Family Practice Vol. 19, No. 3, 278-284
© Oxford University Press 2002
Group interviews in primary care research: advancing the state of the art or ritualized research?
Dalhousie University Department of Family Medicine, Queen Elizabeth II Health Sciences Centre, Abbie J. Lane Building, 8th Floor, 5909 Veteran's Memorial Way, Halifax, NS B3H 2E2, Canada.
Twohig PL and Putnam W. Group interviews in primary care research: advancing the state of the art or ritualized research? Family Practice 2002; 19: 278–284.
Received 13 March 2001; Revised 13 September 2001; Accepted 7 January 2002.
 |
Abstract |
|---|
 Top Abstract Introduction: focus groups and...Group interviews in primary...ConclusionReferences |
|---|
Background. Focus groups have become an important data gathering technique in primary care research.
Objectives. This study provides an integrated review of recent articles that used focus groups as a data collection method to gather information from family physicians.
Methods. Medline was searched for articles that used focus groups with family physicians in a North American setting during the 1990s. Articles that met this criteria were critically evaluated to determine who participated, the number of groups conducted, setting, length, inclusion and exclusion criteria, sampling technique and whether the groups were used as part of a larger study.
Results. The twenty articles discussed herein revealed tremendous variation in how focus group research is conducted and reported.
Conclusions. Focus group research is a popular form of qualitative research in primary care research. Journals reporting qualitative research should require that certain basic information be present, thereby advancing the state of the art and permitting readers to better evaluate these articles.
Keywords. Focus groups, literature search, North America, primary care research.
|
Introduction: focus groups and primary care research in North America |
|---|
|
TopAbstractIntroduction: focus groups and...Group interviews in primary...ConclusionReferences |
|---|
Focus groups, as many researchers note,1–3 have a long pedigree, though for many years the method languished in obscurity. This neglect has been replaced with a renewed interest, and focus groups are now an important methodology in qualitative research. Morgan, surveying the Sociological Abstracts database, noted that the fields of sociology, education, political science, communication studies and public health, to name only a few, are using focus groups and often as a sole method.4 Even a cursory search of MEDLINE offers evidence of the trend. Using ‘focus group’ as a free search term, no articles were identified before 1985, while the same term yielded over 1000 articles in the period 1985–1999. Such impressionistic evidence is compelling. Focus groups have become common in health care research.5–10 They have been used to elicit information from particular age groups,11,12 ethnic populations,13–16 or individuals sharing health concerns.17–20 Focus groups have been used to study different components of the doctor–patient relationship,3 costs21 and perceptions of risk factors.22 They have also been used extensively in health education (Basch23 provides a review), and have proved useful for both exploratory work24 in education and evaluating programs or interventions.25 Finally, focus groups have been used successfully with physician groups,26 including family physicians and GPs.7,27,28
There is little doubt that focus groups have achieved great popularity as a form of qualitative data collection in health care research, and primary care research in particular. Such growth comes with a cost, in the form of "a plethora of inadequate studies, involving poor design and shoddy reporting".29 This has spawned a large number of ‘how-to’ books, chapters and articles.5,9,29–32 While such manuals and guides are extremely useful, they are not a substitute for a reflexive research practice. To cite Morgan (1997: p. 72), "An active awareness of the current state of the art is . . . necessary for doing high-quality work with focus groups. Parroting the received wisdom is not sufficient evidence that the work was done well".30 There is, then, a need to assess focus groups critically as part of the methodological tool kit for primary care research, to understand better how focus groups currently are being utilized and, ultimately, ensuring that our tools are suited to our research objectives. This paper also fits within a broader discussion of the "quality of qualitative research".33–36 This is not a comprehensive review but rather an integrative review of research articles that used focus groups involving primary care physicians in North America, intended to draw out several areas in need of further consideration. The focus on physicians and primary care research is intentionally narrow. Of course, one can find many exemplary studies published in other domains. However, the recent popularity of the method in primary care research in Canada and the USA warrants some critical reflection.
Publications resulting from original focus group research are the most accessible forum for improving the overall quality of interview-based research. Regrettably, many contributors and the journals that publish them do not take sufficient care to ensure that readers are well positioned to judge the quality of the work. Improving on the technique of focus group research (namely, the process) has not been well addressed in the literature. Hoddinott and Pill36 make a similar point in their review of qualitative research:
"The relationship between the subject and the interviewer, together with the context in which the interviews take place, are important details in appraising qualitative research. A published paper should provide sufficient methodological detail for a reader to be able to replicate the study and confirm the findings if required."
Providing readers with this level of detail must be the starting point for improving focus group research and, indeed, all qualitative research in primary care.
|
Group interviews in primary care research |
|---|
|
TopAbstractIntroduction: focus groups and...Group interviews in primary...ConclusionReferences |
|---|
David Morgan implicitly issued a call to researchers to "advance the state of the art" nearly a decade ago.37 In an attempt to answer Morgan, however faintly, a review of the current use of focus groups among primary medical care researchers was undertaken. For the purposes of this assessment, articles were critically evaluated if they included primary care physicians as focus group participants and were conducted in North America. A database of articles was constructed using MEDLINE and Sociological Abstracts, and 20 which met those criteria were selected (see Table 1
). Articles were read to determine the number of groups conducted, who participated, how many people participated and the participation rate, inclusion and exclusion criteria, sampling technique, setting, the role of the researcher in conducting the focus group, the length of focus group and whether the groups were conducted as an independent study or part of a mixed method project. Virtually all of the literature, discussed in depth below, would agree that each of these issues is critical to any assessment of the use of focus groups. Morgan recently concluded that "the reporting of focus group procedures is a haphazard affair at best".4 Certainly, the review of these articles confirms this assessment. What, then, did the articles report for each of these?
|
Groups
Not surprisingly, articles usually reported the number of groups that were conducted, which ranged from a low of two (n = 2), to a high of eight (n = 2), with an average of five groups conducted per project. The range of 3–5 focus groups for projects is well documented in the literature.30 This is predicated on the belief that more groups will not provide new information (‘saturation’).38 This, of course, is highly contingent upon the purpose of the study, the existing state of knowledge on the topic, the participants and the settings. Yet, in two of the articles critically examined, even this basic information was lacking.39,40 It is important to note that the Borkan article suggested that more detailed information about data collection was provided on the Journal of Family Practice website, but the website was not operable when this review was being prepared (Summer and Autumn 2000). This should serve as an important caution as medical journals increasingly turn toward on-line resources to provide additional information on research. If journals are to provide details about methodology via the web, they need to ensure that on-line resources remain available.
Participants
The number of participants per group also warrants some consideration. Typically, focus groups range from as few as four upwards to a dozen participants. Within this range, smaller and larger groups present their own challenges.2,4 The number of participants in projects varied from a low of 1041 to a high of 56.42 Several of the articles reported the range present in the groups, noting, for example, that between four and 12 persons participated.42–46 Often, articles report the cumulative number of participants for all the groups conducted. The number of participants, using simple calculations, range from 3.25 people per group to just over 10 people per group. Typically, groups appeared to consist of 5–8 persons. When only cumulative numbers are reported, rather than the range for the groups, it is difficult to ascertain the exact composition of any one group. Do we know, for example, whether a group was difficult to constitute? Cumulative reporting of participants might mask inadequately attended groups from the reader. Ideally, journals should require that both numbers be reported to permit readers critically to assess the composition of individual groups as well as the entire project.
Participation rates or other figures pertaining to recruitment were rarely reported in the articles examined. Sampling techniques were reported explicitly in all but four of the articles under consideration and, when named, were either ‘purposeful’ or ‘convenience’. Stewart and Shamdasani note that convenience sampling prevails among focus groups and that this is appropriate.2 If experience varies, say, according to age or gender, purposive or theoretical sampling will ensure that these views are captured. Of course, sampling in qualitative research must be guided by the research topic, not population representativeness. One study among those reviewed used purposeful followed by snowball sampling,47 while two others used random sampling techniques.43,44 Tudiver et al. explicitly reported that random sampling was used "because we believed any family physician could inform us on the matter".44 Clearly, researchers want participants in the focus group session who are knowledgeable about the topic under consideration, and purposive sampling or random sampling with an appropriate screening mechanism can yield good results. A focus group is not merely a conversation, but rather a focused discussion. This necessarily means recruiting persons who have something to say on a specified topic.
Not surprisingly, nearly all of the articles offered a description of the participants and most offered some indication of gender and other demographic information. Similarly, the focus group settings are reported with varying degrees of precision, ranging from naming the community to indicating a region. Persons writing about focus groups, and their editors, seem to have achieved a uniform standard of reporting such information.
One interesting trend was noted for all the research articles under review and that is the lack of representation from rural settings. Focus group research among physicians is overwhelmingly conducted in urban or suburban settings. Occasionally, researchers did make efforts to provide a mix of practice settings,40 but this was the exception. Indeed, one article was entirely misleading on this issue. A focus group was held in Winnipeg, Canada, ostensibly to give rural and isolated physicians an opportunity to participate. However, only two of the participants had a self-described ‘rural practice’ while another claimed to have a ‘mixed practice’ of either rural, suburban and urban, or suburban and rural.42 Goldman and McDonald suggest that much qualitative research is conducted in metropolitan centres due to ‘convenience’.48 While there are certainly practical considerations, as Crabtree et al. remind us,49 the exclusion of rural professionals from the vast majority of research should not simply be accepted. Rather, researchers, reviewers and readers need to pose the question why no rural participants were consulted and, more importantly, the implications of their exclusion.
Recruiting rural physicians also raises the important question of whether or not familiarity with one another matters. Familiarity, or ‘acquaintanceship’, is recognized to be an important consideration in focus group composition. Marketing researchers and their clients traditionally have expressed a preference for focus groups to be comprised of strangers,50 and this is perpetuated in many focus group manuals (for examples, see Goldman and McDonald, 1987: p. 3748 and Morgan, 1997: pp. 37–3830). Only one oft-cited study51 has explored the effect of acquaintanceship on the group process, and this study concluded that the effects were minimal and hardly damaging to group process.
More germane is the fact that it is very difficult to avoid acquaintanceship in many settings, including rural locales or where the recruitment pool is limited, as in the case of many groups of health care providers. Working among ready groups is certainly common among qualitative researchers, and familiarity among participants might actually help with group dynamics and disclosure.52 Rather than adhering to an idealized view that participants should not know one another, what needs to be explicated during analysis is the effect of acquaintanceship.
When drawing from a limited pool of physicians, participants will know one another and bring this dynamic to the session. However, this is not only an issue in rural settings. Physicians have well-established organizations, may share work on committees, socialize, etc. Familiarity is a reality if focus groups are conducted with practitioners from the same small community or recruited from an individual setting. It is unavoidable but should not dissuade researchers from such settings.
A related issue is to what extent participants share a common background. Here, we must again cite Morgan who suggested that the goal in any research is "homogeneity in background and not homogeneity in attitudes".30 Many researchers believe that homogeneity among participants allows for more free-flowing conversations. However, what constitutes homogeneity? If focus groups are segmented, they are typically done so according to sex, age, race and socio-economic status. Goldman and McDonald48 have written that
"Traditionally men and women have been segregated in group interviews on [various] assumptions . . . All of these concerns may have once been valid but social observation and actual research experience indicate that these issues are far less relevant now than they were 20 years ago. Today, it is largely inertia and research ritual which perpetuate an automatic segregation of the sexes in almost all group interview projects." (p. 30)
Is it enough to know that all the participants were physicians? Critical evaluation of research articles depends upon other important considerations such as length in practice, practice locale or broad questions of practice profile. Researchers and journals need to work together to provide readers with such details.
Articles under review did describe group composition in broad terms. For example, two of the articles constituted separate focus groups of patients and practitioners.53,54 Barden et al. (1998) divided participants according to practice type.43 Other researchers mixed some practitioners but not others. In one example exploring primary care services provided to the urban underserved in Utah, one focus group contained eight MDs and one DDS, a second group contained four MDs, while the third mixed three physician assistants with eight nurse practitioners.55 In another study39 designed to explore the barriers to using education materials, family and GPs, physician assistants, a nurse practitioner and a registered nurse were apparently mixed. The ‘mix’ of focus groups should reflect the research question. It may be perfectly acceptable to incorporate varying professional, experiential or other perspectives in a group if the intent, to name one example, is to explore the ways in which different participants interact. Alternatively, there are many cases where mixing persons of different experience, status or professional background could impede the group dynamic.
Issues of acquaintanceship, group homogeneity or compatibility2 pertain to the groups' inner interpersonal dynamic, and are rarely addressed in research articles using focus groups. Underlying much of the research is an implicit understanding that membership in a professional community, either singular (e.g. ‘family physician’) or broader (‘primary care provider’), is a sufficient proxy for compatibility. Clearly, professional credentials alone are not sufficient to establish a group's compatibility and there is a need to understand better, and report upon, how participants interact with one another during a focus group.56,57
Incentives
Having dealt with the process questions regarding composition, how does one ensure success, particularly if a research team is interested in pursuing focus group research in settings where the number of potential participants is small and demands on their time heavy? Morgan30 has argued that failure to achieve adequate recruitment is often the most important challenge facing researchers who wish to use focus groups. Five of the 20 articles under consideration explicitly reported offering incentives, while the remaining 15 made no mention of the issue. When reported, incentives included US$100,58,59 continuing medical education credits,53 cinema tickets55 or an unspecified ‘small stipend’.47 There are important ethical debates about paying research participants. Their use and nature must be reported more fully. In this way, readers will be able to turn a critical eye to questions of participation. In addition to material incentives, other strategies used to ensure adequate participation include respected peers carrying out the initial recruitment.60 Morgan suggests that over-recruitment by 20% is common; our experience with family physicians is that once they commit, they generally attend.61,62 Given the limited recruitment pool available for most studies, oversubscription to a session is probably not practical. Again, some description of the recruitment processes will permit readers to identify design weaknesses, and thereby permit a more thorough critical analysis of the literature.
Moderator
Regardless of the amount of attention a project gives to recruitment, these efforts will come to naught unless the sessions are moderated effectively. The role of the focus group moderator or facilitator is acknowledged in nearly every focus group handbook. Greenbaum,63 for example, writes:
"A good moderator will be able to work effectively with the flow of the group rather than feel compelled to stay with the predetermined order of discussion provided in the moderator guide . . . The effective moderator is able to deviate from the guide to explore an important area and then circle back to ensure that other key topics are appropriately covered . . ."
Judith Belle Brown64 echoes this, noting that moderators "play an essential role in the conduct of a successful focus group. Being a good moderator requires observational and facilitation skills. Engaging all the participants in the discussion, promoting a lively interchange, modulating conflict, and all the while following the interview guide . . ."
Given their critical role in a session's flow and, ultimately, its success, it is surprising how little attention is given to the role of the moderator in the articles under review. Readers, at minimum, are told whether the moderator was a member of the research team44,58 or a hired professional.42,43 Occasionally, more detail is provided, such as whether other researchers were present.47,53 Still, in four of the papers under consideration, it was impossible to discern who moderated the sessions or the role of the researcher in the conduct of the groups.39–41,65 Research articles and journals need to ensure that readers can understand both who the moderator was and the role that person played.
If members of the research team are present during the sessions, they will inevitably feel a ‘closeness’ to the data that is otherwise difficult to replicate. Morse has suggested that the presence of the researcher yields insights into the context of the discussion that readers of transcripts or other material who were not present lack. For example, the researchers present will remember pauses (telling or otherwise), non-verbal expressions, interruptions and other cues that may reveal much more than the words on the transcript page.66 It is, therefore, usually desirable for at least one and perhaps more members of the research team to be present at each session.
A related issue is whether the moderator and the group share a common professional background. If so, and if left unchecked, many of the assumptions, beliefs and practices could go unsaid, leaving the researchers with a much less explicit and robust transcript. Slipping into a professional "verbal shorthand can mask subtleties that participants would articulate explicitly for a moderator who is thought to be less knowledgeable about the subject".48 Another concern arises if the moderator shares in the professional culture of the group. Goldman and McDonald (1987: p. 27) suggest that if the moderator is a peer or a perceived ‘expert’ in the area under discussion, "it is difficult to safeguard the group process against a sort of inversion in which participants assume a learning posture and the moderator slips into the role of teacher".48 The purpose of a focus group, of course, is to discover information and not to impart it. Clearly, caution needs to be exercized by the moderator who shares in a professional peer culture, but the key is to recognize the potential pitfall and guard against it. Morgan (1997: p. 49) provides sage advice on this issue: "The best introduction is often the honest admission that the researcher is there to learn from them, but do not carry this attitude to the extreme of faking ignorance."30
Related to the question of facilitator is the interview guide, which was included in few of the articles under consideration.41,42,44,67 Interview guides are important because they set the agenda, provide prompts and, perhaps, ensure comparability across the groups. It is often difficult to anticipate the number of topics that can be considered in a session. Topics that are non-starters with one group may be barn-burners for another. Stewart and Shamdasani suggest that "the more complex a topic, the more emotionally involving the topic, or the greater the heterogeneity of views on the topic within the group, the fewer the topics and specific questions that can be covered".2 To this we need to add the degree of probing necessary (or pursued) and the degree of moderator involvement. All of these factors will determine the number of topics completed during a session.
|
Conclusion |
|---|
|
TopAbstractIntroduction: focus groups and...Group interviews in primary...ConclusionReferences |
|---|
There have been many useful overviews of what to do in focus groups. In addition to the seminal work of David Morgan and Richard Krueger, overviews have been provided in journals such as Qualitative Health Research (see Volume 5, issue 4, 1995 for a special issue on focus groups) and as chapters in various edited collections.5,68 There remains, however, a need to continue to evaluate the ‘state of the art’. This requires vigilance on the part of researchers, reviewers and editors.
Writing in 1974, Harvard Business School Professor W Skinner argued that "simplicity and repetition breed competence".69 While many journals are publishing increased numbers of qualitative articles, what is most striking is how reports vary, even within particular publications. The answer is not to impose ‘qualitative checklists’70 in an uncritical fashion, but rather to encourage journals and authors to provide enough detail to permit critical appraisal. At minimum, this should include a description of the number of groups, the recruitment process, the range of the groups and a description of participants, the participation rate, inclusion and exclusion criteria, the role of the researchers, the length of the sessions and the locales. Additional information, such as the provision of incentives, should also be included where appropriate. If, instead of adherence to innumerable prescriptive dictums regarding focus groups, editors worked toward standardized reporting and required authors to explain their methodological decisions, ritualized research would be replaced by a new vanguard of methodologically sophisticated studies.
|
Acknowledgments |
|---|
We would like to thank all the physicians who agreed to participate in research focus groups. Without them our work is impossible. We would also like to thank Fred Burge, Lois Jackson and Jafna Cox for their involvement in the broader research effort.
|
References |
|---|
|
TopAbstractIntroduction: focus groups and...Group interviews in primary...ConclusionReferences |
|---|
1 Merton RK, Fiske M, Kendall PL. The Focused Interview: A Manual of Problems and Procedures. New York: Free Press, 1990.
2 Stewart DW, Shamdasani DW. Focus Groups: Theory and Practice. Newbury Park: Sage, 1990.
3
Morgan DL, Zhao PZ. The doctor–caregiver relationship: managing the care of family members with Alzheimer's disease. Qual Health Res 1993; 3: 133–164.
4 Morgan DL. Focus groups. Annu Rev Sociol 1996; 22: 129–152.[Web of Science]
5 Brown JB. The use of focus groups in clinical research. In Crabtree BF, Miller WL (eds). Doing Qualitative Research. Thousand Oaks: Sage, 1999: 109–124.
6
Powell RA, Single HM. Focus groups. Int J Qual Health Care 1996; 8: 499–504.
7
Tang KC, Davis A. Critical factors in the determination of focus group size. Fam Pract 1995; 12: 474–475.
8
Kitzinger J. Introducing focus groups. Br Med J 1995; 311: 299–302.
9 Morgan D. Designing focus group research. In Stewart M, Tudiver F, Bass MJ, Dunn EV, Norton PG (eds). Tools for Primary Care Research. Newbury Park: Sage, 1992: 205–230.
10 Khan ME, Anker M, Patel BC, Barge S, Sadhwani H, Kohle R. The use of focus groups in social and behavioural research: some methodological issues. World Health Status Q 1991; 44: 145–149.[Medline]
11 Wayland J, Rawlins R. African American teen mothers' perceptions of parenting. J Pediatr Nurs 1997; 12: 13–20.[Medline]
12
Russell CK. Elder care recipients' care-seeking process. West J Nurs Res 1996; 18: 43–62.
13 Madriz EI. Using focus groups with lower socioeconomic status Latina women. Qual Inquiry 1998; 4: 114–128.
14 Williams GA, Abbott RR, Taylor DK. Using focus group methodology to develop breast cancer screening programs that recruit African American women. J Community Health 1997; 22: 45–56.[Web of Science][Medline]
15 Maillet NA, D'Eramo-Melkus G, Spollett G. Using focus groups to characterize the health beliefs and practices of black women with non-insulin-dependent diabetes. Diabetes Educ 1996; 22: 39–46.
16 Anderson RM, Barr PA, Edwards GJ, Funnell MM, Fitzgerald JT, Wisdom K. Using focus groups to identify psychosocial issues of urban black individuals with diabetes. Diabetes Educ 1996; 22: 28–33.
17 Rafferty NA, Radosh A. Attitudes about AIDS education and condom availability among parents of high school students in New York City: a focus group approach. AIDS Educ Prevent 1997; 9: 14–30.[Web of Science][Medline]
18 Ferrell BR, Grant MM, Funk B, Otis-Green S, Garcia N. Quality of life in breast cancer survivors as identified by focus groups. Psychooncology 1997; 6: 13–23.[Medline]
19 Fox-Young S, Sheehan M, O'Connor V, Cragg C, Del-Marr C. Women's perceptions and experience of menopause: a focus group study. J Psychosom Obstet Gynaecol 1995; 16: 215–221.[Medline]
20 Hospers HJ, Molenaar S, Kok G. Focus group interviews with risk-taking gay men: appraisal of AIDS prevention activities, explanations for sexual risk-taking, and needs for support. Patient Educ Couns 1994; 24: 299–306.[Web of Science][Medline]
21 Taylor TR. Pity the poor gatekeeper: a transatlantic perspective on cost containment in clinical practice. Br Med J 1989; 299: 1323–1325.
22 Morgan DL, Spanish MT. Social interaction and cognitive organization of health-relevant behavior. Sociol Health Illness 1985; 7: 407–422.
23 Basch CE. Focus group interview: an underutilized research technique for improving theory and practice in health education. Health Educ Q 1987; 14: 411–448.[Web of Science][Medline]
24
Howland J, Sargent J, Weitzman M et al. Barriers to bicycle helmet use among children. Am J Dis Child 1989; 143: 741–744.
25 Krueger RA. Focus Groups: A Practical Guide for Applied Research. Newbury Park: Sage, 1988.
26 Ashbury FD, Gospodarowicz M, Kaegi E, O'Sullivan B. Focus group methodology in the development of a survey to measure physician use of cancer staging systems. Can J Oncol 1995; 5: 361–368.[Medline]
27 Jackson L, Yuan L. Family physicians managing tuberculosis. Qualitative study of overcoming barriers. Can Fam Physician 1997; 43: 649–655.[Web of Science][Medline]
28 Brown JB, Sas G. Focus groups in family practice research: an example study of family physicians' approach to wife abuse. Fam Pract Res J 1994; 14: 19–28.[Medline]
29 Krueger RA. Quality control in focus group research. In Morgan DL (ed.). Successful Focus Groups: Advancing the State of the Art. Newbury Park: Sage, 1993: 65–85.
30 Morgan DL. Focus Groups as Qualitative Research. Thousand Oaks: Sage, 1997.
31 Barbour RS, Kitzinger J. Developing Focus Group Research: Politics, Theory, and Practice. Thousand Oaks: Sage, 1999.
32 Greenbaum TL. The Practical Handbook and Guide to Focus Group Research. Lexington: D.C. Health and Company, 1988.
33 Seale C. Quality in qualitative research. Qual Inquiry 1999; 5: 465–478.
34
Chapple A, Rogers A. Explicit guidelines for qualitative research: a step in the right direction, a defence of the ‘soft’ option, or a form of sociological imperialism? Fam Pract 1998; 15: 556–561.
35
Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qual Health Res 1998; 8: 341–351.
36
Hoddinott P, Pill R. Qualitative research interviewing by general practitioners. A personal view of the opportunities and pitfalls. Fam Pract 1997; 14: 307–312.
37 Morgan DL (ed.). Successful Focus Groups: Advancing the State of the Art. Newbury Park: Sage Publications, 1993.
38 Glaser BG, Strauss AL. The Discovery of Grounded Theory. Chicago: Aldine, 1967.
39 Kenner MM, Taylor ML, Dunn PC, Gruchow HW, Kolasa K. Primary care providers need a variety of nutrition and wellness patient education materials. J Am Diet Assoc 1999; 99: 462–466.[Web of Science][Medline]
40 Borkan JM. Examining American family medicine in the new world order: a study of 5 practices. J Fam Pract 1999; 48: 620–627.[Web of Science][Medline]
41 Farber SJ, Egnew TR, Herman BJ. Issues in end-of-life care: family practice faculty perceptions. J Fam Pract 1999; 48: 525–530.[Web of Science][Medline]
42 Rowan MS, Toombs M, Bally G, Walters DJ, Henderson J. Qualitative evaluation of the Canadian Medical Association's counselling guidelines for HIV serologic testing. Can Med Assoc J 1996; 154: 665–671.[Abstract]
43
Barden LS, Dowell SF, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents: results from physician's and parents' focus group discussions. Clin Pediatr 1998; 37: 665–671.
44 Tudiver F, Talbot Y. Why don't men seek help? Family physicians' perspectives on help-seeking behavior in men. J Fam Pract 1999; 48: 47–52.[Web of Science][Medline]
45 Brown JB, Lent B, Sas G. Identifying and treating wife abuse. J Fam Pract 1993; 36: 185–191.[Web of Science][Medline]
46 Craven MA, Cohen M, Campbell D, Williams J, Kates N. Mental health practices of Ontario family physicians: a study using qualitative methodology. Can J Psychiatry 1997; 42: 943–949.[Web of Science][Medline]
47
Gerbert B, Caspers N, Bronstone A, Moe J, Abercrombie P. A qualitative analysis of how physicians with expertise in domestic violence approach the identification of victims. Ann Intern Med 1999; 131: 578–584.
48 Goldman AE, McDonald SS. The Group Depth Interview: Principles and Practice. Englewood Cliffs (NJ): Prentice-Hall, 1987.
49 Crabtree BF, Yanoshik MK, Miller WL, O'Connor PJ. Selecting individual or group interviews. In Morgan DL (ed.). Successful Focus Groups: Advancing the State of the Art. Newbury Park: Sage, 1993: 137–149.
50 Nelson JE, Frontczak NT. How acquaintanceship and analyst can influence focus group results. J Advertising 1988; 17: 41–48.
51 Fern EF. The use of focus groups for idea generation: the effects of group size, acquaintanceship, and moderator on response quantity and quality. J Market Res 1982; 19: 1–13.
52 Jarrett RL. Focus group interviewing with low-income minority populations. In Morgan DL (ed.). Successful Focus Groups: Advancing the State of the Art. Newbury Park: Sage, 1993: 184–201.
53
Beaulieu MD, Hudon E, Roberge D, Pineault R, Forte D, Legare J. Practice guidelines for clinical prevention: do patients, physicians and experts share common ground? Can Med Assoc J 1999; 161: 519–523.
54 Cave A, Maharaj U, Gibson N, Jackson E. Physicians and immigrant patients. Cross-cultural communication. Can Fam Phys 1995; 41: 1685–1690.[Web of Science][Medline]
55
Li LB, Williams SD, Scammon DL. Practicing with the urban underserved. A qualitative analysis of motivations, incentives, and disincentives. Arch Fam Med 1995; 4: 124–133.
56 Kitzinger J. The methodology of focus groups: the importance of interaction between research participants. Sociol Health Illness 1994; 16: 103–121.
57 Albrecht TL, Johnson GM, Walther JB. Understanding communication processes in focus groups. In Morgan DL (ed.). Successful Focus Groups: Advancing the State of the Art. Newbury Park: Sage, 1993: 51–64.
58
Geller G, Holtzman NA. A qualitative assessment of primary care physicians' perceptions about the ethical and social implications of offering genetic testing. Qual Health Res 1995; 5: 97–116.
59 Komaromy M, Lurie N, Bindman AB. California physicians' willingness to care for the poor. West J Med 1995; 162: 127–132.[Web of Science][Medline]
60 Rush BR, Powell LY, Crowe TG, Ellis K. Early intervention for alcohol use: family physicians' motivations and perceived barriers. Can Med Assoc J 1995; 152: 863–869.[Abstract]
61
Burge F, McIntyre P, Twohig P et al. Palliative care by Canadian family physicians in the 1990s: resiliency amid reform. Can Fam Physician, 2001; 47: 1989–1995.
62 Putnam W, Burge F, Tatemichi S, Twohig P. Asthma in primary care: making guidelines work. Can Resp J, 2001; 8(Suppl A): 29A–34A.
63 Greenbaum TL. The Practical Handbook and Guide to Focus Group Research. Lexington: D.C. Health and Company, 1988.
64 Brown JB. The use of focus groups in clinical research. In Crabtree BF, Miller WL (eds). Doing Qualitative Research. Thousand Oaks: Sage, 1999: 109–124.
65 Reid AJ, Biringer A, Carroll JD et al. Using the ALPHA form in practice to assess antenatal psychosocial health. Antenatal Psychosocial Health Assessment. Can Med Assoc J 1998; 159: 677–684.[Abstract]
66
Morse J. ‘Perfectly healthy, but dead': the myth of inter-rater reliability. Qual Health Res 1997; 7: 445–447.
67 Carney PA, Rhodes LA, Eliassen MS et al. Variations in approaching the diagnosis of depression: a guided focus group study. J Fam Pract 1998; 46: 73–82.[Web of Science][Medline]
68
Carey MA, Smith MW. Capturing the group effect in focus groups: a special concern in analysis. Qual Health Res 1994; 4: 123–127.
69 Skinner W. The focused factory. Harvard Business Rev 1974; May–June: 113–122.
70
Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? Br Med J 2001; 322: 1115–1117.
71 Cohen M, Woodward CA, Ferrier B, Williams AP. Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians. CMAJ 1995; 153(2): 169–176.[Abstract]
72 Cohen M, Woodward CA, Ferrier B, Williams AP. Interest in different types of patients. What factors influence new-to-practice family physicians? Can Fam Phys 1996; 42: 2170–2178.[Web of Science][Medline]
73 McConaghy JR. Extending patient care office hours: what factors are important to consider? J Fam Pract 1999; 48(3): 196–201.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  L. A. Curry, I. M. Nembhard, and E. H. Bradley Qualitative and Mixed Methods Provide Unique Contributions to Outcomes Research Circulation, March 17, 2009; 119(10): 1442 - 1452. [Full Text] [PDF]
|
|
|
|
 |
|
 M. J. Yaffe, P. Orzeck, and L. Barylak Family physicians' perspectives on care of dementia patients and family caregivers Can Fam Physician, July 1, 2008; 54(7): 1008 - 1015. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Emslie, F. Whyte, A. Campbell, N. Mutrie, L. Lee, D. Ritchie, and N. Kearney 'I wouldn't have been interested in just sitting round a table talking about cancer'; exploring the experiences of women with breast cancer in a group exercise trial Health Educ. Res., December 1, 2007; 22(6): 827 - 838. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S Reventlow and C Tulinius The doctor as focus group moderator--shifting roles and negotiating positions in health research Fam. Pract., June 1, 2005; 22(3): 335 - 340. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.-M. Feron, F. Cerexhe, D. Pestiaux, M. Roland, D. Giet, C. Montrieux, and D. Paulus GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study Fam. Pract., April 1, 2003; 20(2): 167 - 172. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||