Family Practice Advance Access originally published online on March 16, 2005
Family Practice 2005 22(3):335-340; doi:10.1093/fampra/cmi003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The doctor as focus group moderator—shifting roles and negotiating positions in health research
Research Unit of General Practice and Department of General Practice, University of Copenhagen, Copenhagen, Denmark
Correspondence to Susanne Reventlow; Email: sr{at}gpract.ku.dk, s.reventlow{at}dadlnet.dk
Received 20 April 2004; Accepted 30 December 2004.
Reventlow S and Tulinius C. The doctor as focus group moderator—shifting roles and negotiating positions in health research. Family Practice 2005; 22: 335–340.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
Background. Any research is inextricably entwined with the researcher's positions adopted while collecting data. This represents an important challenge to focus group moderators whose positions within the group influence data collection. This situation is particularly important in health research where moderators are doctors.
Objectives. This study explores the moderator's social interaction with the group, in particular the moderator's position and how it affects data collection, the research process and knowledge production.
Methods. A qualitative study exploring group dynamics and the moderator's positions in focus group discussions, in particular the interaction between the moderator's position and her role as a doctor.
Results. The social construction and negotiation of the doctor's position depended both on the participants' view of the moderator and on the moderator's situational response. The moderator dealt with the participants' expectations and alternated between different positions: those she chose for herself and those chosen for her by the participants. Adoption of an active strategy outlining the moderator's position clarified the framework of data collection.
Conclusions. Doctors using focus groups as research tool to gain insight into people's ideas about illness must be conscious about how their medical background influences their positions during data collection. The focus group moderator must balance between letting participants discuss the topics without being disturbed and actively intervening in the discussion to clarify the process. The researcher has to set the boundaries and guidelines as to how the research is conducted.
Keywords. Focus groups, group processes, professional role, qualitative research, reflexivity, researcher's position, researcher–subject relations.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
Focus group discussions are increasingly being used in medical research to explore people's ideas on health issues.1 The importance of the moderator's role as facilitator has been studied, but the moderator's interaction with the focus group during data collection and the effect of this on the research process has rarely been addressed by medical research.1
Any research and the resulting knowledge is inextricably entwined with the researcher's presuppositions and the positions adopted while collecting data.2,3 A reflexive research practice therefore becomes important.1,2 Reflexivity implies being self-conscious about knowledge production while it is being produced.3,4 In the present study the authors' background in general practice, medical anthropology and education of health professions creates an interdisciplinary space raising our awareness of methodological challenges in the data collection process.
This methodological article based on empirical data explores the moderator's interaction with the focus group while collecting data and outlines how this interaction affects knowledge production.
The study is part of a larger study about women's ideas about osteoporosis and health risks.5,6 Women's comprehension of osteoporosis covered a spectrum of coexisting prototypical models. At the two extremes osteoporosis was conceived either as part of the ageing process or as a threat of disease. The latter comprises both issues of osteoporosis as a disease and as a risk condition. Many women felt a kind of uncertainty about the condition of osteoporosis. The present paper raises some methodological issues. The main result of the empirical data will be presented elsewhere.
We wish to introduce the concept of position and deploy it in a reflexive research process using focus groups. In studies using focus groups, social interaction between several people engaged in discussion is central.7,8 A position in a conversation is a metaphorical concept whereby a person's moral and personal attributes as a speaker are compendiously collected.9 To some extent you can position yourself or be positioned.9 Position in this sense is a socially negotiated identity, but position could also be referred to as the person's subjective approach to the topic. In the context of the present study, positioning is partly determined by the moderator's association with the medical profession, and we will demonstrate how this affects the research project. The moderator works as a GP and at a university and hence assumes various professional roles, which, along with her age and gender, provide her with many positional options.
The aim of the article is to describe the positions assigned to and adopted by the moderator and to discuss how they are influenced by her other professional roles. Furthermore, the article will reflect upon the researcher's effect on the data.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
Focus groups produce knowledge through a discussion between participants exploring a specific set of issues. The group itself directs the discussion under the guidance of a moderator who probes for further explanation, if necessary.8,10 Group members respond directly to each other, offering comments and generating more questions about the topic at hand.11 The groups were planned in detail in advance and issues regarding topic guide, place, group process, and effect of the moderator's medical training were discussed. All participants, including the moderator and the note taker, however, are social agents and the way they interact affects the empirical data. The moderator will always know more about the topic discussed. However, it was anticipated that the moderator's medical training could influence the process, especially when one of the discussion topics was a rather new health issue like osteoporosis. Therefore it was decided that an observer participated in the focus groups taking notes about the group process. This was possible only in the first two focus groups.
Four focus group discussions with 22 women aged 60–61 were conducted in relation to a Danish population health study.12 Participants were purposefully selected based on answers to a questionnaire. The groups were composed of healthy women who had expressed knowledge of osteoporosis (92% of all participants in the questionnaire). Some of the women had personal health experience regarding bone fractures and osteoporosis. Three had got a bone mineral scan and two the diagnosis of osteoporosis. None of the participants were disabled. Each group consisted of four to six participants. The discussions lasted from 120 to 150 minutes and were conducted at the population study centre. The moderator introduced a predetermined set of topics to all groups (Box 1), but each group was allowed to pursue its own themes reflecting the particular group dynamics. In three of the focus groups, the participants discussed a leaflet from the Danish Osteoporosis Association.
BOX 1 Predetermined set of topics
|
The researcher (SR) acted as moderator and introduced herself as researcher working at the population study, anthropologist, and GP. The purpose of this was to be honest about the moderator's medical background and to create a clear and explicit relation to the participants. The moderator also considered it ethical to inform the participants that she worked with health questions in her capacity as a doctor. She emphasized her interest in the participants' personal ideas about osteoporosis and bone fractures and also said that if they had any medical queries they might be addressed at the end.
|
Analysis |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
The group discussions were tape recorded and transcribed verbatim. The notes on the group process were read together with the transcripts. The transcripts served as the textual database for the analysis done by SR. All text was systematically browsed and coded. Perspectives on group interaction,13 and the participants' positions in the focus group focused the reading. Special attention was given to the moderator's positions and this contributed to the choice of categories presented below. The authors discussed the results concerning methodological perspectives of positioning in the focus groups, and the specific expressions of the categories identified were developed.
|
Results |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
Positions were determined by the participants' expectations, knowledge and topic experience, and by the moderator's expectations of herself and her approach to the concrete situations.
The results are grouped into two main categories: (1) the participants' ways of positioning the moderator; and (2) the moderator's choice of position.
The participants' ways of positioning the moderator
Most participants had some pre-defined expectations of the group meetings. Some thought it very exciting to share and discuss their own experiences with other women. Others wanted to help advance research and a third group wanted to receive additional information about osteoporosis, for example:
"... I am interested in this and that's why I'm here today (...) I'm excited to learn more."The proclaimed aim of the main study was to get insight into women's ideas about osteoporosis; still, the participants used this opportunity to acquire more information or to confirm existing knowledge. The moderator was outside the consultation room in terms of space, but the participants placed her in the doctor's position by directing medical questions to the group, for example:
"But these brittle bones—Do they have anything to do with the time you stop having your periods and begin menopause or what?"None of the participants in the groups answered, and after a short while the moderator answered:
Moderator: "Now you naturally ask about this because I am a doctor?"The women told that it was difficult to discuss something with which they had no experience of their own. However, they had many thoughts, imaginations and questions about the topic. They told that they would not ask their own GP about osteoporosis, as they did not relate to any concrete symptoms; however, they appreciated the opportunity to talk to a doctor.Woman: "Yes, exactly."
The moderator promised again to answer questions after the discussion, and explained her reluctance to give answers during the discussion because, first of all, she was interested in hearing about their opinions and imaginations of the topic.
Participants' knowledge and prior experiences influence positions. The participants' variable prior experience affected their ability to engage in discussion. All had prior experience with bone fractures, which they earlier regarded as natural accidents and they gladly gave their own accounts about this topic. Participants with personal experience with osteoporosis obtained a special position in the group as they could give long accounts of their experiences. Most of the other participants' contributions were based on their images and imagination of the condition. They had read or heard about osteoporosis or they had family members or friends with the condition. The issue embraced much uncertainty and was often marked by an undercurrent of danger and worry. When the moderator asked them about osteoporosis, a few felt that she was testing their subject knowledge. For example, one woman said to the moderator:
"You know so much more about this than I do ... I'm just saying, sort of, what I have understood."The feeling of not knowing anything valuable about osteoporosis was common among some women. They felt it difficult to discuss osteoporosis, as they thought that their personal imaginations of osteoporosis were less correct than the medical answers. Concrete experience strengthened the participants' positions and they felt their knowledge more valuable.
The participants used the GP in their own argumentation. The participants sometimes consciously used medical language. This could be interpreted as a way of positioning the moderator as a doctor, for example:
"I have received something called "Vagifem", and you must know that drug."The participants positioned the moderator as the authority: the one who had the right answer, especially concerning issues of osteoporosis and a few personal health issues. Thus, the moderator was used as one who could back a participant's own series of arguments, using medical terminology and knowledge. They also consulted her authority in an attempt to position themselves as unknowing, but at least not naïve in the eyes of the others.
The moderator's choice of position
The moderator noticed how her interaction with the group and her position in it changed. She was placed in the position of the doctor, but was reluctant to assume this position as it conflicted with the purpose of the discussion. Therefore, she tried to facilitate the discussion using different strategies, each with different consequences for data collection. If the moderator started with questions regarding osteoporosis, many women waited to speak or withheld information as they felt insecure about their answers. Inversely, the discussion developed freely when the moderator began to speak openly about the process, her position as a moderator and the importance of the participants' opinions.
The consequences of keeping up an unobtrusive position. The moderator encouraged the women to discuss the subject without interruptions; still, she intervened in order to involve everyone. When questions were raised, she sometimes felt like answering, but chose not to, thereby keeping an unobtrusive position. As a researcher she found it important not to interrupt to clear up medical misunderstandings, she was there to learn from the participants and she was aware of the possible effect of her presence on the participant's confidence to express their opinions freely. Still, she found it difficult not to interrupt to solve obvious medical misunderstanding; for example, a woman explained her experience with osteoporosis:
"It hurts so much that sweat just runs down your body. Everything swells up and every single bone hurts. I tell myself that it has to do with what I eat; after beef, for instance, I can't stand being anywhere."It seemed as if the woman was waiting for the moderator and the doctor's comments. However, she did not interrupt, and the other participants engaged in a massive display of opinions, finally concluding that she might have some kind of rheumatism instead of osteoporosis. Many of the women's scenarios of women having or liable to develop osteoporosis appeared to be founded on the worst case prototypical disease of osteoporosis. The moderator's interaction with the focus group was also affected by her working conditions: the optimal condition for the moderator was to arrive in good time and to be emotionally and intellectually prepared for the group. On one occasion, she came straight from a busy day in general practice and hence responded more quickly to medical questions as she was still influenced by the role of the GP.
On one occasion the participants discussed the value of having a bone scan and one said that she would go home and ask her doctor for a bone scan, just to check if she had osteoporosis. Later, the woman contacted the Population Study Centre and it turned out that the woman had thought that the moderator (as a doctor) had recommended a bone scan as she did not interrupt. The moderator's silence was interpreted as the doctor's consent.
The consequences of taking a more active handling strategy. The moderator found out that she could influence group dynamic by vocalising how she interpreted the process in the group and by stating which position she preferred:
"... you ask me as a doctor—is it because you think that I know more about it? I do know more about the way the health care system thinks about osteoporosis, but I don't know about your own and other women's experiences and ideas about osteoporosis. And I would like to gain more knowledge about this subject. I have no personal experiences with bone fractures or osteoporosis myself."In this way the moderator acknowledged her position as a doctor; at the same time she positioned herself as the novice by revealing her lack of personal experience. One participant noticed that she was younger than them. All participants were thereby encouraged to share their personal experiences, and they were ensured of the validity of their knowledge.
The moderator also used another active communication strategy in order to avoid the position of the doctor. She presented some of the requested information of osteoporosis by handing out leaflets. Using active handling or communication strategies, she managed to adjust and balance the participants' way of positioning her; however, she was still perceived as a doctor. She tried to clarify the frame of the data collection thus expounding her own position as a moderator, not an expert. She simultaneously positioned the participants as experts: they were the ones who had important and valuable experiences, and she invited them to share their knowledge.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
The focus group provides insight into the relational construction of beliefs and social processes of belief formation.14 We chose to use the concept of position as explained by Harré and Langenhove.9 They perceive roles as rather static and formal, while the concept of position implies the possibility of shifting roles during discourse depending on the circumstances.15 This allows us to think of ourselves as subjects able to choose and influence positions, our own as well as those of others.15
The moderator tried to adjust the participants' positioning of her by using various strategies, e.g. to strengthen the women's position by asking about concrete experiences from their everyday lives, to openly acknowledge their view of her as a doctor and to explain that the important issue was to hear their opinions about the topic. By complying with the needs of the focus group—a need which was intertwined with the social interaction between the participants—she managed to uphold the moderator's position as a discussion facilitator.
The constructions of the moderator's positions were not unilateral processes, but were conditional upon the relations in the group. During the focus group discussions, the researcher became increasingly aware of her possibility of shifting between several different positions, as also noted in a qualitative study by Hamberg and Johansson.16 They found that their interviews were influenced by their positions as physicians, women or researchers and that awareness of this factor was crucial to their data interpretation.16 All three positions were associated with power, but, as in our study, power was most marked when the moderator assumed authority in the position of the doctor.16 In this study the moderator was placed in a position of power because she was the moderator controlling the discussion. However, this power was augmented by the participants' sense of her expertise in certain areas of medical knowledge. It was evident when they discussed osteoporosis that some of the women felt that they needed to know more. The participants wanted a dialogue, rather than simply to supply the researcher with information. It is an important issue why participants should be prepared to share their knowledge if the researchers are not prepared to reciprocate.
As recognised by Richards and Emslie, the researcher's role as a doctor influenced data collection.17 The moderator's position was influenced both by what actually transpired in the local, small-scale context of the discussion and in the context of society at large, e.g. specific preconceptions of occupational and social roles. Having recognised how her position was socially constructed and could be negotiated by voicing her position actively, the moderator could influence group dynamics, her own position and, thereby, knowledge production.
Consequences for the research project and knowledge production
The apparent dichotomy between the moderator's own positional perception and that of the participants turned out to be very productive to the research. The moderator took precautions, specifically clarifying the objectives of the discussion and the process. This clarified the frame of the knowledge production and the premises of the actual research.
Focus group discussions create a social dynamic where the construction and negotiation of meaning and discursive reality unfolds during the course of the discussion. It is a function of positions assumed by or given to the participants and the moderator. The idea that knowledge emerges from insight acquired by the researcher through her personal interaction with the focus group participants rests on the assumption that the researcher and the participants recognise each other as conscious social agents.18 Hence, focus group based research generates knowledge that is constructed not primarily at the level of the individual researcher, but by virtue of the collective effort and commitment of the entire group of participants. According to Haraway, the only objective knowledge you can produce is situated knowledge.19 She states that the observer's perspective is always limited and that this determines what the observer can see.19 We believe that knowledge is never objective in the traditional sense of being neutral and detached: it will always be situated. The moderator has to be involved and has to facilitate the discussion. The conditions underlying group interaction and the participants' positions establish the knowledge production framework.
The moderator can never remain a neutral focus group facilitator. The researcher effect is not just an issue for medically qualified researchers, but for all researchers who conduct qualitative research of this nature. The moderator's authority as a doctor created an asymmetric role relationship which to some extent hindered the exchange of experiences. This position was given to the moderator by the women who expected the moderator to be a medical expert. Some of the participants doubted the validity of their own knowledge and wished to incorporate medical knowledge into their own knowledge web. Perhaps this lack of confidence was connected to the fact that many women comprehended osteoporosis as an abstract phenomenon, not a concrete condition.
According to Skjervheim, the researcher can only gain access to social phenomena of interest by recognising herself as a contributing participant.20 Only by conscious intervention did the moderator achieve her aim, which was to unfold the participants' knowledge.
Practical implications of alternating positions
The researcher has to set the boundaries and guidelines as to how the focus group is conducted and has to clarify the process. It is important to develop a strategy for dealing with group interaction and with the moderator's position. In this study an active strategy of expressing the moderator's positioning clearly established the framework for the knowledge production. This paper illustrates that doctors acting as focus group moderators must be conscious about how their medical background influences their position and the discussion. They can be placed in the position of the ‘content expert’ and cannot lean back and pick up data. They have to interact socially with the group and first and foremost clarify the frame of the discussion. It is important to encourage the participants to regard their personal knowledge as valuable from a scientific point of view.
The focus group constitutes an example of Hastrup's point that the world is always experienced from a particular point in a social space.21 Moreover, this point is in constant flux as illustrated by the present paper. The way in which positions affect focus group research depends on both the socio-cultural values ascribed to such positions in society at large and on social networks created in the particular context at hand.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
Funding: this research was funded by The Danish Research Foundation for General Practice.
Ethical approval: Ethical approval was given to the Danish population health study and the studies related to. It was not needed for this specific study.
Conflicts of interest: none.
|
Acknowledgments |
|---|
We are grateful to Professor Kirsti Malterud and to Assistant Professor Charlotte Baarts for their comments.
|
References |
|---|
|
TopAbstractIntroductionMethodsAnalysisResultsDiscussionDeclarationReferences |
|---|
1 Twohig PL, Putnam W. Group interviews in primary care research: advancing the state of the art or ritualized research? Fam Pract 2002; 19: 278–284.
2 Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001; 358: 483–488.[CrossRef][Web of Science][Medline]
3 Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet 2001; 358: 397–400.[CrossRef][Web of Science][Medline]
4 Baarts C, Tulinius C, Reventlow S. Reflexivity—a strategy for a patient-centred approach in general practice. Fam Pract 2000; 17: 430–434.
5 Reventlow S, Hvas AC, Tulinius C. "In really great danger ..." The concept of risk in general practice. Scand J Prim Health Care 2001; 19: 71–75.[CrossRef][Web of Science][Medline]
6 Reventlow S. AM Rivista della Societá Italiana di antropologia medica. Themes in Medical Anthropology. From accident to diagnosis. Cultural response to the risk of osteoporosis. Argo; 2002: 87–99.
7 Barbour RS, Kitzinger J (eds). Developing focus group research. Politics, theory and practice. London: Sage Publications; 1999.
8 Brown JB, Crabtree BF, Miller WL (eds). Doing Qualitative Research. London: Sage Publications; 1999, 109–24.
9 Harré R, Langenhove Lv. Varieties of Positioning. J Theory Soc Behav 1991; 21: 393–407.
10 Morgan DL. Focus groups as qualitative research. Qualitative research methods series 16. London: Sage Publications; 1988.
11 Kitzinger J, Barbour RS. Developing focus group research. Politics, theory and practice. London: Sage Publications; 1999.
12 Drivsholm T, Ibsen H, Schroll M, Davidsen M, Borch-Johnsen K. Increasing prevalence of diabetes mellitus and impaired glucose tolerance among 60-year-old Danes. Diabet Med 2001; 18: 126–132.[CrossRef][Web of Science][Medline]
13 Bloor M, Frankland J, Thomas M et al. Focus groups in social research. London: Sage Publications; 2001.
14 Krueger RA, Casey MA. Focus groups. A Practical guide for applied research. London: Sage Publications; 2000.
15 Davies B, Harré R. Positioning: the Discursive Production of Selves. J Theory Soc Behav 1989; 20: 43–63.
16 Hamberg K, Johansson EE. Practitioner, Researcher, and Gender Conflict in a Qualitative Study. Qualitative Health Research 1999; 9: 455–467.
17 Richards H, Emslie C. The ‘doctor’ or the ‘girl from the University’? Considering the influence of professional roles on qualitative interviewing. Fam Pract 2000; 17: 71–75.
18 Paerregaard K. The resonance of field work. Ethnographers, informants and the creation of anthropological knowledge. Social Anthropol 2002; 10: 319–334.[CrossRef]
19 Haraway DJ. Simians, Cyborgs, and Women. The Reinvention of Nature. London: Free Association Books; 1991.
20 Skjervheim H. Objectivism and the study of man. Oslo: Universitetsforlaget; 1959.
21 Hastrup K. A passage to anthropology between experience and theory. London and New York: Routledge; 1995.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  F Strasser, J Binswanger, T Cerny, and A Kesselring Fighting a losing battle: eating-related distress of men with advanced cancer and their female partners. A mixed-methods study Palliative Medicine, March 1, 2007; 21(2): 129 - 137. [Abstract] [PDF]
|
|
|
|
 |
|
 S. Reventlow and H. Bang Brittle bones: Ageing or threat of disease Exploring women's cultural models of osteoporosis Scand J Public Health, May 1, 2006; 34(3): 320 - 326. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||