3.1.1 General principles

3.1.2 Individual interviews

3.1.2.1        What are individual semi-structured interviews?

Interviews are used in many contexts (journalism, human resource managers, etc.) and for many purposes (entertainment, recruitment of personnel, etc.), hence scientific data collection is only one very specific application, which should not be confused with other applications. The interview is easily trivialized as it is common practice in the media landscape which surrounds us. Fontana and Frey even speak about “the interview society” according to Atkinson and Silverman. Practicing health professionals routinely interview patients during their clinical work, and they may wonder whether simply talking to people constitutes a legitimate form of research ^{(DiCicco-Bloom et al,2006)}. In qualitative research, however, interviewing is a well established research technique and two types can be distinguished: semi-structured and unstructured. Structured interviews are out of scope here, because they consist of administering structured questionnaires producing quantitative data.

Unstructured interviews are more or less equivalent to guided conversations⁽DiCicco-Bloom et al,2006). Originally they were part of ethnographers’ field work, consisting of participant observation and interviewing key informants on an ongoing basis to elicit information about the meaning of observed behaviors, interactions, or artifacts(DiCicco-Bloom et al,2006). There is no list of questions, nor an interview guide, the questions asked are based on the responses of the interviewee, as in the natural flow of a conversation (Britten, 1995).

Semi-structured interviews are often the sole data source in a qualitative research project. A set of predetermined open-ended questions is used to guide the interview, but other questions emerging from the dialogue can be added^{(Britten, 1995)}. Also the iterative nature of the research process in which preliminary data analysis coincides with data collection, results in altering questions as the research process proceeds. Even so, questions that are not effective in eliciting the necessary information can be dropped or replaced by new ones^{(Britten, 1995)}.

Essentially an interview consists of someone who asks questions (interviewer), someone who answers these questions (interviewee) and the registration of those answers in some way (Mortelmans, 2009).

The interview as qualitative research method differentiates from other forms of interviewing used in varied domains. Mortelmans pays attention to four characteristics:

• Flexibility; with flexibility internal and external flexibility is meant: external refers to the iterative use of interviewing and data analysis. Structure and content of the subsequent interview may be changed in function of the analysis of the previous one. Internal flexibility points to the fact that the sequence of the prepared interview questions and themes should stands in function of the interviewee in order to guard the natural flow of the conversation.
• The interviewee leads so to speak the conversation. The interviewer only guards the scope of the conversation and makes sure that all the topics are covered.
• Non-directiveness; the interviewee steers the interview and the interviewer only makes sure that the conversation does not stray too far by means of non-directive interview techniques.
• Direct face-to-face contact is important to built trust and get in-depth information, but this depends on the topic and should be considered case by case.

3.1.2.2        When to use individual semi-structured interviews?

Individual semi-structured interviews are useful to:

• Collect data on individuals’ personal histories, perspectives, and experiences, particularly when sensitive topics are being explored ^{(Mack, 2005)}.
• Elicit a vivid picture of the participant’s perspective (Mack, 2005).
• Provide context to other data, offering a more complete picture^{(Boyce et al, 2006)}
• Learn about the perspectives of individuals, as opposed to, for example, group norms of a community, for which focus groups are more appropriate(Mack, 2005).
• Get people to talk about their personal feelings, opinions, and experiences (Mack, 2005).
• Gain insight into how people interpret and order the world on the research topic ⁽Mack, 2005).
• Address sensitive topics that people might be reluctant to discuss in a group setting (Mack, 2005).
• Elicit information from key informants ^{(Sofaer, 1999)}.
• Examine people’s experiences, attitudes and beliefs ^{(Huston et al, 1998)}.

3.1.2.3        Strengths and weaknesses of the method

Strengths:

• They provide much more detailed information than what is available through other data collection methods, such as surveys (Boyce et al, 2006).
• Questions can be prepared ahead of time. This allows the interviewer to be prepared and appear competent during the interview (Cohen, 2008).
• Semi-structured interviews also allow informants the freedom to express their views in their own terms (Cohen, 2008).
• Semi-structured interviews can provide reliable, comparable qualitative data (Cohen, 2008).

Weaknesses:

• Interviews can be time-intensive because of the time it takes to recruit participants, conduct interviews, transcribe them, and analyse the results. In planning your data collection effort, care must be taken to include time for transcription and analysis of this detailed data (Boyce et al, 2006).
• Interviewers must be appropriately trained in interviewing techniques. To provide the most detailed and rich data from an interviewee, the interviewer must make that person comfortable and appear interested in what they are saying. They must also be sure to use effective interview techniques, such as avoiding yes/no and leading questions, using appropriate body language, and keeping their personal opinions in check ⁽Boyce et al, 2006)
• Data from individual semi-structured interviews are not generalizable in a statistical way, but they are theoretically transferrable, because small samples are chosen and no random sampling methods are used. Individual semi-structured interviews however, provide valuable information, particularly when supplementing other methods of data collection. It should be noted that the general rule on sample size for interviews is that when the same stories, themes, issues, and topics are emerging from the interviewees, then a sufficient sample size has been reached (Boyce et al, 2006).

3.1.2.4        How to plan the research design?

See  “How to plan the research design?”

3.1.2.5        Modalities of data collection

Individual semi-structured interviews are usually conducted face-to-face and involve one interviewer and one participant. Phone conversations and interviews with more than one participant also qualify as semi-structured interviews, but, in this chapter, we focus on individual, face-to-face interviews (Mack, 2005).

3.1.2.6        Data collection tools

The data collection tools to carry out interviews are topic lists, questionnaires and field notes. Topic lists and questionnaires are described here.

Researchers use field notes to record observations and fragments of speech. Field notes should be written up as soon as possible after the events to which they refer. If possible, short “aide-mémoire” or pocket dictaphones may be used in fieldwork settings, to facilitate later expansion of the notes into proper fieldnotes (Bloor et al, 2006). In the chapter on observational techniques field notes are addressed in more detail (here).

3.1.2.7        Sampling

For general issues on sampling, see  “Sampling issues in qualitative research: who and how many?”.

3.1.2.8        Human resources necessary

In the ideal scenario researchers plan, organize, carry out and transcribe the interviews themselves, to be completely immersed in the data, but in practice the interviews are often carried out by subcontractors and the transcriptions are often done by professional typists.

3.1.2.9        Practical aspects

Preparations for the interview see “How to run the data collection” .

Physical organisation of an interview. Take the following rules into account:

1. Interviewee and interviewer should not sit opposite each other, but rather at an angle of 90° or less.
2. The interview should take place in a quiet place where the interviewee feels at ease.
3. Avoid the presence of third parties.

3.1.2.10      Analysis and reporting of findings

See "How to prepare data for analysis",  “How to analyse?” and  “How to report qualitative research findings?” .

3.1.2.11      Examples of KCE reports using the method

• Home monitoring of infants in prevention of sudden infant death syndrome ^{(Eyssen et al, 2006)}
• Making general practice attractive: encouraging GP attraction and retention ^{(Lorant et al, 2008)}
• Osteopathy and chiropractic: state of affairs in Belgium^{(De Gendt et al, 2010)}
• Acupuncture: state of affairs in Belgium (De Gendt et al, 2011)
• Homeopathy: state of affairs in Belgium (De Gendt et al, 2011)
• Burnout among general practitioners: prevention and management ^{(Jonckheer et al, 2011)}
• Evaluation of a fixed personal fee on the use of emergency services ^{(Gourbin et al, 2005)}

[1]           We propose a example of a ‘standard introductive text’ in appendix.

3.1.3 Focus groups

3.1.3.1        What are focus groups ?

A focus group is a particular technique in qualitative research. In order to do a focus group interview a group of individuals is gathered in function of their specific profile or characteristics to explore a limited number of “focused questions” (Sofaer,1999). Groups are generally homogenous on a or several criteria relevant to the focus of the discussion.

“In essence, a focus group is a small (usually 6-12 people) group brought together to discuss a particular issue (..) under the direction of a facilitator who has a list of topics to discuss” (Green and Thorogood, 2009, p. 111).

Focus groups are group semi-structured interviews used for the purpose of collecting information focused on a specific subject or area of concern, for exploration and discovery, in-depth understanding of a problem as it is experienced in context, to assess needs, preferences, attitudes and interests related (in the context of KCE research) to health and health care issues.

It differs from individual semi-structured interviews, as the interaction component is used to bring out insights and understandings in ways which questionnaire items or individual questions may not be able to do. The interaction between the moderator and the group, as well as the interaction between group members, may result in more in-depth information, and to elicit differing perspectives related to carefully designed questions. Focus groups are thus not to be considered as a pragmatic time saving substitute for individual semi-structured interviews (e.g. if for any reason the planning does not allow for individual interviews), as the methodological groundings of both techniques differ.

A focus group is not synonymous to ‘group interview’: For a focus group, people are recruited specifically to participate in a research protocol, using a certain method. It is a group interview in the sense that it gathers data simultaneously from different participants (Green and Thorogood, 2009) However it differs from a group interview in the importance that is attached to the interaction among participants. Participants might change their perspective during the focus group interview because of this interaction. In a group interview the interaction between participants is limited, and occurs mainly between interviewer and interviewees.

Figure 4 – Interaction patterns in a group interview versus focus group interview

Depending on sampling strategy and aims, group interviews can take several forms, e.g. consensus panel, focus group, natural group or community interview (Coreil 2005 cited by Green and Thorogood, 2009).

Focus groups can be used as a single research strategy, as well as in combination with other methods in a multi-method research strategy.

3.1.3.2        Specific questions suitable for the method

The principal feature of focus group interviews is interaction between participants. Kitzinger (2006, p. 22) highlights that this particularity could be used to:

• “Highlight the respondents’ attitudes, priorities, language and framework of understanding.
• Encourage participants to generate and explore their own questions, and to develop their own analysis of common experiences.
• Encourage a variety of communication from participants – tapping into a wide range and different forms of discourse.
• Help to identify group norms/cultural values.
• Provide insight into the operation of group social processes in the articulation of knowledge (e.g. through the examination of what information is sensitive within the group.
• Encourage open conversation about embarrassing subject and to permit the expression of criticism.
• Facilitate the expression of ideas and experiences that might be left underdeveloped in an interview, and to illuminate the research patient’s perspectives through the debate with the group.”
• Allow topics which participants have given little thought in advance to emerge from the discussion (Barbour, 2010).

3.1.3.3        Strengths and weaknesses of the method

The benefits from focus groups highlighted are:

• Interaction between participants (Green and Thorogood, 2009)
• Ability to produce a large amount of data on a topic in a short time (Cohen et al, 2008)
• Access to topics that might be otherwise unobservable (Cohen et al, 2008)
• Access to explore sensitive topics, such as dissatifaction with a service: it can be easier for an interviewee if negative ideas are reported as coming from a group than from one single person (Green and Thorogood, 2009)
• Ability to insure that data directly targets researcher's topic (Cohen et al, 2008)
• Access to comparisons that focus group participants make between their experiences. This can be very valuable and provide access to consensus/diversity of experiences on a topic (Cohen et al, 2008)

The limitations of focus groups are related to the limitations of group interviews:

• Inappropriate to uncover marginal or deviant opinions (Green and Thorogood, 2009)
• Importance of social norms: participants are influencing each other, creating a certain kind of implicit norm (Baribeau, 2010), or consensus.
• Otherwise, group dynamics may contribute to cristallization of opinions.
• Not easy to organize: several selected people have to be gathered in the same place during a couple of hours .

3.1.3.4        How to plan the research design?

Since focus group interviews are a collective data collection technique requiring direct person-to-person contact (several people have to come together at the same moment and in the same place) a careful planning of all activities and related tasks is necessary.

3.1.3.5        Modalities of data collection

The data collection by focus group could vary according to (Cohen et al, 2008):

• The level of standardization of the questions
• The number of focus groups
• The number of participants in each groups
• The level of implication of the moderator

3.1.3.6        Data collection tools

During the preparation of the focus group interviews a set of topics or questions is developed and takes the form of a topic list or questionnaire. For the general principles, see here

A focus group interview is in most cases a structured group process structured by means of an agenda to keep the group focused and on track. A focus-group should be experienced as free-flowing and relatively unstructured, but in reality, the moderator must follow a pre-planned script of specific issues and set goals for the type of information to be gathered. An introduction of up to 15 minutes should be carefully planned, as well as a good opening question. In order to keep the time schedule, as several people are going to participate and answer to the questions, it is important to foresee a maximum duration for each question.

The use of a well designed guide is helpful to compare information from one group to another as it is expected to have more than one focus group for a given topic.

3.1.3.7        Sampling

For general issues on sampling, see  “Sampling issues in qualitative research: who and how many?”

Identification of units of analysis

The starting point for selecting participants for focus groups is to identify the unit of analysis. Is the unit of analysis “individuals for their personal opinions/experience/expertise”, or is it “individuals because they represent organizational perspectives”? It has a major impact on the people invited to the focus group interview and therefore it should be clearly described.

The sample of focus groups will consist of groups of people, instead of individuals. People who are invited to take part need to have an interest in the subject.

Composition of the groups

Ideally groups have to be internally homogenous on criteria relevant to the topic but externally heterogeneous between groups. Homogeneity in the group capitalizes on people’s shared experiences (Kitzinger, 2006).

It is best to select people who do not know one another, but have similar relationships with the topic being investigated (although it could in practice be difficult for particular topics). Selecting participants who are similar may help them to share ideas more freely and develop an in-depth analysis of a topic (homogeneous groups).

Sometimes, heterogeneous groups can be used after the primary analysis of homogeneous focus groups has started. Heterogeneous groups are used to “confront” diverging opinions. In general terms, heterogeneous groups are composed of representatives of all relevant stakeholders.
In this case, the researcher has to pay attention to potential power differences or inequalities between participants. This may prevent some people from talking freely during the discussion and by consequence prevent the collection of rich data (Kitzinger, 2006).

In the Belgian context, focus group interviews can be carried out with French-speaking or Dutch-speaking and even German-speaking, participants. It is advisable to conduct unilingual groups: it is easier and richer for facilitators and participants. For heterogeneous groups, like stakeholders samples, it could be difficult to separate people in groups according to their mother tongue. In this particular case, it is important that participants express themselves in their mother tongue and to be sure that every participant understands the other language. The moderator has to be thus perfectly bilingual.

Number of participants per group

A group of six to twelve people is sufficient for a focus group. The ideal size for a focus group is eight to ten respondents. In general, the smaller the group, the more manageable it is. From experience, a group of 6‑8 participants allows enough time for discussion and is easier to manage. Where the purpose is to generate in-depth expression from participants, a smaller group size may be preferable in combination with carrying out more focus groups to attain saturation.

In order to make sure that a group counts enough participants, it is advisable to recruit 25% more people than required (Green and Thorogood, 2009). If too few participants turn up, one should foresee an additional focus group to substitute for the low attendance.

Number of groups

The number of focus group interviews needed depends on the aims and available resources . It is almost impossible to give clear standardized guidelines on the number of focus groups needed.

It is methodologically important for both approaches to conduct at least two focus groups by ‘type of people’. Using only one focus group to arrive at conclusions is risky since the opinions expressed may have had more to do with the group dynamics (i.e. persuasive skills of one or two members) than a true sampling of the opinions of the population that the group represents. Even the preset number of two focus groups is generally too limited to make in-depth analyses, especially if the topics discussed are rather “broad” or general (see also paragraph analysis on continuous comparative method). Having two homogeneous groups that provide different results suggests that more information is necessary (data saturation is not reached). One rule of thumb is to conduct focus groups until they no longer provide any new information on the topic discussed.

3.1.3.8        Human resources necessary

Three people (from the research team) could chair the focus group interview:

1. The moderator (also called ‘facilitator’) plays a crucial role in the success of a focus group interview and can have a major impact on the outcomes of the data collection. He should lay down some ‘rules’, explain the duration of the focus group interview, plan a break in between, make everybody welcome before hand, do the paperwork (e.g. informed consent) before actually starting the interview. Before the opening question, is it important to ask everybody to introduce themselves briefly. He has “to establish a relaxed atmosphere, enable participants to tell their stories, and listen actively” (Green and Thorogood, 2009, p 126.). Facilitating or moderating focus group interviews requires particular competencies: interpersonal skills (including non-verbal communication skills) are needed as well as a non-biased attitude towards the issues discussed. A focus group moderator should be able to keep the discussion on track and make sure every participant is heard. He/she has to be able to summarize what has been said, to structure the discussion. However he/she should not take position, avoid to make quick assumptions or conclusions, avoid to develop answers for the participants or give advice. Focus groups are intended to make in-depth studies of the perceptions, attitude and opinions of the participants, not of the research team (or moderator). The moderator makes it socially acceptable for participants to have another point of view. If participants get off track or get ahead of the issue being discussed the moderator must pull the group back together. He/she does not need to be an expert in the domain of the research.The moderator needs to use “probing techniques” when necessary: probing is essentially a means of further investigating a topic that has already been introduced. Probing can be used to clarify, to obtain more detail and to assure completeness. For this purpose, see also here. In the particular case of focus group interviews, the moderator could use disagreements in the group to force participants to develop and elucidate their point of view. An experienced interviewer could decide whether or not to follow the lead of the interview or to return to the sequence of the interview guide1 In the particular case of bilingual groups, the moderator has to master both languages.
2. The note-taker will take notes during the discussion while the moderator is introducing questions. The note-taker could sit next to the moderator. Nevertheless, pay attention that if he/she is typewriting on a laptop directly, the sound of the typing on the keyboard is not disturbing. Moderator and note-taker can take turns in asking questions and taking notes (this requires a well functioning team that clearly understands its roles and can adapt to the situation). It should be discussed and reported whether different or the same persons facilitate the respective focus group interviews.
3. The observer is a third facilitator who could be useful to observe the focus group participants (non-verbal language) and to help the moderator in identifying not very talkative participants and in keeping time.

As focus group have to be transcribed afterwards. It is also useful to engage the services of an audio typist.

3.1.3.9        Running of data collection

For general principles see  “How to run the data collection?”.

In the case of focus groups, once the group of respondents is gathered for the discussion, the moderator should give a brief introduction to set everybody at ease[1]. More concretely, the moderator should:

• Explain the purpose of the discussion, how the information collected will be used and reported.
• Introduce note-taker and observer who will remain in the room during the discussion.
• Explain that the discussion is for scientific purposes and that information will solely be used with the context of the research.
• Ensure participants that the rules of confidentiality apply to everyone in the room, including the note-takers, observers.
• Explain how names will be used (real names or pseudonyms).
• Explain the group rules (speak one at a time, avoid interrupting or monopolizing, etc.).
• If the discussion is to be tape-or video-recorded, obtain permission from the respondents first, and explain how the tapes will be used, stored and eventually destroyed. – Tip to increase the quality of the recording: use 2 recorders, preferably stereo recording, one at each side of the table: it is useful to understand everybody and prevent the loss of data in case of disfunctioning of the recorder.

The Moderator will then begin the focus group interview by asking an ‘icebreaker question’ to facilitate the discussion in the group. Afterwards, he/she will come to the focus of the discussion.

Immediately after the focus group a debriefing has to be foreseen with the moderators/facilitators. The debriefing part is an essential step for the analysis. The debriefing exercise is best supported by a template of dimensions, upon which the moderator/facilitator team needs to comment (example in Appendix).

The facilitators should review the notes taken during the focus group and have a first assessment of clarity and understanding.

They should discuss, compare and record observations or impressions about the group not readily apparent from the notes.

Discuss and record any insights or ideas emerging during the interviews while they are still fresh in the mind.

3.1.3.10      Practical aspects

Preparations for the interview

See also part “How to run the data collection? ”

Location & timing

• The location where the focus groups will be held should be carefully selected.
• Accessibility and transport issues (and mobility needs of participants) should be considered.
• Avoid noisy areas where it will be difficult for participants and the moderator to hear each other.
• The setting should be comfortable, non-threatening for the respondents. Refreshments should be provided.
• The focus group table can be organized before hand and this allows the researcher to place name tags in the way he wants.
• Seating should be arranged to encourage participation and interaction, preferably in a circle, with or without name tags. It can be discussed whether tables are needed. Moderators/facilitators (and note takers) should be integrated as much as possible within the discussion setting.
• The timing of the focus group interview need to be acceptable for all potential respondents in order to avoid selective “non-response” as much as possible (take into account the socio-demographic profiles of the targeted participants such as working times, daily activities, family life, etc.).

Duration

The length of the focus group should be between 1 and 3 hours.

Allow sufficient time at the beginning to welcome participants, give them an introduction and let them introduce themselves. This part should not take excessive time (about 10 minutes).

Material

Data are collected through different sources: audio or video-taping can be considered. When focus group interviews are recorded, the equipment should be of good quality and easy to use (check batteries and microphone). For larger groups, it may be necessary to use two tape recorders or multi-channel equipment, strategically placed to maximize the probability of recording contributions from all participants.

“Field notes” are an essential part during data collection. They capture all of the essential “non-verbal” information during the focus group interview.

Information has to be collected in an unbiased manner (avoid to filter out information as pre-interpreting it as unimportant, especially in the first focus groups).

The context of statements made during focus groups should be documented (important for giving meaning to the statements in the phase of analysis).

Try to capture nonverbal behavior of group participants (nonverbal reactions of other participants after a participant statement may indicate consensus or disagreement).

3.1.3.11      Analysis and reporting of findings

For issues on analysis, see  “How to analyse the data?”.

In the particular case of focus groups, separate analyses have to be performed on data gathered “within-focus group” and continuously compared “between focus group”. This is also an iterative process.

It is important that statements be understood in the context which they were made. Nonverbal communication observed during the interview can also be very informative.

For reporting, see part  “How to report qualitative research findings”

Note that findings are reported by focus group as unit of analysis and not by person.

3.1.3.12      Quality criteria

See section part  “How to evaluate qualitative research?”

Vermeire et al propose a checklist specific to critical appraise the quality of focus groups in health care research articles in primary healthcare (Vermeire et al, 2002).

3.1.3.13      Examples of KCE reports using the method

• Evaluation of the Belgian reference reimbursement system (LePolain et al, 2010)
• Evidence-based content of the written information provided by the pharmaceutical industry to the general practitioner (Van Linden et al, 2007)
• Quality development in general practice in Belgium: status quo or quo vadis ? (Remmen et al, 2008)
• Mental health care reforms: evaluation research of ‘therapeutic projects’ (Schmitz et al, 2010)
• Emergency psychiatric care for children and adolescents (Deboutte et al, 2010)