgeable about third-grade children and people of Hispanic origin was necessary to ensure success of the focus groups. Pilot focus groups were conducted to evaluate the clarity and effectiveness of the questions in obtaining answers about fruit and vegetable consumption and the length of time required to answer the questions. After the pilot tests, question content, order, and the number of questions to be asked were revised. Some questions were dropped to shorten the total time of the focus groups. The adult focus groups lasted about 1 to 1.5 hours, and the childrens focus groups lasted about 1 hour. It was observed that 1-hour focus groups were actually too long for some children, and they became restless after 30 minutes. This was observed in more of the Caucasian than the Hispanic children. For some children, a shorter time or some type of activity midway through the session to break it up may have been better. One other change was made in some of the questions for the children after the third focus group. It was observed that some thirdgrade children could not answer the questions if the question was phrased, what do you think other kids like? Many of the children could respond as to what they themselves thought but could not extrapolate to what other kids thought. The questions were rephrased to what do you like?

WHAT KIND OF INCENTIVES SHOULD BE USED?

The importance of offering an incentive for focus group participation cannot be overestimated (Morgan, 1993; Stewart & Shamdasani, 1990). Offering an incentive to focus group participants is a way of thanking them for their time and contribution to a focus group discussion. Adult focus group participants received a $25 incentive certificate, and children received a $10 incentive certificate that could be spent at a local shopping mall. The focus groups were conducted at the migrant laborer camps; when other residents learned of the $25 earned for visiting with the ladies, we had more volunteers than needed. All of the participants appreciated the money, and several of

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the children gave the funds to parents to help pay for things like clothes and school supplies.

WHERE IS THE BEST PLACE TO CONDUCT A FOCUS GROUP?

Previous studies (Hartman et al., 1994; Krueger, 1994; Reed et al., 1998) describe the necessity of careful location selection to conduct focus groups. Appropriate choice of location (Stewart & Shamdasani, 1990) can mean the difference between success and failure in recruiting enough members from the target population. To ensure optimum participation by the target audience, familiar locations that were frequently used by both adults and children were selected for the focus groups (Stewart & Shamdasani, 1990). The northern Idaho adult and children focus groups were held in a community youth center. This facility was in a familiar, well-lit neighborhood, and it had easy access, convenient parking, and an area for child care in an adjoining room. The community youth center was reserved in advance to ensure its availability at the appropriate time. Southern Idaho focus groups were conducted in a variety of facilities that were familiar and convenient for both the Caucasian and Hispanic focus group participants. These facilities included community centers, schoolrooms, a community center at a migrant labor camp, and the activity room of a local church. As with the northern Idaho facilities, the room was reserved in advance, and a rental fee ($25) was paid for the use of the facilities. When needed, child care was provided at the facility for children of the adult focus group participants. This was very important for both Caucasian and Hispanic parents. Without child care, several participants would not have been able to come.

HOW TO RECRUIT PARTICIPANTS

Recruitment of low-income participants was a challenge for a variety of reasons unique to each group. Because circumstances can become barriers to focus group participation, every effort, including the provision of child care, was made to circumvent reasons why lowincome people might not participate (Stewart & Shamdasani, 1990).

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Northern Idaho Recruitment Process

Initial recruitment included impersonal techniques for the northern Idaho focus groups, which were conducted first. Posters and handouts were circulated at convenient sites frequented by lowincome Caucasian parents and their children. These locations included the local Head Start, WIC, Health and Welfare facilities, and retails stores such as Wal-Mart and Kmart. The posters explained what focus groups were, length of time of a focus group, the provision of incentive certificates, and how child care would be arranged. A local telephone number to call if interested was included. This recruiting strategy was not successful. The research team then contacted school superintendents asking if the researchers could send information directly to parents of third graders who received free or reduced-price meals. Because of school confidentiality policies concerning which families received free or reduced-price meals, personal contact with Caucasian parents was not initially possible. Requests were then made to superintendents in five different school districts asking if letters and brochures could be sent to parents whose children qualified for free or reduced-price meals. The letters, brochures, envelopes, and stamps were given to the director of the school lunch programs, who then had the letters addressed and sent to the parents. The letters sent to prospective parents stated where the focus groups would be held in their community, informed them about the availability of child care at the location, and requested they call a local contact person to sign up for a focus group. A total of 88 parents were sent letters in the five school districts. The method of sending letters resulted in two adult (four adults per group) and one child focus group (six children) being conducted. Because of summer vacation, it was decided further recruitment would have to wait until the fall school session. A second letter was sent to 47 parents after school started in the fall of 1995. This resulted in one adult (six adults) and one child focus group (six children) being held. A fourth adult focus group was eventually held with seven adults. After careful consideration, two reasons became apparent as to why the interest in attending focus groups in northern Idaho was so low. First, the University of Idaho is located in Latah County in the town of Moscow, and people in this area are constantly asked to participate in studies associated with the university. Second, low-income people are often apprehensive about taking part in any kind of study

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mainly because of increased anxiety with unfamiliar circumstances and people.

Southern Idaho Recruitment Process

Initial contacts with Hispanic parents and children who qualified as focus group participants were made through superintendent of schools, the director of federal programs, the migrant summer school director, and the migrant school coordinator in three towns. Letters written in Spanish were sent to parents of third-grade children describing the focus groups. Because of the language and cultural barriers, it was essential to have personal contact with the prospective Hispanic parents by people who they knew and trusted. An undergraduate Hispanic student from southern Idaho and her mother, who was well known in the community and had previously served as a Head Start director, made personal contact with each of the Hispanic families. The key to successful recruitment among low-income Hispanic families was their familiarity with the people who did the recruiting. Questions from the family were answered, and reassurance was given concerning their ability to answer the questions and the importance of the focus groups and the information they could provide. Another recruitment method used in southern Idaho with Caucasian and Hispanic low-income children was recruiting subjects at schools in which the majority of children received either free or reduced-price meals. Contact was first made with the principal, and then a volunteer third-grade teacher was recruited. The teacher requested that all of the children be in the focus groups so as to not single out those receiving free or reduced-price meals. The teacher attempted to group the children such that the groups consisted of either all or the majority of the children receiving free or reducedprice meals. The teacher also grouped children by ethnicity. A total of four focus groups were conducted, and two were considered in the data analysis, with two being omitted because the majority of children were not receiving free or reduced priced meals. Using this method, all of the children in the class, but not the school, participated in the focus groups. In summary, a total of 30 Hispanic adults were contacted, with 24 participating in the study, compared to a total of 193 Caucasian adults being contacted, with 21 participating in the study. A total of 125 Caucasian children were contacted, with 27 participating, and a total of 32

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Hispanic children were contacted, with 30 participating. Apparently, a more personal approach in which the potential participants know the recruiter is better than impersonal methods or a situation in which the potential participants do not know the recruiter.

DETERMINATION OF ELIGIBILITY OF SUBJECTS

As adults volunteered and parents called to sign up for a focus group for their children, a screening process was used to verify eligibility. The screening questions were: (a) Is your child in the third grade? (b) Does your child in the third grade receive free or reducedprice meals? and (c) Do either you or your child have high blood pressure or diabetes? If they answered yes to questions 1 and 2, they were considered eligible. If they answered yes to question 3, they were not eligible. The parents were asked if they were familiar with the location of the focus groups and if child care or transportation would be needed. In southern Idaho, the screening process was conducted during the home visits. The same three questions were asked to verify eligibility of the parents and children. The parents of the participant children in one community were sent a letter thanking them for allowing their child to participate in the study and indicating how helpful their child was. The parents were asked to indicate if they received food stamps, WIC vouchers, commodities, food from a food bank, free or reducedprice school meals, a rent subsidy, or had children who attended Head Start. If they so indicated, they were considered low income.

HOW TO CONDUCT FOCUS GROUPS

The Human Subjects Review Board at the University of Idaho approved the study. All participants signed informed consent before taking part in the study, including the children through their parents. The number of people per group ranged from four to nine for the children and four to seven for the adult groups. Small group size was used because small groups are more workable with low-income participants, children, or those of an ethnicity other than Caucasian (Hartman et al., 1994; Krueger, 1994; Reed et al., 1998). Participants in adult focus groups were seated around a table with a microphone to audiotape the sessions. Besides the moderator, there was a team member to write notes of the sessions and a person to

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monitor the tape recorder. Each adult introduced himself or herself to the group and shared some personal information, such as age of children, to get over the fear of talking in a group situation. The opening question was Have any of you been hearing or seeing more information about fruits and vegetables in newspapers, TV, or radio? We are looking for your ideas and practices related to fruits and vegetables. The total question guide included 20 questions and was used as a guide by the moderator during the session (Table 1). Children sat on the floor forming a circle around the microphone and tape recorder during the focus groups along with the moderator and one other adult to help keep the children focused on the questions. During the Hispanic sessions, the childrens questions were asked in either English or Spanish depending on their needs. The questions for the childrens focus groups began with the researcher saying, We want to talk to you about food! How many of you like to talk about fruits and vegetables? This was followed by an explanation of how to use a talking stick, which was a colorfully decorated stick. Only the child who held the talking stick was supposed to talk, so all the children would not talk at once and make transcription more difficult than usual. After the introduction, the children were asked to draw a picture of their favorite fruit or vegetable. The drawing activity was a way of getting the children to become involved in the fruit and vegetable discussion. The children were asked a total of 17 questions, with the first 3 questions pertaining to the fruit or vegetable picture they drew (Table 2). The moderator for the Hispanic focus groups was bilingual in Spanish and English. The person writing the Hispanic group notes also understood Spanish. The use of a note taker who was bilingual, although not professionally trained in assisting in focus groups, was an important asset to the team. Her skills in interpreting the responses and assisting in the Hispanic focus groups were a benefit to the study, as Krueger (1994) also found in his research. During the Hispanic focus groups, the bilingual moderator would determine the language to use based on the needs of the group.

HOW TO DETERMINE THE NUMBER OF FOCUS GROUPS TO CONDUCT

Krueger (1994) states that you know you have conducted enough focus groups when the information you are receiving starts to repeat.

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TABLE 1:

Parents Discussion Guide Questions

Have any of you been hearing or seeing more information about fruits and vegetables in newspapers, TV, or radio? We are looking for your ideas and practices related to fruits and vegetables. What are some of your favorite fruits? What are some of your favorite vegetables? What do you think are some good reasons for adults to eat fruits? What do you think are some good reasons for adults to eat vegetables? What do you think are some reasons that adults dont eat fruits? What do you think are some reasons that adults dont eat vegetables? Do you buy fruits and vegetables and/or do you have a garden at home? If you have a garden, what kinds of fruits and vegetables do you grow? (Distinguish between fruits and vegetables grown.) What kinds of additional fruits and vegetables do you buy to go with the home-grown produce? How do you let your third grader help with shopping? When do you usually think about adding fruits and vegetables to your food purchases? (Probe which fruits or vegetables they are talking about.) What do you consider most important when buying fruits or vegetables? (Probe which fruits or vegetables they are talking about.) How do you decide what your family will eat for the week? What stops you from serving fruits and vegetables at breakfast, snacks, lunch, and dinner? (Probe which fruits or vegetables they are talking about.) What do your children usually do to help with making meals or snacks? What are some of your familys favorite fruit and vegetable dishes? (Probe which fruits or vegetables they are talking about.) When you eat out with your third grader, where do you usually go? How does your third grader decide what to order? What could be done to encourage kids to eat more fruits and vegetables? (Probe which fruits or vegetables they are talking about.) How do your CHILDS friends influence YOUR childs eating habits WHEN CHOOSING fruits and vegetables? (Probe which fruits or vegetable they are talking about.) How can kids be encouraged to eat more fruits and vegetables at breakfast, lunch, and dinner? How can kids be encouraged to choose fruits for dessert with meals? (Probe which fruits and vegetables they are talking about.) How can kids be encouraged to choose fruits for dessert or snacks? (Probe which fruits or vegetables they are talking about.)

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TABLE 2:

Childrens Discussion Guide Questions

How many of you like to talk about fruit and vegetables? (Wait for responses). Now Id like you to draw a picture of a fruit or vegetable. (Wait for drawing, 2 minutes) What do you like about your fruit or vegetable that you drew? (Have them show the picture at the same time.) If no one drew pictures of vegetables, ask them . . . What vegetable they wouldve drawn. What do you like about your vegetable you would have drawn? What are some good reasons to eat fruits? What are some good reasons to eat vegetables? What are some reasons some kids dont eat fruits? What are some reasons some kids dont eat vegetables? Lets pretend you just came home from school. You want to eat some fruit for a snack. What kinds of fruits would you find at your house today? Lets pretend you just came home from school. You want to eat some vegetables for a snack. What kinds of vegetables would you find at your house today? How do you like your fruits and vegetables fixed to eat? How does your FAMILY usually eat fruits or vegetables? When you go shopping with your parents, what kinds of fruits or vegetables do you like them to buy? What are four favorite fruits and vegetables you like your parents to buy? Do they buy these fruits and vegetables for you? Lets think about your friends. What are some of your friends favorite fruits or vegetables? Do you think they eat more or less fruits and vegetables than you? If you were a parent, what could be done to help kids eat more fruits and vegetables for breakfast, lunch, snacks, and dinner? Is there anything else you would like to tell us about fruits and vegetables?

A total of four Caucasian and five Hispanic adult groups were conducted. In actuality, five Caucasian adult groups were conducted, but the tape recorder did not work, so that group was not included in the analysis. A total of six Caucasian and six Hispanic children groups were conducted. Two of the Caucasian groups were not included in the analysis because the children were not from a lowincome background. Thus, four Caucasian children groups were in the analysis.

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A trend noted in both the adult and children groups was that the Hispanic groups were less verbal than the Caucasian. More Hispanic groups needed to be conducted to gather the same amount of information as from the Caucasian groups.

TRANSCRIPTION OF FOCUS GROUP SESSIONS IN TWO LANGUAGES

All the focus group audiotape recordings were transcribed by first creating a word processing document and then converting into an Ethnograph file. Ethnograph v4.0 (Qualis Research Associates, Amherst, MA) is a qualitative data analysis program to assist with coding and sorting key phrases and words and assisting with trend analysis. Each focus group session took from 2 to 10 hours to transcribe, depending on whether it was in English or Spanish and on its length. Some of the Spanish tapes took longer because of the need to interpret some of the vocabulary in Spanish before transcribing it into English. To ensure accuracy of the transcribing of the Spanish tape recordings, two different people transcribed three of the Spanish audiotapes into English. These transcriptions were compared and were found to have an intercoder/transcriber agreement of 97%. The majority of differences were in food terms. For example, one transcriber from South America would transcribe the word as pumpkin, and the second transcriber from Mexico would transcribe the word as squash. Other variations included one transcriber saying that the Spanish word meant strong and the other saying iron. There were no examples of the meaning of the phrases being different between the two transcribers.

ANALYSES OF TRANSCRIPTS

The Ethnograph program v4.0 (Qualis Research Associates, Amherst, MA) for qualitative data analysis assisted the researchers in marking key words and phrases in the transcripts and noticing unique similarities and differences in each focus group. By using specific code words that were linked to the three domains of the social cognitive theory to denote phrases in the transcripts, the transcripts were analyzed within the social cognitive theory. For example, code words for the behavior construct were food preservation, meals, and

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shopping. Personal construct code words included taste, texture, and beliefs. Code words of the environment construct were peers, advertisements, and school. Transcripts were marked as Hispanic or Caucasian and as adult or child. Respondents were identified as male or female. Analysis began immediately after a focus group session by reviewing major trends and issues remembered and writing them down. All transcripts were coded and analyzed by two researchers. Intracoder and intercoder reliabilities were calculated by dividing the agreements by the sum of the agreements and disagreements found in 10 pages of the transcript (Miles & Huberman, 1984). Intracoder reliability was acceptable and was found to be 99% for adult Hispanic groups, 91% for adult Caucasian groups, 98% for child Hispanic groups, and 97% for child Caucasian groups (Miles & Huberman, 1984). Intercoder reliability was also found to be acceptable and was found to be 94% for adult Hispanic groups, 93% for adult Caucasian groups, 94% for child Hispanic groups, and 95% for child Caucasian groups (Miles & Huberman, 1984). After coding procedures were completed, Ethnograph could search the transcripts for phrases that were labeled by the specific code words. With this software, phrases could be nested within other phrases coded with different code words. Both simple and segment analysis techniques were used to analyze this data. Recurring code words and phrases were determined by defining a recurring code word within a group as one that almost all of the participants mentioned. Recurring code words and phrases were determined to be across groups when more than 50% of the groups were coded to have that word or phrase. Code words and phrases that only one or two participants or only one or two groups discussed were not included. It must be mentioned that with children, a lot of parroting happened. In other words, if one child mentioned something, then many of the other children mentioned it also.

SUMMARY

Focus group discussions are a qualitative research method being used more and more by nutrition educators to plan nutrition education programs. Several methodological issues were revealed when working with low-income children and adults of Caucasian and Hispanic ethnicity. Some third-grade children could not stay focused for longer than 30 minutes during a focus group. Thus, it is recommended

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that the focus group session be short with fewer questions or have some kind of activity to break the session. Some third-grade children could not state how they thought others felt, so questions need to be rephrased to how they personally think or feel. The use of a talking stick was well received by the children and made transcription easier because everyone was not talking at once. Incentives in the form of money help with subject recruitment, as does the recruiter being known by the potential participants. This is important for both Caucasian and Hispanic groups. It is also important for the facility to be considered safe and easy to get to, with room for child care. More Hispanic groups needed to be conducted to reach a point in which information collected started to repeat because the Caucasian groups were more verbal. Transcription is more complicated and takes more time when two languages are involved. Two people must transcribe the transcripts and then compare the two versions to determine how close the two versions are in context and meaning. Two researchers need to code and analyze the transcripts to increase the validity of the data. The moderator must be bilingual, and if possible, a second member of the team needs to be bilingual. This makes the conducting of the focus groups and data interpretation easier and more valid.

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